Every finding on record at Highlands Nursing and Rehabilitation

Based on interview, record review, and facility policy review, the facility failed to ensure that three of three residents reviewed for medications (Residents (R) 5, R126, and R135) were free from significant medication errors. Facility staff failed to follow physician orders and administered blood pressure medications outside of ordered parameters. These errors are considered significant because these medications are critical in preventing life=threatening complications by managing blood pressure. The findings include:Review of the facility's policy, titled, Administering Medications, revised 04/2019, revealed Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. The policy noted, Medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.1. Review of R126's electronic medical record's (EMR) Face Sheet revealed the facility admitted R126 on 02/16/2024 with diagnoses of acute and chronic combined systolic (congestive) and diastolic (congestive heart failure, hypotension, unspecified atrial fibrillation, and localized edema. a. Review of R126's physician orders revealed the physician ordered Midodrine HCl Oral Tablet, (a medication used to treat low blood pressure) 5 milligrams (MG), Give one tablet by mouth three times a day for hypotensive episodes. Hold for blood pressure greater than 110/60.Review of R126's Medication Administration Record (MAR) for 03/2026 revealed staff administered Midodrine outside the physician ordered parameter of hold if blood pressure is greater than 110/60, 29 times. These included but were not limited to 03/18/2026 at approximately 3:00 PM for a blood pressure reading of 138/76 and 03/19/2026 at approximately 3:00 PM, for a blood pressure reading of 138/80.b. Review of R126's physician orders also revealed the physician also ordered Metoprolol Succinate ER Oral Tablet Extended Release 24-hour (used to treat high blood pressure) 25mg. Give 0.5 tablet by mouth one time day for hypertension (high blood pressure), Atrial Fibrillation. Hold for blood pressure less than 110/60, heart rate of 60 or less. Review of R126's MAR for 03/2026 reveled staff administered Metoprolol Succinate ER outside the physician ordered parameter of hold if blood pressure is less than 110/60, heart rate of 60 or less on five occasions, including, 03/09/2026 at approximately 9:00 AM, for a blood pressure reading 106/70 with heart rate of 58 and 03/01/2026 at approximately 9:00 AM, for a blood pressure reading 100/76. 2. Review of R5 electronic medical record's Face Sheet revealed the facility admitted R5 on 09/09/2025, with diagnoses of chronic diastolic (congestive) heart failure, hypotension (unspecified) and hypertensive heart disease with heart failure. Review of R5's physician orders revealed the physician ordered Midodrine HCl Oral Tablet 2.5MG, give one tablet by mouth three times a day for hypotension blood pressure hold for a systolic 125 or greater. Continued review of R5's physician ordered revealed the physician also ordered Metoprolol Succinate ER Oral Tablet 25mg, give one tablet by mouth two times a day for hypertension, hold for systolic less than 110 and diastolic less than 60. Review of R5's MAR for March 2026 revealed staff administered Midodrine outside the physician ordered parameter of hold if systolic blood pressure is greater than 125, three times. Including, March 6, 2026, at approximately 9:00 PM, blood pressure reading 128/78 and March 25, 2026, at approximately 9:00 PM, blood pressure reading 130/77. Review of R5's MAR for March 2026 revealed staff administered Metoprolol Succinate outside the physician ordered parameters of hold if systolic blood pressure is less than 110 and diastolic blood pressure is less than 60, 25 times. Including, March 20, 2026, at approximately 9:00 PM, blood pressure reading 99/60 and March 24, 2026, at approximately 9:00 AM, blood pressure reading 103/58. 3. Review of R135's electronic medical record's Face Sheet revealed the facility admitted R135 on 07/15/2022 with diagnoses including unspecified combined systolic (congestive) and diastolic (congestive) heart failure, localized edema and hypertensive heart disease with heart failure. Review of the physician orders for R135 revealed an order for Midodrine HCl Oral Tablet 5MG, give three tablets by mouth three times daily for hypotension, hold for systolic blood pressure greater than 125. Continued review of R135's physician orders revealed an order for Metoprolol Tartrate Oral Tablet 25MG, give one tablet by mouth two times a day for hypertension, no parameters stated. Review of R135's MAR for March 2026 revealed staff administered Midodrine outside the physician ordered parameters of hold if systolic blood pressure was greater than 125, one time, on March 17, 2026, at approximately 3:00 PM, with a blood pressure reading 126/71. Further review of R135's MAR for March 2026 revealed staff administered Metoprolol Tartrate daily for high blood pressure, parameters not clarified. Including, March 1, 2026, at approximately 9:00 AM blood pressure reading 98/59 and March 14, 2026, at approximately 9:00 PM, blood pressure reading 88/60. Interview with Licensed Practical Nurse (LPN)2 on 04/01/2026 at 3:14 PM revealed that prior to medication administration, she performed the five rights to medication as, right resident, right dose, right time, right route, right medication. She continued that following the five rights would also include following the ordered medication parameters written in the order by the physician. LPN2 stated she knew better than to administer medications that are outside the physician order parameters but could not definitively state why she did so. She continued that not following physician orders could harm the resident and could exacerbate a resident's health conditions. In an interview with Registered Nurse (RN)4 on 04/01/2026 at 4:09 PM, she stated prior to medication administration she performs the five rights to medication as, right resident, right medication, and right dose. RN4 could not recall the remaining rights. RN4 stated that following the five rights would include following medication parameters written in the order by the physician. RN4 stated she could see on the MAR that she documented administering medication that was outside the physician order parameters and stated she did not know why she did that. RN4 stated it was probable to exacerbate a resident's health condition by not following physician orders. In interview with RN7 on 04/02/2026 at 9:41 AM he stated prior to medication administration he performs the five rights to medication as, right dose, right resident, right medication. RN7 could not recall the remaining rights. RN7 stated that following the five rights would include following medication parameters written in the order by the physician. RN7 stated a resident can have a problem if physician orders are not followed and could exacerbate residents' health conditions. RN7 stated he must not have read the parameters that day. In an interview with the Pharmacist on 03/30/2026 at 5:45 PM, she stated the pharmacy performed monthly medication review audits of residents taking medications at the facility. She stated she was not concerned to see residents on medications for both high blood pressure and low blood pressure simultaneously because staff were supposed to follow the blood pressure parameters written by the physician prior to administration. In an interview with the facility Nurse Practitioner (NP) on 03/30/2026 at 6:23 PM, the NP stated nursing staff should follow orders as written prior to medication administration and to reach out to her if clarification is needed in understanding the parameters or the order. In an interview with facility Medical Director on 03/31/2026 at 3:29 PM, he stated Metoprolol should be held if the blood pressure is low as there are risks and associated side effects. He continued he expected staff to follow the parameters written in the order. The Medical Director stated he would expect staff to reach out to him for clarification of medication orders or parameters; however, staff had not contacted him. In an interview with the facility Assistant Director of Nursing (ADON) on 04/02/2026 at 12:30 PM, she stated she expected staff to follow the five rights to medication administration and follow physician written order parameters. She also expected staff to reach out to the provider if staff need clarification of physician orders prior to administering medications. She stated no one audited resident MARs and would not be aware of repeat medication errors. She stated a reason for many medication administration errors could be staff going too fast. In an interview with the facility Director of Nursing (DON) on 04/02/2026 at 12:42 PM, she stated she expected staff to follow the five rights to medication administration and follow physician written order parameters. She continued that she expected staff to reach out to the provider if clarification of a medication order was needed, prior to administration. The DON stated no one audited resident MARs and would not be aware of repeat medication errors, unless they were brought to her attention. She stated a reason for many medication administration errors could be staff not paying attention to the physician orders. In an interview with the facility Administrator on 04/02/2026 at 12:51 PM, he stated he expected staff to follow the five rights and physician written orders prior to medication administration. In addition, he would expect staff to reach out to the provider if they needed clarification of physician orders. The Administrator stated staff received routine education regarding medication administration and was not aware of staff committing medication errors on a regular basis, indicating that would be rare.

Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. Necessary Maintenance and Housekeeping was not provided in order to maintain a sanitary, orderly, and comfortable interior. Observation during tour of the building on 02/24/2025 revealed the following: There was a foul odor that smelled of stale urine noted throughout the 1C Unit hallway. The bathroom for room [ROOM NUMBER] had the appearance of dried urine on the floor and the room smelled liked strong stale urine. Additionally, the baseboard surrounding the sink in room [ROOM NUMBER] was pulled away from the sink and pulled away from the section of wall adjacent to the sink. The bathroom for room [ROOM NUMBER] had paint peeling off the wall around the plumbing, ceiling tile was sagging and there was a large water stain on the ceiling tile. The bathroom for room [ROOM NUMBER] smelled like old stale urine, the toilet was missing a seat, and the ceiling tile above the toilet was sagging and stained. room [ROOM NUMBER] had peeling paint on the sink cabinet door and the door was partially off the hinges. The bathroom for room [ROOM NUMBER] had no toilet paper holder attached to the wall, and there was no string on the call light in the bathroom. The 1C shower room had a brown substance that appeared to be fecal matter on the toilet seat and on a lawn chair in the room. Additional observation revealed there were black spots which appeared to be mold and a larger area of brownish discoloration on the ceiling tile in the shower. Also, observation on 02/24/2025 and 02/27/2025, revealed the cabinet in the dining/activity room on the 1C unit was missing baseboard leaving the damaged section of wall exposed. The findings include: Review of the facility policy titled, Safe and Homelike Environment, dated 12/12/2023, revealed the facility would provide housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable environment. Further review revealed orderly was defined as an uncluttered physical environment that was neat and well-kept. Observation on 02/24/2025 at 2:20 PM, revealed a foul odor noted throughout 1C Unit hallway. Observation on 02/24/2025 at 2:27 PM, revealed the bathroom for room [ROOM NUMBER] had the appearance of dried urine on the floor and the room smelled liked strong stale urine. Further observation revealed the baseboard surrounding the sink in room [ROOM NUMBER] was pulled away from the sink and pulled away from the section of wall adjacent to the sink. Observation on 02/24/2025 at 2:46 PM, revealed the bathroom for room [ROOM NUMBER] had paint peeling off the wall around the plumbing. Further observation revealed the ceiling tile was sagging and there was a large water stain on the ceiling tile. Observation on 02/24/2025 at 2:53 PM, revealed the bathroom for room [ROOM NUMBER] smelled like old stale urine. Further observation revealed the toilet was missing a seat. Continued observation revealed the ceiling tile above the toilet was sagging and stained. Observation on 02/24/2025 at 2:59 PM, revealed room [ROOM NUMBER] peeling paint on the sink cabinet door and the door was partially off the hinges. Further observation in the bathroom revealed the toilet paper holder was not attached to the wall, and the toilet paper roll was stored on the back of the commode without a container. Continued observation revealed there was no string on the call light in the bathroom. Observation on 02/24/2025 on 3:04 PM, revealed the 1C shower room had a brown substance that appeared to be fecal matter on the toilet seat and on a lawn chair in the middle of the room. Further observation revealed there were black spots which appeared to be mold and a larger area of brownish discoloration on the ceiling tile in the shower. Observation on 02/24/2025 at 5:10 PM, and 02/27/2025 at 3:45 PM, revealed the cabinet in the dining/activity room on the 1C unit was missing baseboard leaving the damaged section of wall exposed. In an interview, on 02/27/2025 at 3:48 PM, State Registered Nurse Aide (SRNA)16 stated she had been working at the facility for almost six months and the baseboard in the dining/activity room on the 1C unit had been missing as long as she had been there. Further, she stated the other areas of disrepair, including stained ceiling tiles had also been in that condition since she started. Per interview, SRNA16 stated maintenance staff was not in the building on her shift. She stated putting in work orders was the responsibility of first shift and management staff, since they were in the building at the time maintenance was also present. She further stated, maintenance services could be better, but if no one complained about repairs needed, nothing would get fixed. In an interview, on 02/27/2025 at 4:23 PM, Licensed Practical Nurse (LPN)4 stated if staff noticed areas of disrepair, they were to put work orders in the maintenance system. She further stated she noticed some cabinets needed to be replaced and she thought maintenance was aware of this. In continued interview, LPN4 stated she saw maintenance replace some tiles a month or two ago, but not since then. In an interview, on 02/27/2025 at 4:29 PM, the IC Unit Manager stated members of management completed daily rounds on rooms and were to check for repairs needed; however, she did not know who was responsible for rooms 101-112. Per interview, she stated she would put in work orders for the ceiling tiles, and baseboards needing repair, and the missing toilet paper holder which she observed during the unit tour with the State Survey Agency Representative prior to the interview. In further interview, the 1C Unit Manager stated maintenance issues needed to be addressed to provide a comfortable, homelike environment for the residents. She further stated one of the residents who used the bathroom for room [ROOM NUMBER] toileted independently, but might have been missing the commode, which meant housekeeping needed to clean the bathroom more frequently, including a deep clean. In an interview, on 02/28/2025 at 9:00 AM, the Maintenance Director stated his role was to ensure upkeep of the building. He further stated he completed preventative maintenance as well as checked for work orders in the maintenance system for any repairs needed. Per interview, members of the management team were each assigned a group of rooms to round on every day and they were expected to put work orders in for any areas of concern they identified. In continued interview, he stated he received work orders for ceiling tile repair on 1C this morning and had been working on replacing stained and sagging tiles. The Maintenance Director it was important to ensure building upkeep in order to provide a safe, homelike environment for the residents. In an interview on 02/28/2025 at 9:50 AM, the Admissions Coordinator stated she was assigned daily rounds on the section of rooms that included rooms [ROOM NUMBER]. She further stated those daily rounds included checking bathrooms and sinks for maintenance and housekeeping issues. In continued interview, she stated she noticed the ceiling tiles and put in a work order this morning. Per interview, she had not noticed them before today because she might have gotten distracted by other issues while rounding. Additionally, the Admissions Coordinator stated the 1C Unit was in need of environmental upgrades because it was not a comfortable, homelike environment for the residents. Per interview, she stated addressing maintenance issues was important for safety concerns and because no one would want to live in a poorly maintained facility. In an interview, on 02/28/2025 at 1:00 PM, the Director of Nursing (DON) stated she was part of the management team that performed rounds on resident rooms. She stated it was her expectation each manager enter identified issues into the maintenance system and also bring up any environmental concerns in morning meeting. In continued interview, the DON stated she was not aware of the ceiling tiles, baseboards, and other items in disrepair on 1C. Additionally, the DON stated the facility was responsible for providing a safe, homelike environment for the residents. In an interview, on 02/28/2025 at 2:43 PM, the Executive Director (ED) stated he expected members of the management team to conduct rounds on their assigned rooms on a daily basis and give reports of their findings to him each day. Per interview, the ED stated he entered any findings related to building upkeep into the maintenance system and followed up on any issues. The ED stated he doubted the baseboards and other identified items on 1C had been in disrepair for months. In additional interview, the ED stated building maintenance was a constant challenge, and he expected repairs to be completed as soon as any issues were identified.

Based on personnel files, facility policies, Kentucky regulation KRS 216.789 (1), and KRS 216.718 (4), the facility failed to ensure it did not employ or otherwise engage individuals with a disqualifying criminal conviction or finding in the State Nurse Aide Abuse Registry for three of 10 employee files reviewed. Review of the Cook's background check, Statewide Criminal Repository, revealed a Felony Burglary, 3rd degree with a Guilty disposition on 06/02/2016. Additionally, there was no documented evidence Nurse Aide (NA) Abuse Registry checks were completed for the Cook, Business Office Manager, or Administrative Assistant, prior to employment. The findings include: 1. Review of the facility policy titled, Abuse Prevention Program, revised 03/2021, revealed the facility conducted employee background checks per state and federal regulations, and will not knowingly employ or otherwise engage any individual who has been convicted of abuse, neglect, or misappropriation. The facility abuse prevention program provides policies and procedures that govern conducting background checks to avoid hiring persons who have been found guilty of abusing, neglecting, or mistreating individuals. Review of the facility policy titled, Background Check Disqualifying Criteria, undated, revealed as part of the hiring procedures it is the facility's policy to conduct criminal background checks on all applicants offered employment. The policy revealed the Office of Inspector General (OIG) has the authority to exclude individuals from federally funded health care programs and maintains a list of all currently excluded individuals called the List of Excluded Individuals/Entities (LEIE). The facility checks the LEIE on all potential hires to ensure new hires are not on the excluded list. If the applicant is on the list, the applicant is not eligible for hire. Any criminal history report in question or flagged report needs to be sent to the Executive Director and the facility's consulting group Human Resources (HR) for review and approval before orientation. Convictions for a felony robbery offense occurring less than seven years from the date of the criminal background check was considered disqualifying. Review of the Kentucky regulation KRS 216.789 (1), effective 07/14/2022, revealed no long-term care facility shall knowingly employ a person in a position which involves providing direct care services to a resident if that person has been convicted of a felony offense related to theft. Review of the Kentucky regulation KRS 216.718 (4), effective 06/29/2023, revealed direct care service means a service provided to a resident in a long-term care facility by direct care staff. Review of the facility map, revealed the kitchen was on the Ground floor right next to the dining room. Further, the Beauty Shop, smoking patio, and Therapy department were on the Ground floor. Review of the Cook's personnel file, revealed the [NAME] signed on 12/20/2024, he was given information or information was reviewed with him to include policies, and procedures related to Resident Rights and Resident Abuse. Review of the position description Dietary [NAME] signed by the [NAME] on 12/20/2024, revealed an essential responsibility and job function included Maintain effective communication with residents . Review of the Cook's background check, completed on 12/16/2024, revealed results were flagged for the Statewide Criminal Repository, the 7 year County Criminal History, and the Criminal History Nationwide . sections. The background check for the Statewide Criminal Repository revealed Felony Burglary, 3rd degree with a Guilty disposition on 06/02/2016. The 7 year County Criminal History stated to see results in the Statewide criminal repository. The Fraud and Abuse Control information System (FACIS) III section noted no pertinent information was found against the LEIE. In an interview, on 02/28/2025 at 11:27 AM and 02/28/2025 at 1:11 PM, the Director of Nursing Services (DON) stated she did not participate in Human Resources (HR) checks. She stated the [NAME] was hired in December 2024 or January 2025 and no longer worked at the facility. The DON further stated she thought the Cook's felony conviction would make him ineligible to work in the facility. In an interview, on 02/28/2025 at 2:43 PM, the Administrator stated the facility Human Resources (HR) Director was out of the facility for a personal issue, and he was currently covering the role of HR. He further stated the purpose of conducting the background checks was to make sure anyone working in the building did not have a background which was not conducive to providing resident care. The Administrator also stated according to the facility policy, the [NAME] was hired based on the seven year span. He stated the facility hired employees according to a case by case basis depending on what the applicant did. In continued interview, on 02/28/2025 at 2:43 PM, the Administrator stated the facility policy, Background Check Disqualifying Criteria, stated after seven years the applicant could be hired. (However, this policy referred to the LEIE). The Administrator also stated per facility policy, after seven years the facility could bring on board an applicant. When questioned if the facility policy superseded regulation, he stated he could speculate there could be a potential issue if an applicant was hired with a burglary guilty disposition. He also stated the facility wanted to have the best care for residents. 2. Further review of the facility policy titled, Abuse Prevention Program, revised 03/2021, revealed the facility conducts employee background checks per state and federal regulations and will not knowingly employ or otherwise engage anyone with a disciplinary action in effect against a professional license by a state or licensing body including the Nurse Aide Registry. Review of personnel files, revealed no documented evidence the facility conducted Kentucky Nurse Aide (NA) Abuse Registry checks prior to beginning employment with the facility for the Cook, Business Office Manager (BOM), and Administrative Assistant (AA). Per the personnel files, the [NAME] began employment on 12/20/2024, the BOM began employment on 01/09/2025, and the AA began employment on 01/22/2025. In an interview, on 02/28/2025 at 11:32 PM, the Director of Nursing (DON) and Regional [NAME] President (RVP) of Operations, both stated the facility did not complete NA Abuse Registry checks for non-clinical staff. In an interview, on 02/28/2025 at 1:11 PM, the DON stated she was not involved in conducting the NA Abuse Registry checks as they were to be completed by Human Resources (HR). She stated the purpose of the NA Abuse Registry check was to ensure in this type of environment the facility hired people qualified and safe to be around residents. She stated if the NA Abuse Registry checks were not completed, the facility could have someone not qualified or safe to be around the vulnerable population. In an interview, on 02/28/2025 at 2:43 PM, the Administrator stated the NA Abuse Registry checks were to be completed in order to make sure whoever was in the building did not have a background that was not conducive to providing resident care. He stated the NA Abuse Registry checks were to be completed by HR, although he re-iterated she was out of the facility at this time and he was completing the HR duties. He further stated the NA Abuse Registry checks should be completed and records kept for their files.

Based on interview, record review, and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 3 sampled residents investigated for hospitalizations out of a total sample of 29 residents, Resident (R)23, R95, and R107. The findings include: Review of the facility policy titled, Transfer and Discharge, dated 12/12/2023, revealed the facility was to notify the long-term care ombudsman of transfers and maintain evidence the notice was sent to the Ombudsman. 1. Review of R95's admission Record revealed the facility admitted the resident on 07/14/2021 with diagnoses at time of survey including Alzheimer's disease, bariatric surgery status, and alcohol dependence in remission. Review of the facility Notice of Transfer or Discharge, dated 09/03/2024, revealed the resident was sent to the hospital after sustaining a fall at the facility. Further review revealed there was no documented evidence the form was sent to the Ombudsman. 2. Review of R107's admission Record revealed the facility admitted the resident on 03/25/2024 with diagnoses including chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, and interstitial pulmonary disease. Review of the Progress Note, dated 11/17/2024, revealed R107 had become unresponsive and was transferred to the local hospital and admitted for altered mental status. Review of the facility's Notice of Transfer or discharge: Notice of Bed Hold Days, dated 11/18/2024, revealed the facility documented R107 was transferred for altered mental status. Further review revealed the document failed to indicate the local ombudsman had been notified of the transfer. 3. Review of R23's admission Record revealed the facility admitted the resident on 11/22/2015 with diagnoses including Type II Diabetes Mellitus, Unspecified Dementia, Delusional Disorders, and Chronic Kidney Disease Stage III. Review of R23's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive deficit. In an interview, with R23, on 02/26/2025 at 2:28 PM, R23 stated she has been out to the hospital on multiple occasions for different problems. Review of R23's Electronic Medical Record (EMR), under the Census section, revealed the resident was transferred out to the hospital on several occasions, including on 06/28/2024, 07/09/2024, 10/15/2024, 11/04/2024, and 12/03/2024. However, further review of the medical record, revealed no documented evidence the Ombudsman was notified of these transfers to the hospital. In an interview, with the Social Services Director, on 02/28/2025 at 2:15 PM, she stated she was not responsible for notifying the Ombudsman of residents' transfers out to the hospital. She stated Medical Records was responsible; however, the Medical Records person was not working today, and was unable to be reached by phone. In an interview, with the Regional Nurse Consultant, on 02/28/2025 at 2:40 PM, she stated the facility had not been notifying the Ombudsman of any hospital transfers from the facility. She further stated she could not find evidence of emails being sent to the Ombudsman related to transfers. In an interview, on 02/28/2025 at 3:22 PM, Ombudsman 2 stated he had not received any notifications since 05/2021, regarding residents from this facility being transferred to the hospital . In an interview, on 02/28/2025 at 1:00 PM, the Director of Nursing (DON) stated she was not able to provide documented evidence of notification of transfers to the ombudsman. In an interview, with the Executive Director, on 02/28/2025 at 3:10 PM, he stated either social services or medical records were responsible for notifying the ombudsman of resident transfers to the hospital. He stated this would be for both facility initiated or unplanned transfers.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement the Comprehensive Care Plan (CCP) for 1 of 29 residents reviewed for care planning, Resident (R)141. On 01/15/2025, a care plan intervention for a perimeter mattress was added to R141's CCP due to the resident sustaining a fall from bed on the same date. Although the resident sustained another fall from bed on 01/19/2025, the intervention for the perimeter mattress was not implemented until 02/28/2025, during survey. The findings include: Review of the facility policy, titled, Comprehensive Care Plans, dated 11/01/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident that included an assessment of the resident's needs. Further review revealed qualified care team members responsible for carrying out interventions would be notified of their responsibilities for the initial care plan, as well as when changes were made. Review of R141's Admission Record revealed the facility admitted the resident on 01/15/2025 with diagnoses to include vascular dementia with agitation, osteoporosis, and a history of falls. Review of the Health Status Note, dated 01/15/2025, signed by Licensed Practical Nurse (LPN)8, revealed she found R141 lying on the floor by her bed. Additional review revealed the resident denied pain and LPN8's assessment found no sign of injury. Review of R141's CCP, dated 01/15/2025, revealed the facility identified the resident as at risk for falls and listed interventions including keeping the bed in low position, keeping the resident's call light in reach, and utilizing a perimeter mattress. All interventions were dated 01/15/2025. Review of the IDT [Interdisciplinary Team] Note, dated 01/16/2025, revealed the facility determined after R141 fell out of bed, they would install a perimeter mattress to prevent further falls. Review of the Health Status Note, dated 01/19/2025, signed by Registered Nurse (RN) 5, revealed she found R141 lying on the floor beside her bed, on top of pillows and blankets. Additional interview revealed R141 denied pain and RN5's assessment did not reveal signs of injury. Review of the IDT Note, dated 01/20/2025, revealed R141 fell out of bed on 01/19/2025 and was wearing appropriate footwear, but the resident was unable to state what she was doing at the time of the fall. Additional review revealed no documented evidence the facility verified previous care planned interventions, to include the perimeter mattress were in place at the time of the resident's fall. Review of R141's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated severe cognitive impairment. Additional review revealed the facility assessed the resident as having two falls without injury during the look back period. Observation on 02/24/2025 at 3:16 PM; 02/27/2025 at 3:17 PM; and 02/28/2025 at 10:21 AM, revealed R141 had a regular mattress with no perimeter for fall prevention noted. During interview on 02/28/25 at 10:47 AM, Licensed Practical Nurse (LPN)4 stated she did not know if R141 had ever had a perimeter mattress. She further stated she was assigned to the resident, but since she did not put the resident to bed, she would not know what kind of mattress the resident had. In continued interview, LPN4 stated following the care plan was important in order for residents to have everything they need for safe care. During observation and interview, on 02/28/2025 at 10:21 AM, the 1C Unit Manager stated R141 should have a perimeter mattress because it was on her care plan. The 1C Unit Manager then checked and felt the edge of R141's bed, and stated she could not tell if there was a perimeter mattress on the resident's bed. In an additional interview on 02/28/2025 at 10:38 AM, the 1C Unit Manager stated staff just changed R141's mattress to a perimeter mattress. She stated the resident did not have a perimeter mattress before today. During an interview, on 02/28/2025 at 1:00 PM, the Director of Nursing (DON) stated she did not have a comment on why R141 did not have a perimeter mattress in place after falling out of the bed twice. In additional interview, the DON stated the unit manager for each unit was responsible for ensuring care planned interventions were in place. The DON stated, following the care plan was important to prevent accidents and injuries. During an interview, on 02/28/2025 at 2:43 PM, the Executive Director (ED) stated he expected the nursing department to follow up on residents after a fall to ensure care planned interventions were in place.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 sampled residents reviewed for falls, out of a total sample of 29 residents, Resident (R)141. R141 sustained a fall on 01/15/2025 and was found lying on the floor by her bed. The Interdisciplinary Team (IDT) decided a perimeter mattress should be placed on the bed to prevent further falls, on 01/16/2025. However, the perimeter mattress was not placed on the bed, and the resident sustained another fall on 01/19/2025, when she was again found on the floor lying beside her bed. The perimeter mattress was not placed on the bed until 02/28/2025, during the Survey. The findings include: Review of the facility policy, titled, Incidents, Accidents, and Supervision, dated 12/12/2023, revealed the facility was to conduct investigations into incidents, including falls, to identify a root cause and implement corrective actions and interventions. Review of R141's Admission Record revealed the facility admitted the resident on 01/15/2025 with diagnoses including vascular dementia with agitation, osteoporosis, and a history of falls. Review of the facility Health Status Note, dated 01/15/2025, revealed Licensed Practical Nurse (LPN)8 documented she found R141 lying on the floor by her bed. Further review revealed the resident denied pain and LPN8's assessment found no sign of injury. Review of R141's Comprehensive Care Plan (CCP), dated 01/15/2025, revealed the facility identified the resident as at risk for falls and listed interventions including keeping the bed in low position, utilizing a perimeter mattress, and keeping the resident's call light in reach. All interventions were dated 01/15/2025. Review of the facility IDT [Interdisciplinary Team] Note, dated 01/16/2025, revealed the facility determined after R141 fell out of bed, they would install a perimeter mattress for fall prevention. Further review revealed no documented evidence the facility verified previous care planned interventions were in place at the time of the resident's fall. Review of the facility Health Status Note, dated 01/19/2025, revealed Registered Nurse (RN) 5 documented she found R141 lying on the floor beside her bed, on top of pillows and blankets. Further interview revealed R141 denied pain and RN5's assessment did not reveal signs of injury. Review of the facility IDT Note, dated 01/20/2025, revealed the facility noted R141 fell out of bed on 01/19/2025 and was wearing appropriate footwear, but the resident was unable to state what she was doing at the time of the fall. Further review revealed no documented evidence the facility verified previous care planned interventions, to include the perimeter mattress were in place at the time of the resident's fall. Review of R141's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as having two falls with no injury during the look back period. Continued review revealed the facility assessed the resident as requiring maximum assist for transfers and as dependent on staff to push her wheelchair. Observation on 02/24/2025 at 3:16 PM, revealed R141 had a regular mattress with no perimeter for fall prevention noted. In an interview, on 02/24/2025 at 3:16 PM, R141 stated she remembered falling out of bed and sometimes did not want to ask staff to help her to get up because she was afraid she would fall again. Observation on 02/27/2025 at 3:17 PM, and on 02/28/2025 at 10:21 AM, revealed R141 had a regular mattress with no perimeter for fall prevention noted. In an interview, on 02/28/2025 at 10:47 AM, with LPN4, who was assigned to R141, she stated she did not know if R141 had ever had a perimeter mattress. She further stated she did not put the resident to bed, so she would not know what kind of mattress the resident had. During observation and interview, on 02/28/2025 at 10:21 AM, the IC Unit Manager felt of R141's mattress for a perimeter and stated she could not tell by feeling or looking at the mattress if it had a perimeter. In an additional interview on 02/28/2025 at 10:38 AM, the 1C Unit Manager stated they had just changed R141's mattress because it was not a perimeter mattress, but now it was. The 1C Unit Manager walked away and would not engage in further interview. In an interview, on 02/28/2025 at 1:00 PM, the Director of Nursing (DON) stated the process for investigating a resident's fall began with the assigned nurse completing an assessment to check for injuries. The nurse was then to assess the circumstances surrounding the fall, as well as notify the responsible party, the physician, and the DON of the resident's fall. She further stated the clinical team including Nurse Managers, Therapy, and the Nurse Practitioner would determine a root cause and determine an appropriate intervention to prevent further falls. In continued interview, the DON stated it was the Unit Manager's responsibility to ensure care plan interventions were implemented. The DON did not have a comment as to the reason the facility failed to provide a perimeter mattress as care planned for R141, after she fell out of the bed twice. In an interview, on 02/28/2025 at 2:43 PM, the Executive Director (ED) stated the facility process for investigating a fall was to discuss them in morning meetings and break down causal factors in clinical meeting to determine appropriate fall interventions. When questioned about the resident not having a perimeter mattress in place as per the CCP, he stated he did not have that information. He further stated the facility's goal was to keep perimeter mattresses in stock, so if a resident needed one, they could install it quickly.

Based on observation, interview, record review, and review of facility policy, the facility failed to assist residents in obtaining routine dental care for 2 of 7 sampled residents reviewed for dental care out of a total sample of 29 residents, Residents (R) 87 and R95. The findings include: Review of the facility policy titled, Dental Services, dated 12/12/2023, revealed the facility was expected to assist residents in obtaining routine dental services. Further review revealed the policy defined routine services as an annual inspection for signs of dental disease, dental cleaning, and dental x-rays. 1. Review of R87's Admission Record revealed the facility admitted the resident on 02/02/2021 with diagnoses including early onset Alzheimer's disease, type 2 diabetes, and low body mass index. Review of R87's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2025, revealed the facility assessed the resident as having both short and long term memory problems, as severely cognitively impaired, and as unable to make herself understood. Continued review of the MDS revealed the facility did not assess the resident as having pain in chewing and swallowing during the look back period. Observation on 02/28/2025 at 5:13 PM revealed R87 was missing teeth, but was eating without signs of pain. Review of the Summary Report from the visiting dentist, revealed the resident was last seen by a dentist on 04/03/2023, with findings of partial dentition. Per the report, no x-rays were taken because the resident was not yet due for x-rays. However, there was no further documented evidence of an annual dental exam after 04/03/2023. Review of R87's Comprehensive Care Plan (CCP), dated 11/06/2024, revealed the facility identified the resident's teeth were in poor condition, with some teeth missing and included the intervention to provide routine dental services. 2. Review of R95's Admission Record revealed the facility admitted the resident on 07/14/2021 with diagnoses including Alzheimer's disease, bariatric surgery status, and alcohol dependence in remission. Observation on 02/28/2025 at 3:09 PM, revealed R95's resident's teeth were broken, decayed, and significantly yellowed. Review of R95's CCP, dated 06/29/2023, revealed the facility assessed the resident as having partial dentition and tooth decay. Further review revealed the facility documented in the CCP, the dentist recommended not pulling the decayed tooth unless it caused the resident pain. Continued review revealed the facility listed the intervention to coordinate for routine dental services. Review of the Summary Report from the visiting dentist, revealed R95 was last seen by a dentist on 08/04/2023, with findings of some tooth decay that was treated non-invasively during the appointment. However, there was no further documented evidence of an annual dental exam after 08/04/2023. Review of R95's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the facility did assess the resident as having pain in chewing and swallowing during the look back period. Interview was conducted, on 02/28/2025 at 9:45 AM, with the 1C Unit Manager, who was in charge of the unit in which R87 and R95 resided. She stated she was not aware of any reason R87 and R95 would not have received routine dental care in 2024. In an interview, on 02/28/2025 at 11:01 AM, the Social Services Director (SSD) stated her role in the process of obtaining dental care for residents was to ensure the resident had orders and signed consents for dental services. She stated she would then add them to the list to be seen by the dentist who visited the facility. In further interview, the SSD stated she was not sure why R87 and R95 were not seen by the dentist in 2024, but she would check. The SSD failed to provide further information prior to survey exit. In an interview, on 02/28/2025 at 1:00 PM, the Director of Nursing (DON) stated she expected residents to receive routine dental services at least once per year. She further stated the SSD was responsible to make sure all residents were seen each year. In continued interview, the DON stated it was important to provide appropriate dental services to prevent oral pain and difficulty in chewing, which could lead to weight loss. In an interview, on 02/28/2025 at 2:43 PM, the Executive Director (ED) stated he was unsure how often residents should receive routine dental services, but he thought it was once per year. He further stated he expected the facility to follow their policy and ensure they made appropriate referrals to get residents seen by a dentist. In continued interview, the ED stated R87 and R95 were not seen by a dentist in 2024, and he would investigate where the process failed.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 sampled residents reviewed with urinary catheters on Enhanced Barrier Precautions (EBP) out of a total sample of 29 residents, Resident (R) 75. Observation on 02/26/2025 at 2:59PM, revealed Licensed Practical Nurse (LPN)1 touched R75's privacy curtain and sink faucet handles while wearing gloves. She then failed to perform hand hygiene and don new gloves prior to performing suprapubic catheter care. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 01/02/2024, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. All staff shall demonstrate competence in relevant infection control practices. Review of the facility's policy titled, Indwelling Catheter, dated 01/01/2024, revealed, If an indwelling catheter is in use, the facility will provide appropriate care for catheter in accordance with current professional standard of practice and resident care policies and procedures that include, but are not limited to: Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. Review of the (CDC) guidelines, dated 02/27/2024, revealed Gloves should be used whenever healthcare workers anticipate contact with blood, bodily fluids, mucous membranes, nonintact skin, or potentially contaminated surfaces and equipment. The CDC stresses that gloves must be changed between, patient contacts and when moving from contaminated to clean tasks for the same patient. This practice helps ensure that microorganisms are not inadvertently spread . Review of R75's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 02/02/2023 with diagnoses to include unspecified intellectual disabilities, obstructed and reflux uropathy, and chronic kidney disease. Review of R75's Comprehensive Care Plan, dated, 06/27/2023, revealed R75 was care planned for at risk for infection/complications related to suprapubic catheter, and to use Enhanced Barrier Precautions. Interventions included wear gloves and gown during high contact care, initiated 04/03/2024. Other interventions included catheter/peri care at least every shift and as needed, initiated 02/02/2023. Review of R75's Quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/26/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 04 out of 15, which indicated severe cognitive impairment. Review of R75's Physician Orders, located in the EHR, revealed an order for daily cleansing of suprapubic catheter using soap and water. Observation on 02/26/2025 at 2:59PM, revealed LPN1 donned a gown and gloves, closed the privacy curtain, walked to the sink faucet and touched the handles to turn on the faucet and saturate the washcloth with water and cleanser from a bottled no rinse cleanser provided by the facility to all residents. LPN1 then returned to the bedside and proceeded to clean R75's suprapubic catheter wearing the same gloves in which she had touched the privacy curtain and sink faucet handles. Continued observations revealed LPN 1 first wiped catheter with saturated washcloth, working away from the body, several times, changing areas to use on washcloth. LPN1 then folded the washcloth and cleansed skin area around catheter. The skin air dried before LPN1 applied a 4x4 gauze with split middle around catheter and secured with tape. During an interview with the Infection Preventionist (IP), on 02/28/2025 at 10:14 AM, she stated the general process for suprapubic catheter care was to use aseptic technique. When questioned what was to be used to clean the suprapubic catheter, she stated she would have to check the policy. She further stated catheter care involved washing hands, donning gloves and wiping the catheter with a clean wash cloth. The IP stated she planned to implement education on enhanced barrier precautions. She further stated she currently did not perform audits for catheter care, but would perform on the spot correction if she saw a concern. In continued interview with the IP, on 02/28/2025 at 10:14 AM, she stated she provided education related to catheter care during orientation, but there was not an annual skills checkoff or annual training specific to catheter care. The IP stated the purpose of wearing clean gloves while providing catheter care was in order to not introduce new germs to that area. She stated if a staff member donned gloves and then touched the privacy curtain and sink faucet and then performed catheter care with the same gloves, there was the potential to transmit infection to the catheter. During an interview, with the Director of Nursing (DON), on 02/28/2025 at 1:38PM, she stated it was her expectation staff would doff gloves after touching a resident's privacy curtain and sink faucet handles, and then wash hands and don new gloves before performing suprapubic catheter care. The DON stated ongoing training for suprapubic catheter care was completed by watching a video and not an in-person skills check off, and she thought it was completed by staff quarterly. During an interview with the Executive Director, on 02/28/2025 at 2:47 PM, he stated it was his expectation for staff to follow guidelines that would include changing gloves on a regular basis and as necessary. The Administrator stated, after touching potentially contaminated surfaces, staff should wash hands and put on new gloves prior to performing catheter care.

Based on interview, record review and review of the facility's policy, the facility failed to develop a baseline care plan for one (1) of three (3) residents sampled related to elopement (Resident #642). Upon admission, the facility assessed Resident #642 as a high risk for wandering/elopement. However, the facility failed to care plan the resident for his/her high risk for wandering/elopement. Resident #642 exited through the front door and left the faciity on [DATE]. Resident #642 returned to his/her home located eighty-five (85) miles away. Resident #642 did not return to the facility. Immediate Jeopardy (IJ) was identified on 03/12/2024 and was determined to exist on 01/07/2023 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F 655; and 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of an J. The facility was notified of the the Immediate Jeopardy on 03/15/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan on 03/23/2024, alleging abatement of the IJ as past non-compliance on 01/13/2023. An Extended Survey was initiated on 03/22/2024. The SSA (State Survey Agency) validated abatement of the IJ on 03/23/2024 as past non-compliance as alleged on 01/13/2023. The findings include: Review of the facility's policy titled Baseline Care Plan, copyrighted 2023, revealed the facility was to develop and implement a baseline care plan for each resident that met professional standards of quality care. Per policy review, interventions were to be initiated that addressed a resident's current needs to include any health and safety concerns to prevent elopement, decline, or injury in a resident. Further review revealed the interventions were also to address any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. Review revealed once (the baseline care plan was) established, goals and interventions were to be documented in the designated format. Review of the facility's policy titled, Elopements and Wandering Residents, copyrighted 2023, revealed the facility was to ensure residents who exhibited the behavior of wandering and/or were at risk for elopement received adequate supervision to prevent accidents. Continued review revealed the facility was to ensure residents received care in accordance with their person-centered plan of care that addressed the unique factors contributing to the resident's wandering or elopement risk. Per policy review, the facility was equipped with door locks/alarms to help avoid resident elopements. Further review revealed the facility was to establish and utilize a systematic approach to monitor and manage residents at risk for elopement or unsafe wandering. The review revealed the facility's systematic approach was to include identification and assessment of a resident's risk; evaluation and analysis of hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Record review revealed the facility admitted Resident #642 on 01/05/2023, with diagnoses which included alcohol psychosis dementia, vascular dementia with behaviors, major depressive disorder, and agitation. Continued review revealed the facility assessed Resident #642 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), which indicated the resident was cognitively intact. Further record review revealed facility staff noted Resident #642 refused to wear a Code Alert/Wanderguard device on admission. Review of the Wandering/Elopement Risk Scale dated 01/05/2023 at 9:34 PM, completed for Resident #642, revealed the facility assessed the resident with a score of fourteen (14), which indicated he/she was at high risk to wander. Record review revealed Resident #642 exited through the front door and left the faciity on [DATE]. Resident #642 returned to his/her home located eighty-five (85) miles away. Resident #642 did not return to the facility. Review of the Baseline Care Plan dated 01/06/2023, revealed the facility developed a care plan for Resident #642 to reside on a secured memory care unit due to his/her diagnosis of vascular dementia and for the benefits of specialized programming on that type of unit. Per review, the interventions included keeping Resident #642 involved in activities and/or socialization to divert behaviors; daily activity programming; encouraging the family to bring in photos and items to cue and alert the resident of past roles and lifestyle; and providing an activity calendar with reminders of daily events. However, further review revealed no documented evidence the facility addressed the Wandering/Elopement Risk Scale completed for Resident #642 which identified him/her as a high risk for wandering. Review of Resident #642 Progress Note, dated 01/06/2023 at 3:25 PM, revealed documentation noting the resident was refusing to let staff place a Wanderguard device on him/her for safety. However, further review of Resident #642's Baseline Care Plan revealed no documented evidence of interventions to be implemented regarding the level of supervision the resident required after he/she refused to have a Code Alert/Wanderguard bracelet applied on that date. Review of Resident #642's Kardex, which was utilized by the State Registered Nurse Aides (SRNAs) as a care plan tool to guide the resident's care revealed no documented evidence of interventions placed regarding strategies for SRNAs to use to prevent elopement of the resident. In interview with the Minimum Data Set (MDS) Nurse on 03/17/2024 at 10:36 AM, she stated she had not met Resident #642 and had not completed the Baseline Care Plan for the resident. She stated the admission nurse had initiated Resident #642's Baseline Care Plan, as the resident was admitted on [DATE] at 9:34 PM. However, the MDS Nurse stated she had reviewed Resident #642's Baseline Care Plan, and had not increased the resident's supervision. Telephonic (phone) attempts were made to reach Resident #642's admission nurse on 03/17/2024 at 11:47 AM and 11:51 AM, and on 03/18/2024 at 8:43 AM. However, all attempts were unsuccessful, with no way to leave a voicemail. In an interview with Registered Nurse (RN) #4 on 03/14/2024 at 4:07 PM, she stated Resident #642 had resided on the facility's Memory Care Unit. The RN stated she had received report of Resident #642 being a new resident, and that he/she refused to have a Wanderguard placed. She stated Resident #642 stated he/she did not need to be in the facility, and kept saying he/she wanted to leave. In further interview, RN #4 stated Resident #642's supervision was not increased after he/she refused the Wanderguard (device). In an interview with the DNS on 03/17/2024 at 12:29 PM, she stated a staff member called her on 01/07/2023 at dinner time which was around 5:00 PM. She stated the staff member told her Resident #642 was not located on the unit or in the facility, and staff had found the resident's bed covers lumped up. The DNS stated she contacted the ED (Executive Director), and all the department heads and managers were called in to help search for Resident #642, inside and outside the facility. She stated Resident #642 was admitted to the facility from a sister facility because it had been determined the resident needed to be in a secured building. Per the DNS, she was not notified when Resident #642 refused to have a Code Alert/Wanderguard device placed after his/her admission to the facility. She stated her expectation was for staff to implement another intervention to be initiated after Resident #642 refused to wear the (Code Alert/Wanderguard) bracelet. The DNS stated Resident #642's supervision had not been increased. She stated a resident's Baseline Care Plan was to be developed with necessary interventions to keep the resident safe. In interview with the current ED on 03/23/2024 at 1:19 PM, he stated it was his expectation for staff to be vigilant in making sure resident care was provided according to the facility's policy. He stated he expected staff to take the best possible care of all facility residents.

Based on observation, interview, record review, review of facility policy, and Internet Google Maps, the facility failed to ensure all residents were in a safe and supervised environment to prevent elopement for one (1) of three (3) residents sampled for elopement (Resident #642). The facility admitted Resident #642 on 01/05/2023 and he/she eloped from the facility on 01/07/2023 and did not return. The resident exited out the facility's front door when the receptionist, not knowing he/she was a resident, opened the door to let him/her out. Resident #642 was located 85 miles away from the facility. The facility failed to increase the resident's supervision to promote his/her safety, after learning the resident was at high risk for elopement. The facility's failure to ensure its policies were implemented related to elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 03/12/2024, and was determined to exist on 01/07/2023 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F 655; and 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of an J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the the Immediate Jeopardy on 03/15/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan on 03/23/2024, alleging removal of the immediate jeopardy on 01/13/2023. An Extended Survey was initiated on 03/22/2024, and the SSA validated the facility's IJ Removal Plan on 03/23/2024, and determined the immediate jeopardy had been removed and the deficient practice was corrected as alleged on 01/13/2023, prior to initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Elopements and Wandering Residents. copyright 2023, revealed the facility would ensure residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to their risk. Continued review revealed elopement was when a resident left the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Per policy review, the facility was equipped with door locks/alarms to help avoid resident elopements. Review of the policy revealed adequate supervision was to be provided to help prevent accidents or elopements of residents, and the charge nurses and unit managers were to monitor the implementation (of residents') interventions, their response to the interventions, and document that information accordingly. Further review revealed the facility was to establish and utilize a systematic approach to monitor and manage residents at risk for elopement or unsafe wandering. Record review revealed the facility's systematic approach was to include identification and assessment of a resident's risk; evaluation and analysis of hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying intervention when necessary. Review of the facility's policy titled, Elopement (Risk and Missing Resident), dated October 2019, revealed the Care Team Members who had residents under their care were responsible for knowing the location of those residents at all times. Further review revealed in the case of a missing resident, the Care Team Members were to ensure appropriate action was taken. Record review revealed the facility admitted Resident #642 on 01/05/2023, with diagnoses which included vascular dementia with behaviors, major depressive disorder, agitation, and alcohol psychosis dementia. Continued record review revealed the facility assessed Resident #642 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated he/she was cognitively intact. Further review of the record revealed it was noted the resident refused a Code Alert/Wanderguard (devices alerting staff when residents were near exit doors) on admission. Review of the facility's document titled, Wandering/Elopement Risk Scale, for Resident #642, dated 01/05/2023 at 9:34 PM, revealed the facility assessed the resident as a high risk for elopement with a score of fourteen (14). Further review of the document revealed the scoring key for the document was noted as: 0-8 as a low risk for elopement; 9-10 as at risk for elopement; and 11 and above as a high risk for elopement. Review of the Progress Note dated 01/06/2023 at 3:25 PM, revealed Resident #642 refused to let staff place a Wanderguard device on him/her for safety. Review of Resident #642's Care Plan dated 01/06/2023, revealed the facility developed a care plan for the resident to reside on a secured memory care unit due to his/her diagnosis of vascular dementia, and for the benefits of the specialized programming. However, further review revealed no documented evidence of interventions specific to Resident #642's high risk for elopement. Record review revealed Resident #642 exited through the front door and left the faciity on [DATE]. Resident #642 returned to his/her home located eighty-five (85) miles away. Resident #642 did not return to the facility. Review of the facility's investigation dated 01/07/2023, and reported by the facility's former Executive Director (ED), revealed the summary of the investigation noted Resident #642 was (located) at his/her home after leaving the facility, and the police performed a wellness visit with him/her. Per review, Resident #642 told police he/she was fine. Continued review revealed Adult Protective Services (APS) was to be notified to follow up. Review of the Internet weather history for 01/07/2023 for the facility's location revealed the day temperature was 48 degrees Fahrenheit (F) and the night temperature was 37 degrees Fahrenheit. Review of the Internet Google Maps application revealed Resident #642's home was located eighty-five (85) miles from the facility. In a telephone interview with Resident #642's daughter on 03/13/2024 at 3:52 PM, she stated she had not been made aware of the incident until 7:00 PM on 01/07/2023. She stated Resident #642 should not have been allowed to leave because he/she had a state guardian. The daughter stated she found out that a truck driver had picked Resident #642 up from the side of the road after he/she left the facility, and took the resident to his/her home. Resident #642's daughter stated after the resident got home, he/she started a fire in his/her home. She stated Resident #642 was taken to an acute care facility, where he/she was admitted for smoke inhalation from the fire. In addition, she stated Resident #642 was admitted to another long-term care facility. In an interview with Resident #642's State Guardian on 03/13/2024 at 9:45 AM, he stated he had not given permission for the resident to leave the facility. During an interview with State Registered Nurse Aide (SRNA) #4 on 03/14/2024 at 3:55 PM, she stated Resident #642 had not wanted to be at the facility and told staff he/she did not want to be there. SRNA #4 stated the resident appeared angry all the time while at the facility. She further stated she heard that Resident #642 left the facility Against Medical Advice (AMA) and went back to his/her home. In addition, SRNA #4 stated the process at the time was to have the wandering binders at each nurse's station as well as at the front receptionist desk for staff to refer to regarding residents at risk for wandering or elopement. In an interview with Registered Nurse (RN) #4 on 03/14/2024 at 4:07 PM, she stated Resident #642 had resided on the facility's Memory Care Unit. RN #4 stated it was reported to her that Resident #642 had been a new patient and had refused to wear a Wanderguard alarm. She stated Resident #642 said he/she did not need to be there at the facility. Per RN #4, Resident #642 kept saying he/she wanted to leave the facility and had moved his/her bed against the wall so it would be less visible from the doorway. The RN stated Resident #642 had been oriented and therefore, she had not increased supervision of the resident. She stated around 1:00 PM (on 01/07/2023), staff noticed the resident was not in bed; however, his/her covers had been piled up on the bed to appear as if someone was lying there asleep. According to RN #4, they discovered Resident #642 was not in the facility at 1:00 PM. She further stated the resident exited the facility when a family was leaving. RN #4 stated there had been Elopement binders at the nurse's station and receptionist's desk for staff to refer to for residents at risk for elopement. In an interview on 03/14/2024 at 3:39 PM, Receptionist #1 stated she was the person responsible for opening the door that allowed Resident #642 to exit the facility some time between 12:00 PM to 3:00 PM on 01/07/2023. She stated she had let Resident #642 out the door because she did not know he/she was a resident. Receptionist #1 stated Resident #642 was not wearing any type of a code alert bracelet. She stated she found out the person she let out the door was Resident #642 when the Director of Nursing Services (DNS) came to her desk about an hour later, and showed her a picture of the resident. Receptionist #1 further stated she told the DNS she had seen the person and opened the door to let him/her out. She stated there had been a wandering notebook at the receptionist desk at the time she let Resident #642 out the door; however, she had not referred to it. The Receptionist stated she was not supposed to allow people to leave without checking the wandering notebook. Review of the facility's list of residents who were at risk for elopement revealed thirty-five (35) residents' names noted as at risk. In an interview with the DNS on 03/17/2024 at 12:29 PM, she stated she received a call from a staff member on 01/07/2023, at dinner time which was around 5:00 PM. She stated the staff member told her Resident #642 was not located on his/her unit or in the facility, and staff had found the resident's bed covers lumped up. The DNS stated she then contacted the Executive Director (ED), and all of the department heads and managers were called in to help search for Resident #642. The DNS stated they searched inside and outside the facility, and also searched in the community, in homeless shelters, and bars for one (1) to two (2) hours. She said the former ED contacted the police; however, she could not recall if the police came to the facility or not, and there was no copy of the police report available. The DNS stated Resident #642 had been admitted to their facility from a sister facility because the resident needed to be in a secured building. She said she was not notified when Resident #642 refused to have a Code Alert/Wanderguard bracelet placed on him/her. The DNS further stated her expectation was for another intervention to be initiated after the resident refused to wear a Code Alert/Wanderguard bracelet. She additionally stated wandering binders were located at all the nurse's stations and the front reception desk for staff to have as a reference for residents at risk for wandering. In interview with the ED on 03/23/2024 at 1:19 PM, he stated it was his expectation staff were vigilant in making sure residents were provided care according to the facility's policy and ensured the best care possible was provided for them. In interview on 03/13/2024 at 3:25 PM, the former ED stated there had been an investigation completed. She stated Resident #642 ended up (being found) in his/her hometown which was eighty-seven (87) miles away from the facility. She said Resident #642 had a high Brief Interview for Mental Status (BIMS) score (and therefore had been cognitively intact). She stated she had called the police who did a wellness check of the resident with no problems noted; however, they would not do anything because the resident was alert and could make his/her own decisions. The former ED stated she was not aware Resident #642 had a state guardian, and then stated she had tried to call the state guardian several times with no success. She also stated Resident #642 clearly planned to leave the facility, and had even left his/her phone in his/her room on purpose so he/she could not be tracked. In an interview with the facility's Medical Director on 03/20/2024 at 3:15 PM, he stated he was notified of Resident #642's elopement after it happened and had participated in the facility's Quality Assurance Performance Improvement (QAPI) meetings. He stated it was important for staff to have meetings to receive education on residents at risk for elopements, and felt staff needed to be re-educated after the elopement. The Medical Director stated he was very involved in the life of the facility, and thought the exit door keypad codes should be changed and not shared with residents or others.

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure residents were: informed of their rights to conduct resident council meetings without staff present; and that visitors and/or other guests might attend resident council meetings only at the respective group's invitation. The facility failed to address and follow-up with Resident Council grievances, and further communicate the results to residents for seven (7) out of eight (8) sampled residents attending Resident Council meetings (Residents #5, #49, #55, #71, #101, #119, and #128). The findings include: Review of the facility's policy titled, Resident Council Meetings, undated, revealed the facility supported the rights of residents to organize and participate in resident groups. Per policy review, the meeting minutes were to include issues discussed and recommendations from the group. Further review revealed the facility was to act upon concerns and recommendations of the Resident Council by making attempts to accommodate recommendations to the extent practicable, and to communicate the decisions to the Council. Review of the facility's policy titled, Resident and Family Grievances, undated, revealed the facility was to make Prompt Efforts to Resolve resident grievances as defined by the facility's acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. Further review revealed the Grievance Official or appointed staff member was to keep residents appropriately apprised of progress towards the resolution of the grievances. Review of the facility's policy titled, Resident Rights, undated, revealed the facility was to inform residents both orally and in writing, in a language the residents understood, of his or her rights, and all rules and regulations during their stay in the facility. Further review revealed residents had a right to voice grievances and the facility must make prompt efforts to resolve residents' grievances. Observation of the Resident Council meeting, on 03/20/2024 at 2:30 PM, revealed eight (8) residents in attendance as well as a volunteer Ombudsman. Continued observation revealed Resident #101 called the meeting to order. During the Resident Council meeting, seven (7) out of eight (8) residents (Residents #5, #49, #55, #71, #101, #119, and #128) stated the facility had not made them aware of their right to hold meetings without staff present. Six (6) out of the eight (8) residents (Resident #5, #55, #71, #101, #119, and #128) stated during the interview that their grievances were not addressed and/or resolved; and, staff had not communicated the status or the outcome of their concerns with them. The residents stated they were confident that the Resident Council President had taken their grievances and concerns to the facility's administrative staff on their behalf. In an interview on 03/20/2024 at 2:45 PM, Resident #101 stated he/she had informed residents where they could obtain a copy of the resident's rights. However, he/she stated as Council President he/she had not known about conducting meetings without facility staff present. Resident #101 stated he/she had taken residents' grievances and concerns to the facility's administrative staff, but he/she had not received a response or resolution to those concerns. (a). Record review revealed the facility admitted Resident #5 on 03/24/2023. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating no cognitive impairment. (b). Record review revealed the facility admitted Resident #49 on 06/21/2021. Review of Resident #49's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. (c). Record review revealed the facility admitted Resident #55 on 01/17/2020. Review of Resident #55's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. (d). Record review revealed the facility admitted Resident #71 on 08/05/2022 Review of Resident #71's Significant Change in Status (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. (e). Record review revealed the facility admitted Resident #101 on 08/29/2021. Review of Resident #101's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. (f). Record review revealed the facility admitted Resident #119 on 05/12/2023. Review of Resident #119's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. (g). Record review revealed the facility admitted Resident #128 on 05/11/2023. Review of Resident #128's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. In interview on 03/22/2024 at 11:40 AM, the Activities Director (AD) stated he did not recall if residents were aware of their right to meet in Resident Council meetings without facility staff being present. He stated they had previously been informed of their rights to invite staff and others to their council meetings though. He stated grievances discussed in Resident Council meetings were generally provided to the Social Services Director (SSD) to be logged, but if he had been aware of the concerns they would have been discussed in the Interdisciplinary Team (IDT) meetings. In continued interview on 03/22/2024 at 11:40 AM, the AD stated if he was notified of the resolution of residents' grievances he would notify the residents of the results. He stated whatever the residents' concerns were related to, determined the department or staff member who would be responsible for addressing the concern(s). Per the AD's interview, the department/staff member who addressed residents' concerns, would follow-up with the residents with any updates or resolution regarding their concern. He stated there was a Resident Council response form the facility had adapted, but had not utilized appropriately. The AD stated that form was to be implemented moving forward to assure residents' concerns were addressed by the correct department and/or staff member and a resolution was documented and signed off on. He further stated it was disheartening to learn residents had complained about unresolved concerns, lack of communication, and the direct care provided in the facility. In addition, the AD stated if residents were not informed of their rights, then they had no knowledge of how to exercise those rights which was potentially a violation of their rights. In an interview with the SSD on 03/22/2024 at 12:10 PM, she stated her expectations for resident grievances was for whoever was told of the concern would complete the facility's process and update the resident on the outcome. She stated she had not been invited to Resident Council meetings. During the interview, she stated a grievance form was to be completed depending on what the resident's concern was, and she determined if the concern could be resolved immediately. The SSD stated the facility's protocol was for staff who had resolved the resident's concern, to notify the resident of any updates or ensure resolution of a concern was communicated to the resident. She stated any staff member who resolved an issue for a resident, but did not want to make the notification to the resident, could ask her to contact the resident and she would update them. The SSD stated if residents believed they were not being communicated with regarding their concerns, or felt they were not notified about resolutions of their concerns, then the facility needed to make improvements to the grievance process to ensure residents were satisfied. Per interview, the SSD stated she ensured any resident concerns reported to her were addressed and followed-up on. She stated her expectation if a resident's concern was reported, was the staff should follow-up on that concern and notify the resident of the results, or ask someone else to do it. In interview with the Director of Nursing Services (DNS) on 03/22/2024 at 5:40 PM, she stated she was uncertain about whether the right to choose to have no facility staff present during their Resident Council meetings was something the residents had been made aware of. She stated however, residents' rights were posted. The DNS stated the Resident Council grievance process occurred when their concerns were provided to the AD and then shared in the IDT meetings for discussion. She stated those resident concerns were divvied out to the relevant department during the IDT meetings in order for an investigation to be completed. The DNS stated all resident grievances were logged by the SSD. Per the DNS, during the investigation process, updates were to be made to the residents on the progress and/or resolution of the grievance as soon as possible. She stated the goal was to have a resolution to a grievance within five (5) days. The DNS stated the staff or department who received the resident(s') concern and investigated it, would generally be the person(s) to find the resolution. She further stated her expectations for the SSD and administrative staff, IDT members regarding grievances was for them to investigate the concern once identified and ensure resolution. In addition, the DNS stated family, residents or both were to be notified once a resolution was found for the grievance, or for them to at least be updated on the progress of the investigation to appropriate communication occurred. In an interview with the Executive Director (ED) on 03/22/2024 at 5:50 PM, he stated residents had been aware of their right to invite staff and/or others to their Resident Council meetings. He stated he recalled discussing the residents' freedom of choice to have no staff in their Council meetings in general conversation when discussing a resident's requests. He stated grievances were discussed with the IDT members and the concerns were given to the appropriate department or person, in order to find a resolution tailored to the resident's needs or desired outcomes within reason. The ED stated expectations for all facility staff was for all of them to work together to determine how to make things right for the residents and ensure their concerns were addressed immediately. He further stated expectations also included staff to find a resolution and communicate the finding to the residents involved. Additionally, he stated he believed by personalizing resident's needs and requests, the facility could create a safe and homelike environment for all residents.

Based on observation, interview, review of the facility's policy, and review of the manufacturer's drug package insert, the facility failed to ensure all drugs and biological agents were properly labeled and stored in accordance with current accepted professional principles. Observation of the Unit 1B storage room revealed one (1) vial of Tuberculin (TB) Purified Protein Derivative five (5) milliliters (ml) with an open date of 02/12/2024 that had not been discarded after thirty (30) days per facility policy. Additionally, a pink jacket and pink polka dotted bag were observed on the counter on top of the pharmacy medication return tote. The findings include: Review of the facility's policy titled Storage of Medications, revised 08/2020 revealed medications and biologicals were stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Review of the policy under the Procedures/General Guidance section, item eight (8) revealed outdated medications were immediately removed from inventory, disposed of according to procedures for medication disposal and re-ordered from the pharmacy if a current order existed. Review of item nine (9) revealed medication storage areas were kept clean, well-lit and free of clutter. Review of the policy under the Expiration Dating (beyond-use dating) section, item 5a revealed the nurse shall place a date opened sticker on the medication and record the date opened and the date of expiration. The expiration date of the vial or container would be thirty (30) days from the opening date unless the manufacturer recommended another date or regulations/guidelines required different dating. Review of the manufacturer's package insert for Tuberculin Purified Protein Derivative (PPD) dated 10/2021 from Sanofi Pasteur, Incorporated under the storage section revealed an opened vial of PPD which had been entered and in use for thirty (30) days should be discarded. Observation on 03/21/2024 at 9:10 AM during the inspection of Medication Room Unit 1B with Registered Nurse #7 (RN #7)/Unit Manager (UM) revealed one (1) vial of Tuberculin Purified Protein Derivative (PPD) five (5) milliliters (ml) had been opened on 02/12/2024. Additionally, a pink jacket and pink polka dotted bag were observed on the counter on top of the pharmacy medication return tote. During an interview with RN #7/UM she stated she did not know how long the opened vial of PPD could be used before being discarded but she could ask someone and find out. She also stated the nurses were responsible for the inventory of the medication room and the removal of expired or discontinued medications, but it was never done. RN #7/UM stated the pink jacket and pink polka dotted bag should not have been in the medication room. RN #7 asked Licensed Practical Nurse (LPN) #1 if the items belonged to her. LPN #1 stated they did and she knew they did not belong there. During an interview on 03/21/2024 at 10:25 AM with Registered Nurse (RN) #2/Unit Manager (UM) she stated she did her own medication room and cart audits, usually every Monday, She stated she pulled all discontinued and expired medications and placed them in a tote for return to pharmacy. RN #2/UM stated pharmacy made deliveries to the facility two to three times a day but the drivers preferred to take expired or discontinued medications back on nights when their vehicles were not as full of medications. She stated pharmacy also performed random cart and med room audits for expired medications but she could not say how often. RN #2/UM stated it was the responsibility of nursing to monitor the carts for expired and discontinued medications and remove them. During an interview on 03/22/2024 at 9:50 AM with the Director of Nursing Serviced (DNS) she stated the unit managers were responsible for doing a weekly medication room and medication cart audit. She stated expired medications and medications left from discharged residents were placed in the return to pharmacy tote to be taken back to the pharmacy. The DNS also stated the medication storage room was for medication storage only and personal items should not be kept in the medication room. During an interview on 03/22/2024 at 10:10 AM with the Executive Director (ED) he stated medication storage areas were for medication storage only not for personal items. He stated he deferred to his DNS for the maintenance of the medication rooms and the removal of expired medications and of course he expected for the medication rooms to be for medications only and free of expired medicines.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair or other sleeping accommodations for two (2) of seventy-five (75) sampled residents (Resident #22 and Resident #76). Observation on 03/21/2024 revealed Resident #22's and Resident #76's call lights were attached to the wall behind the head of their beds, out of their reach. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, undated, revealed the purpose of the policy was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights would directly relay to a staff member or centralized location to ensure appropriate response. Review of the Policy Explanation and Compliance Guidelines, revealed staff would ensure the call light was within reach of the resident and secured as needed. 1. Review of the clinical record revealed the facility admitted Resident #22 on 03/30/2023. The resident's diagnoses included cerebral infarction, tracheostomy, vascular dementia, anticoagulant therapy, thrombocytopenia, gastrostomy tube (G- tube), epilepsy, malnutrition and hepatomegaly and chronic thrombosis. Review of Resident #22's Minimum Data Set (MDS) Admission Assessment, dated 04/04/2023 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. Observation on 03/21/2024 at 9:40 AM revealed Resident #22 lying in his/her bed with his/her eyes closed. Further observation revealed Resident #22's call light was attached to the wall behind the head of the bed, out of the resident's reach. During an interview on 03/21/2022 at 3:00 PM with Resident #22 it was discovered Resident #22 was non-verbal but could indicate yes or no by nodding his/her head. Resident #22 utilized a communication board for indicating his/her basic needs or spelling out sentences. 2. Record review revealed the facility admitted Resident #76 on 09/17/2019 with diagnoses of Alzheimer's, adult failure to thrive, need for assist with personal care and psychotic disorder with hallucinations. Review of Resident #76's MDS Significant Change of Condition assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) which indicated severe cognitive impairment. Observation on 03/21/2024 at 9:40 AM revealed Resident #76 was sitting up beside the bed in a high back wheelchair with the over the bed table in front of him/her. Resident #76 was observed to be eating breakfast. Resident #76's call light was attached to the wall behind the head of the bed, out of the resident's reach. During an interview on 03/21/2024 at 9:40 AM with Resident #76 when asked how would you get staff in the room to help you if you needed it, Resident #76 stated, I don't know, it's my first day here. During an interview on 03/21/2024 at 9:42 AM with State Registered Nurse Aide (SRNA) #6 she stated it was important for the resident to have a call light in reach for safety and so he/she could get staff help if he/she needed it. During an interview on 03/21/2024 at 9:43 AM, Licensed Practical Nurse (LPN) #1 stated it was important for all residents to have access to their call light for safety. During an interview on 03/22/2024 at 9:50 AM with the Director of Nursing Services (DNS) she stated it was important for call lights to be within reach of all residents while in bed or in a chair so the residents would have their needs met and able to alert staff if they needed help. The DNS stated call bells assessments were completed for residents on admission and if their needs changed. Lastly, the DNS stated all staff were trained on call light use and the importance of answering the call lights timely. During an interview on 03/22/2024 at 10:10 AM with the Executive Director (ED) he stated his expectation for the call lights was staff placed them near the resident at all times so the resident could communicate with staff when they needed anything. He stated all staff were trained on call light use, placement and the importance of the call lights being answered timely.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of six (6) sampled residents was free from abuse (Resident #5). An altercation occurred, on 11/21/2020 between Residents #4 and #5, which resulted with Resident #5 receiving a reddened area on his/her cheek. Refer to F657, F835 and F865 The findings include: Review of the Resident's Rights, cited in the 1987 Nursing Home Reform Law, revealed each resident has the right to receive respect and dignity, and the right to be free from any physical abuse. Review of the facility's policy, Abuse Prevention Program, revised date 02/22/2018, revealed the resident has the right to be free from abuse and protected from abuse by anyone, including other residents, or other individuals. Review of the facility's Long Term Care Facility Self-Reported Incident Form and the facility's investigation, incident dated 11/21/2020 at 11:15 PM, revealed a resident-to-resident altercation occurred, on 2B Unit, between Residents #4 and #5. The investigation revealed Resident #5 became upset when Resident #4 began using his/her walker. The report stated both residents had the same type of walker, and at the same height. Staff heard a commotion and responded to the room of Residents #3 and #4. Licensed Practical Nurse (LPN) #5 and State Registered Nurse Aides (SRNA) #4 and #5 entered the room and witnessed Resident #4 at the bedside of Resident #5. The facility's interview summary with LPN #5, not dated or timed, revealed she was the assigned nurse. LPN #5 was a few doors down the hall from the residents when she heard Resident #4 and #5 arguing, and then heard something hit the floor. The interview revealed LPN #5 saw Resident #4 strike at Resident #5. LPN #5 stated she observed Resident #4 with an open right hand hit the left side of Resident #5's head. Resident #4's hand caught Resident #5 near the eye area. LPN #5 stated she and the SRNAs intervened immediately. The assessments revealed no injuries identified to Resident #4. However, Resident #5's assessment revealed his/her left eye was slightly reddened and without bruising. 1. Observation of Resident #4, on 04/04/2021 at 4:28 AM, revealed he/she appeared asleep, and comfortably resting. Review of Resident # 4's clinical record revealed the facility admitted the resident, on 12/05/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Annual Minimum Data Set (MDS), assessment reference date (ARD) on 10/30/2020, revealed the facility assessed the resident as cognitively intact. Observation of Resident #4, on 04/09/2021 at 1:18 PM, revealed the resident was seated on the side of his/her bed with a walker within reach. The resident was in the room alone, and without a roommate assigned to the room. Interview with Resident #4 in the resident's room, on 04/09/2021 at 1:18 PM, revealed he/she had had five (5) roommates while living at the facility. He/she stated he/she did not recall any issues with Resident #5. Resident #4 revealed there was not any altercation with Resident #5. Continued interview revealed the resident did not recall slapping Resident #4, or issues with the walkers. Resident #5 stated he/she felt safe, and liked being in a room without a roommate. 2. Observation of Resident #5, on 04/04/2021 at 4:20 AM, revealed the resident was in the bed with the appearance of sleeping. Observation of Resident #5, on 04/09/2021 at 1:30 PM, revealed the resident seated in a wheelchair at the end of the corridor. Review of Resident # 5's clinical record revealed the facility admitted the resident, on 10/30/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Admission Minimum Data Set (MDS), assessment reference date 11/05/2020, revealed the facility assessed the resident as cognitively intact. Interview with Resident #5, on 04/09/2021 at 1:30 PM, revealed a recollection of an argument with Resident #4, a long time ago. He stated Resident #4 slapped at him/her and hit him/her near his/her eye. Resident #5 stated they got into an argument over their walkers. The resident revealed the walkers were exactly alike, but he/she did not want him/her using 'my walker. Resident #5 stated the nurses came into our room to check on us. Resident #5 stated he/she was fine and there were no concerns with safety. Review of the Progress Notes/Incident Note for Resident #5, completed by Licensed Practical Nurse (LPN) #5, dated 11/22/2020 at 6:47 AM, revealed Resident #4 hit Resident #5 in the eye. The resident's eye turned red, and skin was intact. Both residents were screaming and yelling at each when Resident #4 threw a walker at Resident #5. Resident #5 threw a cup of cold water on Resident #4. The residents were separated. The Director of Nursing Services (DONS) was notified. Resident #5 was moved to a different unit. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM revealed LPN #5 was no longer employed at the facility. Attempted telephonic interview with LPN #5, on 04/12/2021 at 1:59 PM and at 5:10 PM, unsuccessfully. An additional interview was attempted, on 04/14/2021 at 10:25 PM, unsuccessfully. Telephonic interview with State Registered Nurse Aide (SRNA) #4, on 04/12/2021 at 1:40 PM revealed she was assigned to Residents #4 and #5, on the day of the incident. She explained she was unable to recall the date, since it had been a while back. She stated they (she and the other SRNA) spoke about them being upset. She stated the argument occurred during her shift report. The SRNA stated the off going shift was providing shift report when they heard Residents #4 and #5 arguing loudly. She revealed hearing a commotion with something hitting the floor. She stated she, the other aide, the nurse, all responded and intervened with the residents in their room. She stated Resident #4 was standing at the bedside of Resident #5; however, she did not see the residents hit each other. She stated once the residents calmed down, she stayed with the residents while the nurse made notification to administration, and located a different room for Resident #5. Continued interview revealed Resident #4 preferred to stay in his/her room, without a roommate. She stated Resident #4 was a bully, and had tried to bully the nurses. Attempted telephonic interview with SRNA #5, on 04/12/2021 at 1:57 PM, on 04/13/2021 at 8:45 PM and at 2:15 PM, was unsuccessful. Review of the facility's Resident-to-Resident Allegation investigation summary of interview with SRNA #5, dated 11/21/2020, revealed she was on shift at the time of the altercation between Residents #4 and #5; however, she was working the other end of the hall. The interview revealed she was familiar with both residents. She revealed upon entering the room with other staff, she saw Resident #4 hit the side of Resident #5's face. The interview revealed she assisted the other staff with separation the residents and remaining in the room with the residents while the nurse found a place to move one of the residents. Interview with the Director of Social Services (DSS), on 04/09/2021 at 4:33 PM, revealed her department was responsible for follow-up related to any of the psychosocial concerns with the resident. She revealed a follow-up visit with Resident #4 after the altercation with Resident #5. She stated residents were separated. Resident #5 was moved to a different room, on a different floor. She stated the incident between Residents #4 and #5 was a while back. She recalled Resident #4 blew the incident off, and had no ill feeling with Resident #5. She stated she did refer Resident #4 for onsite psychology evaluation when they returned. She stated Resident #4 had not had any prior, or post incident issues with other residents. Interview with LPN #4, on 04/12/2021 at 1:05 PM revealed being familiar with Resident #4's care needs. She revealed Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 stated the residents must be kept safe. Continued interview revealed Resident-to-Resident altercations were also a type of abuse. She stated the facility was to maintain safety for the residents, even with each other. LPN #4 stated all types of altercations should be prevented, at the moment an argument starts. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 4:30 PM, revealed she was not employed by the facility in November 2020 during the time of Residents #4 and #5's incident. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM and on 04/14/2021 at 10:55 AM, revealed he received notification of a resident-to-resident altercation between Residents #4 and #5. He revealed the facility's staff immediately separated the residents. The LNHA stated Resident # 5 moved to a different room, on a different floor. He stated LPN #5 and SRNA #4 witnessed Resident #4 hit Resident #5. Therefore, the facility substantiated the resident-to-resident altercation. He revealed the staff should have intervened once the residents were heard arguing. He stated resident-to-resident altercation was a type of physical abuse. The LNHA stated it was the facility's responsibility to ensure the residents were free from abuse.

Based on observation, interview, record review, and the facility policy review, it was determined the facility failed to initiate revisions of the behavior care plan for one (1) of six (6) sampled residents (Resident #4). The behavior care plan for Resident #4 was not revised with goals and interventions after the resident-to-resident altercation, on 11/21/2020. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person - Centered, revised December 2016, revealed a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The policy further revealed the comprehensive, person-centered care plan would describe the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas with meaningful interventions; and incorporate risk factors associated with identified problems. The person-centered care plan included measurable objectives and timetables that met the resident's physical, psychosocial and functional needs. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care planning process included the resident's strengths, needs, and culture preferences. Resident assessments are ongoing, and revisions of care plans should be completed as information about the resident, and their conditions change. Review of the facility's policy, Mood and Behavior Management, revised July 2020 revealed the purpose of the policy was to provide interventions for residents exhibiting problematic or distressing moods, and or behaviors. Any mood and/or behavioral symptoms that affected, or has the potential to affect the resident or others, should have a care plan initiated. A supportive environment aimed at prevention, relief, and/or accommodation of their behavior and their mood for the resident should be provided. Interventions were specific to the resident's individualized needs Review of the Long-Term Care Facility Resident Assessment Instrument (RAI), Version 1.17.1, dated October 2019; revealed care planning should be individualized. Care planning and care practices were based on resident preferences, could lead to improved mood, enhanced dignity, and increased involvement in daily routines and activities. Review of Resident # 4's clinical record revealed the facility admitted the resident, on 12/05/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Annual Minimum Data Set (MDS), assessment reference date (ARD) on 10/30/2020, revealed the facility assessed the resident being cognitively intact. The facility documented the resident received antipsychotic and antidepressant for seven (7) of seven (7) days during the look back period. Review of Resident #4's Behavior Symptoms Care Plan, initiated 08/21/2020, revealed the focus was Resident #4 exhibited behavior symptoms of verbal aggression, with the goal of demonstration of effective coping skills related to his/her behavior. An intervention, dated 03/27/2021, for a room change due to his/her roommate taking the remote to the television and not returning it. Interventions included to provide resident personal space, initiated 08/21/2020. Further review of the care plan revealed there were not any interventions associated with the altercation, dated 11/21/2020. Review of Psychiatry Progress Notes for Resident #4, dated 01/04/2021, revealed Resident #4 was bantering and negativistic. The Primary Care Physician (PCP) was aware of the resident's life dissatisfaction and a labile mood. Resident #4 continues the medication regime of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and Trazadone. The resident was loud and complained that staff were stealing from him/her, while exhibiting mild agitation. Further review of the Note revealed a recent dosage decreased of [MEDICATION(S)] (for sleep/appetite) for Resident #4. Review of Psychiatry Progress Notes included a summary for each of the three (3) prior visits, dated 11/04/2020, 11/23/2020, 12/07/2020. Review of summary for visit, dated 11/23/2020, revealed the resident remained upset about an altercation with his/her roommate. The resident continues with [MEDICATION(S)] for management of [CONDITION(S)] Disorder and history of Psychotic Behavior. Review of the summary for visit, dated 12/07/2020, revealed the resident was easily irritated regarding conversation about life satisfaction. Telephonic interview with State Registered Nurse Aide (SRNA) #4, on 04/12/2021 at 1:40 PM revealed she was receiving shift report in the hall when Residents #4 and #5 were over heard arguing with each other followed by a commotion. She explained she was unable to recall the date, since it had been a while back. She stated they (she and the other SRNA) spoke about them being upset during shift report. SRNA stated resident #4 slapped Resident #5. Resident #5 stated he struck back at Resident #4 with his/her walker. Continued interview revealed Resident #4 prefers to stay in his/her room to self without a roommate. She revealed Resident #5 was moved to a different room, on a different floor. Interview with the Minimum Data Set (MDS) Coordinator, on 04/13/2021 at 8:28 AM revealed the care plan addressed the manner and intervention on how to care for each resident. She stated the purpose of the care plan was to provide resolution, or improvement to a resident's problem or focus, a goal and interventions to accomplish the goal. She stated the goal must be realistic and measurable and the interventions were the actions in place to attain the goal to improve or resolve the focus. The MDS Coordinator stated follow-up with an evaluation to see if the problem/focus was improved, if not then the evaluate if the goal was appropriate. She stated the interventions should be reviewed and revised, if needed. She revealed she developed the care plan, along with other staff, if the problem was an issue related to another department. She revealed the Social Services Staff were responsible for setting up the care plans related to behaviors. She stated that she reviews and captures the orders, and revises the care plan as the orders relate to the care plan. She stated when a problem was identified, it should be added in the focus; however, she did not always include a goal or interventions addressing the problem. The MDS Coordinator revealed the care plans were revised during the IDT meeting. She stated the care plans were reviewed at least every three (3) months, with their MDS assessments. Interview with the Director of Social Services (DSS), on 04/09/2021 at 4:33 PM, revealed her department was responsible for revising and updating the behavior care plans. However, she did not revise Resident #4's care plan following the resident -to -resident altercation. Telephonic interview with Licensed Nursing Home Administrator (LNHA), on 04/15/2021 at 10:55 AM, revealed the purpose of the care plan was to identify areas of focus/problems, concerns or needs. Once the focus was determined, a goal and individualized interventions were developed. Continued interview revealed each care plan should have a problem (focus), a goal to accomplish, and interventions to meet the goal. The goal may or may not be met, but should be reviewed and revised, as the resident's needs change. Continued interview revealed the care plan should be person-centered and the interventions should address the needs of the individual resident. During the interview, Resident #4's care plan was reviewed with the LNHA. He stated the interventions on Resident #4's care plan were generic, and not specific to the resident. Further interview revealed during the clinical morning meetings, the notes, medications, and orders were reviewed to determine if care plans revisions were needed. The LNHA stated care plans were updated during, or after the IDT meeting by the responsible department. He revealed the Social Services Director (SSD) was responsible for the psychosocial needs of the residents. He stated the SSD completed the sections in the MDS related to behaviors, and mood, and developed, and revised the care plan in those areas. The LNHA stated the care plan interventions were not revised to address the specific needs of Resident #4, and the resident continued with behaviors.

Based on observation, interview, record review, and the facility's policy review, it was determined the facility failed to maintain an established system of records for receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility was unable to account for eight (8) of thirty-two (32) Controlled Drug Administration Records (CDAR) dispensed by the pharmacy, and received by the facility for Residents #2 and #3. The narcotic drug records were not in order for received and administered controlled drugs. The facility failed to have an effective system to monitor the narcotic medications delivered to the facility, which resulted in the facility not identifying or addressing missing narcotic medications for Residents #2 and #3. In addition, the facility failed to secure eight (8) of eight (8) packs of non-narcotic medications delivered by pharmacy for 1B Unit, on 04/04/2021. The eight (8) medications packs remained on top of the medication cart, unattended. Refer to F602, F608, F610, F835, F865 The findings include: Review of the facility's policy, Storage of Medications, revised August 2020, revealed medications are stored safely, securely, and properly following the manufacturer's recommendations. The medication supply accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications, such as medication aides are permitted to access medications. Medication rooms, carts, and medication supplies remain locked when not attended by persons with authorized access. Review of the facility's policy, Receiving Controlled Substances, revised August 2020, revealed medications classified by the Drug Enforcement Administration (DEA) as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements by the facility in accordance with federal and state laws, and regulations. The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance. Only licensed personnel may receive controlled substances from the pharmacy courier. A nurse signs for the medications, on the pharmacy delivery ticket and inspects the medications for discrepancies. Two nurses in accordance with the facility's policy witness placement of the controlled substances into the secured compartment of the medication cart. Control substance inventory sheets are appropriately placed in the hardbound logbook utilized to track the controlled substances from delivery to disposition. Review of the facility's policy, Storage of Controlled Substances, revised August 2020, revealed medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other laws and regulations. The Director of Nursing, in collaboration with the pharmacy maintains the facility's compliance with federal, and stated laws, and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Scheduled II through V medications and other medications subject to abuse or diversion are stored in permanently affixed, or a double locked compartment separate from all other medications in accordance with state regulations. At each shift change, or when keys are transferred, then a physical inventory of all controlled substances by two (2) licensed personnel, and documented. Immediate reporting to the Director of Nursing when any discrepancy occurred with the controlled substance counts. The controlled substance inventory and the Medication Administration Record (MAR) should be regularly reconciled and documented on the control count sheet, or similar form. The accountability record for the current control substance should be kept in the MAR or a designated book. Completed accountability records submitted to the DNS are on file for five (5) years at the facility, or in accordance with the facility's policy and state regulations. The process for surrendered control substance was appropriate only when a resident/responsible party was on a pass, a therapeutic leave, or upon discharge with a receipt documenting the transaction. (Pharmacy provided the Controlled Drug Administration Record (CDAR), being the same as the accountability record.) Review of the facility's Self-Reported Incident Form, dated 02/01/2021 revealed the report identified the Optional Incident Reports section for Other Missing Medications related to Resident #2's missing medications. The Regional Nurse (Clinical) Consultant, Director of Nursing Services, and the Assistant Director of Nursing Services (ADNS) conducted the investigation with narcotic audits on all units. The facility's investigation revealed Resident #2 was missing one card of thirty (30) [MEDICATION(S)]-Acetaminophen, and one additional resident (Resident #3) was missing one card of thirty (30) [MEDICATION(S)]-Acetaminophen. 1. Observation of Resident #2, on 04/04/2021 at 4:32 AM, revealed he/she was in bed and appeared to be resting comfortably. His/her lights in the room were off and the window blind closed. Review of Resident #2's clinical record revealed the facility admitted the resident on 08/09/2018 with diagnoses of [CONDITION(S)] of Lower Extremity, [CONDITION(S)], and Malignant Neoplasm of Intestinal Tract. Review of the Physician's Orders dated 09/23/2019 revealed [MEDICATION(S)]-Acetaminophen 7.5-325 mg, one (1) tablet by mouth, every six (6) hours. Review of Resident #2's Significant Change Minimum Data Set (MDS) assessment, completed on 03/30/2021, revealed the facility assessed the resident's Brief Interview of Mental Status as seven (7), which indicated the resident's cognition was severely impaired. During observation and interview with Resident #2 in his/her room, on 04/09/2021 at 10:40 AM, the resident stated he/she hurts sometimes, but he/she had pain medication. Review of Resident #2's Controlled Drug Administration Records (CDAR), dated 12/24/2020, revealed [MEDICATION(S)] 7.5-325 mg. two (2) packs of thirty (30) tablets for a total of sixty (60) tablets were delivered. Each pack of thirty (30) tablets had a CDAR for each pack of medication. The facility was unable to provide one (1) of two (2) CDAR. Review of Resident #2's Controlled Drug Administration Records (CDAR) , dated 01/15/2021, revealed [MEDICATION(S)] 7.5-325 mg., two (2) packs of thirty (30) tablets for a total of sixty (60) tablets were delivered for Resident #2. Review of the CDAR revealed the facility was unable to account for one of two (2) packs of [MEDICATION(S)]-Acetaminophen 7.5-325 mg. Review of the Resident #2's Quarterly Minimum Data Set (MDS) assessment, completed on 01/13/2021, revealed the facility assessed the resident Brief Interview of Mental Status as nine (9), being moderately impaired. Review of the facility's interview with Resident #2, dated 02/02/2021, revealed he/she had pain during the past five (5) days in his/her legs and back. Further interview revealed he/she had not received his/her pain medication, and did not ask for any as needed pain medication. Additional interview revealed per medication administration record (MAR), the resident received [MEDICATION(S)] routine. Review of Resident #2, Medication Administration Record (MAR), dated January 2021, revealed sixteen (16) of sixty-two (62) opportunities were not documented for his/her [MEDICATION(S)]-Acetaminophen 7.5-325 mg ordered two (2) times per day for pain. 2. Observation of Resident #3, on 04/04/2021 at 4:40 AM, revealed the light was on in his/her room. However, he/she appeared to be resting comfortably without any distress. Interview and observation of Resident #3, on 04/09/2021 at 10:29 AM revealed he/she did not recall any medication issues, or running out. The resident stated his/her pain medicine controlled his/her pain. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/26/2019 with diagnoses of [CONDITION(S)], Lumbar Spondylolysis and Intervertebral Disc Degeneration in Lumbar Region, and a Lump in the Left Breast. Review of the Physician's Orders, dated 11/05/2020 revealed [MEDICATION(S)]-Acetaminophen 7.5-325 mg, one (1) tablet by mouth, every six (6) hours. Review of the Physician's Orders, dated 09/23/2019 revealed [MEDICATION(S)] Extended-Release (ER), one (1) tablet by mouth two (2) times a day. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment, completed on 11/27/2020, and the Annual MDS, completed on 02/16/2021, revealed the facility assessed the resident's Brief Interview of Mental Status as fourteen (14), which indicated the resident was cognitively intact. Review of Resident #3's Controlled Drug Administration Records (CDAR) dated 01/15/2021, revealed four (4) packs of thirty (30) tablets each for total of one hundred twenty (120) tablets of [MEDICATION(S)]-Acetaminophen 7.5-325 milligrams (mg) were delivered. The facility was unable to provide three (3) of four (4) pages of the CDAR. Review of Resident #3's Controlled Drug Administration Records (CDAR), dated 12/21/2020, revealed one (1) of two (2) CDAR for [MEDICATION(S)]-Acetaminophen 7.5-325 mg. Two (2) cards of thirty (30) tablets and two (2) CDAR, one for each card of medication were delivered. The facility was unable to provide one of two (2) pages of CDAR. Review of Resident #3's Controlled Drug Administration Records (CDAR), dated 12/10/2020, revealed one (1) of two (2) CDAR [MEDICATION(S)]-Acetaminophen 7.5-325 mg. Two (2) cards of thirty (30) tablets and two (2) CDAR, one for each card of medication were delivered. The facility was unable to provide one of two (2) pages of CDAR. Review of Resident #3's Controlled Drug Administration Records (CDAR), dated 12/31/2020, revealed [MEDICATION(S)] Extended-Release (ER) 15 mg tablets, two (2) packs of thirty (30) tablets were delivered to the facility. However, the facility was unable to account for one (1) of two (2) CDAR for [MEDICATION(S)] Extended-Release (ER). The facility was unaware of the missing CDAR for [MEDICATION(S)] ER 15 mg tablets until the State Survey Agency brought it to their attention. Review of the facility's interview with Resident #3, dated 02/02/2021, revealed the resident had pain in the last five (5) days. The pain was located from hips down, especially the right leg, with increased headaches and left rib cage pain. He/she stated the ordered pain medication relieved the pain. He/she revealed the resident received the ordered and scheduled pain medications along with the requested medication as needed. 3. Observation of the 1B Unit Front Medication Cart, on 04/04/2021 at 2:00 AM, revealed eight (8) packs of medication on top of the unsupervised medication cart. Observation revealed a female staff member seated at the computer at the nurses' station without a direct line of vision of the medication cart. Further observation revealed a staff member leaning on the side of the back hall medication cart, without a direct line of vision of the medication cart. Observation revealed a resident in a wheelchair by the medication carts. Review of the medications left on the top of the medication cart with Certified Medication Aide (CMA), on 04/04/2021 at 2:00 AM, revealed [MEDICATION(S)] 5 mg (three cards of thirty = 90 tablets); Aspirin 81 mg (30 tablets); [MEDICATION(S)] 5 mg (two cards of 30 tablets = 60 tablets); of Acetaminophen 325 mg (30 tablets); and [MEDICATION(S)] 88 mg (14 tablets). Interview with staff seated at the computer, on 04/04/2021 at 2:00 AM, and at 4:30 AM, revealed she identified herself as Certified Medication Aide (CMA) and the other staff as Registered Nurse (RN) #5. WHO ???She revealed pharmacy had delivered the medications earlier in her shift. Continued interview revealed she had not secured the medications in the medication cart to prevent anyone from taking them. She stated the medications were not narcotics. She stated the resident in the wheelchair by the medication cart never tried to take anything from the medication carts. Interview with Licensed Practical Nurse #8, on 04/15/2021 at 12:23 PM, revealed she was assigned to Resident #2, on 01/20/2021 when she identified his/her medications were not available. She stated she called the pharmacy for Resident #2's [MEDICATION(S)]-Acetaminophen refill. The pharmacy identified the resident should have a thirty (30) day supply at the facility from the last delivery. The pharmacy revealed the prescription refill request was too soon to refill. She stated she called the Director of Nursing Services (DNS). However, Unit Manager #2 came in during her 7AM-7 PM shift on this day. She revealed Unit Manager #2 reviewed the narcotic binders and reviewed the medication carts. She stated the facility replaced Resident #2's medication. Interview with Unit Manager #2, on 04/15/2021 at 12:11 PM, revealed she was notified by LPN #8 working on 01/30/2021, of Resident #2's [MEDICATION(S)]-Acetaminophen was low, and had called pharmacy to find out the resident should still have medications available in the facility. LPN #8 was told by pharmacy reported it was too soon to refill the prescription. Upon receiving the information about the missing narcotic and too soon to fill, she immediately notified the DNS. She stated she was covering the weekend on call and came in to investigate the missing medications. She revealed she went through the medication carts, verified the placement of the cards were in the correct locations within the cart, completed narcotic counts, and was unable to locate the missing pack of Resident #2 [MEDICATION(S)]-Acetaminophen. Further interview revealed the pharmacy courier delivered medications to one (1) nurse's station related to the COVID status. A nurse from each unit would come and pick-up their medications from the delivery. Each nurse or Certified Medication Aide (CMA) obtained the medications and secured them in the medication cart. She stated the facility had many agency staff. Continued interview revealed the resident's medication levels did not seem to be a concern of the agency staff. She revealed as a unit manager, she was trying to check each week to make sure medications were being ordered from pharmacy, so the resident did not run out. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 11:50 AM, revealed she received notification from the Unit Manager on 01/30/2021 of concerns that Resident #2's [MEDICATION(S)] supply was low. The Unit Manager stated the assigned nurse (LPN #8) had called pharmacy requesting a refill; however, it was too soon. She stated she provided direction to review the medication cart for misplaced narcotics, and ensured the medications were located in the correct sections for each resident. The DNS stated Unit Manager #2 verified the [MEDICATION(S)] was not in a different location on the cart. She stated they were unable to account for two (2) packs of thirty (30) [MEDICATION(S)]-Acetaminophen. She stated Residents #2 and #3 each had one pack of thirty (30) tablets of [MEDICATION(S)]-Acetaminophen 7.5-325 mg tablets unaccounted. The DNS stated the medications should be placed in a locked medication cart to ensure security. She stated medications left on the top of unattended medication carts was a potential risk for the residents to take, and cause harm to oneself. She stated her expectation was for all staff to ensure the medications were secured and the area safe. Telephonic interview with Registered Nurse (RN) #1, on 04/09/2021 at 12:53 PM revealed the process during COVID (minimizing potential exposure) was for the pharmacy delivery person to arrive on the 2C Unit with the medications for all of the units. The pharmacy refused to go to each floor/unit during COVID. A nurse came from each unit to receive the medications for their medication cart. The narcotics came in a separate bag with two (2) pieces of paper. The courier services delivered the narcotic prescriptions in a sealed bag. Upon verification of the medications, the courier's portable kiosk phone was signed to confirm receipt. One paper went to the tray at the front desk, for medical records and the other paper was added to the narcotic book to sign the medication out when the medication was administered. She revealed she met the pharmacy delivery person and received the [MEDICATION(S)] 7.5-325 mg for Residents #2 and #3 during her shift, on 01/15/2021. She stated she signed the narcotics into the double locked narcotic section of the medication carts for both residents, added the Controlled Drug Administration Records (CDAR), and updated the count sheets into the shift count books. She stated she did not have a second nurse to co-sign during the process. RN #1 explained upon completion of a narcotic pack, the empty pack was placed in the shred container, and the CDAR form was put in the medical records cubby. The RN stated all medications should be secured in the medication carts at all times, and locked. Telephonic interview with Regional Clinical Consultant (RCC), on 04/14/2021 at 8:07 AM revealed she was present during the narcotic investigation; however, they were unable to determine what happened to the medications during the investigation. Continued interview revealed they were unable to account for the medication packs for the two (2) residents. The same nurse signed in both medications. She stated during the cart audits, they identified only the two (2) residents with the two (2) cards of unaccounted medications. The RCC stated the information was in the investigation with the findings. Attempted telephonic interview with Licensed Practical Nurse (LPN) #9, on 04/14/2021 at 10:33 AM, on 04/15/2021 at 8:30 AM and at 11:37 AM without success. A return call was requested; however, none was received. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM revealed he conducted the telephonic interview with LPN #9, on 02/03/2021. Upon further review of the interview revealed, she was interested in the facility's monitoring of the empty narcotic cards (packs) and the paper (CDAR) placed in the cubby for medical records. She expressed an interest in who was monitoring the forms to know if they were shredded or taken. Further discussion revealed LPN #9 claimed a couple of weeks prior she had signed for a non-narcotic pack of medications, which was lost. The LNHA stated upon follow-up with the DNS, LPN #9 never followed-up with her. In addition, he stated the DNS did not recall missing any cards of medications reported missing. He stated LPN #9 became tearful, as she spoke of needing hip surgery, and having a lot of hip pain. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM and on 04/14/2020 at 10:55 AM revealed the Director of Nursing Services (DNS) made notification of the medication discrepancy related to Resident #2's pain medication, on 01/30/2021. He stated the investigation was initiated by the Unit Manager while onsite. He stated pharmacy identified the time was too soon to refill since the medication were filled on 01/15/2021 for a months' supply. The facility replaced the medications. He revealed the Regional Clinical Consultant (RCC) assumed lead with the missing narcotic investigation, since the DNS was new to her position. He revealed he did speak with the Director of Operations Consultant (DOC) regarding the occurrence. He stated the facility determined Residents #2 and #3 each had one (1) card of thirty (30) [MEDICATION(S)] 7.5/325 mg tablets (total 60 tablets) missing. During the investigation it was determined Resident #2 and #3's medications were same day delivery; however, the facility was unable to determine what happened to the medications. Further interview and review of the investigation with the DOC and the RCC revealed they were not able to identify a specific person removing the medication, or pin point what happened with the medications, they were unable to determine the medications were diverted. The consultants considered the card of narcotics may have fallen into the trash. He revealed the investigation should have identified the additional missing Controlled Drug Administration Records (CDAR) for the [MEDICATION(S)] and the additional [MEDICATION(S)]-Acetaminophen. Continued interview with the LNHA on 04/15/2021 at 2:20 PM, revealed all medications should be secured from all residents, or anyone passing by. He stated the staff assigned to the medication carts were responsible to ensure the medications were secured and safe. Telephonic interview with Regional Operations Consultant, on 04/14/2021 at 12:55 PM revealed she had been present in the facility during the time of the investigation of the narcotics missing. She stated they were unable to determine if a specific person took the medications. She revealed they had not determined this was a diversion of medications, even though the pharmacy had delivered the medications and the facility had received the medications. However, the medications were not available at time of need.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the residents were free from misappropriation of resident property for two (2) of six (6) sampled residents (Residents #2 and #3). Record review revealed the residents had missing narcotic pain medications. The findings include: Review of the facility's policy Abuse Prevention Program, revised date 02/22/2018, revealed the resident has the right to be free from abuse and protected from abuse, neglect and misappropriation of resident property. The facility's policy identified the residents were protected from the facility's staff, consultants, and staff from other agencies providing services to the residents. Further review revealed misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings, without the resident's consent. Review of the Resident's Rights, cited in the 1987 Nursing Home Reform Law, revealed each resident has the right to a dignified existence. And, the right to be free from abuse and misappropriations of property. Review of the facility's Self-Reported Incident Form, dated 02/01/2021, revealed narcotic pain medications were low and too soon to be refilled by pharmacy for Resident #2, on 01/30/2021. The medication, [MEDICATION(S)] (narcotic controlled pain medication) -Acetaminophen 7.5-325 milligrams (mg) sixty (60) tablets delivered, on 01/15/2021, contained one (1) month's supply. An audit of the medication cart, on 02/01/2021 revealed a second resident, Resident #3 was missing a card of thirty (30) tablets of [MEDICATION(S)]-Acetaminophen 7.5-325 milligrams delivered, on 01/15/2021. Interview with Licensed Practical Nurse (LPN) #8, on 04/15/2021 at 12:23 PM, revealed she was assigned to the 2C Unit, on 01/30/2021 caring for Resident #2 when she identified the resident's [MEDICATION(S)]-Acetaminophen pain medication was not available in the medication cart. She stated she called the pharmacy for the [MEDICATION(S)]-Acetaminophen refill, and was told the resident should have a thirty (30) day supply at the facility. Continued interview revealed the pharmacy informed her the prescription refill request was to soon to refill. She stated this was on a Saturday. LPN #8 stated she notified the Director of Nursing Services (DNS). However, Unit Manager #2 arrived during her shift and reviewed the narcotic binders and the medication carts. LPN #8 stated the medication for Resident #2 was not there and had to be replaced. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 11:50 AM, revealed she received notification from the Unit Manager on 01/30/2021 of a concern that Resident #2's [MEDICATION(S)] supply was low. She stated the Unit Manager stated the assigned nurse had called pharmacy requesting a refill and the pharmacy reported the prescription was to soon to refill. The pharmacy reported they had dispensed the [MEDICATION(S)]-Acetaminophen, on 01/15/2021, which was a month's supply. The DNS stated that an investigation was initiated. She stated that she, the Regional Clinical Consultant (RC), and the Assistant Director of Nursing Services (ADNS) conducted the investigation. The DNS stated Unit Manager #2 initiated the investigation, with narcotic audits, and counts on the medication carts. Unit Manager #2 identified Resident #2's pack of thirty (30), [MEDICATION(S)]-Acetaminophen were missing. 1. Observation of Resident #2, on 04/04/2021 at 4:32 AM, revealed the lights were off in the room while the resident appeared comfortable and resting. Observation of Resident #2, on 04/09/2021 at 10:05 AM, revealed the resident was in the bed, and appeared comfortable. The television was on. He/she was alert and acknowledged the State Survey Agency Surveyor's presence in the room. Resident #2 appeared with an increased action of the tongue when speaking. Review of Resident #2's clinical record revealed the facility admitted the resident on 08/09/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Significant Change Minimum Data Set (MDS) assessment, completed on 03/30/2021, revealed the facility assessed the resident with the Brief Interview for Mental Status with a score of seven (7), which indicated the resident was severely cognitively impaired. Interview with Resident #2, on 04/09/2021 at 10:05 AM, revealed the resident had some pain in his/her legs and back. Resident #2 stated, Tylenol takes care of the pain. However, the resident did not expand during the interview, and had no recall of any medications concerns. 2. Observation of Resident #3, on 04/04/2021 at 4:40 AM, revealed the light was on in his/her room. However, the resident's eyes were closed, and appeared to be resting comfortably without any distress. Observation of Resident #3, on 04/09/2021 at 10:29 AM revealed a welcoming atmosphere by the resident. The rollator was located within reach of the resident. The resident was dressed, groomed and appeared comfortable. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/26/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #3's Quarterly Minimum Data Set (MDS) assessment, completed on 11/27/2020, and the Annual MDS, completed on 02/16/2021, revealed the facility assessed the resident's Brief Interview for Mental Status score as fourteen (14) which indicated the resident was cognitively intact. Interview with Resident #3 in his/her room, on 04/09/2021 at 10:29 AM, revealed his/her pain medications were not an issue as far as his/her memory served. Resident #3 stated his/her pain medications were provided by the nurses, and seemed to help relieve the pain. He/she explained the pain occurred all over his/her body, and in the back. However, his/her pain was manageable with the pain medications. Interview with Licensed Practical Nurse (LPN) #10 on 2C Unit, on 04/04/2021 at 3:06 AM, revealed abuse education was provided during her recent new hire orientation. LPN #10 stated abuse included misappropriations of resident's property. She identified if medications were taken from a resident, it was considered misappropriations of the resident's property, and, should never happen. Telephonic interview with Registered Nurse (RN) #1, on 04/09/2021 at 12:53 PM revealed abuse education was provided by the facility during orientation. RN #1 stated abuse included misappropriation of property, including the resident's medications. Continued interview revealed a resident's items should not be taken by anyone except the resident, as this was personal for each resident. She revealed she received the medication delivered for 2C Unit, on 01/15/2021. She stated they were signed into the narcotic books and placed in the cart. RN #1 stated she was not aware when the medications for the resident went missing. She further stated she was placed on leave during the facility's investigation. Review of the facility's documented telephonic interview with RN #1 by the Regional Clinical Consultant (RCC) and the Director of Nursing Services (DNS), dated 02/04/2021 at 4:00 PM, revealed a review of the receiving process of narcotics upon pharmacy delivery, on 01/15/2021. Continued review revealed shift counts were reviewed. However, the interview did not include information related to misappropriation of the residents' medications. Further review revealed, RN #1 stated she was shocked this happened (missing pain medications), did not know how it happened and did not know how you would not get caught. Telephonic interview with Regional Clinical Consultant (RCC), on 04/14/2021 at 8:07 AM revealed the concern of the potential missing narcotics was identified during a weekend. She revealed an investigation was initiated, and she was lead for the investigation, since the DNS was new to the facility. She revealed medication cart audits were completed, and believed a second resident was identified with missing pain medication. She stated, they were unable to determine who took the medication from the medication cart; therefore, did not determine the medications were diverted. She revealed the investigation was in February, and was unable to recall any details. She revealed misappropriations was a form of abuse, and if the medications were identified as diversion, then this would have been abuse. Attempted telephonic interview with Licensed Practical Nurse (LPN) #9, on 04/14/2021 at 10:33 AM; on 04/15/2021 at 8:30 AM and at 11:37 AM without success. A message was left on the voice mail, requesting a return call. LPN #9 never followed-up with a return call. Review of the facility's investigation of the written interview with LPN #9 conducted by the Licensed Nursing Home Administrator (LNHA), dated 02/03/2021 at 2:20 PM, revealed she completed narcotic counts at the beginning and end of her shift, with the narcotic signature sheets and medications/cards. She stated lately, the agency nursing staff working did not want to co-sign. She stated a discussion occurred with Unit Manager #2 about the process for agency staff to co-sign medications, as they do not come or have an attitude when they do. Further review revealed no interview related to misappropriation of medications related to abuse in the notes. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM revealed he interviewed LPN #9 over the telephone, on 02/03/2021. He stated she was interested in the facility's monitoring of the empty narcotic cards (packs) and the paper Controlled Drug Administration Records (CDAR)/Accountability Records (AR) placed in the cubby (facility designated location for completed forms awaiting retrieval by medical records staff) for medical records. He stated that LPN #9 claimed a couple of weeks prior she had signed for a pack of non-narcotic medications and the pack of medications was lost. LPN #9 stated she had planned to call the DNS to discuss the missing pack of non-narcotic medications. LNHA stated LPN #9 never followed-up with the DNS. In addition, he stated the DNS did not recall reports of any cards of medications missing. He stated LPN #9 expressed an interest in knowing who monitored the CDAR/AR forms. LPN #9 questioned if the CDAR/AR were maintained by the facility or shredded. how the facility maintained the forms and whether or not they were shredded. He stated LPN #9 discussed significant hip pain and became tearful on the telephone. Interview with the Regional Operations Consultant (ROC), on 04/14/2021 at 12:55 PM revealed she had been present in the facility during the time of the investigation of the narcotics missing. She stated they were unable to determine if a specific person took the medications; therefore, they did not identify the missing medications as diversion. The ROC stated, Well, we were just not able to determine what happened to the medications. She stated the meds may have fallen into the trash. Continued interview revealed they just could not determine if anyone took them, or where they went. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/13/2021 at 10:20 AM and on 04/14/2020 at 10:55 AM revealed the Director of Nursing Services (DNS) notified him of the medication discrepancy related to Resident #2's missing [MEDICATION(S)] 7.5/325 mg tablets pain medication, on 01/30/2021. He stated the investigation was initiated by the Unit Manager onsite. Interview revealed Pharmacy identified the time was too soon to refill as the medication had been filled, on 01/15/2021 for a thirty (30) day supply. He revealed the Regional Clinical Consultant (RCC) assumed lead with the missing narcotic investigation, since the DNS was new to her position. The LNHA revealed he did speak with the Director of Operations Consultant (DOC) regarding the occurrence. He stated the facility determined Residents #2 and #3 each had one (1) card of thirty (30) [MEDICATION(S)] 7.5/325 mg tablets (total 60 tablets) missing. During the investigation it was determined Residents #2 and #3's medications were delivered the same day. However, the facility was unable to determine what happened to the medications. Further interview revealed the consultants considered that the card of narcotics may have fallen into the trash. He stated the investigation should have identified the additional missing Controlled Drug Administration Records (CDAR) for the [MEDICATION(S)] and the additional [MEDICATION(S)]-Acetaminophen. The LNHA stated the facility replaced the medications. Further interview and review of the investigation with the DOC and the RCC revealed they were not being able to identify that a specific person removed the medication, or pin point what happened with the medications. The LNHA stated since the RCC was the clinical person, and she was unable to determine that the medications were diverted; he followed her direction. Continued interview with the LNHA on 04/15/2021 at 2:20 PM, revealed all medications should be secured. He stated the staff assigned to the medication carts were responsible to ensure the medications were secured and safe. The LNHA stated medications taken from the residents was a form of misappropriations of the resident's property, and should never happened. Further interview revealed the additional unaccounted medications indicated the investigation did not identify the extent of missing medications. Interview with the Director of Nursing Services (DNS), on 04/15/2021 at 4:20 PM, revealed the missing pain medications from Residents #2 and #3 were misappropriations of resident property, in retrospect. The DNS stated the residents' medications should be protected and safe from loss, and this never should happen. Continued interview revealed abuse education was provided in each new hire employee orientation and agency staff receives abuse education when they were new to the facility.

Based on interview, record review, review of the facility's policy, and review of the Elder Justice Act, it was determined the facility failed to report a reasonable suspicion of a crime to local Law Enforcement when two (2) of six (6) sampled residents (Residents #2's and #3's) narcotic pain medications was not located in the double locked medication cart. The facility investigated, and identified Resident #2's [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg) pack of thirty (30) tablets was missing, on 01/30/2021. In addition, during the investigation, the facility identified Resident #3 had missing [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg), pack of thirty (30) tablets missing. The findings include: Review of The Elder Justice Act, enacted in March of 2010, revealed residential care facilities were required to report any reasonable suspicion of a crime against a resident or person who was receiving care from a federally funded long-term care facility to local Law Enforcement. Review of the facility's policy, Abuse Prevention Program, revised 02/22/2018, revealed the resident has the right to be from abuse, neglect, misappropriation of property. Comprehensive policies and procedures were developed to aid the facility in preventing abuse, and governing the reporting, and filing of accurate documents. The policies govern the process of reporting to law enforcement in accordance with the Elder Justice Act. Reporting to law enforcement was not to exceed twenty-four (24) hours (no later than two (2) hours for reporting when serious bodily injury occurs), once a reasonable suspicion, and objective facts which would lead a reasonable person in the same situation to conclude a crime was committed. Further review revealed misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings, without the resident's consent. Review of the facility's Long Term Care Facility-Self Reported Incident Form/Final Report, which was emailed to the Office of Inspector General/ State Survey Agency (OIG/SSA), on 02/09/2021, and signed by the Licensed Nursing Home Administrator (LNHA), revealed an Optional Incident Report-Other Missing Medications, dated 02/01/2021. The Physician and the Resident's Legal Representative were notified of the alleged incident, on 02/01/2021. Review of the Summary of Incident, revealed, on 01/30/2021, Resident #2 was identified without [MEDICATION(S)]-Acetaminophen, and the pharmacy notified the facility it was too soon to refill. During the facility's investigation it was determined Resident #3 also had pain medications that were missing. However, further review revealed Law Enforcement was not notified of the alleged abuse with misappropriation of property. Review of the controlled narcotic pain medications delivered during December, 2020 and January, 2021 revealed an additional six (6) cards of thirty (30) tablets was not accounted for by the facility. The facility was not aware of the additional missing narcotic pain medications until the State Survey Agency brought the information to their attention. Continued review of the facility's Final Report, Section, Center Response, and the Investigation Summary revealed no documented evidence in the Investigation Report of notification to the Law Enforcement was made related to the missing medication, an occurrence of a reasonable suspicion of a crime. Review of Resident #2's clinical record revealed the facility admitted the resident on 08/09/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Significant Change Minimum Data Set (MDS) assessment, completed on 03/30/2021, revealed the facility assessed the resident's Brief Interview for Mental Status as seven (7), which indicated the resident's cognition was severely impaired. Review of Resident #2's prescription (Rx) for [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg) revealed the pharmacy dispensed the medication on 12/24/2020. Pharmacy delivered two (2) cards of thirty (30) tablets with a Controlled Drug Administration Record (CDAR) for each card of thirty (30) tablets. Again, the facility was unable to account for one of the two (2) CDAR received. Review of Resident #2's prescription (Rx) for [MEDICATION(S)]-Acetaminophen 7.5-325 mg, sixty (60) tablets was dispensed, on 01/15/2021. The manifest revealed the pharmacy delivered two (2) cards of thirty (30) tablets. However, the facility was unable to account for one of the two (2) cards of thirty (30) tablets received. Review of Resident #3's clinical record revealed the facility admitted the resident, on 02/26/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 1:25 PM revealed the narcotic pain medications were identified as missing from the medications carts for Residents #2 and #3. However, they were unable to determine where the medications were misplaced. She stated initially the nurse reported Resident #2's [MEDICATION(S)]-Acetaminophen pain medication was out, and it was too soon to refill per pharmacy. The DNS revealed an investigation continued and identified Resident #3's [MEDICATION(S)]-Acetaminophen pain medication was also missing. She stated the Regional Clinical Consultant (RCC) was the lead on the investigation. Further interview revealed she did not report the missing narcotics to the police. However, it probably should have been reported to the police, since the medications were narcotics. Telephonic interview with Regional Clinical Consultant (RCC), on 04/14/2021 at 8:07 AM revealed she was present during the narcotic investigation. She stated the investigation revealed that two (2) residents were missing one card each of pain medication. During the investigation, they were unable to account for the medication packs for the two residents. The RCC revealed it was never determined the [MEDICATION(S)]-Acetaminophen 7.5-325 mg, two (2) cards of thirty (30) tablets were diverted, even though they were never located. She stated she did not notify the police of the missing narcotic, and it was not her responsibility. Telephonic interview with Regional Operations Consultant (ROC), on 04/14/2021 at 12:55 PM revealed a discussion occurred related to the missing narcotics. She revealed they had not determined it was not diversion of medications even though the pharmacy had delivered the medications, and the facility had received the medications. The ROC revealed the medications may have been knocked off the cart into the trash. Further interview revealed the police notification was not completed. She stated as a consultant, she did not interfere with any reporting to the police. The ROC stated reporting to law enforcement was at the discretion of the Licensed Nursing Home Administrator (LNHA). She stated, if this had been identified as a diversion of medications, then police would have been notified. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/09/2021 and on 04/15/2021 at 2:20 PM, revealed the police was not notified of the narcotic pain medications missing for Residents #2, or #3. He stated discussions occurred with the RCC and the ROC regarding the pain medications missing. Further interview revealed the facility's DNS was new to her position, and the RCC lead the investigation. He stated he depended on the Clinical Consultant's clinical skills for the narcotic investigation and findings for direction with the findings. Further interview revealed the report shared did not identify diversion; therefore, the police were not notified. However, in retrospect, and knowing the extent of the missing medications, the police needed to be notified, and involved. Continued interview and review of the Controlled Drug Administration Record (CDAR) for Resident #2 and #3 with LNHA revealed he was not aware the additional six (6) CDAR were not located for the medications, dispensed, and delivered to the facility. He revealed the CDAR was a record signing out each tablet at the time of administration. And, further stated the CDAR was the record on file to confirm the tablet was removed to be administered. He stated there was no way of knowing if the tablet was provided to the resident, when there was not a record the tablet was removed. He stated there was tracking of that the pharmacy dispensed, delivered, and received by the facility; however, the facility had no record of what happened with the removal of each tablet in December 2020 and January 2021.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide evidence and ensure an allegation of misappropriation of narcotics was thoroughly investigated for two (2) of six (6) sampled residents (Residents #2 and #3). The facility's investigation of Resident #2's narcotic medication identified one card of thirty narcotic tablets were missing, on 01/30/2021. The facility's investigation also identified Resident #3 was missing a card of thirty (30) tablets. Resident #2's and #3's controlled narcotic pain medications delivered in December, 2020 and January, 2021, revealed an additional six (6) cards of thirty (30) tablets were unaccounted for by the facility. The facility was not aware of the additional missing narcotic pain medications until the State Survey Agency brought the information to their attention. The findings include: Review of the facility's policy Abuse Prevention Program, revised date 02/22/2018, revealed the resident has the right to be free from abuse and protected from abuse and misappropriation of resident property. The facility's policy identified the residents were protected from the facility's staff, consultants, and staff from other agencies. The abuse program's policies and procedures govern the development of investigative protocols of theft/misappropriations of resident property, timely and thorough investigations of all reports and allegations of abuse. The individual who conduction the investigation should at a minimum review the resident's medical record to determine the events leading up to the incident, and review all events leading up to the alleged incident. Review of the facility's policy, Storage of Controlled Substances, revised August, 2020, revealed medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other laws and regulations. The Director of Nursing, in collaboration with the pharmacy maintains the facility's compliance with federal, and state laws, and regulations in the handling of controlled substances. Only authorized licensed nursing, and pharmacy personnel have access to controlled substances. Scheduled II through V medications, and other medications subject to abuse or diversion are stored in permanently affixed, or a double locked compartment separate from all other medications in accordance with state regulations. Review of the facility's Self-Reported Incident Form, dated 02/01/2021, revealed narcotic pain medications were low and too soon to refill by pharmacy for Resident #2, on 01/30/2021. The medication, [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg), sixty (60) tablets was delivered, 01/15/2021, and contained one (1) month's supply. Interview with Licensed Practical Nurse (LPN) #8, on 04/15/2021 at 12:23 PM, revealed she was assigned to 2C Unit. LPN #8 stated when she was preparing to administer Resident #2's medication, on 01/30/2021, she identified the resident's medications were not available. She stated she called the pharmacy for Resident #2's [MEDICATION(S)]-Acetaminophen refill. LPN #8 stated pharmacy told her Resident #2's [MEDICATION(S)]-Acetaminophen was last filled, on 01/15/2021, with a thirty (30) day supply. Further interview revealed the pharmacy informed her the request was too soon for a refill. She stated this was on a Saturday, and she called the Director of Nursing Services (DNS). However, Unit Manager #2 came in during her 7AM-7 PM shift on that day. She revealed Unit Manager #2 reviewed the narcotic binders and reviewed the medication carts. LPN #8 stated she looked in various locations in the medication cart and was unable to locate the second card of thirty (30) tablets. Interview with Unit Manager #2, on 04/15/2021 at 12:11 PM, revealed she was notified by LPN #8 working, on 01/30/2021, that Resident #2's [MEDICATION(S)]-Acetaminophen was low, and was told by pharmacy a month's supply was delivered, on 01/15/2021. She stated she spoke with pharmacy, and was told, it was too soon to refill. Unit Manager #2 stated she spoke with the Director of Nursing Services (DNS) about the medications, and pharmacy's inability to refill. She stated the pharmacy was requested to refill the medication and charge it to the facility. Continued interview revealed she reviewed the medications to see if the medications were misplaced into the wrong area, or on the wrong cart. Unit Manager stated she did not locate the medications. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 11:50 AM, revealed she received notification from Unit Manager #2, on 01/30/2021, that Resident #2's [MEDICATION(S)] supply was low. The Unit Manager stated the assigned nurse (LPN #8) had called pharmacy requesting a refill. The pharmacy reported the prescription was too soon for a refill. The pharmacy reported they dispensed the [MEDICATION(S)]-Acetaminophen, on 01/15/2021, a month's supply. She stated Unit Manager #2 initiated the investigation, on 01/30/2021. DNS stated she provided direction to review the medication cart for misplaced narcotics, and ensure the medications were located in the correct sections for the each resident. Unit Manager #2 verified the [MEDICATION(S)] was not in a different location on the cart. 1. Review of Resident #2's clinical record revealed the facility admitted the resident, on 08/09/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's prescription for [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg), revealed two (2) cards of thirty (30) for sixty (60) tablets delivered, on 01/15/2021. Each card contained one CDAR/accountability record. The facility was unable to provide one of two (2) CDAR/accountability records accounting for the removal of each tablet for administration to the resident. Review of Resident #2's, prescription for [MEDICATION(S)]-Acetaminophen 7.5-325 mg, dated 12/24/2020, revealed two packs of thirty (30) tablets delivered. The facility was unable to provide one of two (2) CDAR/accountability records accounting for the removal of each tablet for administration to the resident. Interview with Unit Manager #2, on 04/15/2021 at 12:11 PM, revealed she was not part of the ongoing investigation related to the missing medications. She stated the DNS and some of the other management staff continued the investigation. She revealed as a unit manager she was trying to check each week to make sure medications were ordered from pharmacy, so the resident did not run out; however, this pertained more so to the non-narcotic medications. Unit Manager #2 revealed the flow of narcotics were not monitored on the medication carts, other than the shift change counts. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 11:50 AM, revealed that she and the Regional Clinical Consultant Nurse (RCCN), and the Assistant Director of Nursing Services (ADNS) continued the investigation and audits, on 02/01/2021. She stated they identified Resident #3 was missing [MEDICATION(S)]-Acetaminophen 7.5-325 mg tablets, one (1) card of thirty (30) tablets, delivered, on 01/15/2021. She revealed the Assistant Director of Nursing Services completed the audits on 2C Unit. Continued review of the facility's Self-Reported Incident Form, dated 02/01/2021, revealed an audit of the medication cart, on 02/01/2021, identified Resident #3 was missing [MEDICATION(S)]-Acetaminophen 7.5-325 milligram (mg), one (1) card of thirty (30) tablets, delivered, on 01/15/2021. 2. Review of Resident #3's clinical record revealed the facility admitted the resident, on 02/26/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Assistant Director of Nursing (ADON), on 04/13/2021 at 6:15 PM, revealed 2C Unit narcotic audits were completed, on 02/01/2021. She explained the process for the narcotic audit completed, on 02/01/2021. She stated she took the manifest (delivery paper listing medications delivered), and compared to the narcotic book of what was added and removed to ensure the numbers matched. She stated she looked to see the count was correct on the Controlled Drug Administration Record (CDAR)/accountability record. When those three (3) pages matched, then the audit was completed for each resident. She stated Resident #3's [MEDICATION(S)]-Acetaminophen 7.5-325 mg, four (4) packs of thirty (30) tablets were delivered, on 01/15/2021. She stated there was one (1) card signed out (removed from supply), on 01/15/2021, and another card was signed out, on 01/17/2021. She stated there was one (1) pack of thirty (30) tablets in use, so one (1) pack of thirty (30) tablets was missing. Continued interview revealed she did not think about the number of pills used in the two (2) days, from the delivery date and two (2) cards signed out in two (2) days. She stated she could not recall the number of Controlled Drug Administration Record (CDAR)/accountability record. She further stated whatever was in the event report was the items she identified. She revealed she did not pull any additional information from medical records to review additional Controlled Drug Administration Record (CDAR)/accountability records for Residents #2 or #3. Review of Resident #3, prescription for for [MEDICATION(S)]-Acetaminophen 7.5-325 mg, dated 01/15/2021, revealed four (4) packs of thirty (30) tablets delivered. Review of the Controlled Drug Administration Record (CDAR)/accountability record revealed the facility was unable to provide three (3) of four (4) CDAR/accountability records. The facility was unaware of the additional two (2) missing CDAR for [MEDICATION(S)]-Acetaminophen, Rx # 52, until the State Survey Agency brought the information to their attention. Review of Resident #3's [MEDICATION(S)]-Acetaminophen, dated 12/10/2020, revealed two (2) packs of thirty (30) tablets delivered with one (1) CDAR for each card of medication. The facility was unable to provide one of two (2) CDAR/accountability records accounting each tablet removed for administration to the resident. Continued review of Resident #3's Rx for [MEDICATION(S)]-Acetaminophen, dated 12/21/2020, revealed two (2) packs of thirty tablets were sent with one (1) CDAR for each card of medication. The facility was unable to provide one of two (2) CDAR/accountability records accounting each tablet removed for administration to the resident. Further review of Resident #3's, Rx for [MEDICATION(S)] Extended Release (ER) 15 mg, dated 12/31/2020, revealed two (2) packs of thirty (30) tablets were delivered. The facility was unable to provide one of two (2) CDAR/accountability records accounting for the removal of each tablet for administration to the resident. Observation of the shift narcotic count with Licensed Practical Nurse #2 and Registered Nurse #3, on 04/09/2021 at 7:10 PM, revealed the number of sheets, and cards reflected the numbers identified in the narcotic binder. The staff counted the narcotic by name and number on each card and it reflected the number listed on the CDAR/accountability records. Interview with the Director of Nursing Services (DNS), on 04/13/2021 at 11:50 AM, revealed the medications should be placed in a locked medication cart to ensure their security. She stated her expectation was for all staff to ensure the medications were secured and the area was safe. Review of the 2C, Medication Cart A and Medication Cart B, on 04/14/2021 at 6:15 PM, revealed double locked Telephonic interview with Regional Clinical Consultant, on 04/14/2021 at 8:07 AM revealed she assisted with the missing narcotic investigation; however, they were unable to determine a diversion occurred. She revealed they were unable to account for the medication packs for the two (2) residents with missing medications. She stated the investigation was in February and she was unable to recall any additional details with the time lapse. Interview with the Director of Medical Records (DMR), on 04/15/2021 at 5:55 PM, revealed the Controlled Drug Administration Record (CDAR)/accountability records were sent to the medical records department for filing upon removal from the narcotic book. The nurse removing the individual CDAR placed the page in the medical records box and then Medical Records filed them in the resident's medical record. He stated he reviewed all the areas in medical records looking for the requested records associated with Residents #2 and #3, and was unable to locate any additional forms accounting for the cards of medication. Interview with Licensed Nursing Home Administrator (LNHA), on 04/15/2021 at 6:15 PM, revealed the investigation should have been broader, with a look back period in the prior month, and not just the current month of January. The LNHA stated the investigation process did not identify diversion since a particular person was not identified. He stated at the time diversion did not enter his mind. Upon reviewing the additional cards unaccounted for in December and January indicated Resident #2 was missing two (2) cards of medication, instead of the one (1) initially identified, on 01/30/2021. Upon reviewing Resident #3's Controlled Drug Administration Record (CDAR)/accountability records for the [MEDICATION(S)] and the [MEDICATION(S)]-Acetaminophen she noted the resident was missing six (6), instead of the one (1) card of medication initially identified during the facility's investigation. He stated the CDAR should reflect the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The LNHA stated the breach of the narcotics occurred on 2C Unit, and only the nurses had keys to the medication carts. He stated the nurses pass the keys from the off going shift to the oncoming shift with shift change.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to be administered in a manner that allowed use of its resources effectively and efficiently to maintain an accurate accounting of narcotic medications received, administered and maintained in the facility, as well, as an effective system of documentation of medications administered. In addition, the facility failed to ensure the maintenance of an effective Quality Assurance and Process Improvement (QAPI) Program. The facility was cited for repeat citations for F600 Abuse with Resident-to-Resident, F657 for the lack of person-centered care plan revisions, F835 for administration responsibilities, and F865 related to the QAPI committee performance, on 08/28/2020 and 02/12/2021. The findings include: Review of the Nurse Executive (NE) Position Summary, updated 03/25/2021, revealed the NE's responsibilities included providing supervision and guidance to clinical care team members. Continued review revealed other responsibilities included to implement the facility's policy and procedures, and ensure the facility followed its policy and procedures. Review of the Executive Director (ED) Position Summary, updated 03/25/2021, revealed the ED's responsibilities included leading an effective QAPI Program, ensure the facility maintained compliance with State and Federal regulations. Review of the Plan of Correction (POC), for the 08/28/2020 survey, revealed the facility failed to ensure the plan of correction was followed to sustain compliance related to securing and tracking maintained residents' narcotics. In addition, the facility failed to maintain compliance for the documentation of medications/medical record, tracking of the narcotics administered, Review of the Plan of Correction (POC) for the 08/28/2020 survey, revealed the facility failed to protect two (2) residents from abuse. The POC for F600, Freedom from Abuse, revealed all staff were educated on abuse, with post test, and audits ensuring the education provided was effective. The Interdisciplinary Team, consisiting of Director of the Nursing Services, Assistant Director of Nursing Services, Therapy, Social Services, Unit Managers, Medical Records, and MDS Staff received the abuse education. The POC for F657 revealed nurses were educated on types of abuse, immediate actions and interventions to be used and documented. The IDT was educated on the requirement to develop and implement the comprehensive care plan for new, worsening, and increased behaviors, and/or interventions related to abuse. The POC for F835 for Admistration revealed a new executive director/adminstrator was hired. The new administrator was educated on Abuse with types, immediate action, and interventions to be used, and documented. The administrator was educated on appropriate interventions related to care plans. The POC for F842 revealed the administration of medications documentation not completed. Audits were established; however, the lack of documentation of administration continued. The POC for F865 revealed the new executive director was trained on the QAPI process. The QAPI Committee continued to meet and report data without tracking and trending with identification, and implentation of intervention to prevent repeated citations. Review of the Plan of Correction (POC) for the 02/26/2021 survey, revealed the facility failed to protect two (2) resident from abuse. The POC for F600, Free from Abuse revealed one resident was bit by another resident, and one resident struck another resident with a cane. In addition, the facility was cited for F657 for lack of revisions of person centered interventions. The facility was cited for F835 regarding administration. The POC revealed the Interdisciplinary Team was educated on completing updates and revisions on careplans for residents with behaviors; however the behaviors and abuse continued without resident specific interventions. The POC for F865 for QAPI revealed the administrators, the DNS. and the Director of Medical Records detemined the need to identfiy the root cause and review of orders and progress notes. Resident abuse continued without an effective facility prevention system in place. Interview with the ED, on 11/06/2020 at 1:00 PM, revealed his responsibilities included to ensure the facility maintained compliance in the regulated areas identified on surveys and in the facility. He stated on 09/09/2020 he assumed the ED position full time and worked closely with the Medical Director on the needs of the facility, education, and areas of improvement. He stated he was committed to the residents and the staff to ensure the facility met all quality care measures for care. Interview with the Licensed Nursing Home Administrator (LNHA), on 04/15/2021 at 2:20 PM and at 6:15 PM, revealed responsibilities included to ensure the facility maintained compliance in the regulated areas identified on surveys and in the facility. He stated the administrative staff was not in a stable position during December 2020 and January 2021. He stated an Interim Director of Nursing Services (IDNS) was assigned to the facility during December. She was reviewing audits; however, she reported no concerns identified. The audits being completed by the IDNS occurred during the timeframe of the missing Controlled Drug Administration Record (CDAR)/Accountibility Record (AR). The IDNS audit data did not provide any details of findings related to the number of controlled narcotic cards received, or if the records accouted for all of the CDAR/AR for each of the medications received. He stated she was not tracking or trending any details with the reviews. He stated he was aware of the prior plan of correction related to a similar situation of resident to resident. He stated he had been focused on the more recent deficiencies cited. The ED stated it was his responsibility to ask the additional questions, and to clarify the auditing process. He stated we (the facility) should have identified the additional missing Controlled Drug Administration Records (CDAR)/Accountability Record (AR). He stated the entire process of the medication delivery with review should be tracked and trended ensuring full accountability of the narcotics, as well as the documentation on the medication administration record.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #4) was free from physical abuse. On 03/09/2021, Respiratory Therapist (RT) #1 overheard Resident #4 loudly cussing and calling the housekeeper derogatory names. In response, the Respiratory Therapist went to the resident's room in an attempt to calm the resident. The resident hit the RT and the RT hit the resident back. The Respiratory Therapist identified his response to the resident was reflexive, and he swung his opened-hand back. The facility transferred Resident #4 to the emergency room , later on 03/09/2021, for an evaluation related to the incident. The Radiology report revealed Resident #4 was diagnosed to have mildly displaced bilateral (both sides of nose) nasal bone fractures (broken nose) with associated hemosinus (blood in the sinuses). The findings include: Review of the facility's, Admission Agreement, dated 01/29/2020 and signed by Resident #4, revealed the resident acknowledged he/she was informed verbally, and in writing of his/her Resident's Rights. Review of the Resident's Rights, cited in the 1987 Nursing Home Reform Law, revealed each resident has the right to receive respect and dignity, and the right to be free from any physical abuse. Review of the facility's policy, Abuse Prevention Program, revised 02/22/2018, revealed the resident has the right to be free from abuse and protected from abuse. The facility's policy identified that the residents were protected from the facility's staff, consultants, and staff from other agencies providing services to the residents. Review of Resident #4's clinical record revealed the facility admitted the resident on 01/29/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Annual Minimum Data Set (MDS) assessment, completed on 12/28/2020, revealed the facility assessed the resident's cognitive pattern utilizing the Brief Interview for Mental Status (BIMS). Resident #4's score was nine (9), which indicated the resident was interviewable. Review of the Incident Note in the Progress Note Section, dated 03/09/2021 at 10:48 AM revealed Unit Manger (UM) #1 and the Director of Nursing (DON) entered Resident #4's room and saw blood coming from the resident's nose. Continued review revealed blood was all over the bed. Resident #4 was holding his/her nose. The resident started yelling that orderly hit me in my [OBSCENITY] ing nose. Review of the facility's Self-Reported Incident Form, dated 03/09/2021, revealed physical abuse occurred in Resident #4's room. The Respiratory Therapist (RT) heard the resident cussing when he entered the room to intervene with the behaviors of the resident. The resident struck the respiratory therapist while he (RT) was seated in the resident's wheelchair. The RT stated his instinctive reflex was to strike. Continued review revealed the RT stated he struck the resident in the face using the back of his opened right hand. The facility's report stated the RT immediately reported to the Licensed Nursing Home Administrator (LNHA), that he had struck the resident. Interview with the LNHA, on 03/09/2021 at 2:15 PM revealed Respiratory Therapist (RT) #1 approached him requesting to meet with him in his (administrator's) office. He stated the RT informed him of an incident with Resident #4. The LNHA stated the RT described swatting at the resident after the resident hit him. He stated the RT stated he blocked himself with an open-hand while making contact with the resident's face in a reflexive way. Continued interview revealed the RT stated Resident #4 was holding his/her face, when he left the resident's room. RT #1 further stated he went straight down to the administrator to self-report the occurrence. The LNHA stated he initiated the investigation and the Director of Nursing Services (DNS) initiated assessments for the resident. He stated Resident #4 was not on respiratory therapy services. Telephonic interview with State Registered Nurse Aide (SRNA) #6, on 03/17/2021 at 2:34 PM revealed he worked, on 03/09/2021, but was not assigned to Resident #4. He stated the DNS directed him to assist with Resident #4's change of clothing and linens, and wash him/her up. SRNA #6 stated Resident #4 had blood coming from both sides of his/her nose. He stated the resident's nose and eyes were discolored, purple, and swollen. SRNA #6 stated he provided the resident with towels, and changed part of the linens as the resident allowed. He stated the resident refused to allow him to change his/her clothing. Telephonic interview with SRNA #7, on 03/16/2021 at 3:11 PM revealed she worked, on 03/09/2021, and was assigned to Resident #4. She stated Resident #4 frequently cussed and called staff names. SRNA #7 stated normally she would delay his/her care until the resident was more receptive. She stated residents have behaviors, and you cannot let it bother you. The SRNA stated she told the nurse, or sometimes documented the behavior in the computer. Continued interview revealed she was assisting the nurse in a room and when they came out of the room, the Unit Manager told her and the nurse that Resident #4 had an injury to his/her nose. She stated Resident #4's nose was bleeding quite a bit and it bled from both sides. She stated she provided fresh towels and linens, and the resident would not let them clean him/her up very much. SRNA #7 stated Resident #4 did go out to the hospital later. During interview with Resident #4, on 03/09/2021 at 3:05 PM, he/she stated, That orderly hit me in the nose and that he/she wanted, That Son-of-A-[OBSCENITY] (SOB/him) out of here. Resident #4 stated that he/she did not touch that SOB. Observation of Resident #4, on 03/09/2021 at 3:05 PM, and at 3:45 PM revealed he/she was in the bed with the head of bed raised. The resident was wearing facility gloves and holding a white towel with a red substance on the towel. He/she was wiping a red substance (appearance of blood) from his/her nares (nasal openings). Resident #4 had an area on the upper left side of his/her shirt with a red, moist substance pooled on the shirt. The red substance was on two (2) additional towels lying in the bed, on the pillowcase, and the sheet on the resident's bed. Continued observation revealed Resident #4 had a bright red, moist appearing substance below his/her nose, and across his/her bilateral cheeks. In addition, there was a dark red, dried substance smeared across the resident's bilateral cheeks and on his/her forehead. Resident #4''s nose appeared swollen and discolored across the bridge of his/her nose. Continued observation revealed a dried red substance on his/her arms, clothing and face. Interview with Unit Manager (UM) #1 in her office, which was located across the corridor from Resident #4's room, on 03/09/2021 at 3:10 PM revealed she was in the copier room following the morning meeting when the incident occurred. She stated at approximately 11:00 AM, the Director of Nursing Services (DNS) stated Resident #4 needed an assessment for injuries. The UM stated she and the DNS went directly to assess the resident. Upon arrival to Resident #4's room, they noted the resident's nose was bleeding. She stated there was blood on his/her clothing, and linens. The UM stated Resident #4 stated, The orderly hit me in the nose. UM #1 stated the facility did not have an orderly. She stated the only other person was the Respiratory Therapist, who was new to the facility. The UM stated the RT had been working out of her office earlier, and being so close to Resident #4's room, made it easy to hear when Resident #4 cussed and hollered out at staff. She stated the resident's assigned nurse and SRNA were both in another resident's room. Interview with Licensed Practical Nurse (LPN) #1 in the corridor, on 03/09/2021 at 3:20 PM revealed she was Resident #4's assigned nurse. LPN #1 stated Resident #4 was on a blood thinner, [MEDICATION(S)]. She stated the resident had been bleeding from both nares since earlier in the shift (after the incident occurred). LPN #1 stated she and the assigned State Registered Nurse Aide (SRNA) #7 were providing care in a different resident's room further down the corridor when the incident occurred. LPN #1 stated the Unit Manager (UM) notified her of Resident #4's facial injuries. Continued interview revealed the Nurse Practitioner (NP) visited the resident and ordered an x-ray of the resident's face. She stated the only other male staff on the unit was the new Respiratory Therapist. Continued interview with LPN #1 revealed all residents should be free of any type of abuse and staff should never hit a resident. Record review revealed a Physician's Progress Note, dated 03/09/2021 at 6:54 PM (late entry),which was documented by Nurse Practitioner (NP) #1 following a medical evaluation with Resident #4. Further review of the Note revealed nursing requested an immediate evaluation of Resident #4 related to being punched in the nose. Further review revealed a traumatic injury to the nose occurred. The Note stated the resident laid on (his/her) back and refused to raise the head of the bed (HOB). NP #1 noted nasal [CONDITION(S)] and purplish discoloration to the face with bright red blood streaming from bilateral nares (opening to nose). The NP ordered a stat portable x-ray of the resident's face to rule out facial and orbital (facial bones around his/her eyes) fractures. In addition, ice packs to the nose and [MEDICATION(S)] (controlled pain medication) were ordered. Interview with Nurse Practitioner (NP) #1, on 03/16/2021 at 3:40 PM revealed a post injury assessment was completed, on 03/09/2021 after Resident #4 received an injury to his/her nose. She stated nursing requested an immediate evaluation of the resident. The NP stated she responded, as requested. NP #1 stated the resident was very upset upon her arrival, and rightfully so. She stated the resident's nose was swollen, and purple from bruising. He/she was bleeding from both sides of the nose. Continued interview revealed the resident said the orderly punched him/her in the nose. The NP stated the resident revealed the person hit him/her with his fist in the nose. NP #1 stated the injury's appearance was consistent with a closed fist impact to the nose. Upon examination of the resident's nose, she believed bone injury was involved. Therefore, she ordered mobile x-rays for an evaluation. Review of Resident # 4's emergency clinical record, dated 03/09/2021 revealed the facility transferred the resident to the emergency room for evaluation. Further review of the record revealed the following: Assault by the Respiratory Therapist (RT) during the morning at the long-term care facility (LTC) listed as the chief complaint. The emergency room doctor ordered a CT scan of (Resident #4's face). The CT scan revealed mildly displaced bilateral (both sides of nose) nasal bone fractures (broken) with associated hemosinus (blood in the sinuses). The acute care emergency department discharged the resident to the LTC facility. Telephonic interview with the Respiratory Therapist (RT), on 03/11/2021 at 9:12 AM revealed he worked, on 03/09/2021 at the facility. He stated this was his fifth (5th) shift. The RT stated he was in the office just up, and across the hall from Resident #4's room around 11:00 AM. He stated he was aware the housekeeper was cleaning in the area of Resident #4. RT stated he heard Resident #4 call the housekeeper derogatory names. He stated the resident was calling the Housekeeper a [OBSCENITY] , a cunt, and whore, and believed he heard the resident call the Housekeeper the N word, but just could not be sure of that. However, he stated he felt he needed to intervene. The RT stated he previously had a good rapport with the resident. He explained Resident #4 was not on respiratory therapy services. He stated he had been in the room before when the resident was cussing and calling the staff names. Continued interview revealed he knocked on the door, and asked for permission to enter. The resident agreed. He stated he was trying to converse with the resident, yet the resident continued to curse and yell. He stated he stepped back to the doorway and looked for staff, which he did not see. Therefore, he returned to the bedside to speak with the resident. As he sat in the resident's wheelchair, Resident #4 swung a closed fist and hit his left cheek. The RT stated he raised his arm with an opened-hand, blocking himself from the resident. He stated he might have made contact with the resident, as he was removing himself from the situation. He stated it was a reflex, and no intentional contact was made with the resident. Interview with Resident #4, on 03/18/2021 at 2:45 PM revealed his/her injury was caused by the orderly. He/she stated, The orderly hit me in the nose with his fist. The resident stated, The orderly does not need to be here. He should be locked up. Continued interview with Nurse Practitioner (NP) #1, on 03/16/2021 at 3:40 PM revealed the radiology reports from the emergency medical evaluation, on the evening of 03/09/2021, were consistent with a closed fist injury to the bridge of the nose. She further stated this type of injury was of a significant impact, or force to this area of the nose, and meant for the face. Interview with Director of Nursing Services (DNS), on 03/16/2021 at 1:02 PM, revealed the Licensed Nursing Home Administrator (LNHA), on 03/09/2021 made her aware Resident #4 had possibly been abused by a staff member. She stated the Unit Manager was in the copier room. She ask the UM to join her with the assessment. The DNS stated upon entering Resident #4's room, they saw the resident's nose was bleeding. She stated they initiated assessments, and requested the Nurse Practitioner (NP) to evaluate the resident. Continued interview revealed Resident #4 received first aide pending the NP's evaluation. The DNS directed SRNA #6 to assist Resident #4 with a change of linens and help wash him/her. She stated the resident told her the orderly hit him/her in the nose. The DNS stated they initiated skin assessments on all of the residents unable to verbalize concerns. Staff initiated interviews with the residents interview-able. Interviews and skin assessments revealed no other resident with injuries, or concerns for their safety in the facility. Interview with the Licensed Nursing Home Administrator (LNHA), on 03/19/2021 at 6:15 PM revealed he completed the alleged physical abuse investigation. The LNHA stated interviews, policy reviews, and record reviews were completed. The facility substantiated the allegation. Continued interview revealed the Respiratory Therapist (RT) should have sent a staff member in to address Resident #4's behaviors. He stated the RT was working on his fifth (5th) shift at the facility, and had no reason to be in Resident #4's room, as the resident wasn't on the caseload. He stated the encounter between the RT and Resident #4 never should have occurred. Further interview revealed Resident #4 did sustain an injury related to the Respiratory Therapist's direct contact with the resident. He stated it was the facility's responsibility to ensure the residents remain free from abuse.

Based on interview, record review and review of the facility's policy and program, it was determined the facility failed to implement their written Abuse Prevention Program, related to protecting residents from abuse and related to implementation of the abuse program. This affected one (1) of six (6) sampled residents (Residents #4). The facility contracted with respiratory services for a Respiratory Therapist (RT) onsite. The facility allowed the Respiratory Therapist (RT) to begin his services with residents at the facility without knowledge of his screening, or the criminal background status. In addition, the facility allowed the Respiratory Therapist to engage with the residents without completing the facility's mandated orientation packet for contracted employees, which included the facility's abuse and dementia training. On [DATE], an incident occurred with the RT and Resident #4, in which the RT hit Resident #4. Radiology reports revealed Resident #4 sustained mildly displaced bilateral (both sides of nose) nasal bone fractures (broken) with associated hemosinus (blood in the sinuses). The findings include: Review of the facility's policy Abuse Prevention Program, revised [DATE], revealed the resident has the right to be free from abuse and protected from abuse. The facility's policy committed the residents were protected from the facility staff, consultants, and staff from other agencies providing services to the residents. The facility conducts employee background checks per state and federal regulations. The facility will not knowingly employ or otherwise engage any individual convicted of abusing, neglecting, mistreating individuals, misappropriation or anyone with a disciplinary action in effect against a professional license by state or licensing body including the nurse abuse registry. The facility developed comprehensive policies and procedures to aid in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Topics included abuse prevention. The facility's abuse prevention and intervention education programs included training staff to understand and manage a resident's verbal or physical aggressions. The facility conducts background checks to avoid hiring persons found guilty by a court of law of abusing, neglecting, or mistreating individuals. Review of the facility's Agreement for Respiratory Care Consulting Services, Equipment, and Supplies, dated [DATE] revealed contracted services provided included a qualified respiratory care practitioner, equipment, and supplies to provide consulting, education, and staffing services. The scope of the agreement between the contracted company and the facility was to provide respiratory practitioners. The Respiratory Practitioner shall at all times during the term of this agreement, maintain all state and federal licenses, registrations, certifications, and memberships. Upon request of the facility, the company will provide the facility with current copies of all required professional licenses, registrations, certifications, and memberships of each practitioner. Practitioners shall abide by and be subject to all of the facility's policies, procedures, rules, and regulations while performing services for the facility. Interview with the Licensed Nursing Home Administrator (LNHA), on [DATE] at 2:15 PM revealed the morning meeting had ended around 11:00 AM when he was approached by the Respiratory Therapist (RT), who requested to meet with him in his (administrator's) office. He stated the RT revealed an incident had occurred with Resident #4. Further interview revealed the RT described the incident as swatting at the resident after the resident hit him. He stated the RT reported to him that he blocked himself with an open-hand while making contact with the resident's face as a reflex. The LNHA stated according to the RT, Resident #4 was holding his/her face, when he (RT) left the resident's room. He stated the RT informed him that he came straight down to self-report the conflict. The LNHA stated he initiated the investigation and the Director of Nursing Services (DNS) initiated assessments for the resident and interviews with the residents that could be interviewed. During the survey, the State Survey Agency (SSA) requested the facility's personnel file for the Respiratory Therapist (RT), on [DATE]. However, the facility did not have a personnel file located in the facility for the RT. Interview with the Licensed Nursing Home Administrator (LNHA), on [DATE] at 3:20 PM, revealed he did not have any personnel file onsite for the Respiratory Therapist. He stated he did not have the criminal record check, as the contracted company completed the required packet for new contracted staff in the facility. He stated the Respiratory Care Company did all the verifications before a contracted staff started services at the facility. He stated his office secured the contracted staff's personnel file and Human Resources Department (HR) secured the facility staff's personnel files. Further interview revealed a mandatory packet was given to new employees. The packet included abuse training, resident rights, a basic dementia review, and any additional information to get the staff started with the facility. The LHNA stated all agency, or contracted staff must complete the packet before going to the unit and working with the residents. He stated it was the Respiratory Therapist's fifth (5th) shift. However, continued interview with the LHNA revealed he had not requested any of the screening checks completed by the contracted company prior to the RT engaging with residents, and working the units. He stated they were in contract with the company, and trusted the checks had been completed. Further interview with the LHNA revealed he was unable to determine if the screenings met the requirements if he had not reviewed them. In addition, the facility failed to ensure the RT completed the mandated packet,which included abuse and dementia training. Review of Resident # 4's clinical record revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident's cognitive pattern utilizing the Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15) indicating the resident was severely impaired, and not interviewable. Continued review of the MDS assessment revealed the resident exhibited verbal behavioral symptoms directed towards others occurred one (1) to three (3) days. Review of Resident #4's Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident's cognitive pattern utilizing the Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating the resident was moderately impaired; however, interviewable. Continued review of the MDS assessment revealed the resident exhibited verbal behavioral symptoms directed towards others occurred one (1) to three (3) days during the look back. Review of the Incident Note/Progress Note Section, dated [DATE] at 10:48 AM, revealed Unit Manager (UM) #1 and the Director of Nursing (DON) entered Resident #4's room and saw blood coming out of the resident's nose. Blood was all over the bed. Resident #4 was holding his/her nose. The resident started yelling that orderly hit me in my [OBSCENITY] ing nose. Interview with Resident #4, on [DATE] at 3:05 PM, revealed the orderly hit him/her in the nose. He/she stated that orderly me in the nose, and bloodied my nose. The resident stated he/she wanted the Son-of-A-[OBSCENITY] (SOB/him) out of here. Resident #4 stated he/she did not touch that SOB. Observation with Resident #4, on [DATE] at 3:05 PM, and at 3:45 PM revealed he/she was in the bed with the head of bed raised. The resident had bright red, moist appearing substance below his/her nose, and across his/her face. He/she was wiping a red substance (appearance of blood) from his/her nares (nasal openings). The red substance was noted on two (2) additional towels lying in the bed, on the pillowcase, and on the sheet on the resident's bed. The resident was wearing facility gloves and holding a white towel with a red substance on the towel. Telephonic interview with Housekeeper (HKP) #3, on [DATE] at 3:25 PM, revealed she was familiar with Resident #4. She stated she had concerns when Resident #4 called her all kinds of names. She stated she told her manager the resident called her names two (2) weeks ago, such as F .N . She stated she went to wipe his/her bedside table off when Resident #4 said, don't touch my stuff you F-N-N. She stated she finished her duties in the room, and walked out. She stated she did not feel they should be talked to in such a disrespectful way. HKP #3 stated her manager did not do anything about the resident, or address the behaviors with any of the staff. She stated everyone, residents and staff should be safe. Interview with Director of Nursing Services (DNS), on [DATE] at 1:02 PM, revealed the Licensed Nursing Home Administrator (LNHA), on [DATE] notified her Resident #4 potentially sustained an injury by a staff member, and needed an assessment completed. She and the Unit Manager assessed the resident in his/her room. She stated the resident's nose was visibly bleeding. Continued interview revealed they provided first aid, and requested the Nurse Practitioner (NP) to evaluate the resident. She stated the resident told her the orderly hit him/her in the nose. She stated upon further evaluation and medical examination it was determined Resident #4 received a broken nose. Further interview with the DNS revealed they had policies in place to protect the residents. She stated the facility was to ensure all of the residents were protected from abuse. She stated there was a screening process to ensure each staff was never convicted of abuse, or similar crimes against elderly, or others. Continued interview revealed reference checks were completed before hiring and the abuse registry was checked to determine if the person had any record for abuse. The DNS stated newly hired staff completed orientation. She stated the agency staff and contracted staff completed a small packet of information before working with residents. The packet contains training related to abuse for protecting the resident, and to whom to report immediately, The DNS stated staff must protect the residents and should never hit a resident, and must be responsible. Interview with Licensed Nursing Home Administrator (LNHA), on [DATE] at 6:15 PM revealed he completed the alleged physical abuse investigation. He stated the root cause was related to the behaviors Resident #4 was exhibiting. The LHNA stated the Respiratory Therapist should not have been in the resident's room, as the resident was not on his caseload. He stated the RT was a contracted staff, and normally they ask for the screening information from the contracted company. He stated he was responsible for the contracted staff. The LNHA stated the contracted staff and agency staff must complete their abuse training, the same as the regular hired staff. He stated the RT was on his fifth (5th) shift, and he he had not had the screening records prior to engaging with residents. Continued interview revealed the contracted staff was to complete the abuse-training packet before engaging with the residents The LNHA stated it was the facility's responsibility to ensure the residents remain free from abuse. He stated Resident #4 did sustain an injury related to the Respiratory Therapist's direct contact with the resident. Further interview revealed the facility notified the police related to the incident.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to ensure two (2) of twenty-seven (27) sampled resident's care plans were implemented, Resident #8 and Resident #25. Resident #8 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place. Resident #8's care plan was revised to include the new placement of a catheter but there was no documented evidence to show that catheter care was provided between his readmission on [DATE] through [DATE]. In addition, the resident had a history of a Pulmonary Embolism (PE) and Atrial Fibrillation (A-Fib) and the facility failed to develop a plan of care for continued monitoring and assessment of the discontinued anticoagulant medication related to his/her history of A-Fib and PE. On [DATE], Resident #8 was admitted to the hospital with multiple diagnoses to include Sepsis related to a UTI, requiring intravenous antibiotic therapy. Resident #8 expired on [DATE]. (Refer to F684 and F690) Immediate Jeopardy was identified on [DATE] and determined to exist [DATE] and the facility was notified of Immediate Jeopardy related to Resident #8 on [DATE]. The facility provided an Allegation of Compliance (AoC)/Plan of Correction, alleging past non-compliance, however, after review and validation of the AoC, it was determined the Immediate Jeopardy had not been removed due to the facility's failure to order and obtain laboratory orders and monitor for hyper/hypoglycemia for a sampled resident, Resident #25. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses to include Type 2 Diabetes Mellitus. Resident #25's care plan was created to include interventions to monitor for signs and symptoms of hyper/hypoglycemia and complete labs as ordered. There was no documented evidence the facility monitored for these signs and symptoms and labs ordered were not obtained. Resident #25 was admitted to acute care on [DATE] with a critical high blood glucose level of 1,148 requiring an intravenous insulin drip. Resident #25 expired on [DATE]. (Refer to F684) The facility's failure to have a system in place to ensure residents were provided treatment and monitored per the plan of care has caused or is likely to cause serious injury, harm, impairment or death. The facility was notified on [DATE] of the ongoing Immediate Jeopardy. The findings include: Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised [DATE], revealed a comprehensive, person-centered care plan included measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs and was developed and implemented for each resident. Continued review revealed the facility derived the care plan interventions from a thorough analysis of the information gathered as part of the comprehensive assessment. Further policy review revealed each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementations of his/her plan of care including the right to receive the services and/or items included in the plan of care. The policy revealed the comprehensive, person-centered care plan described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and identified the professional services responsible for each element of care. 1. Review of the facility's policy Urinary Catheter Care, revised [DATE], revealed the purpose of this procedure prevented catheter-associated urinary tract infections. Continued review revealed staff observed the resident for complications such as checking the urine for unusual appearance (color, blood, etc.), and to observe for other signs and symptoms of urinary tract infection or urinary retention; and, report findings to the provider immediately. The facility initially admitted Resident #8 on [DATE] with diagnosis to include history of Transient Ischemic Attack (TIA), Left Hemiplegia, and Atrial Fibrillation (A-Fib). Other diagnoses included Hypertension (HTN), Cardiomyopathy, Chronic Kidney Disease (CKD), Dysphagia, Pulmonary Embolism (PE), and Obstructive Reflux Uropathy. Review of Resident #8's closed clinical record revealed the facility readmitted the resident with an indwelling urinary catheter on [DATE] after a brief stay at an acute care facility. Review of the Minimum Data Set (MDS), dated [DATE] and [DATE], revealed Resident #8 was assessed to have an indwelling catheter. Review of Resident #8's care plan revealed the facility revised the care plan [DATE] to include the risk for infection and complications related to an indwelling urinary catheter. The listed interventions included assess quarterly and as needed for appropriateness of continued use of catheter, catheter/peri-care at least every shift and as needed, document and notify provider of abnormal findings, document catheter output every shift, encourage fluids, keep drainage bag below the level of the bladder, and observe for symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of the Physician orders, revealed after Resident #8's re-admittance to the facility on [DATE], there were no orders entered regarding care and monitoring of his/her indwelling catheter. Review of Resident #8's Medication/Treatment Administration Record (MAR/TAR), dated May, June, July, August, and September of 2020, revealed no documented evidence of care and monitoring for Resident #8 while his/her catheter was in place until being transferred to acute care on [DATE]. Review of the Progress notes, dated [DATE] through [DATE], revealed no continued monitoring or assessment of Resident #8's indwelling catheter. Review of the Nurse Practitioner (NP) note, dated [DATE], revealed tea colored urine present in Resident #8's indwelling catheter. Continued review revealed the NP ordered a Urinalysis Culture and Sensitivity (UA), Complete Blood Count (CBC), and a Basic Metabolic Profile (BMP) for evaluation of a Urinary Tract Infection (UTI). Further record review Resident #8 was transferred to acute care and was admitted with diagnoses to include Sepsis related to UTI and Pneumonia requiring intravenous antibiotic therapy. Resident #8 expired on [DATE]. Interview with MDS Coordinator #1, dated [DATE] at 1:32 PM, revealed MDS updated the care plan as needed, mainly during morning meeting. She revealed she would update the care plan for indwelling catheters including interventions, but would not enter orders into the computer regarding the catheter. She stated the Unit Managers (UMs) were responsible for entering identified missing orders into the system. Multiple unsuccessful attempts were made to interview Certified Nurse Aides (CNAs) who cared for Resident #8: CNA #18 on [DATE] at 11:05 AM and 1:04 PM; CNA #19 on [DATE] at 11:23 AM and 1:12 PM; and, CNA #12 on [DATE] at 11:32 AM and 1:20 PM. Messages left were not returned. Interview with CNA #16, on [DATE] at 11:30 AM, revealed information regarding a resident with an indwelling catheter was not normally passed on in the end of shift report. Continued interview revealed catheter care was documented in the CNA kiosk under personal hygiene; however, no specific care was completed. Interview with UM #3, on [DATE] at 5:15 PM, revealed the UM should have identified that monitoring, assessing and care orders for the indwelling catheter were not entered into the computer during morning meeting when all readmissions, notes, and orders were reviewed every day. She revealed orders would have been needed to change the catheter and perform catheter care. Interview with the Medical Director, on [DATE] at 3:33 PM, revealed he expected staff to follow the care plan for a resident with an indwelling catheter. He revealed he expected staff to perform catheter and peri-care for residents and work to discontinue the catheter as soon as possible when applicable. The Medical Director revealed it was important to ensure indwelling catheter care was completed for the safety of the resident. Further review of Resident #8's closed clinical record revealed the resident had a history of Atrial Fibrillation (A-Fib) and Pulmonary Embolism (PE). Review of the Physicians Orders, dated [DATE], Resident #8 was started on an anticoagulant (blood thinner), Eliquis five (5) milligram (mg) due to his/her diagnosis of PE. Continued review of the Physician's Orders revealed Eliquis was discontinued [DATE] due to the resident having hematuria (blood in the urine) present when readmitted into the facility. However, review of the resident's plan of care revealed no care plan was developed for continued monitoring and assessment of the discontinued anticoagulant medication related to his/her history of A-Fib and PE. Record review revealed the resident had complaints of chest pain and congestion on [DATE]; however, there was no documented evidence of monitoring the resident. Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 9:16 AM, when the resident complained of chest pain/respiratory issues he charted once on the COVID assessment but did not chart any additional assessments or monitoring of Resident #8 on [DATE]. Review of the progress note by LPN #8 on [DATE], revealed Resident #8 complained of chest pain and his/her chest hurting for 2 days, and Resident #8 expressed wishes to be sent to the hospital. LPN #8 notified the provider, a new order was received to give Resident #8 oral Nitroglycerin. Per the progress note, the medication was given and she notified the responsible party of the transfer. Review of the hospital records for Resident #8 revealed he was admitted to the Emergency Department on [DATE] with multiple diagnoses to include Large PE and DVT in Right Femoral. The resident expired on [DATE]. Interview with Interim Director of Health Services (IDHS), on [DATE] at 8:56 AM, revealed she would expect staff to monitor the resident due to his/her history of PE and A-Fib. Interview with the Medical Director (MD) on [DATE] at 3:33 PM, revealed for a resident with a history of PE who had their anticoagulant medication discontinued, the staff would need to monitor for changes in their respiratory rate, and watch for complaints of chest pain. Interview with the Executive Director (ED), on [DATE] at 10:09 AM, revealed he would expect staff to monitor residents for respiratory distress if they had a respiratory diagnosis. 2. Review of the facility's policy Nursing Care of the Resident with Diabetes Mellitus, revised ,d+[DATE], revealed the purpose of these guidelines was to review the most common and serious conditions and complications associated with diabetes, to prevent recurrent hyper/hypoglycemia, recognize, manage, and document the treatment of complications. Continued review revealed Diabetic Ketoacidosis (DKA) or Hyperosmolar (Non-Ketotic) Coma included the following symptoms: (this is a life threatening emergency that needs immediate medical attention) a. high blood sugar, b. ketones in urine, c. nausea/vomiting, d. lethargy, e. weakness, f. short, labored, rapid respirations, g. abdominal pain, h. dehydration, i. diminished urine, j. sweet or fruity smelling breath, k. dry/flushed skin, l. decreased awareness/senses, m. loss of consciousness and/or n. coma. Continued review revealed signs and symptoms of hyperglycemia may include increased thirst, dry mouth, headache, lethargy, restlessness, and anorexia. Review of the policy revealed if these or other abnormal conditions existed to notify the provider. Further review revealed kidney disease, foot complications such as dry skin, and gastroparesis may be associated with prolonged poorly controlled diabetes. The facility admitted Resident #25 on [DATE] with diagnoses to include Esophageal Obstruction, Severe Protein-Calorie Malnutrition, Adult Failure to Thrive, and Type 2 Diabetes Mellitus. Review of Resident #25's MDS, dated [DATE], revealed the facility assessed the resident with Diabetes Mellitus and a Brief Interview of Mental Status (BIMS) exam score of ,d+[DATE] and determined the resident was interviewable. Review of Resident #25's care plan, dated [DATE], revealed the facility care planned the resident as at risk for complications and symptoms of hyper/hypoglycemia. Interventions listed included diet as ordered, document and notify the provider of abnormal findings, labs as ordered, observe for signs and symptoms of hyperglycemia such as: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath, stupor and coma, observe for signs and symptoms of hypoglycemia such as: sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination and staggering gait. Review of the Physician's Orders, dated [DATE] through [DATE], revealed no orders pertaining to the monitoring for signs and symptoms of hyper/hypoglycemia for Resident #25 and review of the MAR/TAR revealed no documented evidence of hypo/hyperglycemia monitoring was being performed. Review of Resident #25's Kardex, used primarily by the CNAs as a tool to help identify how to care for residents, revealed under the Monitor section, it was noted the resident was diabetic with no further instruction. Review of the Progress Notes, dated [DATE] through [DATE], revealed no documentation of continued monitoring for signs and symptoms of hyper/hypoglycemia. Interview with LPN #6, on [DATE] at 4:15 PM, revealed signs of hyperglycemia included thirst, hunger, irritability, and high sugars; and signs for hypoglycemia would include lethargy, altered mental status, and decreased responsiveness. He revealed both complications required further assessment such as checking the resident's blood glucose level, provider notification and completion of a Change in Condition Assessment. Interview with UM #1, on [DATE] at 9:45 AM, revealed signs of hyperglycemia included increased thirst, and increased sugar. Continued interview revealed signs of hypoglycemia included cold, clammy, increased confusion, more assistance with ADLS. She continued that if the resident was hypoglycemic she would give glucagon, orange juice is able to swallow and notify the provider. Further interview revealed if the resident presented with signs of hyperglycemia, she would recheck the resident blood glucose and would notify the provider before administering any insulin. Continued review of the resident's closed record revealed orders were not obtained per the plan of care. Review of the NP Visit Note, dated [DATE], revealed the NP noted Resident #25 to have a diagnosis of Type 2 DM and for the plan of care to include labs of CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipids in the morning ([DATE]), CBC and BMP (Basic Metabolic Panel) every week for four (4) weeks then every other week. Interview with UM #1, on [DATE] at 9:47 AM, revealed her signature was on the order form for the labs ordered on [DATE], which indicated she had entered the orders. She attempted to locate the orders in the system but was unable to find them; therefore, stating she must have not entered them and the labs were not obtained per the resident's plan of care. Record review revealed the resident was sent out to the hospital and readmitted on [DATE] with a note from the NP, dated [DATE], to continue routine labs as ordered; she was referring to the initial labs she ordered on [DATE]. However, record review revealed the labs were not ordered and therefore not completed, per the plan of care. Continued review revealed on [DATE] Resident #25 experienced a decline in mental status. A NP progress note, dated [DATE] revealed Resident #25 was weaker, not wanting to get out of bed, participate in therapy or even sit up and Resident #25 reported he/she just felt bad and didn't want to get out of bed. Further review of the NP progress note revealed she ordered labs including a CBC, a BMP, which Resident #25 refused for two (2) attempts but complied with the third attempt. The facility was notified of a critical high blood glucose level of 1,148 on [DATE]. Continued review of the progress notes revealed on [DATE] Resident #25 was admitted to acute care with the diagnosis of Non-Ketotic Coma. Interview with LPN #6 on [DATE] at 8:13 AM, revealed a care plan was an organized plan of care for the specific resident needs, and is tailored to that resident. Floor nurses completed the initial care plan on admission. He revealed the care plans were updated with the changes of care needed for the resident and that the IDT reviewed them and made the updates. LPN #6 revealed the floor nurses make updates to the care plan as well as MDS and the care plans were accessible in the system to all nurses. LPN #6 continued to say it was important to follow the care pan so the residents received the proper care they need and if the care plan is not followed it could lead to poor or erroneous care. Interview with the Interim Director of Health Services (IDHS), on [DATE] at 8:56 AM, revealed a care plan was like a road map to a resident's care. She continued and stated it was a collection of the resident's problems, goals, and interventions to reach those goals. The IDHS revealed if staff identified an issue with a resident, they would discuss it in morning clinical meeting. Further interview revealed all nursing staff have access to the care plans at all times. Interview with the Medical Director, on [DATE] at 3:59 PM, revealed he expected the care for a resident with DM to include continued monitoring of signs and symptoms of hypo/hyperglycemia such as any changes in mental status and notification of any changes. Interview with the Executive Director (ED), on [DATE] at 10:09 AM, revealed the care plan is developed for the individual resident to instruct the staff how to provide care to the residents. Further interview revealed he would expect staff to follow the care plan and update the interventions as needed based on the resident needs. He revealed if the care plan was not followed, the resident's goals would possibly not be met.

Based on interview, record review and review of the facility policies, it was determined that the facility failed to have an effective system to ensure two (2) of twenty-seven (27) sampled residents received quality of care and treatment, Resident #8 and Resident #25. Resident #8 had a history of blood clots and was receiving an anticoagulant medication. The facility failed to ensure staff monitored the resident after the anticoagulant medication was discontinued, on [DATE]. Resident #8 was sent to an acute care facility, on [DATE], with multiple diagnoses which included Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT). Resident #8 expired at the hospital, on [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist [DATE] and the facility was notified of Immediate Jeopardy related to Resident #8 on [DATE]. The facility provided an Allegation of Compliance (AoC)/Plan of Correction, alleging past non-compliance, however, after review and validation of the AoC, it was determined the Immediate Jeopardy had not been removed due to the facility's failure to order and obtain laboratory orders on a sampled resident, Resident #25. Resident #25 had multiple diagnoses, which included Esophageal Obstruction, Severe Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus (DM), Gastroparesis and Adult Failure to Thrive. The resident was admitted to the facility on [DATE] and the provider ordered labs on [DATE] to obtain a baseline for the resident. The nurse signed off on the orders on the original order sheet but failed to enter the lab orders correctly into the computer. Resident #25 was admitted to the hospital on [DATE] and returned to the facility on [DATE] with diagnoses to include Acute Renal Failure, Malnutrition from Peptic Stricture, Hypernatremia, Chronic back and shoulder pain with a note from the provider on [DATE] to continue labs as ordered. However, there was no documented evidence the labs were collected. Resident #25 was admitted to the hospital on [DATE] with critical high labs, which included blood glucose of 1,148 and was started on an insulin drip. Other critical labs included BUN 230 (,d+[DATE] normal), Cr 11.8 (0XXX,d+[DATE].27 normal), and Potassium of 6.7 (3XXX,d+[DATE] normal), Carbon Dioxide (CO2) of 47.4 (,d+[DATE] normal), Alanine Aminotransferase (ALT) of 88 (,d+[DATE] normal) and Aspartate Aminotransferase (AST) of 68 (,d+[DATE] normal) - ALT and AST measure the liver function. Resident #25 expired at the hospital on [DATE]. The facility's failure to have an effective system in place to ensure the residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, or death. The facility was notified on [DATE] of the ongoing Immediate Jeopardy. The findings include: 1. When asked for a facility policy regarding indication/monitoring of residents on an anticoagulant medication, the facility provided the Coumadin Monitoring Policy and Tracking Log. Resident #8 was prescribed Eliquis. Review of the Resident #8's closed clinical record revealed the facility originally admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses to include a history of Transient Ischemic Attack (TIA), Atrial Fibrillation (A-Fib), Hypertension (HTN), Cardiomyopathy, Chronic Kidney Disease (CKD), and Pulmonary Embolism (PE). Continued review revealed Resident #8 was readmitted to the facility after an acute care stay on [DATE]. Review of the Physicians Orders, dated [DATE], Resident #8 was started on an anticoagulant (blood thinner), Eliquis five (5) milligram (mg) due to his/her diagnosis of PE. Continued review of the Physician's Orders revealed Eliquis was discontinued [DATE] due to the resident having hematuria (blood in the urine) present when readmitted into the facility. Review of Resident #8's care plan, dated [DATE] and [DATE], revealed he/she was not care planned for continued monitoring and assessment of the discontinued anticoagulant medication related to his/her history of A-Fib and PE. Interview with MDS Coordinator #1, on [DATE] at 1:32 PM, revealed their job function was to complete the MDS, set the Assessment Reference Date, and updating the care plan. She revealed when a resident was admitted she reviewed the documents to find what the resident needs to be care planned for, she completed the admission assessment, and updated the care plan with anything new that was for the clinical side of care. MDS Coordinator #1 revealed they played a part in the morning clinical meeting, including reviewing any new orders, any possible falls, any medication changes, or anything new that was happening with the residents. Review of the progress notes revealed on [DATE] Licensed Practical Nurse (LPN) #6 received an order from the NP for a Chest X-Ray for cough and congestion. The x-ray was obtained and the results showed the heart was modestly enlarged and atelectasis in left upper lung (indicative of pneumonia). Interview with LPN #6 on [DATE] at 3:15 PM, revealed if a resident experienced a change in condition he would assess the resident and call the provider if further evaluation or treatment was needed. Continued interview revealed the CNA may have alerted him about Resident #8 complaining of chest pain, but when he assessed him/her, he identified the issues to be more respiratory in nature. He notified the provider and she ordered Chest X-Ray on [DATE]. Further interview with LPN #6 on [DATE] at 9:16 AM, revealed the nurses on the floor completed COVID assessments twice daily which included vital signs, temperature, any shortness of breath, cough, fever, chills, weakness, aches, loss of smell/taste, nausea/vomiting/diarrhea, and decreased appetite. He revealed when Resident #8 complained of chest pain/respiratory issues he charted once on the COVID assessment but did not chart any additional assessments or monitoring of Resident #8 on [DATE]. Review of the SBAR Communication Form (change of condition), dated and signed [DATE] at 11:45 AM, revealed LPN #8 assessed Resident #8 to have no shortness of breath and he/she had chest pain for two (2) days with no relief. Review of the progress note by LPN #8 on [DATE], revealed Resident #8 complained of chest pain and his/her chest hurting for 2 days, and Resident #8 expressed wishes to be sent to the hospital. LPN #8 notified the provider, a new order was received to give Resident #8 oral Nitroglycerin. Per the progress note, the medication was given and she notified the responsible party of the transfer. Interview with LPN #8, [DATE] at 1:38 PM, revealed she was the nurse assigned to care for Resident #8 on [DATE]. She revealed that Resident #8 had complained of chest pain to the CNA, who in turn notified her. Continued interview revealed the day prior on [DATE] she remembered the CNA notifying LPN #6 that Resident #8 had some concerns. She revealed when the CNA notified her of the chest pain on [DATE], she ran to Resident #8's room and assessed him/her , notified the provider, received an order for Nitroglycerin and transferred the resident to acute care. Review of the hospital records for Resident #8 revealed he was admitted to the Emergency Department on [DATE] with multiple diagnoses to include Large PE, DVT in Right Femoral, and a Superficial Vein Thrombosis (SVT) in the left lower extremity, Elevated Troponin, and Sepsis from Pneumonia and UTI. Continued review of the records revealed the hospital reached out to the facility and learned Resident #8 was not on any anticoagulants. Further review revealed an Echocardiogram was completed that showed a large mobile clot in transit originating in the right atrium. Resident #8 had a Central Venous Catheter placed for intravenous antibiotic therapy and he/she required Heparin therapy (anticoagulant). On [DATE] resident #8 had a mechanical thrombectomy (removal of a blood clot) and suffered Pulseless Electrical Activity (PEA) post-procedure subsequently expiring the same day. Interview with Interim Director of Health Services (IDHS), on [DATE] at 8:56 AM, revealed she would expect staff to have advocated for Resident #8 in terms of monitoring and questioning the provider on whether or not the facility should restart his/her anticoagulant due to his/her history of PE and A-Fib. Interview with the NP on [DATE] at 10:19 AM, revealed she performs rounds on the residents with acute issues every day except for Thursdays. The NP revealed she was aware Resident #8 had a history of PE and A-Fib and she recalled that he was on an anticoagulant but it was discontinued due to hematuria. She continued that the restart of any anticoagulant would have needed to be evaluated and no labs would have been needed to monitor the discontinued use of his/her Eliquis. She further stated she would have not been the provider to follow-up on his/her anticoagulant medication. Interview with the Medical Director (MD) on [DATE] at 3:33 PM, revealed he completed the regulatory visits over a course of two (2) months, and would see residents when acute issues arose. He revealed for a resident with a history of PE who had their anticoagulant medication discontinued, the staff would need to monitor for changes in their respiratory rate, and watch for complaints of chest pain. Continued interview revealed he was unaware that Resident #8's anticoagulant was discontinued and he should have been notified of the discontinuation by the NP due to Resident #8's history of PE and A-Fib. Interview with the Executive Director (ED), on [DATE] at 10:09 AM, revealed he was aware the residents on anticoagulants needed to be monitored and that monitoring would be based on the provider's orders. He revealed he would expect staff to monitor residents for respiratory distress if they had a respiratory diagnosis and to notify the provider if any concerns arose. 2. Review of the facility's policy, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], revealed that the physician would identify and order the diagnostic and lab testing based on the resident's diagnostic and monitoring needs, staff would process test requisitions and arrange for tests, and the laboratory would report test results to the facility. Review of Resident #25's closed record revealed he/she was admitted to the facility on [DATE] with diagnoses to include Esophageal Obstruction, Severe Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus (DM), Gastroparesis and Adult Failure to Thrive. Resident #25 was admitted with a Nothing by Mouth (NPO) order and had placed prior to admission a Gastronomy Tube (G-Tube) for decompression and a Jejunostomy Tube (J-Tube) used for continuous tube feeding. Review of the Discharge Summary from acute care sent to the facility for Resident #25 for admission on [DATE] and readmission on [DATE] revealed no indication of blood glucose monitoring or treatment. Review of Resident #25's MDS, dated [DATE], revealed Resident #25 was assessed to have DM. Review of Resident #25's care plan, revised on [DATE], revealed he/she was care planned for DM with interventions to include blood sugars as ordered, medications as ordered, diet as ordered, dietician to assess as needed, to document and notify the provider of abnormal findings, document snack/meal intake, labs as ordered, and to monitor for signs and symptoms of hypo/hyperglycemia. Review of the Physician's Orders, dated [DATE] through [DATE], revealed no orders pertaining to the monitoring for signs and symptoms of hyper/hypoglycemia for Resident #25. Review of the Physician's Admission Assessment, dated [DATE] revealed no indication of DM treatment or monitoring for Resident #25. Review of the Admission Nursing Assessment V2, completed on [DATE], revealed Resident #25 was alert and oriented, was able to make his needs known, was independent for ambulation and transfers, was continent of bowel and bladder, and no obvious issues related to respiratory status. Review of the NP Visit Note, dated [DATE], revealed the NP noted Resident #25 to have a diagnosis of Type 2 DM and for the plan of care to include labs of CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipids in the morning ([DATE]), CBC and BMP (Basic Metabolic Panel) every week for four (4) weeks then every other week. Review of the 3-Part Order Form, dated [DATE], revealed the Unit Manager (UM) #1 signed off on the lab orders indicating they were entered into the system, per policy. However, the facility failed to produce lab results related to the above ordered labs. Interview with UM #1, on [DATE] at 9:47 AM, revealed at the time of Resident #25's admission on 12//,d+[DATE] the NP wrote new orders and left them at the nurse's station for the floor nurse or the unit manager to enter and sign off on them. She revealed if there was a signature present on the 3-Part Order form it would be understood that nurse who signed the form put the orders into the computer. She verified it was her signature on the order form for the labs ordered on [DATE], which indicated she had entered the orders. She attempted to locate the orders in the system but was unable to find them; therefore stating she must have not entered them. Interview with the NP, on [DATE] at 01:30 PM, revealed she was aware Resident #25 was not on any diabetic medication and his/her glucose was not being monitored per the hospital paperwork. She continued that with Resident #25 being malnourished and diabetic, she would have based further diabetic treatment on his/her admission labs she ordered on [DATE]. She revealed she didn't get the lab results because the nurses failed to enter the labs in to the system. The facility was able to provide documentation showing only the CBC and Lipid labs entered into the lab system on [DATE] but failed to provide any documentation regarding results of those labs. Interview with the Regional Operations Manager from the lab services provider, on [DATE] at 3:00 PM, revealed he was unable to find any lab orders entered for Resident #25 from dates [DATE] through [DATE]. He continued that if there was an active order for a lab draw that was not yet collected, it would show as Outstanding. He revealed the process for entering labs was to obtain the order from the provider, enter it into the lab system, print off the requisition form, place it into the binder located at the nurse's station, and the phlebotomist would come in the next morning to draw the labs based on the form in the binder. Therefore, if the form wasn't in the binder, the lab would not be collected. He continued that at times the phlebotomist would have to print off the requisition form due to the facilities failing to do so. Based on the provided documentation from the facility, the Regional Operations Manager was able to run an audit based on the form's Standing Order Number. Continued interview revealed from the audit he could verify on [DATE] at 7:03 PM an order was placed for a CBC and Lipids by UM #1 and the requisition form was printed. However, there was no evidence the other labs were entered. Further interview revealed the Lab Technician Log that was kept by the lab services provider showed on [DATE] the phlebotomist did not go to the facility due to lab services not being needed. The Regional Operations Managers revealed the requisition form was not received, therefore never activated on the clinical side of the services, and that is why before he ran the audit he was unable to pull up any orders for Resident #25 for the dates provided. Continued Record Review revealed Resident #25 was sent to acute care on [DATE] for general weakness and noted frothy sputum from his/her nose and mouth and returned to the facility on [DATE] with diagnoses to include Acute Renal Failure, Malnutrition from Peptic Stricture, Hypernatremia, and Chronic back and shoulder pain. Review of the NP Visit note, dated [DATE], revealed her continued plan of care was to continue tube feeds and water flushes as ordered, continue NPO status, and routine labs as ordered. However, review of Resident #25's active orders while admitted to the facility revealed no labs were entered into the system on [DATE] and therefore not obtained. Interview with Medical Records, on [DATE] at 01:30 PM, revealed when there was a new admission he reviewed any paperwork that was sent over from the hospital and competed an IDT review to go over in morning clinical meeting. He revealed he did not recall seeing any treatment or monitoring documentation on the hospital paperwork regarding Resident #25. Continued interview with the NP, on [DATE] at 9:16 AM, revealed that in the past the facility sometimes entered new orders and sometimes did not. She revealed she was not aware that the facility failed to obtain the ordered labs for Resident #25. Continued interview revealed when Resident #25 was readmitted to the facility on [DATE], his previous orders from his/her initial admission were still in the computer. Per interview, that was why she noted on her plan of care for the resident, dated [DATE], to continue routine labs as ordered; she was referring to the initial labs she ordered on [DATE]. Interview with the Medical Director, on [DATE] at 9:37 AM, revealed he was aware that Resident #25 was admitted with the diagnosis of Type 2 DM and revealed the discharge paperwork from the hospital had no indication he was being monitored or what their treatment was regarding his/her DM. He revealed that after the admission labs and assessments were completed, the providers would evaluate proper orders and treatment for Resident #25's DM. Interview with the ED, on [DATE] at 2:08 PM, revealed when providers wrote orders on the 3-Part Order form they were given to the nurses to enter into the system and a copy was given to Medical Records, who would bring them to the morning clinical meeting where all new orders were reviewed. He revealed if labs were ordered on [DATE], they should have been entered into the computer. Continued interview revealed he could not recall if the missed labs were identified in morning meeting and he was not sure how they were missed. Further review of the Resident #25's MAR/TAR, dated ,d+[DATE] through ,d+[DATE], revealed no documented evidence hypo/hyperglycemia monitoring was being performed per the plan of care. Review of the Progress Notes, dated [DATE] through [DATE], revealed no documentation of continued monitoring for signs and symptoms of hyper/hypoglycemia. Continued review revealed on [DATE] Resident #25 experienced a decline in mental status. A NP progress note, dated [DATE] revealed Resident #25 was weaker, not wanting to get out of bed, participate in therapy or even sit up and Resident #25 reported he/she just felt bad and didn't want to get out of bed. Interview with CNA #15, on [DATE] at 8:59 AM, revealed he provided care for Resident #25 often. He revealed Resident #25 was independent with most activities when first admitted to the facility. Further interview revealed days before being sent out on [DATE], Resident #25 started to decline. CNA #15 revealed Resident #25 became incontinent and would smear things on himself. He revealed incidents such as those happened on night shift and he received the information in shift report. Interview with CNA #14, on [DATE] at 7:36 PM, revealed she provided care for Resident #25 often. Per the staffing schedule CNA #14 worked on the unit where the resident resided for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. She revealed when Resident #25 was first admitted he/she would request ice and would need assistance rolling in bed or standing up but was independent when ambulating. She revealed toward the end of his/her stay Resident #25 began to decline. She described his/her decline as the resident did not want to get out of bed, he/she became incontinent and would often take off their brief and leave it on the floor. She continued stating Resident #25 would stay in the bed completely covered up, and she noticed his breathing declined, although she was unable to describe it any further, and they he/she was less responsive. Continued interview revealed she would enter Resident #25's room at times and he/she would be laying at the opposite end of the bed, just very out of his normal self. Further interview revealed she reported these findings to the nurse and most of the time the nurses checked on the resident. She revealed the nurse would mostly ask about pain medication and administer it when appropriate. Interview with LPN #6, on [DATE] at 4:15 PM, revealed signs of hyperglycemia included thirst, hunger, irritability, and high sugars; and signs for hypoglycemia would include lethargy, altered mental status, and decreased responsiveness. He revealed both complications required further assessment such as checking the resident's blood glucose level, provider notification and completion of a Change in Condition Assessment. However, there was no documented evidence further assessment was completed. Further review of the progress notes revealed the NP was notified on [DATE] of a mental decline. A Change in Condition was completed, and new orders were received for a STAT CBC, and BMP. The labs were unable to be collected for two (2) attempts due to documented resident refusal. Resident #25 was compliant with the third attempt of obtaining the labs on [DATE]. Review of the lab results, dated [DATE], revealed Resident #25 had a critical high blood glucose of 1,148 mg/dL (,d+[DATE] normal), BUN 230 mg/dL (,d+[DATE] normal), Cr 11.8 mg/dL (0XXX,d+[DATE].27 normal), and Potassium of 6.7 mmol/L (3XXX,d+[DATE] normal). Resident #25 was transferred to acute care. Review of the progress notes, dated [DATE], revealed Resident #25 was admitted to acute care with a diagnosis of Non-Ketotic Coma. Review of Resident's #25 hospital documentation after admission on [DATE], revealed while in the Emergency Department, the Physician assessed him to be severely demented, and bedridden at baseline. Continued review revealed Resident #25 was started on an intravenous insulin drip, had a BiPAP applied and required 7 Liters of fluid due to severe dehydration. Continued review revealed on [DATE] an emergent exploratory laparotomy was performed and showed a small bowel perforation causing sepsis. Resident #25 was admitted to the Intensive Care Unit (ICU) and expired on [DATE].

Based on facility policy review, record review, observation, and interview it was determined the facility failed to have an effective system to ensure one (1) of twenty-seven (27) residents received care and services for an indwelling urinary catheter, Resident #8. Resident #8 returned to the facility after an acute care stay on [DATE] with an indwelling catheter in place. However, from [DATE] to [DATE] there was no documented evidence the facility performed care and services for Resident #8's indwelling catheter or obtained laboratory tests as ordered by the physician. Resident #8 was admitted to acute care, on [DATE], with multiple diagnoses, which included a Urinary Tract Infection (UTI) and Sepsis, requiring intravenous antibiotic therapy. Resident #8 expired at the hospital on [DATE]. The facility's failure to have an effective system in place to ensure the residents received quality of care, treatment, and services for an indwelling urinary catheter has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist [DATE] and the facility was notified of Immediate Jeopardy related to Resident #8 on [DATE]. The facility provided an Allegation of Compliance (AoC)/Plan of Correction, alleging past non-compliance, however, after review and validation of the AoC, it was determined the Immediate Jeopardy had not been removed due to the facility's failure to order and obtain laboratory orders on a sampled resident, Resident #25 (Refer to F684). The facility was notified on [DATE] of the ongoing Immediate Jeopardy. The findings include: Review of the facility's policy Urinary Catheter Care, revised [DATE], revealed the purpose of this procedure was to prevent catheter-associated urinary tract infections. Continued review revealed to observe the resident for complications such as, check the urine for unusual appearance (color, blood, etc.), to observe for other signs and symptoms of urinary tract infection or urinary retention, and to report findings to the provider immediately. Further review of the policy revealed information that should be documented included date/time care was given, staff member performing the care, note the color/clarity/odor of urine, any problems at the catheter-urethral junction, any complaints while care was being performed, how the resident tolerated the care, or if they refused care along with signature and date. Review of the facility's policy, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], revealed that the physician will identify and order the diagnostic and lab testing based on the resident's diagnostic and monitoring needs, staff will process test requisitions and arrange for tests, and the laboratory will report test results to the facility. Review of Resident #8's closed record revealed he/she was admitted to the facility on [DATE] with multiple diagnoses to include Chronic Kidney Disease (CKD), and Obstructive/Reflux Uropathy. Continued review revealed he/she was readmitted to the facility on [DATE] after an acute care stay with an indwelling urinary catheter in place. Review of the Minimum Data Set (MDS), dated [DATE] and [DATE], revealed Resident #8 was assessed to have an indwelling urinary catheter. Review of Resident #8's care plan revealed it was revised on [DATE] to include the insertion of a indwelling catheter with interventions to assess quarterly and as needed for appropriateness of continued use of a catheter, catheter/perineum care at least every shift and as needed, document and notify the physician of abnormal findings, document catheter input every shift, encourage fluids, keep tubing and drainage bag below the level of the bladder, and to observe for symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior or change in eating habits. Review of Resident #8's Physician Orders, dated [DATE] - [DATE], revealed one (1) order was entered on [DATE] for Resident #8's indwelling catheter: irrigate with thirty milliliters (30mL) every shift. Continued review revealed no further orders for continued care and monitoring for Resident #8's catheter were entered when he/she was readmitted into the facility on [DATE]. Review of the Medication/Treatment Administration Record (MAR/TAR), dated June-July-August-[DATE], revealed there was no documented evidence of care and monitoring for Resident #8's indwelling catheter. Review of the progress notes, dated [DATE] through [DATE], revealed no documented evidence of care or monitoring of Resident #8's indwelling catheter. Interview with MDS Coordinator #2, on [DATE] at 12:29 PM, revealed the indwelling catheter assessments that were completed on admission and quarterly should be completed by the nurse on the floor or the unit manager. She continued that the indwelling catheter was addressed on the admission assessment and the diagnosis along with the care instructions for the catheter would be attached. Interview and record review with Licensed Practical Nurse (LPN) #6, on [DATE] at 3:15 PM, revealed he reviewed Resident #8's chart for catheter orders, he only saw an active order to irrigate the catheter. Continued interview revealed he would expect to see orders for care and monitoring of the catheter for Resident #8. He revealed although he was not the admitting nurse, if he had identified orders were not in the computer, he would have notified the MD to obtain orders specific to catheter care and monitoring. Further interview with LPN #6, on [DATE] at 3:30 PM revealed catheter care should be completed every shift and the catheter should be changed out every month. Continued interview revealed he would monitor the resident for signs and symptoms of infection, to include fever, redness, swelling, decreased output, and color of input. He also revealed that if he identified these concerns he would notify the physician to obtain further instruction and would document his notification of the physician and responsible party. However, record review revealed this was not completed for Resident #8 per the resident's plan of care or the facility's policy. Interview with LPN #9 on [DATE] at 01:40 PM, revealed that if a resident was readmitted back into the facility after an acute care stay with an indwelling catheter in place, orders would be needed to continue to care for the catheter. Orders such as to monitor input/output, catheter care, and to change the catheter as ordered would be expected for resident with a catheter. She revealed it would be either the receiving nurse's responsibility to obtain these orders or the unit manager if they were helping. Interview with Unit Manager (UM) #1 on [DATE] on 11:14 AM, revealed residents with an indwelling catheter should be listed on the clinical board to ensure they were followed up on and remained on the clinical board until discontinued use was verified. She revealed when an order was placed into the computer, the nurse would have entered it in such a way to ensure it populated on the MAR/TAR. She stated if there were no care orders entered for a catheter on a resident, she would expect the nurse to call the provider and obtain appropriate orders. Interview with UM #3 on [DATE] at 5:15 PM, revealed the nurse that accepted the resident on admission was responsible to input any new orders listed on the discharge summary from the sending facility (acute care). She continued the unit manager should have identified that the indwelling catheter orders were not entered into the system in morning clinical meeting. She continued care should have been completed on Resident #8's catheter and although there was no documentation regarding the care. In addition, the CNA would not have been able to overlook the catheter while in the resident's room but there was no documentation to prove that care was completed. Multiple unsuccessful attempts were made to interview Certified Nurse Aides (CNAs) who cared for Resident #8: CNA #18 on [DATE] at 11:05 AM and 1:04 PM; CNA #19 on [DATE] at 11:23 AM and 1:12 PM; and, CNA #12 on [DATE] at 11:32 AM and 1:20 PM. Messages left were not returned. Interview with CNA #16, on [DATE] at 11:30 AM, revealed information regarding a resident with an indwelling catheter was not normally passed on in the end of shift report. She stated she would become aware of a resident having an indwelling catheter when she made rounds on her residents and noticed it when she entered their room. Continued interview revealed catheter care was documented in the CNA kiosk under personal hygiene. She went on to reveal that if the drainage bag was not properly attached to the bed it could be dangerous for the resident due to being pulled. Furthermore, she would notify the nurse of she noticed any bleeding, pus, or drainage around the insertion site or if the urine was an unusual color. She revealed that if the catheter was not anchored to the resident properly it could cause possible discomfort, become dislodged and be painful for the resident causing swelling or an infection. Interview with the Medical Director, on [DATE] at 3:33 PM, revealed he would expect staff to perform catheter care and good hygiene practices on a resident with an indwelling catheter in place. He would expect the indwelling catheter be clean, anchored and changed every four (4) weeks to help prevent infection. Further interview revealed he would expect staff to call and obtain orders for care and monitoring of Resident #8's indwelling catheter if there were no orders. Further review of Resident #8's closed record revealed a Nurse Practitioner (NP) note, dated [DATE], stating she assessed the resident due to his/her complaint of nausea/vomiting and lower abdominal pain. Further review of the note revealed the provider ordered a Complete Blood Count (CBC), Basic Metabolic Profile (BMP), and Urinalysis with Culture and Sensitivity (UA) for evaluation for possible Urinary Tract Infection (UTI). Further review of Physician's Orders, dated [DATE], revealed the Nurse Practitioner (NP) ordered a CBC, BMP, and UA related to tea colored urine. However, there was no documented evidence these labs were obtained. Interview with Registered Nurse (RN) #2 on [DATE] at 2:54 PM, revealed she was the nurse working when the provider ordered the CBC, BMP, and UA on [DATE]. Continued interview revealed a Certified Nurse Assistant (CNA) notified her of Resident #8 having urinary issues, she assessed the resident and received orders for a UA. She revealed she did not recall if she collected it, but if the order was placed toward the end of her shift, she would have left it for the next nurse to collect. Continued review of Physician's Orders, dated [DATE], revealed another CBC, BMP and UA was ordered related to tea colored urine. Interview and record review with Unit Manager (UM) #3 on [DATE] at 5:15 PM, revealed UM #3 entered the new orders for a CBC, BMP, and UA on [DATE], but she revealed she entered those orders to assist the floor nurse, but could not recall if those orders were ever collected. Review of CBC lab results, dated [DATE], from the ordered CBC on [DATE], revealed Resident #8's White Blood Cells (WBC) count at 14.9 (normal 4XXX,d+[DATE].8), Neutrophils (Absolute) at 10.7 (normal 1XXX,d+[DATE].6) and Monocytes at 1.23 (normal 0XXX,d+[DATE].1) which were indicative of infection. Continued review revealed the facility could not provide documentation of the UA results that were ordered on [DATE] or [DATE]. Continued interview with LPN #6 on [DATE] at 10:30 AM revealed that scheduled labs were noted on the Medication or Treatment Administration Record (MAR/TAR). He continued if labs were ordered and not collected the resident could end up in the hospital. He revealed if the WBC count is high, it means that the resident has an infection and could possibly need antibiotics and if not treated the resident could go septic (infection in the blood). LPN #6 revealed when lab results are faxed to the unit, the nurse would place them into the NP binder so she can review them or if they are critical he would call the provider immediately. Further interview revealed that if a unit manager placed an order in the completer for labs, they would call the assigned nurse for that resident and notify them. He revealed he could not recall UM #3 notifying him of the UA ordered on [DATE] for Resident #8. Continued interview with LPN #9 on [DATE] at 1:40 PM, revealed if an order for a UA was entered, the nurse should get that sample as soon as possible if suspected for a UTI, and if the resident had an indwelling catheter it would be easier to obtain the sample. LPN #9 revealed if labs results were received and the WBC was elevated, it would mean that the resident had an infection, and if not treated they could potentially become septic. Continued interview with UM #1 on [DATE] on 11:14 AM, revealed if a resident's labs came back and showed a high WBC and this was not treated it could potentially lead to sepsis, whereas if it was caught the resident could be treated in-house with antibiotics instead of being sent out to acute care. Continued interview with UM #3 on [DATE] at 5:15 PM, revealed the floor nurse would input the lab orders but if that nurse did not have access to the lab system, she would enter them. She revealed she would collect the lab results that were faxed to the units and she would distribute them to the nurses, who would then place labs into the lab book for the provider to review them the next day. UM #3 revealed the floor nurse was responsible to enter the orders into the system and to collect any UAs that the provider orders. Interview with the NP on [DATE] at 10:19 AM, revealed if lab results were received and were not critical, nurses would place the results into a book for her to review the next day. At that time, she would either place new orders or document no new orders. If the results were critical, the lab would call the facility with the critical high values, and the nurse would notify her. Continued interview revealed she recalled Resident #8 having a significant history of chronic UTI's and that was why she ordered the labs and UA on [DATE]. She recalled the UA not being collected and would expect the nurses to collect the sample as soon as possible so treatment could begin. She revealed she would have waited for the UA results to come back before she started Resident #8 on any new treatment. Interview with the Medical Director, on [DATE] at 3:33 PM, revealed he would expect the nursing staff to collect labs as ordered and notify the provider per policy. He continued he expected staff to collect ordered UAs and have them sent to the lab, and the provider would review the results the next day unless ordered STAT. Interview with Interim Director of Health Services (IDHS), on [DATE] at 8:56 AM, revealed if a UA was ordered the floor staff would be notified to collect the sample or the unit managers could also collect the needed sample and if it not ordered STAT, it would be collected the next morning. Continued interview revealed she would expect staff to collect labs as ordered, whether STAT or scheduled, including UAs. She continued that if the provider writes orders for a resident she would expect the nurses to carry out the orders. Interview with the Executive Director (ED), on [DATE] at 10:09 AM, revealed if a resident was readmitted back into the facility with an indwelling catheter, such as Resident #8, he would expect the facility to evaluate the need for the catheter and would expect staff to enter all orders pertaining to the care and monitoring of a resident with a catheter in place. Continued interview with the ED revealed he would expect staff to collect all labs, including UAs, as ordered. He revealed if a resident with an UTI went untreated that resident could become septic. Continued review of the progress notes revealed Resident #8 was transferred to acute care on [DATE] related to complaints of chest pain for two (2) days. Review of the hospital records, dated [DATE], revealed Resident #8 was admitted with multiple diagnoses which included a UTI and Sepsis requiring intravenous antibiotic therapy. The resident expired at the hospital on [DATE].

Based on interview, record review, and review of the Plan of Correction (POC) for the 08/28/2020 Abbreviated Survey, the Administrator's job description and facility's policies, it was determined the facility's Administration failed to ensure the facility was administered to in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and failed to maintain substantial compliance related to ensuring the residents were free from abuse; implementation of care plans; timely revisions of care plans; and, failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) Program. This was evidenced by the repeat deficiencies from the Abbreviated Survey, conducted on 12/16/2020. (Refer to F600, F656, F657, F835, F865) The facility's failure to have an effective system in place to ensure the residents were assessed and monitored appropriately and had continued urinary catheter care has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 01/08/2021 and determined to exist 06/02/2020 and the facility was notified of Immediate Jeopardy related to Resident #8 on 01/08/2021. The facility provided an Allegation of Compliance (AoC)/Plan of Correction, alleging past non-compliance, however, after review and validation of the AoC, it was determined the Immediate Jeopardy had not been removed due to the facility's failure to order and obtain laboratory orders on a sampled resident, Resident #25. The facility was notified on 2/12/2021 of the ongoing Immediate Jeopardy. The findings include: Review of the Job Description for the Executive Director (ED), dated August 2019, revealed the ED was responsible for the efficient and profitable operation of the community; community compliance with the company's policies and procedures and state and federal regulations; and, providing the highest quality of care possible. In addition, the ED was responsible to lead an effective QAPI Program. Review of the facility's policy Administrative Management (Governing Board), revised October 2017 revealed the governing board was the supreme authority, and had full legal authority and responsibility for the management and operation of the facility. In addition, the governing board was responsible for, but not limited to oversight of the care and services in accordance with professional standards of practice and principles, the establishment and ongoing review of all administrative programs governing the facility's management and operations, including QAPI. Record review revealed the facility admitted Resident #8 on 07/21/2017 with diagnoses that included Atrial Fibrillation, Hypertension, Chromic Kidney Disease, Pulmonary Embolism, and Obstructive/Reflux Uropathy. Continued review revealed Resident #8 was readmitted to the facility after an acute care stay on 06/02/2020 with an indwelling urinary catheter in place. Resident #8 was care planned for the indwelling catheter and staff was to monitor for signs and symptoms of infection, along with care for the catheter. However, there was no documented evidence the facility performed catheter care nor, collected the provider ordered laboratory tests for evaluation of a possible Urinary Tract Infection (UTI). Resident #8 was admitted to acute care on 09/24/2020 with diagnoses that included UTI and Sepsis (blood infection) requiring intravenous antibiotic therapy. Record review revealed the facility admitted Resident #25 on 12/08/2020 with diagnoses that included Severe Protein/Calorie Malnutrition, Type 2 Diabetes Mellitus (DM), and Adult Failure to Thrive. Continued review revealed Resident #25 was care planned for Type 2 DM and staff was to monitor for signs and symptoms of hyperglycemia/hypoglycemia, along with labs as ordered. However, further review revealed no documented evidence the facility monitored Resident #25 for signs and symptoms of hyperglycemia/hypoglycemia. In addition, the facility failed to collect the provider ordered laboratory tests. Resident #25 was transferred to an acute care hospital on 01/12/2020 due to a critical blood glucose level of 1,148 milligrams/deciliter {mg/dL} (normal is 65-99) and required continuous intravenous insulin therapy. Interview with the Regional Nurse Consultant (RNC), on 02/10/2020 at 2:57 PM, revealed it was the responsibility of the Governing Body to ensure that the QAPI meetings and processes of the facility occurred. Continued interview with the RNC, who is a member of the Governing Body, revealed she was able to ensure the POC from the August 2020 survey was implemented by being present at the facility's morning meetings, reviewing the meeting minutes, and sitting in the QAPI meetings. She stated she performed walking rounds throughout the facility. Continued interview revealed new orders and one-hundred percent (100%) of the progress notes from the previous day were reviewed during the daily morning meetings and this was currently still occurring. She stated that by monitoring the morning meetings she could ensure the care plans were being followed through; orders were entered correctly and were being implemented. The RNC stated even though all the notes and orders were being reviewed in morning meeting, she was unable to answer how the labs were missed for Resident #25. Interview with the Executive Director (ED), on 02/10/2021 at 2:55 PM, revealed he was ensuring that the Plan of Correction (POC) from the August 2020 survey was being implemented through the monitoring of audits. He stated the facility continued audits through the compliance date to ensure the processes were in place and were followed. Further interview revealed continued monitoring occurred through the QAPI process. The ED stated that 100% of all progress notes and new orders were reviewed daily. He stated he continued this process, and it was ongoing. The ED stated the reviews were conducted seven (7) days a week. Further interview revealed it was the responsibility of the Governing Body to provide management oversight and to ensure the facility was in compliance. Continued interview with the ED revealed he participated in clinical meetings to ensure the care plan process was followed; reviews were being completed as necessary; and, morning meeting clinical guidelines were being followed. He stated he was present during the morning meeting for oversight and to ensure everything was reviewed. However, during continued interview, related to Resident #25, the ED could not give an explanation how the resident's lab orders were missed. He stated that it must have been human error. When interviewed related to Resident #28 missed labs that were ordered on 12/28/2020 by the Nurse Practitioner, the ED did not give an explanation.

Based on interview, record review and review of the facility's policy and Plan of Correction (POC) for the Abbreviated Survey, dated 08/28/2020, it was determined the facility failed to have an effective system to maintain a Quality Assurance Performance Improvement (QAPI) that developed and implemented plans of action to correct quality deficiencies. This was evidenced by the repeat deficiencies from the Abbreviated Survey, conducted on 12/16/2020, related to the facility's failure to ensure residents were free from abuse and neglect, proper implementation of care plans, timely care plan revision, an effective QAPI Plan was in place, and failure to administer the facility in a manner to maintain substantial compliance. (Refer to F600, F656, F657, F835, F865) The facility's failure to have an effective system in place to ensure the residents were assessed and monitored appropriately and had continued urinary catheter care has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 01/08/2021 and determined to exist 06/02/2020 and the facility was notified of Immediate Jeopardy related to Resident #8 on 01/08/2021. The facility provided an Allegation of Compliance (AoC)/Plan of Correction, alleging past non-compliance, however, after review and validation of the AoC, it was determined the Immediate Jeopardy had not been removed due to the facility's failure to order and obtain laboratory orders on a sampled resident, Resident #25. The facility was notified on 2/12/2021 of the ongoing Immediate Jeopardy. The findings include: Review of the facility's Quality Assurance and Performance (QAPI) Program - Governance and Leadership, revised March 2020, revealed the QAPI Program was overseen and implemented by the QAPI Committee, which reported its findings, actions and results to the Administrator and governing body. Continued review revealed the Administrator was ultimately responsible for the QAPI Program and for interpreting its results and findings to the governing body. The governing body was responsible for ensuring that the QAPI Program was implemented and maintained to address identified priorities, was sustained through transitions of leadership and staffing, was adequately resources, was based on data/resident and staff input, and other information that measured performance and focused on problems and opportunities that reflected processes, functions and services provided to the residents. The responsibilities of the QAPI Committee were to collect and analyze performance data, identify monitor and improve facility systems and process, identify and help to resolve negative outcomes and/or care quality problems, utilize root cause analysis to help identify where identified problems point to underlying systematic problems, help implement systems to correct potential and actual issues in quality of care, and to establish benchmarks and goal by which to measure improvement. During the Abbreviated Survey, it was identified the facility failed to ensure residents were free from abuse and neglect, proper development/implementation of care plans occurred, appropriate care plan timing and revisions occurred, an effective QAPI plan was in place to identify and monitor quality deficiencies to maintain substantial compliance based on repeat deficiencies, and to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain substantial compliance based on repeat deficiencies. These were repeat deficiencies for the facility which was cited 08/28/2020. Review of the facility's Plan of Correction (POC), with a compliance date of 09/23/2020, revealed for tags: F600, F656, F657, F835 and F865, the facility provided education to staff, completed audits and held ADHOC QAPI meetings as alleged. Review of the audits revealed the facility completed care plan audits on 09/09/2020 and random bowel and bladder audits on 09/09/2020 five (5) times a week for six (6) weeks as alleged. Continue review revealed education was provided to current staff and new staff as alleged in the facility's POC. Record review revealed the facility provided no documented evidence their QA audits identified issues related to Resident #8's catheter care nor continuation of monitoring of signs and symptoms of hypo/hyperglycemia for Resident #25, along with failure to obtained labs as ordered for both residents. Continued review revealed Resident #8 and Resident #25 were discharged from the facility and were reviewed as closed records. Interview with the Regional Nurse Consultant (RNC), on 02/10/2020 at 2:57 PM, revealed she reviewed meeting minutes, was present at meetings, continued monitoring by performing walking rounds in the facility and would sit in the QAPI meetings. Continued interview revealed the QA committee becomes aware when any issues arise during the morning clinical process. Further interview revealed the morning meeting reviews orders for accuracy, labs, and new admissions/readmissions. Further interview revealed reviewing these items left the team with opportunities to identify areas of concern. The RNC revealed staff could report quality concerns to the committee through the grievance process and become aware of negative trends or performance through clinical, risk management, and Nutritionally at Risk (NAR) meetings. Further interview revealed when the committee identified a concern, through the QAPI process the concern was monitored to ensure implementation and improvement had occurred. Continued interview with the RNC revealed an identified issue was considered resolved based on the outcomes of audits that had been monitored. However, the audits provided by the facility failed to identify the negative outcomes for Residents #8 and #25. Interview with the Executive Director (ED), on 02/10/2020 at 2:55 PM, revealed the QA committee was made aware of issues through the grievance process, clinical meetings, audits, and identified patterns and trends. He revealed the committee was aware when there was a negative trend or deviation occurring through the information the facility monitored and reviewed. Continued interview revealed if a negative trend was occurring for falls or infections, as an example, the committee would provide education, form an action plan, and continue to monitor and review for improvements. He revealed staff can report quality concerns to the committee via a corporate hotline, or through talking with staff on the floor while performing rounds. The ED revealed through follow-up with audits or action plans, the committee would know if corrective action had been implemented. He continued that if they identified any concerns the committee would work to come up with other solutions and possibly add different interventions. Further interview revealed the committee was aware of improvement when they reviewed the outcomes and if it seemed to be working well, the committee could possibly apply the same concept to other areas. Continued interview revealed typically an issue was monitored for six (6) weeks and based on the audit outcomes, they may choose to extend the monitoring. He revealed looking at data through the QA process they would determine to extend or possibly reduce if applicable. Further interview revealed the QA process was completely at least monthly, but due to recent survey findings the committee had been meeting more often. Continued interview revealed the ED believed the QA process in his facility worked well. Continued interview revealed the QA committee did not identify any issues regarding diabetes care and orders. Further interview revealed if orders including labs for Resident #25 were prescribed, they should have been entered into the computer. He revealed he was not aware the labs ordered on 12/10/2020 for Resident #25 were not entered appropriately and was not sure if this was identified during the morning meetings. A follow-up interview with the Execute Director (ED), on 02/10/2020 at 3:35 PM, revealed the failure to identify the labs ordered on 12/10/2020 for Resident #25 was human error and he was not sure how the labs were missed.

Based on observations, record review, interviews, and review of facility policy it was determined the facility failed to protect three (3) of twenty-seven (27) sampled residents, (Residents #1, #23 and #26) from verbal and/or physical abuse. On [DATE], Resident #2 bit Resident #1 on the lip and right ear which resulted in injuries, and required sutures. Additionally, on [DATE], Resident #26 was verbally abused by Licensed Practical Nurse (LPN) #10 in a hallway in front of other residents and staff. Lastly, on [DATE], Resident #23 was hit in the face with a cane by Resident #24. The findings include: Review of the facility's policy, Abuse Prevention Program, revised [DATE], revealed the residents have the right to be free from both verbal and physical abuse. Further review revealed the facility should protect residents from abuse from other residents, facility staff, and staff from other agencies. In addition, the administration should implement measures to address factors that may lead to abusive situations, identify and assess all incidents of abuse, and investigate any allegations of abuse. Review of the facility's policy, Resident Rights, revised [DATE], revealed residents have the right to be treated with respect, kindness, and dignity. Additionally, residents have the right to be free from verbal, sexual, physical, and mental abuse. Review of the facility's policy, Resident-to-Resident Altercations, revised [DATE], revealed all altercations should be investigated and reported to the Nurse Supervisor, the Director of Nursing Services, and the Administrator. Facility staff should monitor residents for aggressive/inappropriate behaviors towards residents/staff, document the behaviors in the resident's clinical records, and include all interventions and effectiveness. 1. Review of the clinical record revealed, the facility admitted Resident #1, on [DATE] and readmitted the resident, on [DATE], with diagnoses to include dementia, schizophrenia, major depressive disorder, and anxiety. Further review revealed Resident #1 was diagnosed with COVID-19, on [DATE], and resided on a secured COVID-19 Memory Care unit at the time of the incident. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of five (5), indicating the resident was severely impaired. Review of Resident #1's Behavior Comprehensive Care Plan, dated [DATE], revealed Resident #1 exhibited behavior symptoms of wandering, impulsivity, abruptly rises from wheelchair and walks with unsteady gait. He/she was at times anxious, irritable, and restless. Further review revealed Resident #1 exhibited behaviors of walking in to others and getting in others' personal space. The goal for this behavior was Resident #1 would be free of unidentified complications related to behavior. Interventions for Resident #1 included: removing resident from situations, providing personal space, allowing resident to vent feelings, approaching resident in a calm and friendly manner, explaining procedures prior to start, familiarizing resident with own belonging and surroundings, observing for resident needs, and providing diversional activities. Review of Resident #2's closed clinical record revealed the facility admitted Resident #2 , on [DATE], with diagnoses that included dementia and major depressive disorder. Further review revealed Resident #2 was diagnosed with COVID-19, on [DATE], and resided on a Secured Memory Care Unit at the time of the incidents. Review of the annual MDS, dated [DATE], revealed the facility assessed Resident #2 with a BIMS score of three (3), indicating the resident was severely impaired. Review of Resident #2's Comprehensive Care Plan, revised [DATE] with a target date of [DATE], revealed Resident #2 was at risk for alterations in mood and/or behavior symptoms related to dementia and depression. He/she was at times irritable with staff, and occasionally verbal with residents. The goal for this behavior included Resident #2 would have improved mood state as evidenced by a decrease in frequency of mood symptoms. Interventions included: to administer medications as ordered and observe for adverse side effects, assist the resident in developing a program of activities that was meaningful and of interest, to have behavioral health consults as needed, to encourage the resident to express feelings, and to notify behavior health specialists of no improvement, worsening or changes in resident's mood. Per record review and interview, Resident #2 was transferred to a local hospital on [DATE] and later expired prior to the State Survey Agency entrance. He/she did not return to the facility. Interview with the Unit Manager (UM #2)/ Licensed Practical Nurse (LPN), on [DATE] at 3:45 PM, revealed she was responsible for units 1B/1C. Per interview, she stated Resident #2 bit the arm of Certified Nurse Assistant (CNA) #5 on [DATE], while CNA #5 was providing care. She additionally stated this was a new behavior for Resident #2. Review of the document, titled, First Report of Injury, dated [DATE] at 1:20 PM, revealed CNA #5 incurred surface wound and bruises to the right upper arm, while CNA #5 and CNA #3 were transferring the resident from the bed to the wheelchair. During the transfer, the resident leaned in and bit CNA #5 on her right arm. CNA #5 received treatment at an urgent care center. Interview with CNA #5, on [DATE] at 10:08 AM, revealed Resident #2's health declined after his/her diagnoses of COVID-19. Per interview, Resident #2 had not displayed behaviors of biting prior to [DATE] when CNA #5 was bitten on the arm while transitioning Resident #2 to another room after lunch. Record review, revealed was no documented evidence the facility investigated the incident involving Resident #2 biting CNA #5. Review of the facility's investigation, dated [DATE], completed by the Executive Director (ED), revealed Resident #1 was found sitting in the hallway with blood on his/her gown and lacerations to his/her top lip and right ear. Per the facility's investigation, the resident's lacerations were inconsistent with an injury sustained from a fall. Review of the Emergency Department (ED) records, dated [DATE], revealed Resident #1 presented to the ER at 9:23 AM. His/her injuries included lacerations to the lip and right ear. Further review revealed Resident #1 received (5) five sutures to the upper lip and (10) ten sutures to the right ear. Resident #1 was discharged from the ER and returned to the facility on [DATE] at 7:57 PM. Review of the facility's Self-Reported Incident Form, dated [DATE], indicated Resident #2 bit Resident #1 due to bloody residue in Resident #2's mouth. The facility sent Resident #1 to the emergency room (ER), where he/she received sutures, and returned to the facility. Room changes were made and a stop sign was placed on Resident #2's door. Resident #2 was placed on fifteen (15) minute checks. An attempt were made to contact CNA #7 on [DATE] at 2:00 PM. However CNA #7 was no longer with the agency and no phone number was available. Telephone interview with agency CNA #4 on [DATE] at 1:47 PM, revealed at the time Resident #2 bit Resident #1, she and another CNA were gathering trays outside of the unit and did not witness the event. Furthermore, CNA #4 stated after the nurse arrived blood was noticed on the sheets and on Resident #2's mouth. An additional interview on [DATE] at 1:55 PM, revealed CNA #4 did not know about Resident #2 biting a CNA on [DATE] until after Resident #2 bit Resident #1. Telephone interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:23 AM, revealed she was agency staff and had completed one (1) or two (2) shifts at the facility. LPN #3 was assigned to the memory care COVID-19 unit, Red Zone, and had additional residents she was responsible for during the shift. LPN #3 stated two (2) CNAs were assigned to the Red Zone. However when Resident #2 bit Resident #1, there was no supervision on the Red Zone. Furthermore, she stated she was unaware of the incident on [DATE] when Resident #2 bit CNA #5 until after the resident-to-resident incident. In addition, she stated it would have been helpful to know about the previous incident prior to the second incident. Interview with ED, on [DATE] at 2:48 PM, revealed Resident #2 was not able to get out of bed at the time of the incidents. However, after the resident bit CNA #5's arm, it should have raised a concern for other residents' safety. An additional interview with the ED, on [DATE] at 8:54 AM, revealed the expectation for supervision on the memory care unit was to keep an eye on the residents to ensure they did not get hurt. He also indicated during busy times such as shift change and meal times, the COVID-19, red zone of the Memory Care Unit, should be monitored and staff should be present. 2. Review of the clinical record revealed the facility initially admitted Resident #26 on [DATE] with diagnoses including osteomyelitis, chronic kidney disease, adjustment disorder with anxiety, and peripheral vascular disease. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #26 with a BIMS' score of fifteen (15), indicating the resident was cognitively intact. Review of Resident #26's Behavior Comprehensive Care Plan, revised [DATE], revealed the resident exhibited impatience and intolerance of staff, verbal behaviors at times, discussing staff ineptness at length. The goal for this behavior was to accommodate resident as much as possible. The interventions included approaching the resident in a calm friendly manner, listening to the resident's needs and adjusting the plan as appropriate, and allowing the resident to vent feelings. Review of the facility's interview with Resident #26 on [DATE] at 9:45 PM, revealed Resident #26 wanted his/her laundry taken down and food from McDonald's brought up from a friend arriving at 5:00 PM. Further review revealed the resident's assigned aide was on break. Continued review revealed the aide at the nurses' station did not acknowledge the resident's request and the resident's nurse was in another resident's room. Resident #26 called a nurse from another floor to assist with his/her tasks. Resident #26 stated LPN #10 overheard the conversation, left her medication cart, took the laundry, and got on the elevator. When LPN #10 returned to the floor, Resident #26 asked why she did not acknowledge him/her. LPN #10 responded, I am the only nurse and don't have time for you, people walk on egg shells around you, and I am tired of dealing with you. Continued interview revealed Resident #26 told LPN #10 her attitude was ridiculous, she did not do her job, and did not follow doctor's orders. Additionally, he/she also accused LPN #10 of running off and bullying another nurse. LPN #10 replied, That's not true, she doesn't like you. LPN #10 left the unit, while walking away stated, I'm tired of the mother fucking bullshit. LPN #10 returned with the nurse and confronted the nurse she was accused of bullying. However Resident #26 did not recall exactly what was said. At the end of the interaction, LPN #10 walked away and said, I don't know what (his/her) fucking problem is, (he/she) thinks (he/she) runs this god damn place. Resident #26 returned to his/her room and had no additional contact with the resident. Review of a written statement by a CNA included in the facility's investigation, undated, revealed CNA witnessed the incident. LPN #10 took Resident #26's laundry downstairs, when LPN #10 returned to the unit, Resident #26 got angry and told LPN #10 she was neglecting him/her and told LPN #10 she was an incompetent nurse and he/she would get her fired along with a few other people. LPN #10 got upset regarding the neglect accusations and told Resident #26 she was tired of him/her disrespecting her, talking to her as if she was scum. Resident's #26 later responded, I don't like you and said LPN #10's nursing skills were stupid and so was she. He/she also responded he/she got another nurse fired and LPN #10 would be next. Observation of Resident #26 on [DATE] at 3:00 PM, revealed the resident was up in a wheelchair, well-groomed with non-slip socks in place, and a drink on the bedside table next to his/her wheelchair. The room was clean without odors. Interview with Resident #26 on [DATE] at 3:00 PM, revealed he/she felt safe at the facility and did not feel he/she was abused. However, he/she was disgusted with the behavior of LPN #10, indicating it was some of the worst profanity he/she had heard. During the interview, Resident #26 stated, It's a closed case. Resident #26 stated LPN #10 was trying to push another nurse out. Interview with LPN #10 on [DATE] at 2:39 PM, revealed she was taking care of Resident #26 on [DATE]. LPN #10 stated Resident #26 wanted a bag of dirty clothes taken downstairs. When she returned upstairs, Resident #26 was fussing and cussing and accused her of neglect. LPN #10 stated she told Resident #26 she was tired of walking on pins and needles around him/her. She stated that they both continued the argument, which included verbal cussing in the hallway in front of the nurse's station. LPN #10 stated Resident #26 said he/she would get her fired. Further interview revealed LPN #10 stated she was later terminated after the facility conducted their investigation. LPN #10 stated she had reported Resident #26's behavior before to management and they did not do anything. Additionally LPN #10 indicated she was not the only nurse he/she talks to in the same manner. Interview with LPN #6 on [DATE] at 1:38 PM, revealed he was familiar with Resident #26 and the verbal altercation between Resident #26 and LPN #10 on [DATE]. LPN #6 stated Resident #26 would often test staff to their limits. The LPN also stated he was on the elevator and heard shouting from the elevator regarding the care LPN #10 gave Resident #26. LPN #6 further stated, Resident #26 was particular about his/her treatment and who he/she allowed to perform treatments. The LPN stated LPN #10 had not exhibited behaviors previously and was dumbfounded by her behaviors. LPN #6 further stated he had been trained many times on abuse and named several types of abuse including physical, verbal, and sexual. Interview with the Executive Director (ED) on [DATE] at 3:18 PM revealed he was notified on the evening of [DATE] regarding the verbal altercation between Resident #26 and LPN #10. The ED stated LPN #10 had brought a nurse from another floor to the unit and had an open inappropriate confrontation with other residents and staff present. LPN #10 was sent home after the incident. Further interview revealed Resident #26 had a skin and psychosocial assessment. The facility performed facility wide education on abuse and resident rights. Additionally, the ED stated Resident #26 did not feel abused. However, it was determined LPN #10 had an inappropriate interaction with Resident #26 and LPN #10 was terminated. Furthermore, the ED indicated he felt it was borderline verbal abuse and believed the facility made the right decision to terminate LPN #10. 3. Review of Resident #23's clinical record revealed the facility admitted Resident #23 on [DATE], with diagnoses including encephalopathy, Alzheimer's, and dementia. Resident #23 resided on a secured memory care unit at the time of the incident on [DATE]. Review of the Admission MDS dated [DATE], revealed the facility assessed Resident #23 with a BIMS score of three (3), indicating the resident was severely impaired. Review of Resident #23's Behavior Care Plan, initiated [DATE], revealed Resident #23 exhibited behavior symptoms of refusing medications, pacing, intrusive wandering, yelling related to dementia with behavioral disturbances. The goal for this behavior included Resident #23 will demonstrate effective coping skills related to behavior. Interventions included: administer medications as ordered, approach in a calm, friendly manner, allow to vent feelings or needs, familiarize resident with own environment, if resident becomes combative or resistive, postpone care or activity and reapproach after composure regained, maintain safe environment for resident, provide diversional activities, and provide resident personal space. Observation of Resident #23 on [DATE] at 3:01 PM, revealed Resident #23 up in a bedside chair, asleep, wearing a WanderGuard on his/her left ankle. Resident #23 showed no signs of injury, edema, bruising, or swelling. Resident #23 was non-interviewable. Staff interviews revealed when Resident #24 was initially admitted to the facility, Resident #23 and Resident #24 shared the same room, 104. Review of the clinical record revealed the facility admitted Resident #24 on [DATE], with diagnoses including sepsis, diabetes, chronic kidney disease, and bipolar disorder. Resident #24 resided on a secured COVID-19 memory care unit at the time of the incidents. Review of the Admission MDS dated [DATE], revealed the facility assessed Resident #24 with a BIMS score of twelve (12), indicating the resident had moderate impairment. Review of Resident #24's Behavior Care Plan, initiated [DATE] revealed Resident #24 was at risk for alterations in mood or behavior. The goal for this focus was he/she would have improved mood state. Interventions for this goal were accomplished by administering medication as ordered, assisting the resident to identify strengths and positive coping skills, behavioral consults, ensure light remain on and ensure cell phone was charged and within reach. Record review revealed Resident #24 resided at the facility for twelve (12) days. The facility discharged Resident #24 to family on [DATE]. Review of Resident #24 Progress Notes dated [DATE] at 8:09 AM entered by UM # 2 revealed revealed Resident #24 hit Resident #23 with a cane when Resident #23 came into his/her room. UM #2 also documented the Nurse Practitioner and Guardian were notified. Resident #24 was made 1:1 for two (2) hours and then placed on fifteen (15) minute checks until seen by the Nurse Practitioner. In addition, Resident #24 changed rooms and was placed on a different unit. Interview with Resident #24 on [DATE] at 9:02 AM, revealed when admitted to the facility on [DATE], Resident #23 was his/her roommate. Resident #24 reported, Resident #23 came onto his/her side, stole his/her water, and grabbed his/her ankle. Further interview revealed Resident #24 could not recall the day it happened. The resident stated Resident #23 came back into his/her room, and started getting into his/her stuff the night of [DATE]. Resident #24 stated he/she hit Resident #23 in the face with his/her cane and said, It left a mark. Resident #24 further explained, Resident #23 left the room after he/she was hit. Continued interview revealed a nurse, he/she could not recall her name, came in and moved Resident #24 to room [ROOM NUMBER], and later he/she was moved into room [ROOM NUMBER]. Observations of Resident #24 on [DATE] at 9:02 AM revealed he/she had no roommate. Continued interview revealed the room was clean and bare. Resident #24 stated he would be discharged Saturday, [DATE]. Further review revealed Resident #24 was awake, dressed lying in bed, with his/her belonging within reach with a WanderGuard on his/her left ankle with his/her door shut. Interview with CNA #10 on [DATE] at 10:27 AM, revealed she was agency staff and it was her first time in the facility. She stated at the time of the incident, she was at the nurses' station and heard two (2) men yelling on the other side of the plastic barrier, which denoted the yellow unit. CNA #10 additionally stated, the other CNA on the unit was at the nurses' station with her and there was no supervision on the other side of the plastic barrier at the time of the altercation. She stated the nurse on the unit was not present at the time of the incident. CNA #10 stated she was not familiar with the resident and not given a rundown to the unit/residents until 2 AM. Further interview with CNA #10 revealed, there were five (5) or six (6) residents on the yellow zone of the memory care unit the night of the incident. She stated Resident #23's room was diagonal from Resident #24. CNA #10 stated Resident #23 wandered into Resident #24's room and Resident #24 hit Resident #23 with a cane. Telephone interview with CNA #11 on [DATE] at 5:00 PM, revealed she worked for an agency and had worked at the facility around three (3) times. However, she had not worked on the memory care unit. CNA #11 stated she was at the nurses' station when she witnessed what sounded like a heated argument in the yellow zone. When she approached the incident, Resident #23 was standing outside of the door of Resident #24's room with a bloody nose. She stated Resident #24 was holding a cane and stood in his/her room with the door cracked. CNA #11 stated she separated the residents. Further interview revealed CNA #11 then had the other agency CNA on the floor watch the residents while she found the nurse on another unit. CNA #11 further explained, the yellow unit was on the same hall of the memory care unit and separated by a plastic barrier wall. CNA #11 stated, at the time of the incident there was no one supervising the yellow unit and approximately five (5) or six (6) residents resided in the yellow zone. Further interview with CNA #11, revealed she felt it was worrisome all CNAs assigned to the unit were agency staff. She stated, the information she received in report was inaccurate. Finally, CNA #11 stated she had not received training on the floor or facility abuse training; however, she had received agency abuse training. Interview with UM #2 on [DATE] at 9:26 AM, revealed Resident #23 and Resident #24 were originally roommates when Resident #24 arrived to the facility on [DATE]. Further interview with the Unit Manager revealed that on [DATE] or [DATE], Resident #24 was moved to room [ROOM NUMBER] during the night shift because Resident #23 was getting into Resident #24's stuff. Interview with UM #2 on [DATE] at 8:22 AM revealed, she was the nurse assigned to the floor on [DATE]. She stated the incident happened between 11:30 PM and 11:40 PM on 1C Unit. UM #2 stated one of the agency CNA asked her to go to the 1B Unit. UM #2 stated the CNA told her a resident had hit another resident. She stated the resident told her that (he/she) was in my room and I got (him/her) good with my cane. UM #2 stated she assessed Resident #23 and cleaned his/her bloody nose. Continued interview with UM #2 revealed Resident #23 was the only resident who was not alert and oriented. She stated that there were no residents on the unit that needed 1:1 supervision. The UM further stated normally there was no one on the yellow zone to provide supervision. Interview with MDS Coordinator #2 on [DATE] at 10:14 AM, revealed she was aware Resident #23 went into other residents' rooms and belongings. She stated she tried to update the care plans as behaviors were discovered. MDS Coordinator #2 further stated Resident #23's care plan should have been updated after behaviors were displayed. Telephone interview with the Executive Director (ED), on [DATE] at 3:00 PM, revealed he was aware Resident #23 had gone through Resident #24's belongings, and a room change was initiated after the incident. He further stated his expectations on the yellow zone unit on the memory care unit would be frequent resident checks. The ED stated, anytime a resident-to-resident incident occurred it raised a concern. Additionally he stated, we try not to have agency staff work on the memory care unit, but it happens.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to revise the Comprehensive Care Plan for two (2) of twenty-seven (27) sampled residents (Residents #2 and #23). On [DATE], Resident #2 bit Certified Nursing Assistant (CNA) #5 on the arm. However, there was no documented evidence of revision to the resident's Comprehensive Care Plan. On [DATE], Resident #2 again displayed the biting behavior. Resident #2 bit Resident #1's ear and lip which resulted in sutures to those areas. Staff reported that on [DATE] or [DATE], Resident #23 rummaged through the belongings of his/her roommate, (Resident #24) and was moved to another room. However, on [DATE], Resident #23 wandered into Resident #24's room and again went through Resident #24's belongings. Resident #24 struck Resident #23 in the face with his/her cane, resulting in a bloody right nostril. There was no documented evidence the facility revised Resident #23's care plan. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised [DATE], revealed the Interdisciplinary Team (IDT) was to review and update residents' care plans when there had been a significant change in a resident's condition. Review of the facility's policy titled, Resident-to-Resident Altercations, revised [DATE], revealed all altercations were to be reported to the Nurse Supervisor, the Director of Nursing Services (DNS), and the Administrator and were to be investigated. The policy stated if two (2) residents were involved in an altercation, staff were to make the necessary changes in the care plan approaches for each of the involved residents. 1.Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Dementia and Major Depressive Disorder. Further review revealed Resident #2 was diagnosed with COVID-19 on [DATE]. Resident #2 resided on the secured COVID-19 Memory Care Unit in November when the incident occurred. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #2 with a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Further review revealed the facility transferred Resident #2 to a local hospital on [DATE] related to a decline. The resident later expired at the hospital prior to the State Survey Agency's Abbreviated Survey. Review of Resident #2's Comprehensive Care Plan revealed a behavior care plan last reviewed on [DATE]. Continued review of the care plan revealed Resident #2 was at risk for alterations in his/her mood and/or behavior symptoms related to the diagnoses of Dementia and Depression. Further review revealed Resident #2 was at times irritable with staff and other residents, and occasionally was verbal with other residents. Per the care plan, the goal for Resident #2's behaviors included improved mood state for the resident as evidenced by a decrease in frequency of mood symptoms. Interventions included: administration of medications for the resident as ordered and to observe for adverse side effects and provide the resident with a program of activities that was meaningful and of interest. Further review of the interventions revealed Resident #2 would receive behavioral health consults as needed, and staff was to notify the behavior health specialists of no improvement, worsening or changes in the resident's mood/behaviors. Review of the facility's incident report, First Report of Injury, noted on [DATE] at 1:20 PM, revealed CNA #5 had incurred a surface wound and bruises to the right upper arm. Per the Report of Injury, while CNA #5 and a teammate were transferring a resident (Resident #2) from the bed to his/her wheelchair, the resident leaned in and bit CNA #5 on the right arm. Continued review revealed CNA #5 received treatment for the wound, with four (4) follow up visits necessary. Continued review of Resident #2's Comprehensive Care Plan, revealed no documented evidence the care plan had been revised/updated to include the biting behavior of the resident. In addition, there was no documented evidence of additional interventions implemented to assist in preventing further episodes of Resident #2 biting other staff or residents, as he/she had done on [DATE]. Review of the facility's Investigation Report (IR) dated [DATE] and completed by the Executive Director (ED), revealed Resident #1 had been found sitting on his/her buttocks on the floor across from his/her room with blood on the resident's gown and lacerations to his/her lip and ear. Continued review revealed a trail of blood drops led to Resident #2's bed; Resident #2 was unable to ambulate or get out of bed. The facility transferred Resident #1 to the hospital. Resident #1 required sutures. Interview with CNA #5 on [DATE] at 10:08 AM and on [DATE] at 1:22 PM, revealed Resident #2's health had declined after he/she was diagnosed with COVID-19. Per interview, Resident #2 had not displayed behaviors of biting anyone prior to the [DATE] incident, when the resident bit her on the arm. Continued interview revealed she reported her bite to an agency nurse who was working that day. Per interview, CNA #5 was unaware of who updated residents' care plans or if any additional interventions had been implemented after Resident #2 bit her. CNA #5 further stated it would have been helpful for staff to have been made aware of Resident #2's biting incident to help keep other staff or residents safe from being bitten. Interview with Unit Manager (UM) #2 of the facility's 1B and 1C Units on [DATE] at 2:34 PM and [DATE] at 3:03 PM, revealed the facility's responsibility was to protect the residents and keep them safe. The UM stated biting was a new behavior, as Resident #2 had not displayed until he/she bit CNA #5 on [DATE]. UM #2 stated agency LPN #4 was assigned to the COVID Unit on [DATE]. She further indicated the nurse who filled out the incident report or MDS would responsible for revising Resident #2's care plan. Continued interview revealed incidents or changes in a resident's condition were discussed in the facility's morning meeting. However, she did not remember if the incident was discussed in the morning meeting. In addition, she stated she was unaware of any documentation or revision of Resident #2's care plan after the incident when the resident bit the CNA. UM #2 further stated updates/revisions to Resident #2's care plan after the incident would have helped and prevented Resident #2 from biting someone else. Telephone interview with LPN #4 on [DATE] at 2:22 PM, revealed she worked PRN for the facility and did not remember the residents or the incident on [DATE] or [DATE]. Interview with MDS Coordinator #1 on [DATE] at 3:04 PM, revealed an incident which involved a resident biting a staff person was considered a behavior. The MDS Coordinator stated the facility's Social Services staff were responsible for updating residents' behavior care plans. She further stated if an incident occurred on a weekday, Monday through Friday, residents' care plans were updated immediately, and the incident would have been discussed in the facility's morning meeting. Interview with MDS Coordinator #1 on [DATE] at 1:32 PM, revealed during the clinical morning meeting, they would review new orders, any possible falls, medication changes, anything new occurring with the residents, admissions/readmissions, new diagnosis, new orders, and any new interventions. She also stated this was the time care plans would be updated as needed. Interviews with the Social Services Director (SSD) on [DATE] at 2:25 PM, [DATE] at 12:15 PM, and via a telephone interview on [DATE] at 10:24 AM, revealed she had no knowledge of the incident, which had occurred on [DATE] involving Resident #2 biting CNA #5. She stated typically, in clinical meeting, all new admissions, readmission, behavior notes, and general notes were reviewed. She additionally stated she ensured interventions were implemented by safety checks and follow up. An additional interview with SSD, on [DATE] at 10:24 AM revealed she had not updated Resident #2's care plan. The SSD stated if she had been made aware of Resident #2's first biting incident which occurred on [DATE], she would have revised his/her behavior care plan to address this new behavior. She stated she also would have had a psychology consult performed; and would have discussed the incident with the IDT regarding additional interventions to implement. She stated if an incident related to a resident's behavior occurred on a weekday, it was the facility's process for Social Services to update/revise the resident's care plan that same day. Further interview revealed an MDS Coordinator or Unit Manager were also able to update residents' care plans after a behavior. Telephone interview with the facility's Regional Nurse Consultant (RNC) /acting Director of Nursing Services (DNS) on [DATE] at 3:13 PM, revealed she was unaware of any documentation or interventions made after the incident involving Resident #2 biting CNA #5. Continued interview revealed she was unsure why Resident #2's care plan was not updated after this incident. Additionally, she stated she did not recall being notified of a change in condition for Resident #2 or any documentations or interventions implemented after the CNA was bit. She stated when an incident happens, the CNA would report to the UM, DNS, and ED and an investigation would be started. In addition, they would obtain written statements, and evaluate if the resident was a danger to self or others and would take the appropriate actions. She also stated the MDS Coordinator was responsible for updating care plans. The RNC further stated Resident #2's care plan should have been updated/revised to address the first incident involving the resident biting CNA #5, as there had been the potential for him/her to cause harm to other residents or staff. Interview with the Executive Director (ED) on [DATE] at 2:48 PM, revealed no interventions or care plan updates/revisions were immediately implemented after the incident involving Resident #2 biting CNA #5. Continued interview revealed in the clinical morning meeting notes, medications, and orders were reviewed to determine if things needed to be revised. The ED stated care plans were updated during or, after the IDT meeting by the MDS Coordinator. He stated care plans were typically updated immediately or on the next day depending on the time of day an incident occurred. Further interview revealed Resident #2 had not been able to get out of bed at the time of the incidents without assistance; however, it should have raised a concern for other residents' safety. 2. Review of Resident #23's medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Encephalopathy, Alzheimer's Disease, and Dementia. Continued review revealed Resident #23 resided on a secured yellow memory care unit at the time of the incident on [DATE]. Review of Resident #23's Admission MDS dated [DATE], revealed the facility assessed Resident #23 to have a BIMS score of three (3), indicating the resident was severely cognitively impaired. Review of Nursing Progress Notes dated [DATE], [DATE], and [DATE] revealed Resident #23 demonstrated wandering behaviors, rummaging through his/her roommate's belongings, and putting food in his/her roommate's bed. Review of the facility's Comprehensive Care Plan for Resident #23 revealed it included a Behavior Care Plan, initiated on [DATE]. Review of the Behavior Care Plan revealed, Resident #23 exhibited behaviors of refusing medications, pacing, intrusive wandering, and yelling with behavioral disturbances related to his/her Dementia diagnosis. Continued review revealed the goal included Resident #23 would demonstrate effective coping skills related to his/her behavior. Per review, the interventions for the Behavior Care Plan included: to administer medications as ordered; approach the resident in a calm, friendly manner; allow him/her to vent feelings or needs; and familiarize the resident with his/her own environment. Additional interventions included: if Resident #23 became combative or resistive to care, staff should postpone the care or activity and re-approach the resident after he/she regained his/her composure. Review of the care plan further revealed additional interventions for maintaining a safe environment for Resident #23, providing diversional activities, and providing the resident his/her personal space. Review of Resident #23's care plan revealed no documented evidence the care plan was revised/updated after Resident #23 grabbed Resident #24's ankle and got into his/her belongings on [DATE] or [DATE]. Review of the Long Term Care Facility - Self-Reported Incident Form, completed by the ED and dated [DATE], revealed Resident #23 wandered into Resident #24 room and was in his/her personal belongings. Resident #24 hit Resident #23 in the nose with his/her cane, which resulted in a bloody nose. Interview with MDS Coordinator #3 on [DATE] at 10:14 AM, revealed she was aware of the incident of Resident #23 entering another resident's room and going through his/her belongings. She stated she tried to update residents' care plans as concerns or issues were discovered. MDS Coordinator #3 stated Resident #23's care plan should have been updated after the behaviors of wandering and rummaging through other residents' belongings were displayed. Telephone interview with the Executive Director on [DATE] at 3:00 PM, revealed he was aware of the incidents where Resident #23 had rummaged through Resident #24's belongings. The ED stated he was not aware if the residents' care plans were updated/revised.

Based on observations, interviews, record reviews, and review of the facility's policies it was determined the facility failed to ensure the environment remained as free of accident hazards to prevent injuries for two (2) of twenty-seven (27) sampled residents (Resident #2 and #23). Resident #2 experienced a change in behaviors and bit staff; however, there was no documented evidence the facility addressed this change in behavior to protect other staff and residents. Resident #2 bit Resident #1, who sustained injuries requiring medical intervention. Resident #23 wandered in and out of rooms, entered Resident #24's room and bothered the resident's personal belongings. However, there was no documented evidence the facility increased monitoring of the resident to protect the resident or others. Resident #23 later entered Resident #24's room again, and was hit with a cane and sustained a bloody nose. The findings include: Review of the facility's policy, Accidents and Incidents- Investigating and Reporting, revised [DATE], revealed all accidents or incidents involving residents and employees should be investigated and reported to the Administrator. Additionally, the Nurse Supervisor/Charge Nurse and/or the department director/ supervisor should initiate and document investigation of the incident or accident. Review of the facility's policy, Safety and Supervision of Residents, revised [DATE], revealed three (3) types of approaches to safety: facility-oriented, individualized, and systems. Facility-oriented approach to safety addressed safety to groups of residents, where safety risks were identified on an ongoing basis through employee monitoring, reporting process and training. Additionally, employees should be trained on potential accident hazards and should try to prevent avoidable accidents. As an individualized resident-centered approach, the interdisciplinary team (IDT) should analyze information from assessments and observations to identify hazards or risks for individual residents. The IDT should target interventions to reduce risks, including adequate supervision. Further review revealed interventions to reduce risk of hazards consisted of; communicating specific interventions to all relevant staff, providing training, ensuring interventions were implemented, and documenting interventions. As a systems approach, resident supervision should be a core component, where the type and frequency of resident supervision would be determined by the resident's assessed needs and identified hazards. Identified resident risks and environmental hazards included unsafe wandering. Review of the facility's policy, Wandering- Unsafe Resident, revised [DATE] revealed the resident's care plan would indicate the resident's risk for safety issues and interventions, such as a detailed monitoring plan. Review of the facility's policy, Change in Condition, dated [DATE], revealed for a Non-urgent Change in Condition all symptoms and unusual signs should be documented in the medical record and, communicated to the Nurse Practitioner (NP). The charge nurse should notify the physician/NP and family/responsible party prior to the end of shift. Review of the facility's policy, Resident-to-Resident Altercations, revised [DATE], revealed all altercations should be investigated and reported to the Nurse Supervisor, the Director of Nursing Services, and the Administrator. Facility staff should monitor residents for aggressive/inappropriate behaviors towards residents/staff, document the behaviors in the resident's clinical records, and include all interventions and effectiveness. 1. Review of the clinical record revealed, the facility admitted Resident #2 on [DATE], with diagnoses to include dementia, and major depressive disorder. Resident #2 was diagnosed with COVID-19 on [DATE] and resided on a secured COVID-19 Red zone of the memory care unit at the time of the incidents. Record review revealed Resident #2 was transferred to a hospital on [DATE] and later expired. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely impaired. Review of Resident #2's Behavior Care Plan, reviewed [DATE], revealed Resident #2 was at risk for alterations in mood and/or behavior symptoms related to dementia and depression. He/she was at times irritable with staff, occasional verbal with residents. The goal for this behavior included Resident #2 would have improved mood state as evidenced by a decrease in frequency of mood symptoms. Interventions included: administer medications as ordered and observe for adverse side effects, assist the resident in developing by providing the resident with a program of activities that was meaningful and of interest, behavioral health consults as needed, encouraging the resident to express feelings, and to notify behavior health specialists of no improvement, worsening or changes in the resident's mood. Record review revealed the facility admitted Resident #1 (alleged victim) on [DATE] and readmitted him/her on [DATE] with diagnoses that included dementia, schizophrenia, major depressive disorder, and anxiety. Further review revealed Resident #1 resided on a secured COVID-19 memory care unit at the time of the incident. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #1 with a BIMS score of five (5), indicating the resident was severely cognitively impaired. Review of Resident #1's Comprehensive Care Plan, dated [DATE] revealed Resident #1 exhibited behavior symptoms of wandering, impulsivity, abruptly rises from wheelchair and walks with unsteady gait. Resident #1 exhibited behaviors of walking in other residents' rooms and getting in others personal space. The goal for this behavior was Resident #1 would be free of unidentified complications related to behavior. Interventions for Resident #1 included: removing resident from situations, providing personal space, allowing resident to vent feelings, approaching resident in a calm and friendly manner, explaining procedures prior to start, familiarizing resident with own belonging and surroundings, observing for the resident's needs, and providing diversional activities Review of the facility's incident report, First Report of Injury, received [DATE] at 1:20 PM, revealed Certified Nurse Assistant (CNA) #5 incurred surface wound and bruises to the right upper arm, while she and CNA #3 were transferring a resident (Resident #2) from the bed to wheelchair. During the transfer, the resident leaned in and bit CNA #5 on her right arm. Interview with Unit Manager (UM) #2, for units 1B/1C on [DATE] at 3:45 PM revealed Resident #2 bit the arm of CNA #5 on [DATE]. Further interview revealed this was a new behavior for Resident #2. Continued interview with UM #2 on [DATE] at 2:34 PM, revealed incidents or changes in residents' conditions were discussed in the morning meetings. However, she was unaware of any documentation or interventions after this incident and did not remember if the incident was discussed in morning meeting. Additionally, UM #2 stated interventions would have helped to prevent Resident #2 from biting someone else. Interview with CNA #5 on [DATE] at 10:08 AM revealed Resident #2's health declined after diagnoses of COVID-19. Per interview, Resident #2 had not displayed behaviors of biting prior to [DATE] when he/she bit her on the arm. An additional interview with CNA #5, on [DATE] at 1:22 PM, revealed she reported her bite to an agency nurse; however, she could not recall her name. CNA #5 additionally stated she was unaware if any interventions were implemented after she was bitten. She stated it would have been helpful for staff to be aware of the incident for the care of the residents and to keep them safe. Interviews with CNA #3 on [DATE] and [DATE] revealed, she witnessed Resident #2 bite CNA #5. CNA #3 stated she assisted CNA #5 transfer Resident #2. She further stated Resident #2 became aggravated, but CNA #5 went ahead and transferred the resident. Upon transfer, Resident #2 bit CNA #5. Additionally, CNA #3 stated Resident #2 did not have a history of biting and it was a new behavior. Continued interview revealed CNA #3 was not aware of any interventions after the incident. However, she stated the second bite might have been prevented. Review of the facility's investigation report, completed by the Executive Director (ED) on [DATE], revealed Resident #1 was found sitting in the hallway with blood on his/her nightclothes and lacerations to the top lip and right ear. The lacerations were inconsistent with an injury sustained from a fall. Continued review revealed CNA #7 and CNA #4 saw Resident #1 on the floor and notified a nurse. After Resident #1 was transported to the ER (emergency room ), a trail of blood was noticed leading to Resident #2's bed from the hallway. CNA #7 no longer worked for the agency and no phone number was available. Telephone interview with agency CNA #4 on [DATE] at 1:47 PM revealed she did not witness Resident #2 bite Resident #1. CNA #4 stated after the nurse arrived to Resident #2's room they noticed blood on the sheets and on the resident's mouth. Additional interview on [DATE] at 1:55 PM revealed CNA #4 did not know about Resident #2 biting a CNA on [DATE] until after Resident #2 bit Resident #1. Telephone interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:23 AM, revealed she was agency staff and had completed one (1) or two (2) shifts at the facility. LPN #3 stated she was assigned to the memory care COVID-19 unit, RED Zone. The LPN stated she had additional residents she was responsible for during the shift. LPN #3 stated two (2) CNAs were assigned to the RED Zone, however when Resident #2 bit Resident #1, there was no supervision on the RED Zone. Furthermore, she stated she was unaware of the incident on [DATE] when Resident #2 bit CNA #5 until after the resident-to-resident incident. In addition, she stated it would have been helpful to know about the previous incident prior to the second incident. Telephone interview with Regional Nurse Consultant (RNC) on [DATE] at 3:13 PM revealed she was unaware of any documentation or interventions made after Resident #2 bit CNA #5. Further interview revealed there was a potential Resident #5 could cause harm to others. Interview with Executive Director (ED) on [DATE] at 2:48 PM, revealed no interventions were immediately implemented after Resident #2 bit CNA #5. Further interview revealed an investigation was not initiated after the incident. The ED stated Resident #2 was not able to get out of bed at the time of the incidents. However, it should have raised a concern for other residents' safety. Additionally, he stated the fifteen (15) minute checks initiated after Resident #2 bit Resident #1 could not be found. An additional interview with ED on [DATE] at 8:54 AM revealed the expectation for supervision on the memory care unit was to keep an eye on the residents to ensure their safety. He stated during busy times such as shift change and meal times, the Red Zone should be monitored, and staff should be present. 2. Review of Resident #23's clinical record revealed the facility admitted Resident #23 on [DATE], with diagnoses including encephalopathy, Alzheimer's, and dementia. Resident #23 resided on a secured Yellow Unit, memory care unit at the time of the incident on [DATE]. Review of the Admission MDS dated [DATE], revealed the facility assessed Resident #23 with a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely impaired. Review of Resident #23's Behavior Care Plan, initiated [DATE], revealed Resident #23 exhibited behavior symptoms of refusing medications, pacing, intrusive wandering, yelling related to dementia with behavioral disturbances. The goal for this behavior included Resident #23 would demonstrate effective coping skills related to behavior. Interventions included: administer medications as ordered, approach in a calm, friendly manner, allow to vent feeling or needs, familiarize resident with own environment, if resident becomes combative or resistive, postpone care or activity and re-approach after composure regained, maintain safe environment for resident, provide diversional activities, and provide resident personal space. Observation of Resident #23 on [DATE] at 3:01 PM, revealed Resident #23 up in the bedside chair, asleep, wearing a WanderGuard on his/her left ankle. Resident #23 was non-interviewable. Review of the clinical record revealed the facility admitted Resident #24 on [DATE], with diagnoses including bipolar disorder. Resident #24 resided on a secured COVID-19 memory care unit at the time of the incidents. Review of the Admission MDS dated [DATE], revealed the facility assessed Resident #24 with a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating the resident had moderate impairment. Review of Resident #24's Behavior Care Plan, initiated [DATE] revealed Resident #24 was at risk for alterations in mood or behavior. The goal for this focus was he/she would have improved mood state. Interventions for this goal were accomplished by administering medication as ordered, assisting the resident to identify strengths and positive coping skills, behavioral consults, ensure light remain on and ensure cell phone was charged and within reach. Interview with Resident #24 on [DATE] at 9:02 AM, revealed when admitted to the facility on [DATE], Resident #23 was roommate his/her roommate. Resident #24 reported, Resident #23 came onto his/her side, stole his/her water, and grabbed his/her ankle. Resident #24 reported the event and was moved to another room. He/she additionally reported, Resident #23 came back into his/her room, started getting into his/her stuff the night of [DATE]. Resident #24 stated he/she hit Resident #23 in the face with his/her cane and said, It left a mark. Resident #24 stated Resident #23 left the room after he/she hit him/her. Interview with CNA #10 on [DATE] at 10:27 AM, revealed she was agency staff and it was her first time in the facility. She stated at the time of the incident, she was at the nurses' station and heard two (2) residents yelling on the other side of the plastic barrier, which denoted the yellow unit. CNA #10 stated, the other CNA on the unit was at the nurses' station with her. She stated there was no supervision on the other side of the plastic barrier at the time of the altercation. She also indicated, the nurse on the unit was not present at the time of the incident. CNA #10 stated she was not familiar with the resident and was not given a rundown to the unit/residents until 2:00 AM. Further interview with CNA #10 revealed, there were five (5) or six (6) residents on the yellow zone of the memory care unit the night of the incident. CNA #10 stated Resident #23 wandered into Resident #24's room. Continued interview revealed Resident #24 hit Resident #23 with a cane. The CNA stated another CNA went to find UM #2, but it took a while. Telephone interview with CNA #11 on [DATE] at 5:00 PM, revealed she worked for an agency and had worked at the facility around three times, but not on the memory care unit. CNA #11 stated she was at the nurse's station when she witnessed what sounded like a heated argument in the yellow zone. She stated when she approached the resident, he/she had already been hit and was standing outside of the door of the other resident's room with a bloody nose. CNA #11 stated the other resident, had a cane in his/her hand, and was standing in his/her room with door cracked. She stated she separated the residents and had the other agency CNA to watch the residents while she found the nurse on another unit. CNA #11 stated, at the time of the incident there was no supervisor on the unit. She also stated, she had previously asked the nurse on the floor if there should be someone supervising on the Yellow Unit, since it was hard to see through the clear plastic barrier. Further interview with CNA #11, revealed after the incident a third CNA was assigned to the yellow zone. CNA #11 stated it was worrisome that all the CNAs assigned to the unit were agency staff. She stated the information she received in report was inaccurate. Interview with UM #2 on [DATE] at 8:22 AM revealed, she was working as a floor nurse on [DATE]. She stated the incident happened between 11:30 PM and 11:40 PM on 1C. At the time, she was working on another unit, 1B, and did not witness the incident. UM #2 said she worked both halls after 11:00 PM when the other nurse went home. UM #2 stated the CNA had come to get her on 1B and told her a resident had hit another resident. She stated the resident stated that he/she was in my room and, I got (him/her) good with my cane. UM #2 stated she assessed Resident #23 and cleaned his/her bloody nose. She also assigned a CNA to watch Resident #23, notified the Director of Nursing Services (DNS), and filled out an incident report in point click care (PCC). Further interview revealed UM #2 was advised to move Resident #24 to another floor and put him/her on 1:1 supervision. UM #2 stated Resident #23 was the only resident who was not alert and oriented and no one on the unit needed 1:1 supervision. She further stated normally there was no one on the yellow zone for supervision. Telephone interview with the Executive Director on [DATE] at 3:00 PM, revealed he was aware Resident #23 had rummaged through Resident #24's belongings, and a room change was initiated after the incident. He further stated his expectations on the Yellow Zone of the memory care unit would be frequent resident checks. The ED stated, anytime a resident-to-resident incident occurred it raised a concern.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to protect two (2) of thirteen (13) sampled residents from abuse (Resident #1 and Resident #2). On 07/09/2020, before the facility admitted Resident #2, the facility received documentation from the hospital's case manager that Resident #2's displayed inappropriate sexual behaviors toward the opposite sex. The facility admitted Resident #2 on 07/12/2020, to the secured Memory Care Unit (MCU); however the facility did not have a plan in place to protect residents from Resident #2's known sexual inappropriate behaviors. Interviews and record review revealed Resident #2 immediately displayed inappropriate sexual acting out behaviors towards Resident #1 three (3) separate times within four (4) hours of his/her admission on 07/12/2020. The facility did not report the incident and failed to initiate an investigation for the reported behavior toward the resident on 07/12/2020. The facility failed to increase Resident #2's supervision until after the third incident of inappropriate sexual acting out behavior. On 07/22/2020, interviews revealed the facility continued the 1:1 supervision initiated on 07/12/2020. However, record review revealed, on 07/22/2020, staff found Resident #2 in Resident #1's room, alone, and staff observed the resident standing over Resident #1 Staff did not immediately notify administration. However, staff documented on the MCU morning report sheet, dated 07/22/2020, of the incident. The facility did not initiate an investigation for 07/22/2020 incident that occurred while the resident reportedly remained under one on one supervision. Administration reported the resident remained on one on one supervision until 07/26/2020 when the facility removed the 1:1 supervision with the determination Resident #2 had not displayed inappropriate sexual behaviors since 07/14/2020. In addition, the facility admitted Resident #1, on 03/27/2020. Resident #1 exhibited inappropriate behaviors, which included to seek out, attempt to physically touch and flirt with the opposite sex, and wandered into other residents' rooms. On 07/30/2020 at approximately 9:00 AM, therapy staff found Resident #2 on top of Resident #1 in Resident #2's bed. Staff interviews revealed the therapist observed and reported to unit staff that Resident #2's face was placed into Resident #1's crotch. On 07/30/2020, the facility moved Resident #2 from the secured unit to an unlocked unit. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused, or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on, 08/14/2020, and determined to exist on 07/30/2020. The facility provided an acceptable Allegation of Compliance (AoC) on 08/26/2020, alleging removal of the Immediate Jeopardy (IJ) on 08/25/2020. The State Survey Agency validated the removal of the Immediate Jeopardy on 08/25/2020, as alleged, prior to exit, on 08/28/2020 with the remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at a scope and severity of a D while the facility develops and implements a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse Prevention Program, undated, revealed resident rights included to be free from abuse. The facility prevented abuse by identifying patterns and identification of the occurrence of abuse. The facility will protect residents during an investigation of abuse and complete a thorough investigation of all reported allegations of abuse. In addition, sexual abuse is the non-consensual sexual contact of any type with a resident. Furthermore, the facility required staff to report any suspected abuse immediately to Administration. Review of the facility's policy, Accidents and Incidents, dated July 2017, revealed the department director promptly initiated and documented an investigation for an accident or incident. The Report of Incident Accident Form would be used for all documentation of the obtained data, which included the date, time, nature of incident, circumstances, location, names of witnesses, residents involved, notifications, assessment, any corrective action taken, follow-up and signature of the person completing the report. The facility did not provide a policy on supervision of a resident or 1:1 supervision of a resident. The facility did not provide a policy on behavior management. Review of Resident #1's clinical record revealed the facility admitted the resident, on 03/27/2020, with multiple diagnoses, which included Traumatic Brain Injury (TBI), Behavior disorders, and wandered. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15) and determined the resident was not interviewable. The facility assessed the resident to not exhibit physical, verbal, or other behaviors. However, the facility assessed that the resident wandered. The facility developed a comprehensive care plan which included to keep the resident safe in relation to the resident's wandering. Review of Resident #1's Progress Note, dated 04/10/2020 at 10:29 AM, revealed the mental health provider ordered [MEDICATION(S)] and [MEDICATION(S)] (medications to help decrease a behavior). The reason noted for the ordered medications included increased verbal and physical inappropriate behavior toward residents. Continued review revealed, on 05/22/2020, staff noted the resident was physically hugging residents. On 07/17/2020, stated the resident had sought out a resident of the opposite sex resident and they redirected the resident. However, the resident continued to seek out this resident. Further review revealed Resident #1 also displayed assertive behavior toward this resident when approached. The medical provider and nursing supervisor had knowledge of the behaviors. Review of Resident #1's Medication and Treatment records, dated July 2020, revealed the resident's orders did not include to monitor for effectiveness of the medications for the behaviors exhibited. Observations, on 08/04/2020 at 3:28 PM, revealed that upon entry into the Memory Care Unit, fourteen (14) residents sat in chairs across from the nurse's station. Certified Nursing Assistants (CNA) #3, #4 and #8 and one (1) nurse, Unit Manager (UM) #1 stood at the nurses' station and talked. CNA #8 could not identify Resident #1, who was care planned to keep safe related to his/her behaviors of wandering into other residents' rooms. Staff searched the hallway, and checked other residents' rooms. Further observation revealed CNA #4 found Resident #1 at the opposite end of the hall, in another resident's room. Interview with CNA #4, on 08/04/2020 at 3:35 PM, revealed Resident #1 wandered all the time into rooms and gravitated into the opposite sex residents' rooms. CNA #4 stated staff had to search for the resident often. According to CNA #4, Resident #1 liked to flirt. Interview with CNA #8, on 08/04/2020 at 3:35 PM, revealed Resident #1 sought opposite sex residents on the unit and liked to touch them. She stated Resident #1 liked to flirt and gravitated toward Resident #2 when the resident resided on that unit. CNA #8 stated staff searched for Resident #1 often because they could not visually locate the resident. Further observations, on 08/07/2020 at 9:05 AM, revealed upon entry to the MCU, CNAs #1 and #8 assisted in the dining hall for breakfast, and Licensed Practical Nurse (LPN) #5 sat inside the nurse's station and worked on the computer. The staff could not locate Resident #1 in the hall or dining hall. CNA #8 proceeded to open resident doors with LPN #5 and both Resident #1's name. LPN #5 found Resident #1 in a room with a closed door at the opposite end of the hall. Staff could not identify the last time they observed the resident. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 07/12/2020, with multiple diagnoses, which included Dementia with Behavioral Disturbances, Post Traumatic Stress Disorder ([CONDITION(S)]), and Communication Deficit. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident was interviewable. The facility assessed that the resident did not exhibit physical (including abusing others sexually), verbal, or other behaviors under section E0200.1. Review of Resident #2's Nursing Note, dated 07/12/2020 at 11:19 PM, revealed the unit aide instructed Resident #2 twice to not touch Resident #1's breasts. Staff notified the DON after the first two (2) occurrences. Staff continued to attempts to keep Resident #2 away from female residents. However, record review revealed Resident #2 touched Resident #1's breast a third time. Review of the Abuse prevention policy revealed staff would initiate an investigation for any reported abuse by staff, to ensure residents were kept safe during the investigation process. However, the facility did not provide an investigation for the 07/12/2020 reported sexual abuse. Review of Resident #2's Clinical Progress Note, dated 07/22/2020 at 3:49 PM, revealed staff found Resident #2 with Resident #1 in Resident #1's room. Resident #2 stood over Resident #1, who sat on the bed when staff found the residents. Staff did not know what occurred before they found the residents alone together. Staff removed Resident #2 from the room. Resident #2 behaviors included to follow female residents during the shift. Continued review revealed, on 07/22/2020 at 11:41 PM, the facility informed Resident #2's family to find new placement as Resident #2 was inappropriate on the MCU. The facility's policy stated staff would immediately report all suspected abuse. The facility did not provide an incident report for 07/22/2020. Review of facility's Progress Note, dated 07/26/2020 at 11:03 PM, revealed staff checked on Resident #2's location throughout the shift and monitored Resident #2 when staff saw female residents in the area close to the resident. Staff did not follow policy. Review of Resident #2's behavioral note, dated 07/30/2020 at 2:19 PM, revealed the Assistant Director of Nursing (ADON), documented therapy staff reported to the facility they found Resident #2 with Resident #1 in bed together with the head of Resident #2 in the mid-area of Resident #1 abdomen. The facility moved Resident #1 off the secured unit onto an unsecured unit. However, the facility did not initiate the close supervision by staff after the staff reported the abuse and while the facility completed an investigation. The facility did not the follow the policy for the prevention of abuse which included to protect the residents's from abuse when the facility identified a pattern for the potential of abuse. The policy referred to the definition of sexual abuse as the non-consensual sexual contact of any type with a resident. Record review revealed the facility assigned LPN #7 on 07/30/2020 to the MCU day shift. Further review revealed LPN #7 did not complete documentation in Resident #1's and Resident #2's clinical chart for 07/30/2020 reported incident by therapy staff. Further observations, on 08/05/2020 at 9:30 AM, revealed Resident #2 walked up and down the unsecured hall 2 C without supervision by staff. The assigned CNA's, nurse, and medication technician provided care in resident rooms and passed medications. The resident eventually sat in a chair in the activity room in a chair, which did not allow staff to visualize the hall. Later, a resident of the opposite sex wheeled into the activity room and placed himself/herself behind the wall near where Resident #2 sat. Resident #2 continually observed the resident's motions with focused intent and interest to the resident until he/she left. Record review revealed on 07/30/2020, the MCU had twenty-seven (27) residents on the unit. Interview with the Occupational Therapy Assistant (OTA), on 08/16/2020 at 1:18 PM, revealed her assigned unit included therapy to the residents in the MCU. She stated she worked 07/30/2020 on the MCU and returned to Resident #2's room, located at the opposite end of the unit, with roommate at approximately nine (9) AM. She stated she observed the position of the door as closed or almost closed. She stated she walked into the room, saw Resident #2 laying on top of Resident #1 with his/her face in Resident #2's crotch. She stated both residents appeared dressed. However, she stated Resident #1's sweat pants appeared pulled down slightly at the hip level. She stated she called out to Resident #2 as to what was he/she doing on top of him/her and Resident #2 got up and stood at the bedside. The OTA stated she ran to the door, and told staff she found Resident #2 on top of Resident #1 with his/her face in the crotch to the staff, and staff ran back to the room. The OTA stated when staff returned to the room, Resident #2 now stood by the window and Resident #1 remained curled in the bed. The OTA stated, clinical staff notified the DON and the DON came to the resident's room. The OTA stated the DON interviewed her on the unit, without writing tools or a computer, and verbally interviewed her about her observations. The OTA stated the DON did not request a written statement or a signature of a hand written or typed statement by the DON on 7/30/2020 or 7/31/2020. Interview with the Reliant Therapy Supervisor, on 08/06/2020 at 2:30 PM, revealed the OTA reported to her on 07/30/2020 approximately at 9:30 AM. She state the OTA reported she found Resident #2 on top of Resident #1 while in bed with Resident #2's face placed into the crotch of Resident #1. She stated the OTA initially reported this by a text message. Review of a text message, dated 7/30/2020 at 9:34 AM, revealed the OTA text the statement that she had found Resident #2 on the bed on top of Resident #1 with Resident #2's face in Resident #1's crotch and that Resident #2 should not be on the MCU around residents with poor cognition. Interview with the CNA #1, on 08/06/2020 at 2:55 PM, revealed she worked 07/30/2020. The CNA stated staff knew Resident #2 exhibited previous inappropriate sexual behaviors before 07/30/2020. She stated Resident #1 sought out the opposite sex and touched residents and flirted. In addition, staff monitored Resident #2 around the opposite sex. She stated, on 07/30/2020, the OTA yelled down the hallway, reported she found Resident #2 on top of Resident #1, and staff ran to the room. She stated the facility did not allow residents to cohort in the MCU because the residents could not make decisions. She stated her location at the time of the incident included dining hall at the opposite side of the hall and staff could not see that far down the hall. She stated by the time staff entered the room the residents had separated and did not appeared harmed. She stated the facility moved Resident #2 off the floor the same day. Interview with CNA # 9, on 8/07/2020 at 1:07 PM revealed she worked 07/30/2020. She stated staff knew Resident #1 frequently went to the opposite sex, flirted, and touched residents. She stated staff knew Resident #2 history of inappropriate sexual behaviors. She stated her routine included to place two (2) briefs on Resident #1 to prevent anything from happening to him/her. She stated she did this because Resident #1 always gravitated toward the opposite sex on the unit. She stated Resident #1 entered into Resident #2's room continuously before the incident and staff often found Resident #1 in Resident #2's room when staff searched for the resident. She stated Resident #1 could not give consent for relations due to poor cognition. CNA #9 stated the OTA reported she found Resident #1 on top of Resident #1. She stated the OTA specifically stated she saw Resident #2's face in the crotch of Resident #1. She stated the DON requested a written statement, which she provided. Continued interview revealed her written report included staff found Resident #1 standing by the window and Resident #2 in the bed curled up in a fetal position as her observation. She stated neither resident appeared to be undressed or redressed. She further stated her written statement included the OTA reported to staff she found Resident #2 on top of Resident #1 with Resident #2's face placed into Resident #1's crotch. Interview with CNA #8, on 08/12/2020 at 3:05 PM, revealed she worked MCU daily and worked on 07/30/2020. She stated Resident #1 could not give consent because she/he could not make decisions. She stated Resident #1 wandered into resident rooms, flirted, and sought out the opposite sex. She stated Resident #2 required 1:1 supervision after admission because he/she fondled the opposite sex on the unit. However, she stated the 1:1 did not last after a couple days. She stated the OTA stated what she had observed, which she further stated exhibited sexual abuse. She stated her statement included the report the OTA verbalized about the crotch. She stated Resident #2 understood what he/she did because he/she appeared too high level for the unit and did not require staff's assistance. She stated the OTA appeared very upset. Interview with Licensed Practical Nurse (LPN) # 7, on 08/13/2020 at 9:45 AM, revealed that on 07/30/2020 she worked the MCU. She stated the facility staff had heard of a resident on the MSU who staff closely monitored for sexual behaviors but she did not have knowledge as to whom. She stated she knew residents on the MCU unit wandered. However, she did not receive report that Resident #1 sought out the opposite sex and was unable to keep up with his/her whereabouts because the resident walked quickly and quietly. She stated Resident #2 returned to his/her room and observations of Resident #1 included him/her wandering up and down the hall. She stated she stood by the dining hall while she worked on the medication cart, on the opposite side of the unit of Resident #2's room. She stated the OTA ran down the hall and yelled Resident #2 had been observed on top of Resident #1 in the resident's bed. She stated all staff went to the room. She stated Resident #2 appeared unharmed, in bed on his/her side asleep. She stated the aides reported later in the day the OTA told them at the time of the incident the OTA observed Resident #2's face in the crotch of Resident #1. However, she stated when she notified the DON immediately of the OTA's report she stated the OTA only reported that she found two (2) residents in bed together. She stated the DON did not direct her to complete skin assessments to the other residents or any other directive. She stated she completed a skin assessment for Resident #1. However, she stated she did not remove Resident #1's clothing. Instead, she reviewed the clothing on Resident #1 to see if the pants seemed displaced and checked his/her arms and face. She stated the facility removed Resident #2 from the unit the same day, and watched Resident #1 for change in condition. Review of Resident #2's Hospital Referral Packet, dated 07/09/2020, revealed on 07/08/2020 at 1:00 PM, Case Management (CM) noted Resident #2 displayed inappropriate behavior toward a female worker which included verbal and physical behaviors. The CM noted Resident #2 touched the worker's breasts. The hospital provided male workers after the incident. In addition, the CM noted the resident did not have the need for skilled care because the resident took care of his/her personal care needs. Interview with Case Manager (CM), on 08/13/2020 at 10:46 AM, revealed resident referrals included documentation of any inappropriate behavior the resident may have displayed while hospitalized . She stated the CM spoke directly to the facility's liaison about the referral, history, and the packet information was sent to the Liaison. She stated the liaison contacted the facility. She further stated she verbally reported and then documented on the email to the liaison of Resident #2 behavior with review of the chart. Interview with the Hospital Liaison, on 08/13/2020 at 11:50 AM, revealed she saw the information provided by the hospital in regard to Resident #2's inappropriate behaviors. She stated she sent the documentation to the facility and the facility discussed all referrals to decide if the facility would be capable to care for the resident's needs. She stated the facility email included the chain of all correspondences. Review of the facility's process chart for review of admissions, undated, revealed residents with known behaviors fell under the yellow category, which required review before the facility accepted the resident. Record review requested to the facility's Admission Coordinator, on 08/13/2020, or the email chain from the hospital about Resident #2's referral as the coordinator stated she could provide. However, with follow-up on 08/13/2020 at 5:00 PM, the Administrator stated the facility could not provide the documents because at the current time legal representation had the email and was completing a review. The Administrator further stated the email contained personal emails as to the reason for the review. Interview with Unit Manager (UM) #3, on 08/14/2020 at 1:50 PM, revealed she was not in the facility on 07/30/2020. However, the next day in the facility clinical meeting staff discussed the OTA's report of the observed incident between the residents. The UM stated the supervisor stated the OTA reported she observed Resident #2 laid on Resident #1 in the bed with Resident #2's face placed into Resident #1 crotch per discussion. The UM stated the facility met to discuss all referrals and provided Resident #2's referral to her and other documentation on 07/12/2020 before admission. The UM stated she reviewed the referral and noted the CM's note on inappropriate behavior. She stated the DON and the facility reviewed potential admissions and would have known about the behavior. She stated the facility did not plan 1:1 supervision before admission to the unit and wondered why the facility assigned Resident #2 to the MCU due to the apparent high function of the resident. The UM further stated, due to poor cognition, Resident #1 could not make decisions, give consent and required full care. Furthermore, Resident #2 did not require assistance, able to make decisions, and the facility placed the resident in the MCU because the family requested a locked unit to keep the resident from an elopement. Interview with the ADON, on 08/14/2020 at 2:09 PM, revealed the facility discussed Resident #2 prior to admission. She stated the facility knew prior to admission the resident's history of inappropriate behavior. She stated the facility did not initiate 1:1 supervision when the facility admitted a resident. She stated that after the reported first two (2) incidents of inappropriate behavior on 07/12/2020, the facility should have initiated 1:1 immediately. She stated she placed a late entry note into Resident #1's and Resident #2's chart on 07/31/2020 for the incident that occurred on 07/30/2020. However, she stated the floor nurse should have also documented the incident and did not know if the staff completed the note. She stated she spoke to staff on 07/31/2020 from the MCU. She stated the facility did not have a reason to disbelieve the OTA and the three aides reported the same as the OTA reported statement. However, the facility determined Resident #2 could not have gotten up as quickly as he/she did without the facility staff seeing the resident at or in the bed. Therefore, the facility questioned if the validity of the abuse report by the OTA. The ADON further stated the family wanted the resident in the secured unit due to the issues with the resident previous elopements. The ADON further stated she re-interviewed staff on 07/31/2020 and typed their written statements. Interview with the DON, on 08/07/2020 at 10:00 AM, revealed the DON stated upon request for Resident #2's incident report for the inappropriate behavior on 07/12/2020. The DON stated the staff notified her on 07/12/2020, but the facility did not have prior knowledge of Resident #2's prior behaviors. The DON further stated she did not know if she had a report. Review of Resident #2's Nursing Note, dated 07/12/2020 at 11:19 PM, revealed the unit staff notified the DON of the two episodes of Resident #2's inappropriate behavior toward a resident. Review of emailed documentation by the facility's ADON, on 08/06/2020 at 2:46 PM, revealed the ADON sent protected typed documents for interviews with staff. Review of CNA #15's typed statement for 07/30/2020, revealed the ADON documented the CNA reported the OTA stated she found Resident #2 in bed on top of Resident #1. The CNA entered the room and observed Resident #2 on the bed asleep and Resident #1 stood at the side of the room. The CNA did not sign the typed statement. Further review of the emailed documentation for CNA #15 revealed an unprotected view revealed red highlighted words, which were marked out. The red marked out words which included a typed statement of the CNA interview and included the OTA lady came to the lunchroom and stated (Resident #2) had (his/her face) in (Resident #1's) crotch. Interview with the DON, on 08/07/2020 at 10:00 AM, revealed the investigation for the 07/30/2020 reported abuse included the twelve (12) pages provided. She stated the facility did not have knowledge of previous behaviors for Resident #2's before admission. She stated staff notified her on 07/12/2020 of Resident #2's inappropriate behavior toward a resident. She stated the 07/12/2020 incident was reported as an unusual event. The DON stated if she had written an incident report for the event she did not remember where she placed the form. Continued interview with the DON, on 08/12/2020 at 12:00 PM, revealed she became aware of Resident #2's behavior with the 07/12/2020 phone call by staff. The DON stated Resident #2 touched Resident #1 on 07/12/2020, and had rubbed the other resident's breasts. She stated the definition of abuse included inappropriate touching of a person or resident. She stated, on 07/30/2020, staff and the OTA, stated the OTA found Resident #2 laid onto of Resident #1. The DON stated clinical staff informed her when they arrived to the room, Resident #1 stood by the window and Resident #2 laid in bed asleep. The DON further stated she did not feel the floor staff believed the OTA. The DON stated the OTA wrote a statement on the day of the incident 07/30/2020, which stated she found the residents in bed with Resident #2's head in the mid-section of Resident #1's abdomen. Furthermore, the DON stated the five (5) day completion of the investigation did not identify a root cause. She stated the facility moved the resident to an unsecured floor. She stated the facility did not experience further issues from the Resident #2. Interview with the Administrator, on 08/14/2020 at 3:07 PM, revealed the facility did not review Resident #2's referral. Therefore, the facility did not have knowledge the resident wandered or exhibited inappropriate behaviors. The facility alleged it completed the following steps to removed immediate jeopardy effective 08/25/2020: 1. The facility moved Resident #2, on 07/30/2020, to a secured unit and placed on one to one (1:1) supervision. 2. The facility performed a full skin assessment of Residents #1 and #2 on 07/30/2020 with no changes noted. 3. The facility placed Residents #1 and #2 on 1:1 supervision on 08/14/2020, which continues. 4. Psychiatric services assessed Resident #1 on 08/17/2020 and Resident #2 on 08/11/2020. 5. The facility assessed residents with a Brief Interview for Mental Status (BIMS) exam score of greater than eight (8) on 08/19/2020 with no exceptions noted. 6. The facility performed skin assessments on all residents with a BIMS of less than eight (8) on 08/24/2020. 7. The Vice President of Operations or the Senior Clinical Consultant reviewed all allegations of abuse, neglect and exploitation since on 06/01/2020 and 08/20/2020, with no exceptions noted. 8. The Senior Clinical Consultant provided education to the Executive Director, Director of Nursing Services and the Assistant Director of Nursing Services (ADNS) on 08/20/2020. The education topics included enacting appropriate interventions to protect all residents after an allegation and documentation required in the electronic medical record (EMR) related to an allegation of abuse and the interventions enacted. 9. The ADNS provided education to licensed nurses on 08/19/2020 and 08/20/2020 related to the process of notification of any type of abuse, actions taken, interventions to be used, and the necessary documentation. In addition, education included the types of abuse, 1:1 documentation, which included an order entered on the EMR and an intervention on the comprehensive care plan. Hourly supervision of the team member assigned to 1:1 with documentation at least once per shift. Continued education included completion of incident reports and discontinuation of interventions and the necessary steps. 10. The Senior Clinical Consultant educated all Department Managers on 08/24/2020 regarding the types of abuse, when and to whom to report to. 11. The Staff Development Registered Nurse (SDRN) and the ADNS provided education to the State Registered Nurse Assistants (SRNA) on 08/24/2020 related to types of resident abuse, what and when to report, and actions to take if witnessed. 12. All new hire nursing staff, ancillary staff, and agency staff will be educated during the orientation process. Any existing staff not educated by 08/24/2020 will not be allowed to perform direct resident care or report to their workstation until the facility has provided them with the education. 13. The Senior Clinical Consultant provided education to the Interdisciplinary Team (IDT) on 08/20/2020 and 08/24/2020. The IDT consists of the DNS, ADNS, Therapy, Social Services, the Dietician, Unit Managers, Medical records staff, and the Minimum Data Set Coordinator. The education included review of occurrences, the documentation required after review, and insuring all documentation is present and complete. In addition, the IDT received education on the types of abuse, actions to be taken, and the reporting process. The State Survey Agency verified the following actions were taken to remove immediate jeopardy, 08/25/2020, as alleged: 1. Observation of Resident #2, on 08/28/2020 at 2:20 PM, revealed he/she was located on the second floor, partially secured location. Unit B and Unit C separated with a keypad combination for movement between units. State Registered Nurse Aide (SRNA) #19 was present at the door entrance of the resident's room, and in direct visual line of the resident. Ongoing hourly documentation by SRNA #19 observed on the resident's Certified Nurse Aide (CNA/SRNA) Hourly Documentation form. Review of the documentation revealed the notes included additional documentation as the resident's activities changed within the hour. Review of Resident #2's hourly 1:1 documentation logs, dated 08/15/2020 to current, revealed staff assigned to Resident #2 documented the resident's activities hourly. 2. Review of the full skin assessment document completed with Resident #1 and Resident #2, dated 07/30/2020, revealed no changes with the skin. Interview with the DNS, on 08/28/2020 at 5:00 PM, revealed the complete full skin assessments with Resident

Based on observations, interview, record review and review of facility policy, it was determined the facility failed to have an effective system to ensure residents' Comprehensive Care Plans (CCP) were developed and implemented for six (6) of thirteen (13) sampled residents, (Resident #1, Resident #2, Resident #3, Resident #4, Resident #6 and Resident #8). The facility admitted Resident #1, on 03/27/2020, with known Behavior Disorders and Wandering. Observation, interview and record review revealed Resident #1 walked up and down the Memory Care Unit, entered other resident rooms, attempted to touch, hug, or kiss the opposite sex. Often times staff had to search the unit to locate Resident #1. The resident's care plan included to maintain a safe environment and provide diversional activities. The facility admitted Resident #2 on 07/12/2020 with known sexual behavior displayed toward the opposite sex. The facility initiated one to one (1:1) supervision on 07/12/2020 because the resident inappropriately touched Resident #1 multiple times. However, the facility did not maintain this supervision. On 07/30/2020, staff found Resident #1 and Resident #2 alone in a room on a bed. Staff reported to have observed Resident #2 on top of Resident #1 with Resident #2's face in the crotch of Resident #1. The facility failed to implement the residents' care plans. Resident #2 was assessed as being severely cognitively impaired and at a high risk for elopement. The Comprehensive Care Plan was initiated, on 07/13/2020, related to the resident's risk for elopement; however, the Care Plan did not include the necessary supervision level to keep the resident safe during the resident's [CONDITION(S)] appointments. On 08/04/2020, the facility sent resident #2 unassisted by facility staff to his/her [CONDITION(S)] appointment, even though the facility was fully aware of the resident's risk and history of elopement. At 11:14 AM, the resident arrived at the hemodialysis clinic building and walked alone into the building's foyer. At 11:15 AM, he/she exited the building, unsupervised. The resident was found around 1:00 PM, at a McDonald's restaurant, one-half (0.5) miles away from the hemodialysis clinic. To get from the clinic to McDonald's, Resident #2 had to cross six (6) streets and one (1) major interstate highway. The facility admitted Resident #3, on 04/02/19, with extensive assist needs and known incontinence of bladder and bowel to which the facility's interventions included to provide incontinent care when needed. In addition, the facility admitted Resident #4, on 02/10/2020, with total assist care needs with known incontinence of bladder and bowel. The facility interventions included to initiate brief checks every two (2) hours, routine checks on the residents for assistance with incontinence care. However, observations and interviews revealed staff were unable to provide routine checks and incontinent care to residents. Resident interviews revealed staff did not respond to the call bell and they were often left in urine and fecal matter for hours at a time. The facility did not implement the resident's care plans. The facility admitted Resident #6 on 12/18/2020, with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan was initiated, on 12/17/2019 stating Resident #6 is at risk for pain related to Pressure Wounds on Right Hip and Left Lateral Foot, with interventions stating to administer pain medications as ordered. However Resident #6 went from 05/29/2020 at 6:00 AM until 06/01/2020 at 12:00 AM without his/her scheduled pain medication (a total of three (3) whole days); not implementing Resident #6's interventions for pain prevention. Refer to F-697. The facility admitted Resident #8 on 06/24/2020, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 had a current active order for [MEDICATION(S)] ten (10) mg by mouth every six (6) hours as needed for pain, with a start date of 06/29/2020. The Comprehensive Care Plan was initiated, on 06/25/2020 with a focus stating Resident #8 is at risk for pain with an intervention which stated to notify physician of unrelieved or worsening pain. However, Resident #8 stated the facility would not reorder his/her pain medications timely and he/she would run out when another dose could be requested. The facility failed to implement care plan interventions for pain prevention and notification of pain to the physician. Resident #4's CCP, dated 10/15/19, revealed the facility's identified focus included incontinence. The intervention for staff included to check routinely for incontinence and provide care. In addition, the facility's focus for ADL care included toilet and personal hygiene care. Staff's interventions included to check on the resident routinely and provide care to the resident with two (2) staff. However, interviews revealed the resident often was not provide incontinence care and laid soiled for hours. The facility's failure to have an effective system in place to ensure resident care plans were implemented for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy (IJ) was identified, on 08/24/2020 and determined to exist on 07/30/2020. The facility provided an acceptable Allegation of Compliance (AOC) on 08/25/2020, alleging removal of the IJ on 08/25/2020. The State Survey Agency validated the removal of the Immediate Jeopardy on 08/25/2020, as alleged, prior to exit on 08/28/2020 with the remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.21 Comprehensive Resident Centered Care plans (F656) at a scope and severity lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: 1. Review of Resident #1's clinical record revealed the facility admitted the resident, on 03/27/2020, with multiple diagnoses, which included Traumatic Brain Injury (TBI), Behavior disorders, and wandered. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15) and determined the resident was not interviewable. The facility assessed the resident as not having exhibited physical, verbal, or other behaviors. However, the facility assessed the resident wandered. Continued review of the clinical progress notes, dated 04/10/2020 at 10:29 AM, revealed staff documented the facility notified Resident #1's provider of increased verbal and physical aggressive sexual behaviors toward staff and residents which the provider ordered medication to reduce the resident's reported behaviors. On 07/17/2020, staff documented the resident's seeking behaviors toward the opposite sex. On 07/20/2020, staff documented they found the resident with Resident #2 alone in a room and could not determine if inappropriate behavior occurred. In addition, on 07/30/2020, staff documented the facility found the resident in a room with Resident #2, on the bed underneath Resident #2. In addition. Resident #2 had his/her face positioned into Resident #1's crotch. Review of the facility's focused care plan for Resident #1, revealed the facility's identified focus included exhibits of behavior symptoms dated 03/30/2020 with revision on 04/08/2020, which included wandering. The facility's interventions included to maintain a safe environment and provide diversional activity. However, the facility did not follow the care plan policy to revise the resident's care plan after 04/08/2020 for the clinical documentation for seeking behaviors and verbal and physical sexual behaviors toward staff and residents. In addition, the resident's care plan did not reflect a revision for the sexual abuse which occurred on 07/30/2020. Observations, on 08/04/2020 at 3:28 PM, revealed upon entry into the MCU, fourteen (14) residents sat in chairs across from the nurses station. Three (3) aides, Certified Nursing Assistant (CNA) #3, #4 and #8 and one (1) nurse, Unit Manager (UM) #1 stood at the nurses' station and talked. CNA #8 did not identify Resident #1 visually and went to the resident's room without locating the resident. The CNA opened the door to the resident's room to find the bed empty. Further observation revealed CNA #4 walked Resident #1 out of a room at the opposite end of the hallway and escorted to the desk. Staff attempted to converse with the resident unsuccessfully. According to the resident's care plan staff to maintain a safe environment and provide diversional activity. Interview with CNA #4 and CNA #8, on 08/04/2020 at 3:35 PM, revealed Resident #1 wandered into resident rooms all the time and they would have to search for the resident. CNA #8 stated most of the men's rooms were on opposite side of the unit and the resident wandered into these rooms all the time. CNA #4 stated Resident #1 wandered all the time up and down the hall of the unit. CNA #4 stated the unit staffed 2 (two) aides on day shift on 08/04/2020. However, CNA #4 stated the unit needed three (3) at all times to maintain constant supervision of the residents to follow the resident's care plans. Continued observations on 08/04/2020 at 3:45 PM, revealed Resident #1 reached out for CNA #4 while standing in the nurses station area and continued to attempt to put his/her arms around the CNA. CNA #8 stated the resident just liked the men and grabbed at them all the time. Further observations, on 08/07/2020 at 9:05 AM, revealed upon entry to the MCU, CNA #1 and CNA #8 assisted in the dining hall for breakfast, and Licensed Practical Nurse (LPN) # 5 sat inside the nurse's station and worked on the computer. The staff could not locate Resident #1 in the hall or dining hall. CNA #8 proceeded to open resident doors and LPN #5 proceeded at the opposite hall to open doors, and call Resident #1's name. LPN #5 found Resident #1 in a room with a closed door at the opposite end of the hall. Staff could not identify the last time they observed the resident. Interview with CNA #14, on 08/14/2020 at 6:15 AM, revealed all twenty-nine (29) residents on the MCU required every 2-hour checks for evaluation and to change their briefs and incontinent care. The CNA stated Resident #1 required a brief change at least once a night. CNA #14 stated with two ( 2) staff on the unit, residents could not be checked every two (2) hours for care. She stated staff couldn't follow the care plan for the residents. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 07/12/2020, with multiple diagnoses, which included Dementia with Behavioral Disturbances, Post Traumatic Stress Disorder ([CONDITION(S)]), and Communication Deficit. Review of the Admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of seven (7) out of fifteen (15) and determined the resident was interviewable. The facility assessed the resident did not exhibit physical (including abusing others sexually), verbal, or other behaviors under section E0200.1. Review of Resident #2's CCP, dated 07/12/2020, revealed the facility's identified focus included exhibited behavior of sexual misconduct. The interventions staff provided included one to one (1:1) supervision with removal of the resident from a situation; approach in a kind friendly manner, and provide diversional activities. Review of Resident #2's Nursing Note, dated 07/12/2020 at 11:19 PM, revealed staff told Resident #2 twice to not touch the opposite sex residents in an inappropriate manner. Staff found Resident #2 in Resident #1's room; and Resident #2 had rubbed Resident #1 inappropriately for a third time. The facility failed then initiated 1:1 supervision, after the resident inappropriately touched the same resident for the third time. The facility did not provide an incident report for 07/12/2020. The facility did not provide documented evidence of the 1:1 supervision by staff for Resident #2. In addition, the facility did not provide evidence of the identified clinical staff assigned to Resident #2 for 1:1 observation. Review of Resident #2's Psychology Diagnostic Assessment, dated 07/20/2020, revealed the provider completed a second BIMS evaluation with a score of fourteen (14) out of 15 and determined the resident's cognition was intact. Review of Resident #2's clinical progress note, dated 07/22/2020 at 3:49 PM, revealed staff found Resident #2 with a female resident in a room. Staff stated Resident #2 stood over the resident when staff found the residents. Staff noted they did not know what occurred before they found the residents alone together. Staff removed Resident #2 from the room. Furthermore, the staff noted Resident #2's behavior included to follow female residents. Review of Morning Team Meeting/Memory Care Unit Note, on 08/07/2020 at 1:40 PM, revealed on 07/22/2020 staff wrote under the section of behaviors staff found Resident #2 standing over a female resident in a resident's room. The facility did not provide 1:1 documented supervision for Resident #2. Nor, did the facility provide evidence of the clinical staff assignment for Resident #2's 1:1 observation. Review of facility Progress Note, dated 07/26/2020 at 11:03 PM, revealed staff checked on Resident #2's location throughout the shift and monitored Resident #2 when staff saw female residents in the area close to Resident #2. However, the resident was to have 1:1 supervision. Review of the facility's Behavioral Note, dated 07/30/2020 at 2:19 PM, revealed the Assistant Director of Nursing (ADON), stated that therapy staff had reported to have found Resident #2 with Resident #1 in bed together with the head of Resident #2 in the mid-area of Resident #1 abdomen. The facility moved Resident #1 off the secured unit onto an unsecured unit without further supervision. Further observations, on 08/05/2020 at 9:30 AM, revealed Resident #2 walked up and down the unsecured hall of the assigned unit without staff supervision. The two (2) assigned CNA's, nurse, and medication technician provided care in resident rooms and passed medications. The resident eventually sat in a chair in the activity room in a chair, unable to be visualized by staff. Later, a resident of the opposite sex wheeled into the dining area and placed himself /herself behind the wall near Resident #2. Resident #2 continually observed the resident's motions until he/she left. Interview with CNA #8, on 08/12/2020 at 3:05 PM, revealed staff implemented resident care plans for supervision by working together. However, when the floor scheduled had two (2) CNA's on the unit, it became difficult to follow the care plan. She stated resident care plans for residents with behaviors of wandering included to allow the resident to wander. However, staff kept residents safe which included to keep the doors closed. She stated on 08/07/2020, staff did not monitor Resident #1 to ensure the resident remained safe because the staff had to search to locate the resident. The CNA further stated on 07/30/2020 staff did not follow the care plan for either resident, which allowed the resident to be in the room together. However, she stated Resident #2 did not require direct supervision after the first several days. She stated she did not know what the resident's care plan stated for behavioral care or safety. Record review of the CCP for Resident #1, revealed the intervention of diversional activity and to maintain a safe environment had the letter K next to the intervention. CNA #8 stated the K meant Kardex for the CNA care guide with the intervention added to the CNA documentation for care. Interview with CNA #14, on 08/14/2020 at 6:15 AM, revealed Resident #2 did not continue 1:1 supervision after the first couple of days after admission. She stated the facility did not have staff to provide 1:1. She further stated, when staff went on lunch or a break, the unit had one staff on the floor to supervise the residents, which is not reasonable. She stated care plans guided resident care. However, the care plans on the MCU contained the same items for safety and supervision. She stated she knew what needed to included when she documented on the KIOSK (electric charting for aides). However, she could not say she reviewed resident care plans because the unit o had her provide care to twenty-nine (29) residents. Interview with LPN #7, on 08/13/2020 at 9:45 AM, revealed when she worked on 07/30/2020 she did not review either resident's care plan. She stated the aides guided her as to what the residents needed. She stated she did not know Resident #1 wandered into resident rooms or had behaviors toward men. She also stated she did not receive information that Resident #2 displayed sexual behaviors. She stated that care plans directed resident care and staff expectations included to follow the care plan. However, she stated staff could not review all residents' care plans on a floor when placed on a floor they do not normally work. She further stated the facility completed the care plan to ensure the residents remained safe and met their individual need. Observation, on 08/04/2020 at 2:26 PM, revealed upon entry off the elevator onto the 2C Unit, a strong odor immediately became apparent. The odors included a strong musty ammonia odor and a unusually strong, putrid smell. The odors increased when staff toured the unit and walked to the end of the hall. The strong odors caused staff's eyes to water and throat to burn. Interview with CNA #2, on 08/04/2020 at 2:41 PM, revealed the aide identified the strong musty odor and putrid smell as urine and stool from the residents. She stated the unit smelled since she came onto shift at seven (7) AM and it did not get better throughout the day. She stated the facility provided a second aide an hour earlier in the day for help. CNA #2 stated up until that time, she did not have help. She stated with as many of the residents on the floor, the residents waited for care, which included bladder and bowel ADL care. The CNA stated it would not feel good to wait for staff to come and sit in a brief wet and dirty until time allowed. Interview with Un-sampled Resident A, on 08/04/2020 at 2:50 PM, revealed the resident's room location included the end of the hallway for 2C. The resident stated the facility always smelled like urine. Interview with Un-sampled Resident B, on 08/04/2020 at 3:00 PM, revealed the resident stated the facility smelled like an [NAME] with all the urine not cleaned. Observation, on 08/05/2020 at 9:35 AM, revealed upon entry to the 2C unit and tour, the strong odor of urine became apparent as soon as staff entered the unit and increased in intensity when staff toured the unit to the end of the hall at room [ROOM NUMBER]. 3. Review Resident #3's clinical record revealed the facility admitted the resident on 04/02/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), date 07/06/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of 15 and deemed the resident was interviewable. The facility's assessment revealed the resident was always incontinent of urine and bowel with a two (2)-person assist for care for toilet use. Review of Resident #3's CCP, dated 10/03/2019, revealed the facility's focus included assistance with Activity of Daily Living (ADL) care, which included personal hygiene and toilet use. The interventions included the resident required extensive assist with personal hygiene and was dependent on two (2) staff members to complete incontinent care. Staff's responsibilities included to check the resident routinely and provide incontinent care as needed. In addition, the resident required extensive two (2) person assist with transfer and bed mobility. Observation on 08/05/2020 at 9:30 AM, revealed the resident required an wheelchair for ambulation around the facility. Interview with Resident #3, on 08/05/2020 at 9:30 AM, revealed he/she wore a brief for incontinence. Resident #3 stated he/she had sat in a wet or dirty brief daily for over three (3) to four (4) hours with the day shift. The resident stated he/she would be incontinent after eleven o'clock but staff did not come change the brief until the morning shift came onto the floor. The resident stated he/she felt degraded when lying in fecal matter, urine or both. The resident stated he/she could not walk and get up on his/her own, and was dependent on staff to assist with his/her personal care. Resident #3 stated if he/she could complete the task by himself/herself he/she would. In addition, the resident stated up until his/her fall, which caused his/her injury, he/she was independent. Resident #3 stated the lack of care appeared worse on night shift. 4. Review of Resident #4's clinical record revealed the facility admitted the resident on 08/16/19 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated , 05/11/2020, revealed the facility assessed the resident with a BIMS of 15 out of fifteen (15) and determined the resident was interviewable. The facility assessed the resident as usually incontinent of bladder and bowel with extensive assist of two (2 ) staff for personal and toilet care needs. Review of Resident #4's CCP, dated 10/15/19, revealed the facility's identified focus included incontinence. The intervention for staff included to check routinely for incontinence and provide care. In addition, the facility's focus for ADL care included toilet and personal hygiene care. Staff's interventions included to check on the resident routinely and provide care to the resident with two (2) staff. Observation, on 08/10/2020 at 2:25 PM, revealed Resident #4's illuminated call light above the resident's door had been active upon arrival to the floor. However, there was no audible call alarm noted at the nurses' station or on the hallway. Further observation revealed staff, which included two (2) aides, a medication technician, and Unit Manager (UM) #1 were sitting or standing behind the nurse's station. At 2:36 PM, the medication tech sat and asked if Resident #4 had an active call light, came out of the nurse's station, searched the hall for an activated call light, and stated it was Resident #4 who needed help. Staff entered at 2:36 PM. Observations revealed it took eleven (11) minutes for staff to respond to the resident's request for assistance. During the interview with Resident #4, on 08/10/2020 at 3:40 PM, the resident stated he/she waited 15 minutes for staff to respond to the call light. The resident stated he/she called because he/she had a wet brief, full of urine. The resident stated he/she often laid in urine and stool, sometimes hours at a time, waiting to have staff come to the room to change the brief. The resident stated that at night it could be hours before staff responded. He/She stated he/she could not care for his/her needs and was totally dependence on staff. Resident #4 stated due to his/her medication he/she urinated often. He/She stated it took two (2) staff to clean him/her and the facility did not always have staff and residents have had to wait in wet, cold and stool filled briefs. In addition, the resident stated in recent weeks he/she had been ill and developed loose stools, which required even more frequent brief changes. Resident #4 stated he/she stayed in a dirty brief all night and staff did not respond to the call light. Observation, on 08/14/2020 at 5:20 AM, revealed one nurse and one aide on the 2C unit. CNA #12 worked alone on the hallway and gathered trash. Licensed Practical Nurse (LPN) #8 stood at the medication cart at the opposite hall. Interview with Resident #4, on 08/14/2020 at 5:30 AM, revealed he/she waited from 7:00 PM to 12:00 AM for staff to check him/her or answer the call light. He/she stated the call light went off and he/she had to reactivate it and gave up. Resident #4 stated she/he had the brief changed when the nurse came in to administer a medication at 12:00 AM. The resident stated he/she told the nurse that it was not a very nice feeling to sit in wet cold stool. Interview with CNA #12, on 08/14/2020 at 5:22 AM, revealed there was one aide and one nurse working. Further interview revealed the residents' needs were not met because they could not be in every room to care for the residents' multiple needs or complete every two (2) hour rounds on all the residents. CNA #12 stated they did the best they could, but they could not take care of the residents. The CNA stated he could not follow Resident #4's care plan because he could not care for every resident every two (2) hours. Interview with Registered Nurse (RN) #7, on 08/14/2020 at 5:30 AM, revealed with one aide and one nurse, residents who required two (2) for transfers, or care meant it took both staff off the floor. The RN stated residents did not receive their care needs because both staff could not handle the floor. RN #7 stated this meant care plans could not be followed. The RN stated UM #2 left late and was aware of staff's concerns to be able to meet the residents' needs. Continued interview revealed the staff instructions included to do the best they could and they pulled another aide from another floor when needed. RN #7 stated there was not enough staff on the unit to meet the resident's needs, and on the other units as well. The RN stated Resident #4 told her that he/she had laid in stool for four (4) hours at 12:00 AM when she delivered the resident's medication. According to RN #4, when they assisted Resident #4 and removed the blue pad, the pad stuck to the resident's lower back. Interview with UM #3, on 08/14/2020 at 1:50 PM, revealed the residents' care plans included providing care, supervision, and monitoring the residents and their needs. She stated it was everyone's responsibility to follow the care plans. UM #3 stated it was important for staff to follow the residents' care plans to ensure staff provided the residents' assessed care needs. Interview with the Administer, 08/14/2020 at 3:30 PM, revealed the facility had not identified any issues with residents' care plans or staffs' implementation of the care plans. The Administrator stated he would refer to the DON for any known issues. However, the DON did not present issues to him with review of resident care plans. 5. Review of Resident #2's medical record revealed the facility admitted the resident, on 07/12/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Hospital Discharge Summary, dated 07/12/2020, revealed the resident had wandered from his/her family's home multiple times, as well as walking out of the hospital, on 07/11/2020, without the staffs' knowledge. The hospital determined Resident #2 required twenty-four (24) hour observation on a locked unit related to his/her elopement risk. Review of Resident #2's Wandering/Elopement Risk Scale from his/her admission assessment, dated 07/12/2020, revealed the resident was assessed to be at high risk for elopement, and interventions should be initiated or planned to assess his/her risk. Further review of the admission assessment revealed the resident was assessed to have a memory problem, and he/she exhibited behavioral symptoms, such as wandering and exit seeking/history of elopement. Continued review revealed Resident #2 had a wander/elopement alarm implemented for him/her related to the assessed findings. Review of Resident #2's Comprehensive Care Plan, undated, revealed a Focus, initiated on 07/13/2020, of resident was an elopement risk due to: disoriented to place, recent history of wandering away from home, and impaired safety awareness. The goal, with a target date of 11/01/2020, was the resident would not leave the facility unattended. Interventions, all initiated on 07/13/2020, included to observe for unmet needs with wandering/exit seeking, such as needing to toilet, pain, hunger, thirst, and intervene as indicated. Another intervention was to place the resident's profile in the elopement book. The next intervention was to redirect the resident when wandering or exit seeking; and the last was to apply a wander alert bracelet to the left ankle, checking placement every shift and function daily. However, despite being aware (notified by the [CONDITION(S)] clinic) the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The State Survey Agency (SSA) requested, on 08/14/2020, the list of staff who had escorted Resident #2 to his/her [CONDITION(S)] appointments or a transport sign in/out book. However, this information was never provided to the SSA; the facility stated they would have to look back through their staffing to see who escorted the resident to his/her [CONDITION(S)] appointments. Interview with Unit Supervisor #2, on 08/14/2020 at 10:31 AM, revealed she was the staff member who would ride to the [CONDITION(S)] clinic with Resident #2. She stated staff would assist the resident to [CONDITION(S)] when the facility had staff available to use for this purpose. She stated his/her care plan was specific to his/her elopement risk noting it addressed the fact the resident wore an elopement/wander guard bracelet to monitor him/her because Resident #2 was a known wanderer. Interview with the Director of Nursing (DON), on 08/12/2020 at 3:30 PM, revealed she was unaware of Resident #2's history of wandering and elopement upon admission. She stated the resident did have a care plan in place for wandering and elopement and was placed on the locked unit related to his/her admission assessment with the identified risk of elopement. However, the DON stated the care plan failed to address the need for Resident #2's supervision during [CONDITION(S)]. Interview with the Administrator, on 08/14/2020 at 3:00 PM, revealed the resident had the needed supervision required per his/her care plan. He stated he believed once the resident was inside the [CONDITION(S)] clinic, he/she was no longer the facility's responsibility. Therefore, he indicated the facility did not need to provide the resident the required assistance to attend [CONDITION(S)]. 6. Review of Resident #6's medical record revealed the facility admitted the resident on 12/18/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated, 08/07/2020, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed Resident #6 had no presence of pain during a pain assessment interview. Review of Resident #6's Comprehensive Care Plan revealed a focus of resident is at risk for pain due to pressure wounds on right hip and left lateral foot initiated on 12/17/2019. The goal stated resident will verbalize adequate relief of pain with a target date of 11/08/2020. Interventions include: administer pain medications as ordered initiated 12/17/2019; notify physician of unrelieved or worsening pain initiated 12/17/2019; observe for side effects for pain medications, observe for constipation, new on set of increased agitation, restlessness, confusion, hallucinations dysphoria, nausea [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of thirteen (13) sampled residents (Resident #2). The facility admitted Resident #2, on 07/12/2020, with the diagnosis of [CONDITION(S)] with Behavioral Disturbance. On admission, there was documented evidence, per the discharging hospital's history and physical, which stated the resident had a history of eloping from the hospital and the hemodialysis ([CONDITION(S)]) clinic. There was also documented evidence the facility assessed Resident #2 as being at high risk for elopement, on 07/12/2020. Review of the Hemodialysis Clinic's treatment notes for Resident #2, dated 07/14/2020, revealed the clinic contacted and expressed to the facility the resident could not ride on the external transportation service alone, as he/she had a history of wandering and was an elopement risk. The facility had agreed to send an employee from the nursing facility to accompany Resident #2 to the [CONDITION(S)] clinic to ensure his/her safe arrival. However, on 08/04/2020 around 11:00 AM, Resident #2 was sent to the [CONDITION(S)] clinic without facility staff on an external transport service. The resident arrived at the hemodialysis clinic, at 11:14 AM, and walked alone into the hemodialysis clinic building's foyer; he/she then exited the building at 11:15 AM. The hemodialysis clinic noticed, at 12:00 PM, the resident had not arrived for his/her treatment and alerted the facility at 12:00 PM. The facility then sent two (2) staff members to look for the resident. The facility was notified by the resident's sister he/she had been located, at 1:00 PM, at a McDonald's restaurant, which was one-half (0.5) mile from the hemodialysis clinic. Resident #2 had to cross six (6) streets and one (1) major interstate highway to get to McDonald's. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 08/14/2020 and was determined to exist on 07/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/27/2020, alleging removal of the Immediate Jeopardy on 08/25/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 08/28/2020, prior to exit on 08/28/2020, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Safety and Supervision of Residents, revision date July 2017, revealed the purpose of the policy was to make the environment as free from accident and hazards as possible. Resident safety with supervision and assistance to prevent accidents were facility-wide priorities. Further review revealed the interdisciplinary team (IDT) would analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. The care team would target interventions to reduce individuals' risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility's policy titled, Elopement (Risk and Missing Resident), dated October 2019, revealed the care team members who had residents under their care were responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action was taken. Review of the facility's contract agreement with the hemodialysis clinic titled, Skilled Nursing Facility (SNF) Outpatient [CONDITION(S)] Services Agreement, dated 11/02/2016, revealed for the transportation of [CONDITION(S)] ([CONDITION(S)]) residents, the nursing facility would be responsible for arranging for suitable and timely transportation to and from the [CONDITION(S)] clinic. This included the selection of the mode of transportation and the qualified personnel to accompany the [CONDITION(S)] residents. Review of the external transport service contract, revision date January 2016, revealed the transportation service was a subscription service, shared ride public transportation for people with disabilities who could not ride fixed-route buses independently. Review of Resident #2's medical record revealed the facility admitted the resident on 07/12/2020 with diagnoses including Heart Failure, Dependent on Renal [CONDITION(S)], [CONDITION(S)] with Behavioral Disturbance, and [CONDITION(S)] in Chronic Kidney Disease. Review of Physician's Orders revealed an active order, with a start date of 07/13/2020, that the resident was admitted to the secured unit for the diagnosis of Dementia. Another order, with a start date of 07/14/2020, stated the resident was to have [CONDITION(S)] on Tuesday, Thursday, and Saturday related to [CONDITION(S)] at the outside hemodialysis clinic. Review of the Hospital Discharge Summary, dated 07/12/2020, revealed the resident had wandered away from his/her family home multiple times, as well as walking out of the hospital unassisted, on 07/11/2020, without the staff's knowledge. The hospital determined Resident #2 would need admission to a twenty-four (24) hour observation locked unit related to his/her elopement risk and wandering behaviors. Review of Resident #2's Wandering/Elopement Risk Scale from his/her admission assessment, dated 07/12/2020, revealed the facility assessed the resident to be high risk for elopement, and interventions should be initiated or planned to assess his/her risk. Further review of the admission assessment revealed the resident was assessed to have a memory problem, and he/she had behavioral symptoms such as wandering and exit seeking/history of elopement. Continued review revealed Resident #2 had a wander/elopement alarm implemented for him/her. Review of Resident #2's Comprehensive Care Plan, undated, revealed a Focus, initiated on 07/13/2020, that the resident was an elopement risk due to: disoriented to place, recent history of wandering away from home, and impaired safety awareness. The goal, with a target date of 11/01/2020, was the resident would not leave the facility unattended. Interventions, all initiated on 07/13/2020, included to observe for unmet needs with wandering/exit seeking, such as needing to toilet, pain, hunger, thirst, and intervene as indicated. Another intervention was to place the resident's profile in the elopement book. The next intervention was to redirect the resident when wandering or exit seeking; and the last was to apply a wander alert bracelet to the left ankle, checking placement every shift and function daily. Review of Resident #2's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) of seven (7) out of fifteen (15) indicating the resident was severely cognitively impaired. Continued review revealed the resident had not exhibited any wandering behaviors since assessment. Further review revealed the resident was receiving [CONDITION(S)]. Review of the [CONDITION(S)] Clinic Patient Notes, dated 07/15/2020, revealed, on 07/14/2020, the [CONDITION(S)] Clinic's Social Worker (DCSW) spoke with Unit Supervisor #2, at the facility, about the external transport service the facility was utilizing. This note stated the DCSW informed Unit Supervisor #2 that Resident #2 could not ride this transport service alone because (he/she) had a history of running away after being dropped off at the clinic. Resident #2 was a known elopement risk, as he/she had done so in the past with this transport service. Further review revealed the DCSW met the resident, on 07/14/2020, in the foyer of the clinic building to ensure his/her safety, as she did not think the facility would be sending a staff member with the resident. The DCSW stated she believed this to be necessary because Resident #2 was newly admitted to the nursing home facility, on 07/12/2020, and she did not think staff at the nursing home would have had time to arrange for assistance. She stated this way she could ensure his/her safe arrival to the facility, without the chance for Resident #2 to elope. Further review of the [CONDITION(S)] Clinic Patient Notes, dated 07/23/2020, revealed, on 07/21/2020, the DCSW noted at 12:00 PM that Resident #2 had not arrived for his/her [CONDITION(S)] appointment. The DCSW contacted the nursing home facility and spoke with Licensed Practical Nurse #12, who stated the external transport system did not pick up Resident #2 at the scheduled time, as the facility staff member was not available to ride with Resident #2 at that time. However, continued review of the notes revealed LPN #12 stated the resident would ride alone when the external transport arrived again, and she, the DCSW, would meet the resident at the [CONDITION(S)] clinic lobby to ensure the resident did not wander off. The DCSW stated this was incorrect, as she spoke with Unit Supervisor #2 when the resident was admitted informing the nursing home facility of the resident's risk for elopement and the need to have nursing home facility staff escort him/her into the [CONDITION(S)] clinic. The DCSW stated she would contact the nursing home facility's Director of Nursing (DON). Further review revealed the [CONDITION(S)] clinic's DON and the DCSW contacted the nursing home facility's DON, on 07/21/2020. Per the [CONDITION(S)] Patient Clinic Notes, the nursing home facility's DON stated they did not have the staff to ride with Resident #2, on 07/21/2020, and felt he/she could ride the transport service alone. The nursing home facility's DON stated staff were unaware of the resident's wandering behavior and the degree of intervention he/she would need to receive [CONDITION(S)], even though the facility had been informed by the DCSW of his/her prior elopement behaviors and the need for facility assisted transport. Per the [CONDITION(S)] Patient Notes, the DCSW informed the nursing home facility of two (2) local nursing homes that provided onsite [CONDITION(S)] if they could not provide him/her with the needed assistance and monitoring during transport to prevent his/her elopement chances in the future. Further review of the [CONDITION(S)] Clinic Patient Notes, dated 08/04/2020, revealed, on 08/04/2020, the DCSW documented at 12:00 PM that the [CONDITION(S)] clinic's receptionist notified her Resident #2 had not arrived for his/her appointment. The DCSW then contacted the nursing home facility but could not reach anyone, so she contacted the external transport to see if the resident had been picked up from the nursing home. Per the notes, external transport informed her they had picked up the resident and dropped him/her off at the clinic building around 11:17 AM. The DCSW then contacted the nursing home, finally speaking with the nursing home facility's DON who stated someone from the nursing home facility had contacted the [CONDITION(S)] clinic to inform the clinic that Resident #2 was on his/her way. The nursing home facility's DON, per notes, further stated she thought someone would be meeting Resident #2 in the lobby. Again, per notes, the DCSW stated this was incorrect. The DCSW revealed in the notes, the nursing home facility's DON further stated the facility would send two (2) staff members to find the resident, as they knew the resident's location. Further review of the [CONDITION(S)] Clinic Patient Notes, dated 08/04/2020, revealed the DON of the [CONDITION(S)] clinic was notified of Resident #2 wandering off from the building by the DCSW when she (DCSW) became aware of it. The [CONDITION(S)] clinic DON then reviewed the cameras and saw Resident #2 enter the foyer unassisted and alone, get on and off the elevator, and exit the building (the [CONDITION(S)] clinic was on the first floor, and the elevator was not needed to enter the [CONDITION(S)] clinic as this building holds many other medical offices; to enter the [CONDITION(S)] clinic one would enter the foyer and walk past the elevators into a second door which entered into the [CONDITION(S)] clinic). The [CONDITION(S)] clinic DON stated Resident #2 was never escorted into the facility as he/she had been in the past by nursing home facility staff. Review of the Facility's Progress Notes for Resident #2, dated 08/04/2020 at 12:18 PM, revealed the facility made a call to the [CONDITION(S)] clinic stating Resident #2 was on his/her way, and the DCSW would meet him/her at the transport service to walk the resident into the facility. However, this note was written by the Assistant Director of Nursing (ADON) after the facility was notified the resident never arrived for his/her [CONDITION(S)] appointment; per the DCSW notes, she stated she informed the nursing home facility's DON a little after 12:00 PM. The State Survey Agency (SSA) requested, on 08/14/2020, the list of staff who had escorted Resident #2 to his/her [CONDITION(S)] appointments or a transport sign in/out book. However, this information was never provided. The facility stated they would have to look back through their staffing to see who had escorted the resident to his/her [CONDITION(S)] appointments. The SSA also requested an incident report or investigation regarding the elopement on 08/04/2020. However, the facility failed to provide one, stating they did not believe the elopement to be their fault; therefore, there was no need to complete an incident report. Observation of the [CONDITION(S)] Clinic video recordings, dated 08/04/2020, of the building's foyer/front entrance area revealed, at 11:14 AM, the external transport cab pulled up to the front entrance of the [CONDITION(S)] clinic building, and Resident #2 exited the cab alone from the back seat and entered the front foyer of the building. Continued review revealed, at 11:15 AM, the resident stepped onto the elevator, and the transport cab left the front entrance; the driver did not exit the cab to assist or ensure the resident entered the actual [CONDITION(S)] clinic. Per additional review at 11:16 AM, Resident #2 exited the elevator and then exited out the building through the front doors. An additional observation revealed Resident #2 never entered the [CONDITION(S)] clinic office, only the building's front foyer area that led to the front door of the [CONDITION(S)] clinic. Interview with the [CONDITION(S)] clinic's Director of Nursing (DON), on 08/13/2020 at 11:30 AM, revealed when the DCSW made her aware Resident #2 never arrived to the clinic, they contacted the external transport service to see if the resident had been picked up from the nursing home facility. She stated the external transport service confirmed the resident was picked up from the nursing home facility. Per interview, this prompted the [CONDITION(S)] clinic's DON to watch their security cameras. She stated the cameras revealed Resident #2 exited the transportation service's car; walked into the foyer of the office complex (that houses many offices and clinics); got on and moments later, off the elevator; and exited the building. She stated in the past, nursing home staff had always entered the foyer and the [CONDITION(S)] clinic's front door with the resident, which ensured he/she had been checked in with the receptionist. She stated this requirement had been communicated to the facility in detail with Resident #2's Unit Supervisor. She stated the communication was regarding the need for the nursing home staff's assistance to ensure the resident's safety and prevent him/her from eloping before he/she entered the clinic and was handed off to the [CONDITION(S)] clinic's staff. The [CONDITION(S)] clinic's DON stated this was important because Resident #2 had a known history of elopement in the past. Interview with Resident #2's sister, on 08/13/2020 at 9:32 AM, revealed her sibling was seen walking the street in front of a local McDonald's restaurant, on 08/04/2020 around 1:00 PM. To get from the clinic to McDonald's, Resident #2 had to cross six (6) streets and one (1) major interstate highway. Review of the local weather history, on 08/04/2020, revealed the temperature had a high of eighty-nine (89) degrees Fahrenheit with cloudy skies. She stated Resident #2 was escorted into the restaurant; then, she contacted the nursing home facility to let them know she found him/her walking the streets, and he/she was safe. The resident's sister further stated Resident #2 was admitted to a Long Term Care facility so he/she could have increased supervision and a secure place to stay because he/she had eloped in the past. She stated she was very upset the elopement occurred, as the facility had assured her that her sibling would be monitored and had no chance of eloping. To get from the clinic to McDonald's, Resident #2 had to cross six (6) streets and one (1) major interstate highway. Review of the local weather history, on 08/04/2020, revealed the temperature had a high of eighty-nine (89) degrees Fahrenheit with cloudy skies. There was no documented evidence of an assessment of Resident #2 once he/she was located. Interview with the [CONDITION(S)] clinic's Social Worker (DCSW), on 08/12/2020 at 11:14 AM, revealed she had expressed concern with Unit Supervisor #2 by phone when Resident #2 was admitted to the facility, according to the 07/15/2020 [CONDITION(S)] Clinic Patient Notes. She stated at that time she expressed the need for nursing home facility staff to assist Resident #2 to the [CONDITION(S)] clinic. This also included accompanying him/her inside the building to ensure he/she was left with one of the [CONDITION(S)] clinic's staff. The DCSW stated this was necessary because she feared the resident might elope if he/she was not properly handed off to one of the [CONDITION(S)] clinic's staff. Interview with Unit Supervisor #2, on 08/14/2020 at 10:32 AM, revealed she was the one who would frequently escort Resident #2 to his/her [CONDITION(S)] appointments because she was available to assist the resident at those times. She stated other staff would assist him/her to the appointment also, and who accompanied the resident depended on which staff member was available to assist at the time of his/her appointment. She stated she was aware of the resident's history of elopement and knew he/she was at risk for wandering. However, she was unable to comment if staff assisted the resident to the [CONDITION(S)] clinic, on 08/04/2020, and stated, to her knowledge, staff had assisted him/her on this date. Further, the Unit Supervisor stated, on 08/04/2020, she met Resident #2 and his/her sister at the McDonalds restaurant, around 1:00 PM, and assisted the resident to his/her [CONDITION(S)] appointment. She stated there was no documented evidence there had been an assessment performed after the resident had been located. An additional interview with Unit Supervisor #2, on 08/14/2020 at 11:47 AM, revealed she had never spoken over the phone with the DCSW regarding Resident #2 and his/her risk of elopement and need for staff assistance. She stated the only time she spoke with the DCSW was when she accompanied the resident to the [CONDITION(S)] clinic, and it was nothing more than saying hello. She stated she was the unit manager/supervisor where Resident #2 resided, until he/she was moved from the unit (Refer to F689). She stated she would be the person to contact regarding the resident's care at the time he/she was admitted . Interview with the Assistant Director of Nursing (ADON), on 08/14/2020 at 11:43 AM, revealed the nursing facility called and informed the [CONDITION(S)] clinic, on 08/04/2020, Resident #2 was on his/her way for treatment. She stated, since the resident was admitted , he/she normally had someone to assist him/her to the appointment. She stated the [CONDITION(S)] clinic contacted the facility, on 08/04/2020, stating the resident never arrived to receive [CONDITION(S)]. The ADON stated she told the clinic that Resident #2 had left the faciity on the external transport service alone, and she would notify the DON. She also stated she was aware of the resident's elopement risk because the resident's Power of Attorney (POA) told the facility she wanted the resident to remain on a locked unit due to Resident #2's history of prior elopements. Interview with the Director of Nursing (DON), on 08/12/2020 at 3:45 PM, revealed she spoke with Resident #2's POA regarding the need for assistance to go to [CONDITION(S)]. The DON stated the POA verbalized the resident could attend [CONDITION(S)] on his/her own, and this would be a trial run for the resident. The DON stated she felt as though Resident #2 was appropriately supervised, and once the resident was inside the [CONDITION(S)] clinic, he/she was no longer the facility's responsibility. She stated they found him/her not long after the facility was alerted, and he/she had walked out of the [CONDITION(S)] clinic and was at a nearby McDonald's restaurant with his/her sister. Per interview, she stated Unit Supervisor #2 then escorted Resident #2 to the [CONDITION(S)] clinic to be dialyzed. The DON stated they did not have the staff, on 08/04/2020, to escort the resident into the [CONDITION(S)] clinic as they normally did. Interview with Resident #2's POA, on 08/13/2020 at 10:12 AM, revealed she was relieved when Resident #2 was admitted to a locked unit. She stated the facility assured her the resident would be safe and observed so he/she could not elope. Therefore, the POA stated she would never agree for the resident to go alone to [CONDITION(S)] because he/she had a history of elopement there in the past. An additional interview with the DCSW, on 08/14/2020 at 4:01 PM, revealed the receptionist told her Resident #2 was on his/her way to receive [CONDITION(S)] treatment. She further stated it was not communicated to her from the nursing facility's Administrator that Resident #2 would be arriving alone. Interview with the Administrator, on 08/14/2020 at 10:33 AM, revealed he expected residents to be appropriately supervised. He stated, on 08/04/2020, he called the [CONDITION(S)] clinic when Resident #2 was known to be going alone to the [CONDITION(S)] clinic and talked with and relayed the information about the resident coming to [CONDITION(S)] unaccompanied to the DCSW. He further stated the DCSW had agreed to meet the resident on his/her [CONDITION(S)] days to ensure his/her safe arrival. The Administrator stated he felt this was not an elopement, and the facility did everything required of them because once the resident arrived at the [CONDITION(S)] clinic, he/she was no longer the facility's responsibility. The facility alleged it completed the following steps to remove the immediate jeopardy, effective 08/25/2020: 1. The facility entered into an agreement with the Transportation Company for an escort with Resident #2 from the facility and into the [CONDITION(S)] Center related to the resident's elopement risk for the Saturday [CONDITION(S)] Session. Transportation escort would sign Resident #2 into the [CONDITION(S)] Center. Resident #2's care handed over to the [CONDITION(S)] Center Staff. Upon completion of the [CONDITION(S)] session, the reverse occurs for return to the facility. The facility provides transport services on Tuesday and Thursday sessions. 2. The facility will provide a transportation log to sign the resident from the facility with appointment location, and employee name. Upon return, the same will occur with appointment location. The form returned to the facility staff member. 3. The staff assigned to the resident with 1:1 status would be responsible to remain with resident during transportation, and stay with resident during appointments. 4. The facility admission assessment and quarterly assessment with each resident are completed and reviewed for wandering and elopement risk. 5. The facility IDT re-assessed all residents for wandering and/or elopement risk score on 08/20/2020. Care plan interventions reviewed for all residents identified at risk. The care plan revision based upon the risk score, when indicated. 6. The MDS Team audited the residents comprehensive care plans at risk for wandering/elopement on 08/20/2020 for accuracy, and thoroughness. Any comprehensive care plan requiring modification was complete with appropriate interventions. 7. The ADNS provided education on the process of identifying a resident at risk for elopement, intervention related to wandering/exit seeking behaviors, documentation related to interventions in place, and the process for notification if an elopement occurs to the licensed nurse on 08/20/2020. The education included the process for a resident assessed with elopement risk and/or wandering, immediate actions, interventions used, and documentation required for the given situation. The interventions entered on the comprehensive care plans and linked to Point of Care (POC) for the State Registered Nurse Aides (SRNA). Discontinued interventions should include a written order in the hard chart, entered into the EMR, and discontinued on the comprehensive care plan. 8. An audit related to the elopement risk and wandering education was conducted to ensure education provided was effective. The audit will consist of ten (10) questionnaires completed five (5) times weekly for one (1) month, two (2) times a week for two (2) weeks, and then monthly for two (2) months. The Director of Nursing Services (DNS) or the Senior Clinical Consultant (SCC) will complete the nurse progress notes audits. 9. The facility held an ADHOC Quality Assurance Performance Improvement (QAPI) meeting on 08/20/2020 related to the deficiencies on 08/14/2020. During the meeting, review of the audits, actions, and education performed by the facility, after 08/14/2020. The QAPI team includes the Executive Director, DNS, Medical Director, and at least three (3) other Department Directors. The State Survey Agency verified the following steps were implemented to remove the Immediate Jeopardy on 08/25/2020, as alleged. 1. Review of the facility's agreement with the Transportation Company, dated 08/12/2020 for an escort with Resident #2 from the facility and into the [CONDITION(S)] Center related to the resident's elopement risk for the Saturday [CONDITION(S)] Session. Transportation escort would sign Resident #2 into the [CONDITION(S)] Center. Resident #2's care handed over to the [CONDITION(S)] Center Staff. Upon completion of the [CONDITION(S)] session, the reverse occurs for return to the facility. The facility provides transport services on Tuesday and Thursday sessions. 2. Further review of the the facility's transportation log for Resident #2 revealed the facility provided a transportation log to sign the resident from the facility with appointment location, and employee name. Upon return, the same will occur with appointment location. The form will be returned to the facility staff member. Review of the form revealed none had been completed at this time. Interview with Executive Director, on 08/28/2020 at 5:25 PM, revealed they have the services set up for Resident #2. However, they have not required the use of them as of this time. He stated the facility had been able to meet the transportation need and staff to go with the resident at this time. 3. Observation of Resident #2, on 08/28/2020 at 2:20 PM, revealed State Registered Nurse Aide (SRNA) #19 was present at the door entrance of the resident's room, and in direct visual line of the resident. Ongoing hourly documentation by SRNA #19 was reviewed on the resident's Certified Nurse Aide (CNA/SRNA) Hourly Documentation form. The documentation revealed additional notes were made when the resident's activities changed. Interview revealed the staff assigned to a resident with 1:1 status would be responsible to remain with resident during transportation, and stay with resident during appointments, of course if we are agency then we would stay at the facility and regular would go with the resident. Interview with State Registered Nurse Aid (SRNA) #10, on 08/28/2020 at 8:59 AM revealed she was familiar with the care of Resident #2. She stated, We make sure the assigned resident with 1:1 status are watch during the entire shift. She stated she has been his/her 1:1 assigned staff. She stated she Resident #1 and Resident #2 were placed on 1:1 over the past two (2) weeks. Interview with SRNA #15, on 08/28/2020 at 10:06 AM revealed she was familiar with the care of Resident #2. She stated she has been his/her 1:1 assigned staff. Interview with SRNA #16, on 08/28/2020 at 10:18 AM revealed the education received for Resident #2's 1:1 service was provided by the ADNS. She stated assigned staff was to remain with the resident during the 1:1 status. He stated the assigned staff would be responsible to remain with resident during transportation, and stay with resident during appointments. Interview with SRNA #19, on 08/28/2020 at 2:20 PM, revealed he was agency staff, and routinely worked at this location. He stated his assignment today was for Resident #2's 1:1 services. Interview with the Director of Nursing Services, on 08/28/2020 at 5:15 PM, revealed assigned staff remained with Resident #2 throughout the shift. Further interview revealed the only time this would differ was with an agency staff assigned, then we would have our staff go with the resident for his/her appointments. Any resident assigned 1:1 would require the staff be with him/her throughout the shift for monitoring and documentation. 4. Review of the facility's admission assessment and quarterly assessment and with each resident a Minimum Data Set (MDS) assessment was completed and reviewed for wandering and elopement risk. Interview with the Director of Nursing Services, on 08/28/2020 at 10:10 AM, revealed the MDS was completed on all new admissions, and quarterly for all residents. She stated the residents were evaluated for elopement risk and wandering. Once a resident was identified as an elopement risk, then the steps were taken for their wanderguard bracelet placement. The DON stated they would also have a picture placed in the binder kept at the front desk. She stated the MDS timeframes were set by CMS requirements. 5. Review of the re-assessed wandering and elopement risk score for all residents, was completed on 08/20/2020 by the Interdisciplinary Team (IDT). Review of the care plan audit and interventions revealed all residents identified at risk received revised care plans related to the risk score and indicators. Interview with the DNS on 08/28/2020 at 10:35 AM revealed the review of wandering and elopement risk care plans on 08/20/2020, was to ensure the interventions were in place for each resident based on the risk score. She stated the Regional MDS Support (Clinical Reimbursement Specialist/CRS) reviewed the care plans after the IDT reviewed the re-assessed wandering and elopement risk score for all residents, on 08/20/2020. She stated the CRS updated the care plans for elopement risk and wandering risk. 6. Review of Resident #2's care plan intervention, dated 08/14/2020, revealed one on one (1:1) with staff; and to remove the resident from the situation was added to care plan. Interview with the Director of Nursing Services, on 08/28/2020 at 10:10 AM, revealed the MDS was completed on all new admissions, and quarterly for all residents. She stated the residents were evaluated for elopement risk and wandering. 7. Review of the Education Rosters for the licensed nursing staff, on 08/19/2020 and 08/20/2020, revealed the rosters were signed and dated. The agenda with the roster-included abuse, 1:1 education with documentation, incident reports (completion) with addition, or discontinuation of interventions related to the comprehensive care plans. Review of the Education Rosters for the licensed nursing staff, on 08/19/2020 and 08/20/2020, revealed the rosters were signed and dated. The agenda identified

Based on observation, interview, record review, review of facility job descriptions, and review of the facility's abuse policy, it was determined the facility's Administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services for two (2) of thirteen (13) sampled residents from abuse (Resident #1 and Resident #2). Interview and record review revealed the facility admitted Resident #1 on 03/27/2020 who developed inappropriate behavior toward residents and paced the unit by wandering with entry into resident rooms to where staff searched for the resident's location. The facility admitted Resident #2 to the Memory Care Unit (MCU) on 07/12/2020, with known inappropriate sexual acting out behaviors. However, the facility did not prepare interventions prior to the admission to a unit for cognitive impaired residents to prevent abuse. On, 07/12/2020, Resident #2 exhibited three (3) episodes of sexual abuse behaviors, with notification to the Director of Nursing (DON) after the second episode. Interviews revealed staffing for the unit did not meet the needs for proper supervision and on 04/22/2020; staff found Resident #2 with Resident #1 in his/her bedroom, alone, and for an undermined amount of time. On several occasions staff witnessed Resident #2 touching Resident #1 inappropriately. On 07/30/2020, contracted therapy staff observed Resident #2 on top of Resident #1 with his/her face placed into Resident #1's crotch while in bed. However, the facility determined after interviews with facility staff, who did not witness the event, the reported observation as invalid because facility staff did not witness the incident. Therefore, the facility failed to implement the facility abuse policy, report within two (2) hours, and complete a thorough abuse investigation to determine if abuse occurred. In addition, because of the facility failure to follow the abuse policy a root cause could not be determined to allow the facility to implement and correct identified issues. The staff did not implement both residents care plans to protect the residents and revisions to the care plans not completed because of not following the abuse policy. The facility admitted Resident #2, on 07/12/2020, and on admission there was documented evidence, per the discharging hospital's history and physical, which stated the resident had a history of [REDACTED]. There was also documented evidence the facility assessed Resident #2 as being at high risk for elopement, on 07/12/2020. The facility had agreed to send an employee from the nursing facility to accompany Resident #2 to the [MEDICAL TREATMENT] clinic to ensure his/her safe arrival. However, on 08/04/2020 around 11:00 AM, the facility sent Resident #2 was sent to the [MEDICAL TREATMENT] clinic without facility staff on an external transport service. The resident arrived at the [MEDICAL TREATMENT] clinic, at 11:14 AM, and walked alone into the [MEDICAL TREATMENT] clinic building's foyer; he/she then exited the building at 11:15 AM. The facility was notified by the resident's sister he/she had been located, at 1:00 PM, at a McDonald's restaurant, which was one-half (0.5) mile from the [MEDICAL TREATMENT] clinic. Staff and resident interviews revealed there was not adequate staff to address residents' care needs. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, provide supervision to prevent elopement, or implement comprehensive care plans, has caused, or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on, 08/14/2020, and determined to exist on 07/30/2020. The facility provided an acceptable Allegation of Compliance (AoC) on 08/26/2020, alleging removal of the Immediate Jeopardy (IJ) on 08/25/2020. The State Survey Agency validated the removal of the Immediate Jeopardy on 08/25/2020, as alleged, prior to exit, on 08/28/2020 with the remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at a scope and severity of a D while the facility develops and implements a Plan of Correction and monitored the effectiveness of the systematic changes. (Refer to F 600, F 607, F 609, F 610, F656, F 657, F 689, and F 725) The findings include: Review of the Executive Director (ED) Position Summary, dated 8/2019, revealed the ED ensured to maintain compliance with State and Federal regulations, work effectively with the care team on risk mitigation, event management and adhered to the code of conduct and integrity. In addition, the ED responsibilities included to lead an effective Quality Assurance Process Improvement (QAPI) program, and adhere to the code of conduct. Review of the Director of Nursing (DON) Position Summary, dated 8/2019, revealed the DON's responsibilities included to implement the facility policy and procedures, ensure to follow a continuous Quality Improvement Program (QIP). In addition, the DON ensured the staff and the facility met the resident needs, followed the care planning process, provided accurate and detailed medical and record documentation and followed the compliance of regulations at all times. In addition, the DON reported to the Executive Director. Review of the facility's policy, Abuse Prevention Program, undated, revealed the facility developed policies and procedures for the abuse program to aid the facility to prevent abuse. The abuse policy components included the facility-prevented abuse with the identification of patterns and occurrences. The resident rights included to be free from abuse. The definition of sexual abuse included the non-consensual sexual contact of any type to or with a resident and required all staff to report a witnessed or believed occurrence of abuse. The facility encouraged any staff to report concerns of abuse to the facility without the fear of retaliation. The facility identified the Administrator or DON to complete an immediate report (no later than two (2) hours) to the State Survey Agency and Adult Protective Services. The facility protected residents with the completion of a thorough investigation of all reported allegations and protected residents while the facility conducted the investigation. The facility completed accurate documents relative to the incident of abuse, followed the Elder Justice Act, provided ongoing review and analysis of the abuse incident, and implemented changes to prevent future occurrences of abuse. In addition, the facility strived to maintain adequate staff for all shifts to ensure the facility met the needs of the residents, which may allow abuse more likely to occur. Interview and record review during survey revealed on 07/30/2020, the contracted Occupational Therapy Assistant (OTA) found Resident #1 and Resident #2 in a room together unsupervised. Interview with the OTA, on 08/06/2020, revealed she reported to the facility staff that she had observed Resident #2 on top of Resident #1, in bed, with Resident #2's face in the crotch of Resident #1. Interviews with Licensed Practical Nurse (LPN) #1, on 08/13/2020, and Certified Nursing Assistant (CNA) #1, CNA #8 on 8/06/2020 and CNA#9 on 8/07/2020, revealed the OTA reported to them the same information. Record review and interviews revealed the facility did not follow its polices, as they failed to complete assessments for the residents on the unit; and the facility moved Resident #2 off the unit to an open unit without further supervision. Interview with the DON revealed the facility did not believe the OTA's report based on the interviews with the floor staff. However, the DON stated the facility reported the incident and conducted an investigation. However, record and interviews revealed the facility reported the incident as an unusual occurrence with the description as Resident #2 attempted to get out of bed with Resident #1 and with doing so hit Resident #1's mid-region of the abdomen. Review of the facility's investigation packet revealed it only included two statements, one by Licensed Practical Nurse #1 and Certified Nursing Assistant #1. Per the facility's policy, the facility was to complete an immediate report (no later than two (2) hours) to the State Survey Agency and Adult Protective Services; and protect residents with the completion of a thorough investigation of all reported allegations and protected residents while the facility conducted the investigation. Interview with the DON revealed she completed the 5-day final report. However, record review revealed the facility did not submit a report to the State Survey Agency and did not determine a root cause of the incident to implement interventions to protect the other residents. The facility was made aware that Resident #2 had a history of [REDACTED]. The facility sent the resident to the [MEDICAL TREATMENT] clinic without facility staff on an external transport service. The resident arrived at the [MEDICAL TREATMENT] clinic, at 11:14 AM, and walked alone into the [MEDICAL TREATMENT] clinic building's foyer; he/she then exited the building at 11:15 AM. The [MEDICAL TREATMENT] clinic noticed, at 12:00 PM, the resident had not arrived for his/her treatment and alerted the facility at 12:00 PM. The facility then sent two (2) staff members to look for the resident. The facility was notified by the resident's sister he/she had been located, at 1:00 PM, at a McDonald's restaurant, which was one-half (0.5) mile from the [MEDICAL TREATMENT] clinic. Resident #2 had to cross six (6) streets and one (1) major interstate highway to get to McDonald's. Interviews with staff and residents revealed there was not enough staff to monitor residents who required 1:1 supervision. In addition, staff and resident interviews revealed residents' call lights were not answered timely and residents had to lay soiled for several hours at times. Interview with the DON on 08/28/2020 at 5:30 PM, revealed the administrative body's responsibilities included to monitor and ensure the facility's polices were implemented and to identify concerns with recommended changes. She stated the process provided the opportunity to provide optimal care to the residents. She stated she monitored for policy and procedure implementation with monthly QAPI and morning meetings. Interview with the ED, on 08/14/2020 at 3:07 PM, revealed that he, the DON and the ADON conducted the abuse investigations for the facility. He stated he audited the investigation after completion and stated the DON completed thorough investigations on the abuse allegation. He stated the investigations allowed the administration to identify the root cause and start the QAPI process if the facility identified issues. However, the facility did not identify issues with the ongoing investigation; he had not reviewed the conclusion of the investigation. In addition, he believed the DON continued the investigation ten (10) days after the initiation by the OTA. The ED further stated the responsibilities for his position included to ensure the facility met the resident needs and the facility followed state and federal regulations. Interview with the DON, on 08/28/2020 at 5:30 PM, revealed the facility had not identified a high number of residents with complaints of slow or no response for care needs. She stated the facility used agency staff, however less agency staff had been used in the past month. The DON stated the facility did not have to initiate their emergency staffing plan, which included to remove all non clinical tasks from the clinical team and utilize the administration to complete the non clinical tasks (ie: pass ice), to meet resident needs because the facility did not identified issues with staff unable to provide care or supervision of the residents. She further stated as the DON, she was responsible for all nursing care issues in the facility. In addition, the DON stated Resident #4 met with her and other administrative department managers weekly to discuss care and services. She further stated, complaints from residents about call bell response was a common complaint. Interview with the Administrator, on 08/28/2020 at 5:30 PM, revealed the facility's assessment, which included clinical staffing levels required to meet the need of the care for residents the facility was able to accept. He stated the facility's current census was one hundred and twelve (112) with the capacity of one hundred and fifty-four (154). Further interview revealed the facility scheduled aides for first and second shift to care for ten (10) to thirteen (13) residents each. He stated on the night shift the facility scheduled an aide to care for twenty (20) to twenty (24) residents. However, the facility failed to review and revise the facility's assessment to determine the resources to meet the residents' needs from a day to day perspective in an emergency. Interview with the Administrator, on 08/14/2020 at 10:33 AM, revealed he expected residents to be appropriately supervised. The Administrator stated he felt this was not an elopement, and the facility did everything required of them because once the resident arrived at the [MEDICAL TREATMENT] clinic, he/she was no longer the facility's responsibility. The facility alleged it completed the following steps to removed immediate jeopardy effective 08/25/2020: 1. The Vice President of Operations or the Senior Clinical Consultant reviewed all allegations of abuse, neglect and exploitation since on 06/01/2020 and 08/20/2020, with no exceptions noted. 2. The Senior Clinical Consultant provided education to the Executive Director, Director of Nursing Services and the Assistant Director of Nursing Services (ADNS) on 08/20/2020. The education topics included enacting appropriate interventions to protect all residents after an allegation and documentation required in the electronic medical record (EMR) related to an allegation of abuse and the interventions enacted. 3. The Senior Clinical Consultant educated all Department Managers on 08/24/2020 regarding the types of abuse, when and to whom to report to. 4 The Senior Clinical Consultant provided education to the Interdisciplinary Team (IDT) on 08/20/2020 and 08/24/2020. The IDT consists of the DNS, ADNS, Therapy, Social Services, the Dietician, Unit Managers, Medical records staff, and the Minimum Data Set Coordinator. The education included review of occurrences, the documentation required after review, and insuring all documentation is present and complete. In addition, the IDT received education on the types of abuse, actions to be taken, and the reporting process. 5. The Senior Clinical Consultant provided 1:1 education to the Executive Director (ED), Director of Nursing Services (DNS), and the Assistant Director of Nursing Services (ADNS) on 08/20/2020. The education related to enacting appropriate interventions to protect all residents after an allegation was made, and during the investigation process. Education provided included the required documentation in the electronic medical record (EMR) related to the allegation, and the interventions enacted. 6. The Senior Consultant provided the Interdisciplinary Team (IDT) education on 08/20/2020 with requirements for developing and implementing the comprehensive care plan for new, worsening, and increased behaviors, and abuse. 7. An audit of one-hundred per cent (100%) of Nurse Progress Notes will be completed five (5) times weekly for one (1) month, two (2) times a week for two (2) weeks and then monthly for two (2) months to ensure the behaviors and abuse notations are followed upon with appropriate interventions. Auditing for the development, and implementation of the comprehensive care plan, as needed. The Director of Nursing Services (DNS) or the Senior Clinical Consultant (SCC) will complete the nurse progress notes audits. 8. The facility held an ADHOC Quality Assurance Performance Improvement (QAPI) meeting on 08/20/2020 related to the alleged deficiency on 08/14/2020. During the meeting, review of the audits, actions, and education performed by the facility, after 08/14/2020. The QAPI team includes the Executive Director, DNS, Medical Director, and at least three (3) other Department Directors 9. The facility held an ADHOC Quality Assurance Performance Improvement (QAPI) meeting on 08/20/2020 related to the deficiencies on 08/14/2020. During the meeting, review of the audits, actions, and education performed by the facility, after 08/14/2020. The QAPI team includes the Executive Director, DNS, Medical Director, and at least three (3) other Department Directors. The State Survey Agency verified the following steps were taken to remove immediate jeopardy on 08/25/2020, as alleged: 1. Review of an email from the Regional Senior Clinical Consultant, dated 08/28/2020, revealed she reviewed six (6) abuse investigations, on 08/20/2020. She stated the investigations that occurred between 06/01/2020, and 08/20/2020 were completed at the facility. Interview with the Vice President of Operations (VPO), on 08/28/2020 at 5:40 PM revealed the Senior Clinical Consultant reviewed the six (6) alleged abuse investigations completed by the facility through the look back period of 06/01/2020. All six (6) investigations were reviewed on 08/20/2020. 2. Review of the education provided by the Senior Clinical Consultant (SCC) provided to the Executive Director, Director of Nursing Services and the Assistant Director of Nursing Services (ADNS), on 08/20/2020. The education topics included enacting appropriate interventions to protect all residents after an allegation and documentation required in the electronic medical record (EMR) related to an allegation of abuse and the interventions enacted. Continued interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:30 PM, revealed the abuse education provided by the Senior Clinical Consultant (SCC) addressed the types of abuse, training the staff, resident protection and safety, identification of abuse, reporting allegations to the administrator immediately. Any person identified with a history of abuse during the screening process prior employment the not be considered for employment. Continued interview with the Facility Administrator, on 08/28/2020 at 6:55 PM, revealed the abuse education provided by the Senior Clinical Consultant (SCC) addressed everything, types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action. The SCC reviewed the interventions, and actions taken. 3. The Senior Clinical Consultant educated all Department Managers on 08/24/2020 regarding the types of abuse, when and to whom to report abuse. Review of the roster, dated 08/24/2020, revealed the Senior clinical Consultant educated the Department Managers. Continued interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:30 PM, revealed the abuse education provided by the Senior Clinical Consultant (SCC) addressed the types of abuse, training the staff, resident protection and safety, identification of abuse, reporting allegations to the administrator immediately. Any person identified with a history of abuse during the screening process, will not be considered for employment. 4. Review of the Interdisciplinary Team (IDT) Roster, dated 08/20/2020 and 08/24/2020, revealed the Senior Clinical Consultant provided the abuse education for the IDT. The roster included the Executive Director (Facility Administrator), Director of Nursing Services, Medical Records Director, Director of Social Services, Social Services Assistant, Business Office Manager, Assistant Director of Nursing Services (former Director of Staff Development), Director of Environmental Services & Housekeeping, Activities Director, and Regional Nurse Consultant. The agenda included education on the types of abuse, actions taken, and the reporting process. Additional, review of occurrences, the documentation required after review, and ensuring all documentation present and completed. Interview with the Assistant Director of Nursing Services (ADNS), on 08/27/2020 at 10:20 AM, revealed she received education during the IDT for review of occurrences, the documentation required after review, and ensuring all documentation was present and complete. She stated they received education on the types of abuse, actions taken, and the reporting process for our facility. Continued interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:30 PM, revealed the Senior Clinical Consultant (SCC) provided the abuse education received. Continued interview with the Facility Administrator, on 08/28/2020 at 6:55 PM, revealed the abuse education provided by the SCC addressed interventions, and actions taken. He revealed the types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action were The SCC reviewed the care plans. 5. Review of the Agenda, and Education Roster, dated 08/20/2020 revealed the Senior Clinical Consultant provided the education which included 1:1 services with clients assessed as elopement risk, and, or with behaviors. The development, and revision of the care plans for each of the residents identified with 1:1 services, elopement, or wandering behaviors were listed. The roster included the Executive Director (Facility Administrator), Director of Nursing Services, Assistant Director of Nursing Services (former Director of Staff Development). The agenda included education on the types of abuse, actions taken, and the reporting process. Additionally, review of occurrences, documentation required after review, and ensuring all documentation completed. Interview with the Assistant Director of Nursing Services (ADNS), on 08/27/2020 at 10:20 AM, revealed she received education with the Senior Clinical Consultant (SCC) for review of occurrences, the documentation required after review, and ensuring all documentation was present and complete. She provided education on the types of abuse, actions taken, and the reporting process for the facility,and revising and updating the care plans. The 1:1 education related to the staffing needs, documentation required. Continued interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:30 PM, revealed the Senior Clinical Consultant (SCC) provided the education to her, the Executive Director, and the Assistant Director of Nursing Services. She revealed the education pertained to the 1:1 services, documentation of the 1:1 services. The care plans required revisions with elopement, and wandering. The persons identified must have a physician's orders [REDACTED]. The nurses must document every shift about the 1:1 and reflect the care plan interventions. Continued interview with the Facility's Administrator, on 08/28/2020 at 6:55 PM, revealed the abuse education provided by the SCC addressed interventions, and actions taken. He revealed the types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action taken. 6. Review of the Interdisciplinary Team (IDT) Roster, dated 08/20/2020 and 08/24/2020, revealed the Senior Clinical Consultant provided the abuse education for the IDT. The roster included the Executive Director (Facility Administrator), Director of Nursing Services, Activities Director, Business Office Manager, Medical Records Director, Director of Social Services, Social Services Assistant, Assistant Director of Nursing Services (former Director of Staff Development), Director of Environmental Services & Housekeeping, and Regional Nurse Consultant. The agenda included education on the types of abuse, actions taken, and the reporting process. Additional, review of occurrences, the documentation required after review, and ensuring all documentation present and completed. Interview with the Assistant Director of Nursing Services (ADNS), on 08/27/2020 at 10:20 AM, revealed she received education during the IDT for review of occurrences, the documentation required review with the care plan, and ensuring all documentation was present, complete and reflective of the care plan. She stated they received education on the types of abuse, actions taken, and the reporting process for the facility. Revising and updating the care plans was also included. Continued interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:30 PM, revealed the Senior Clinical Consultant (SCC) provided the abuse education received during the IDT. Continued interview with the Facility Administrator, on 08/28/2020 at 6:55 PM, revealed the abuse education provided by the SCC addressed interventions, and actions taken. He revealed the types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action were taken. 7. Review of the IDT's review of the comprehensive care plan updated based on the nurses progress notes, dated 08/21-25/2020 An audit of one-hundred per cent (100%) of nurse progress notes was completed for four (4) of five (5) times for the first week, and ongoing for first one (1) month initiated and the remainder pending for two (2) times a week for two (2) weeks and then monthly for two (2) months to ensure the behaviors and abuse notations are followed upon with appropriate interventions. Auditing for the development, and implementation of the comprehensive care plan, completed. The Director of Nursing Services (DNS) with the IDT reviewed the care plans with the nurse progress notes. 8. Review of the ADHOC Roster and Agenda, dated 08/20/2020, revealed the Executive Director, Director of Nursing Services, and The Medical Director via telephone reviewed the citations, and scope and severity of Immediate Jeopardizes for citations F600 abuse and neglect, F656 for development and implementation of the comprehensive care plans, and F689 Accidents. Interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:35 PM, revealed the Senior Clinical Consultant (SCC) provided the abuse education received during the IDT. Further interview with the Executive Director (ED/Facility Administrator), on 08/28/2020 at 6:55 PM, revealed the ADHOC meeting was completed to review the immediate jeopardies status on going at the facility. He stated they discussed the audits and education on going to relieve the IJ status. He stated the facility called the medical director via telephone to discuss ongoing plans. The types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action were taken to the ADHOC QAPI meeting to discuss 9. Review of the ADHOC Roster and Agenda, dated 08/20/2020, revealed the Executive Director, Director of Nursing Services, and the Medical Director via telephone reviewed the citations, and scope and severity of Immediate Jeopardies for citations F600 Abuse and Neglect, F656 for Development and Implementation of the Comprehensive Care Plans, and F689 Accidents. During the meeting, review of the audits, actions, and education performed by the facility, after 08/14/2020. The QAPI team includes the Executive Director, DNS, Medical Director, and at least three (3) other Department Directors. The facility held an ADHOC Quality Assurance Performance Improvement (QAPI) meeting on 08/20/2020 related to alleged deficiency on 08/14/2020. Interview with the Director of Nursing Services (DNS), on 08/28/2020 at 5:35 PM, revealed the Senior Clinical Consultant (SCC) provided the abuse education received during the IDT. Interview with the Executive Director, on 08/28/2020 at 5:55 PM, revealed he was notified of the ongoing plans at the facility. He stated they discussed the audits and education ongoing to relieve the IJ status. He stated the facility notified the medical director via telephone to discuss ongoing plans. Further interview with the Executive Director (ED/Facility Administrator), on 08/28/2020 at 6:55 PM, revealed the ADHOC meeting was completed to review the immediate jeopardies status on going at the facility. He stated they discussed the audits and education to relieve the IJ status. He stated the facility notified the medical director via telephone to discuss the ongoing plans. The types of abuse, screening for employment, training, prevention, reporting, protection, investigation, and corrective action were taken to the ADHOC QAPI meeting to discuss.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two (2) of thirteen (13) sampled residents (Residents #6 and #8). Resident #6 went from 05/29/2020 at 12:00 PM until 06/01/2020 at 12:00 AM without his/her scheduled pain medication Interview with the resident revealed he/she was in pain during this time. In addition, the facility failed to provide the resident with any alternative pain management that would alleviate his/her pain. The facility failed to reorder Resident #8's pain medication. Resident #8 went without needed pain medication for over twenty-four (24) hours. (Refer to F-602) The findings include: Review of the facility's policy titled, Pain Management, revision date January 2020, revealed the policy was to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including pain management. Review of the facility's policy titled, Medication Administration General Guidelines, undated, revealed the policy was to ensure medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications could do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). 1. Review of Resident #6's medical record revealed the facility admitted the resident, on 12/18/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 08/07/2020, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the resident had no presence of pain during a pain assessment interview. Review of Resident #6's Comprehensive Care Plan revealed a Focus, initiated on 12/17/2019, that stated the resident was at risk for pain due to pressure wounds on right hip and left lateral foot. The goal stated the resident would verbalize adequate relief of pain, with a target date of 11/08/2020. Interventions, all initiated on admission included: administer pain medications as ordered; notify physician of unrelieved or worsening pain; observe for side effects from pain medications, such as constipation, new on set of increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls and report occurrences to the physician; and therapy to screen as indicated. Review of Resident #6's May 2020 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order had a start date of 12/18/2019 and an end date of 05/25/2020. Continued review of Resident #6's May 2020 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Progress Notes revealed a note, dated 05/24/2020 at 4:49 PM, which stated the resident voiced complaints of pain and requested his/her PRN [MEDICATION(S)]-Acetaminophen pain medication. This medication was re-ordered the previous weekend (sixty (60) tablets on 05/22/2020); however, the medication was not available in the medication cart. The note stated a call was placed to the pharmacy. Further review revealed the facility was informed by the pharmacy that a ten (10) day supply was delivered on 05/22/2020 at 10:34 PM. There was no documented evidence any follow-up or any other pain interventions were provided at that time. (Refer to F-602) Continued review of Resident #6's Progress Notes revealed a note, dated 05/25/2020 at 11:26 AM, which stated the pharmacy was notified of the missing medications and more tablets were requested to be sent Stat (immediately). Further review of Resident #6's Progress Notes revealed a note, dated 05/25/2020 at 11:28 AM, which revealed a pain assessment was completed with the resident to which he/she stated was comfortable at this time. The Physician was notified with new orders for [MEDICATION(S)]-Acetaminophen 7.5-325 mg by mouth every six (6) hours routinely for pain. Per the notes, a call was placed to the pharmacy to have new medication sent Stat. Further review revealed the Director of Nursing (DON) was notified, and calls were placed to Resident #6's family and the Ombudsman. The note stated Resident #6 was resting quietly in bed at this time with all needs met. Review of Resident #6's Progress Notes revealed a note, dated 05/29/2020 at 1:11 PM, which stated the resident's [MEDICATION(S)]-Acetaminophen medication was unavailable and awaiting the arrival from Pharmacy. On 05/30/2020 at 12:07 AM, a note stated [MEDICATION(S)]-Acetaminophen was not available and was reordered. On 05/30/2020 at 5:31 AM, a note stated [MEDICATION(S)]-Acetaminophen was not available, and Pharmacy was notified. On 05/30/2020 at 11:07 AM, a note stated the [MEDICATION(S)]-Acetaminophen medication was unavailable. Per notes, Pharmacy stated they needed a new script as the Physician only gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/30/20/2020 at 5:42 PM, a note stated [MEDICATION(S)]-Acetaminophen medication unavailable, pharmacy stated they needed a new script. Review of Resident #6's Progress Notes, on 05/31/2020 at 11:34 AM, revealed the [MEDICATION(S)]-Acetaminophen medication was unavailable, and pharmacy stated they needed a new script. On 05/31/2020 at 5:35 PM, a note stated [MEDICATION(S)]-Acetaminophen medication unavailable. There was no documented evidence the staff contacted the Physician to obtain a new script for the medication. Further review revealed there was no documented evidence the facility contacted the Physician to obtain an emergency dosage of the medication from the facility's emergency box; no documentation of a pain assessment during this time; and, no documented evidence of non-pharmacological interventions for pain management. Review of Resident #6's May 2020 eMAR, revealed [MEDICATION(S)]-Acetaminophen tablet 7.5-325 mg every six (6) hours was scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. However, the medication was not signed out to indicate it had been administered on 05/27/2020 at 6:00 PM; on 05/29/2020 at 6:00 PM; on 05/30/2020 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM; and, on 05/31/2020 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of the Pharmacy's Delivery Manifest revealed, on 05/25/2020 at 10:29 PM, the facility received twelve (12) [MEDICATION(S)]-Acetaminophen 7.5-325 mg tablets (a three (3) days' supply). Additional review of the Pharmacy's Delivery Manifest revealed the [MEDICATION(S)]-Acetaminophen medication was not delivered again until 9:59 PM on 05/31/2020. Further review of Resident #6's medical record revealed he/she went thirty-one (31) hours without pain medication after requesting medication for pain on 05/24/2020. However, there was no documented evidence of non-pharmacological interventions provided, pain assessment, or any alternatives in pain management for the resident until the next day, 05/25/2020. In addition, Resident #6 went from 05/29/2020 at 12:00 PM until 06/01/2020 at 12:00 AM without his/her scheduled pain medication. This was a total of ten (10) missed doses. Interview with Resident #6, on 08/14/2020 at 9:02 AM, revealed he/she recalled going without pain medication. He/she stated this happened a couple of months ago. Resident #6 stated when he/she asked for pain medication the facility would state it was on the way or not available. The resident stated staff never offered him/her any other method of pain prevention and stated both knees hurt so bad the pain would would keep him/her from sleeping at night. Resident #6 stated the staff would attempt to prop his/her legs on pillows to alleviate the pain, but this was not effective. 2. Review of Resident #8's medical record revealed the facility admitted the resident on 06/24/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Admission MDS Assessment, dated 06/30/2020, revealed the facility assessed the resident as having a BIMS' score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed from the resident's pain assessment interview, he/she experienced pain frequently which made it difficult to sleep at night and limited his/her day-to-day activities. Resident #8 rated his/her pain a four (4) out of ten (10) on a zero (0) to ten (10) pain scale. Review of Resident #8's Comprehensive Care Plan revealed a Focus, with an initiation date of 06/25/2020, the resident was at risk for pain related to a Lumbar one (1) fracture related to Pleural Effusion, [CONDITION(S)] Disc Disease, and Generalized Discomfort. The goal stated the resident would verbalize adequate relief of pain, with a target date of 10/08/2020. Interventions, initiated, on 06/25/2020, included: administer pain medications as ordered; notify physician of unrelieved or worsening pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care; observe for side effects of pain medication, such as constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, falls, and report occurrences to the physician; observe for signs of non-verbal pain: changes in breathing, vocalizations, mood/behavior changes; and report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain or discomfort. Review of the Controlled Drug Administration Records provided by the facility from 05/01/2020 to 08/28/2020, revealed, from 07/12/2020 at 3:00 AM until 07/16/2020 at 7:00 PM, a Controlled Drug Administration Record could not be provided or located. Therefore, during this time period, the only evidence of a pain medication being given was from the eMAR, on 07/14/2020 at 12:38 PM, when a dose of [MEDICATION(S)] IR 20 mg was administered. Interview with Resident #8, on 08/27/2020 at 10:45 AM, revealed the resident had a lot of pain related to the fracture in his/her back. The resident stated he/she would request pain medication every six (6) hours as needed to keep the pain under control. Resident #8 stated at times the facility would not order pain medications timely enough so when he/she asked for the medication, it would not be available to him/her. Resident #8 stated when this occurred, staff told him/her the medication had been ordered and would soon arrive. However, he/she stated it had taken up to a day to get his/her pain medication after requesting it. The resident stated the pain was often excruciating and unbearable, making it hard to perform his/her regular activities like putting on socks and shoes. He/she stated due to not receiving pain medications or having such a delay in the pain medications, he/she felt like it took longer for the medication to work when he/she did finally receive the medication. The resident stated he/she could not recall the specific time he/she went almost a day without the pain medication, but it frequently occurred where staff would not order pain medication timely. Resident #8 stated he/she had to wait two (2) to three (3) hours before a dose could be administered because the medication was being delivered from the Pharmacy. Interview with LPN #11, on 08/28/2020 at 1:51 PM, revealed often there were times she went to administer a resident's pain medication, and it was not available because it had not been reordered when it should have been. She stated she had to contact pharmacy and get the medication STAT (sent as soon as possible, immediately) to the facility for it to be available to administer. She stated she had to go through medications, reordering the ones that had a low number, to help ensure there was enough available to the resident. LPN #11 stated availability was a common problem, and she had mentioned it to management in the past. She stated if the medication was not available for the medication pass, she would contact the Physician to see if there was anything else he/she wanted to be done. She stated she would also monitor the resident for any signs or symptoms of pain and ensure he/she was not exhibiting any signs of pain. Further, LPN #11 stated she could not recall a time when Resident #8 (who she cares for frequently) went without his/her pain medication, or was in prolonged pain. Interview with the Director of Nursing (DON) and the Administrator, on 08/28/2020 at 5:35 PM, revealed they were unaware of any residents experiencing pain. They stated the only instance in which pain medication was unavailable was for Resident #6 when they noted [MEDICATION(S)]-Acetaminophen medication was missing. During the investigation for the incident on 05/25/2020 involving Resident #6's pain medication, the DON stated Resident #6 was not in any pain at that time. They stated the facility had a Nexsys Automated Dispensing Cabinet for any medications staff might need if the resident ran out of medications or there was a new admission. Further interview revealed there should not be a time when a resident should not have medications to give to them. Both stated staff should assess residents for pain and ensure residents were having their pain managed; if not managed, the Physician should be notified.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents were free of any significant medication errors, for two (2) of thirteen (13) sampled residents, (Resident #6 and Resident #8). Resident #6 went from 05/29/2020 at 12:00 PM until 06/01/2020 at 12:00 AM without his/her routine scheduled pain medication, [MEDICATION(S)]-Acetaminophen 7.5-325 milligrams (mg), ordered to be administered every six (6) hours. Resident #8, had pain related to the fracture in his/her back and would request pain medication every six (6) hours as needed to keep the pain under control. Resident #8 stated at times the facility would not order pain medications timely enough so when he/she asked for the medication, it would not be available to him/her. However, he/she stated it had taken up to a day to get his/her pain medication after requesting The findings include: Review of the facility's policy, titled Medication Errors with a revision date of July 2020, revealed the purpose of the policy is to ensure residents remain free from medication errors. Review of the facility's policy titled, Pain Management, with a revision date of January 2020, revealed the policy was to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including pain management. Review of the facility's policy titled, Medication Administration General Guidelines, undated, revealed the policy was to ensure medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications could do so only after they had been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). 1. Review of Resident #6's medical record revealed the facility admitted the resident, on 12/18/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 08/07/2020, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the resident had no presence of pain during a pain assessment interview. Review of Resident #6's Comprehensive Care Plan revealed a Focus, initiated on 12/17/2019, which stated the resident was at risk for pain due to pressure wounds on right hip and left lateral foot. The goal stated the resident would verbalize adequate relief of pain, with a target date of 11/08/2020. Interventions, all initiated on admission included: administer pain medications as ordered; notify physician of unrelieved or worsening pain; observe for side effects from pain medications, such as constipation, new onset of increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls and report occurrences to the physician; and therapy to screen as indicated. Review of Resident #6's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's May 2020 eMAR (Electronic Medication Administration Record), revealed [MEDICATION(S)]-Acetaminophen tablet 7.5-325 mg every six (6) hours was scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. However, the medication was not signed out to indicate it had been administered on 05/29/2020 at 6:00 PM; on 05/30/2020 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM; and, on 05/31/2020 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of Resident #6's Progress Notes revealed a note, dated 05/29/2020 at 1:11 PM, which stated the resident's [MEDICATION(S)]-Acetaminophen medication was unavailable and awaiting the arrival from Pharmacy. On 05/30/2020 at 12:07 AM, a note stated [MEDICATION(S)]-Acetaminophen was not available and was reordered. On 05/30/2020 at 5:31 AM, a note stated [MEDICATION(S)]-Acetaminophen was not available, and Pharmacy was notified. On 05/30/2020 at 11:07 AM, a note stated the [MEDICATION(S)]-Acetaminophen medication was unavailable. Per notes, Pharmacy stated they needed a new prescription as the Physician only gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/30/20/2020 at 5:42 PM, a progress note stated the [MEDICATION(S)]-Acetaminophen medication was unavailable, pharmacy stated they needed a new prescription. Review of Resident #6's Progress Notes, on 05/31/2020 at 11:34 AM, revealed the [MEDICATION(S)]-Acetaminophen medication was unavailable, and pharmacy stated they needed a new prescription. On 05/31/2020 at 5:35 PM, a note stated [MEDICATION(S)]-Acetaminophen medication unavailable. There was no documented evidence the staff contacted the Physician to obtain a new prescription for the medication. Further review revealed there was no documented evidence the facility contacted the Physician to obtain an emergency dosage of the medication from the facility's emergency box; no documentation of a pain assessment during this time; and, no documented evidence of non-pharmacological interventions for pain management. Interview with Resident #6, on 08/14/2020 at 9:02 AM, revealed there was a time when he/she could remember being without his/her pain medication. He/she stated when she/he asked for it the staff would tell her the medication was unavailable or that the medication was on its way from pharmacy. He/she stated during this time he/she remembers his/her knees were in so much pain and Tylenol was not effective in managing his/her pain, and caused him/her to toss and turn during the night. Interview with LPN #11, on 08/28/2020 at 1:51 PM, revealed often there were times she went to administer a resident's medication, and even pain medication and it was not available. She stated this was often because it had not been reordered when it should have been. She stated in order to administer medications appropriately she had to contact pharmacy and get the medication STAT (sent as soon as possible, immediately) to the facility for it to be available to administer. She stated she had to go through medications, reordering the ones that had a low number, to help ensure there was enough available to the resident. LPN #11 stated availability was a common problem, and she had mentioned it to management in the past. She stated if the medication was not available for the medication pass, she would contact the Physician to see if there was anything else he/she wanted to be done. She stated she would also monitor the resident for any signs or symptoms of pain and ensure he/she was not exhibiting any signs of pain. Interview with the Advance Practitioner Registered Nurse (APRN) on 08/27/2020 at 10:03 AM revealed it was her expectation residents received their medications per the physician order. She stated they prescribe medications for a reason and therefore they should be given as ordered. Resident with pain medications should be administered as they help manage their pain. 2. Review of Resident #8's medical record revealed the facility admitted the resident on 06/24/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Admission MDS Assessment, dated 06/30/2020, revealed the facility assessed the resident as having a BIMS' score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed from the resident's pain assessment interview, he/she experienced pain frequently which made it difficult to sleep at night and limited his/her day-to-day activities. Review of Resident #8's Comprehensive Care Plan revealed a Focus, with an initiation date of 06/25/2020, the resident was at risk for pain related to a Lumbar one (1) fracture related to Pleural Effusion, [CONDITION(S)] Disc Disease, and Generalized Discomfort. The goal stated the resident would verbalize adequate relief of pain, with a target date of 10/08/2020. Interventions, initiated, on 06/25/2020, included: administer pain medications as ordered; and report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain or discomfort. Review of the Controlled Drug Administration Records provided by the facility from 05/01/2020 to 08/28/2020, revealed, from 07/12/2020 at 3:00 AM until 07/16/2020 at 7:00 PM, a Controlled Drug Administration Record could not be provided or located. The only documented evidence of a pain medication being given was from the eMAR, on 07/14/2020 at 12:38 PM, when a dose of [MEDICATION(S)] IR 20 mg was administered. Interview with Resident #8, on 08/27/2020 at 10:45 AM, revealed the resident had a lot of pain related to the fracture in his/her back. The resident stated he/she would request pain medication every six (6) hours as needed to keep the pain under control. Resident #8 stated at times the facility would not order pain medications timely enough so when he/she asked for the medication, it would not be available to him/her. Resident #8 stated when this occurred, staff told him/her the medication had been ordered and would soon arrive. However, he/she stated it had taken up to a day to get his/her pain medication after requesting it. The resident stated the pain was often excruciating and unbearable, making it hard to perform his/her regular activities like putting on socks and shoes. He/she stated due to not receiving pain medications or having such a delay in the pain medications, he/she felt like it took longer for the medication to work when he/she did finally receive the medication. The resident stated he/she could not recall the specific time he/she went almost a day without the pain medication, but it frequently occurred where staff would not order pain medication timely. Resident #8 stated he/she had to wait two (2) to three (3) hours before a dose could be administered because the medication was being delivered from the Pharmacy. Interview with LPN #11, on 08/28/2020 at 1:51 PM, revealed often there were times she went to administer a resident's pain medication, and it was not available because it had not been reordered when it should have been. She stated she had to contact pharmacy and get the medication STAT (sent as soon as possible, immediately) to the facility for it to be available to administer. LPN #11 stated availability was a common problem, and she had mentioned it to management in the past. She stated if the medication was not available for the medication pass, she would contact the Physician to see if there was anything else he/she wanted to be done. She stated she would also monitor the resident for any signs or symptoms of pain and ensure he/she was not exhibiting any signs of pain. Interview with the Director of Nursing (DON) and the Administrator, on 08/28/2020 at 5:35 PM, revealed they were unaware of any residents experiencing pain. Further interview revealed it was their expectation for residents to receive their medications per the Physician orders. They stated the resident would not be ordered a medication if it was not needed, so receiving the medications was important. The DON stated to her knowledge, the facility had no medication errors to report, she stated she was unaware of any in the facility, and she further stated the facility had no monitoring system in place, such as reviewing of the eMAR, to ensure residents were receiving their medications as ordered. They stated they were unaware Resident #6 went without his/her pain medication during this time. They stated the facility had a Nexsys Automated Dispensing Cabinet for any medications staff might need if the resident ran out of medications or there was a new admission. Further interview revealed there should not be a time when a resident should not have medications to give to them. They stated residents should be monitored for pain and if they were out of the medication then the Physician should be alerted as well as pharmacy to have the medication delivered timely. They stated without being properly medicated with pain medication the resident could end up in pain or discomfort.

Based on interview, record review and review of policy it was determined the facility failed to implement a Comprehensive Care Plan (CCP) for one (1) of seventeen (17) sampled residents, Resident #1. Resident #1 reported to Registered Nurse (RN) #1 he/she had difficulty breathing on 06/01/2020 at 7:30 AM. Interviews revealed staff failed to notify the medical provider at 06/01/2020 at 7:30 AM, and did not provide ordered and care planned respiratory medication, or continually monitor the resident when the resident showed a significant change of condition with oxygen saturations seventy to eighty (70 - 80) percent (%) while on oxygen. Further interviews revealed when a secondary assessment completed by Licensed Practical Nurse (LPN) #1 at 9:30 AM, occurred, staff did not notify the provider and provide necessary medication when the LPN assessed the resident's oxygen levels in the fifties (50's). The facility transferred the resident by nine one one (911) emergency services for respiratory distress three and a half (3.5) hours after the initial complaint and assessment. The findings include: Review of the policy Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed the CCP included objectives, timetables to meet the residents' physical, psychological, and functional needs. The CCP services include the services provided by staff to attain or maintain the residents' highest practical well-being. In addition, the CCP interventions provided information to aid in the prevention, reduce a residents decline, or maintain the residents' functional status. Review of COVID-19 Resident Policy, undated, revealed the facility initiated the policy for early detection and effective triage of a potentially infectious resident. The facility monitored residents for fever and respiratory symptoms every shift. In addition, the facility staff monitored the residents' throughout the shift for potential or actual symptoms of a respiratory infection. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 03/15/18 with the [DIAGNOSES REDACTED]. Further review revealed the physician ordered [MEDICAL CONDITION] (a supportive respiratory machine) every night for the resident's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 04/01/2020, revealed the facility completed a cognitive assessment with the Brief Interview for Mental Status (BIMS) exam. The facility assessment revealed a score of twelve (12) out of a possible fifteen (15) and the facility determined the resident was interviewable. The facility [DIAGNOSES REDACTED]. Record review of the clinical recorded oxygen saturation summary revealed Registered Nurse (RN) #2, recorded Resident #1's saturation of eighty-nine (89) % while on oxygen on 5/30/2020 at 3:04 AM and 3:32 AM. Further review of the clinical record revealed staff did not document further assessments, medication administered, or notification to a provider. Interview with Registered Nurse (RN) #2, on 06/10/2020 at 9:19 AM, revealed RN #2 assessed Resident #1's oxygen saturation at eighty-nine (89) % on two occasions on 05/30/2020 within thirty (3) minutes when assessed for COVID-19 symptoms. He stated at the time of the low oxygen level he did not complete an in-depth respiratory assessment, did not provide ordered respiratory treatments, and did not notify the provider or oncoming staff of the abnormal finding; nor did he review Resident #1's care plan. RN #2 stated the CCP addressed a resident's health concerns and addressed the care staff needed to follow at all times. He stated a nurse's responsibilities included to follow the care plan to take care of residents. Review of the CCP Focus for Resident #2's risk for respiratory distress, revised on 01/10/2020, revealed the resident's risks included the need for oxygen, use of the [MEDICAL CONDITION] machine, SOB, [MEDICAL CONDITION] and Obesity. The facility interventions directed staff to administer ordered medications, document abnormal findings and notify provider, give aerosol, or [MEDICATION NAME][MEDICATION NAME] (misted medication for SOB symptoms), and to observe for Signs and Symptoms (S/S) of changes in respiratory status. The S/S for respiratory status changes included increased respirations and or heart rate, decreased oxygen saturation, sweating, and changes in skin color. Further review revealed the S/S for respiratory distress included decreased oxygen saturation, increased respirations, increased heart rate, sweating, and changes in skin color. The interventions included to document abnormal findings in the residents chart and notify the provider. Interview with the Lead Care Coordinator (LCC), on 06/08/2020 at 1:10 PM, revealed staff verbally reported on 06/01/2020 Resident #1's pulse oximeter (a device that reads oxygen levels) at the bedside with oxygen at the level of fifty (50) percent. Normal range for oxygen included above ninety (90) % with or without oxygen. Interview with Licensed Practical Nurse (LPN) #1, on 06/09/2020 at 2:36 PM, revealed Resident #1 requested assistance, on 06/01/2020 at 9:30 AM, because the resident reported not breathing well. He stated the resident appeared sweaty and was breathing heavy and fast. LPN #1 stated the resident appeared to have respiratory distress and he stated his assessment found the resident's oxygen level in the fifties (50's) while on oxygen. He stated he left the room to look for equipment to provide the ordered nebulizer but stated he did not provide respiratory medication to the resident nor did he immediately notify the provider of the resident's assessment. LPN #1 stated the Nurse Practitioner (NP) came onto the floor after 10:00 AM, assessed the resident, and requested 911 for transfer because of the resident's condition of respiratory distress. Continued interview revealed the facility required staff to review resident care plans but LPN #1 stated he did not have time to review resident care plans. He stated care plans specified the care residents required to maintain their status. He stated the facility expected all staff to follow resident care plans at all times. He further stated not following the care plan might lead to a resident's death because of what the staff did not do for the resident. Furthermore, LPN #1 stated he did not complete documentation of his assessment and findings. He stated the responsibility belonged to the assigned nurse. Interview with Registered Nurse (RN) #1, on 06/09/2020 at 12:04 PM, revealed Resident #1 complained of SOB at the beginning of the shift at 7:30 AM. She stated she assessed the resident oxygen level while on oxygen at seventy to eighty (70 to 80) percent. She stated she did not administer the rescue inhaler and nebulizer (misted medication) ordered by the provider for SOB, but notified the provider by a text message. She stated she continued medication pass for the floor residents after the initial findings and assessment of Resident #1. She further stated she did not document any of the assessment findings or events with the exception of the order to send out the resident per the provider. Review of RN #1's text message, dated 06/01/2020 at 9:53 AM, revealed RN #1 sent a message to the NP which reported Resident #1 complained of breathing difficulty. Continued interview with RN #1, on 06/10/2020 at 12:29 PM, revealed she did not review Resident #1's care plan. She stated she knew how to access the CCP in the computer and she stated the reason to follow a CCP included to help the resident feel better and to prioritize the care to meet resident goals. She stated a nurse's responsibilities included to follow the CCP daily. She stated resident health may decline if the CCP was not followed. She further stated care of the resident included the care plan and all nurses knew to follow the care plan. Interview with the Unit Manager (UM) #1, on 06/10/2020 at 9:05 AM, revealed she did not compare the care staff provided to the care specified in the CCP to insure the CCP was implementeded. She stated she expected staff to review resident care plans and she stated staff implementeded resident care plans to provide proper care to each resident at all times. UM #1 stated staff who did not implement the resident care plan might cause the resident condition to change. She further stated the clinical team, which included the UM, reviewed the clinical chart to ensure staff implementeded, reacted, and completed all required components for a discharged resident. She further stated the clinical team did not identify issues for 06/01/2020 for Resident #1's care or required documents before discharged to the emergency room . However, review revealed the clinical chart did not include both clinical nurse's findings and observations, the time reported, medications provided or the events around the resident's decline and emergent transfer. Therefore, a clinical team completed inaccurate review for care and services provided by the staff as indicated by the residents CCP. Interview with the MDS coordinator, on 06/10/2020 at 2:16 PM, revealed the facility collected data from several sources to complete a resident's CCP. She stated the CCP followed interventions from a select sub type and individual interventions to meet the goal of the residents' focus. She stated the facility reviewed CCP's and updated quarterly and the facility instructed staff to review the residents' care plans. She state the CCP directed resident care to improve or maintain the health of a resident. She stated the facility expected all staff to follow resident care plans at all times. She further stated a poor outcome for the resident may occur when staff did not follow the care plan. Interview with the Director of Nursing (DON), on 6/10/2020 at 2:52 PM, revealed resident care plans provided information for how to provide care of the resident. She stated the basics identified the problem and the facility completed interventions specific to the resident needs. She stated she expected staff to implement the CCP because the interventions provided specific care for a resident and care of a resident with a change of condition included close monitoring and communication with the provider because the resident might decline quickly. She further stated she and the UM had not completed any CCP audits on the floor. She stated she expected staff to provide care per the CCP at all times. She stated the facility did not review the resident's care plan; this occurred when the resident returned. However, record review revealed staff failed to document, provide interventions, administer medication, and notify the provider with a change of condition after staff identified S/S of respiratory changes and distress. Therefore, the staff failed to follow the resident's CCP. Interview with the Administrator, on 06/11/2020 at 8:29 AM, revealed the clinical nursing team reviewed residents' unplanned discharges the next day. He stated he did not receive a report from the DON of identified issues with the response, care, clinical chart documentation or following the care plans for Resident #1. He stated he expected facility staff to provide competent nursing care to meet the needs for each resident. He stated competent care included attentiveness, monitored changes of conditions, completed assessments, documentation, and implementing provider orders and care plans.

Based on interview, record review, and facility policy review it was determined the facility failed to provide respiratory care and services for one (1) of seventeen (17) sampled residents, Resident #1. Record review revealed Resident #1's physician ordered daily and as needed (PRN) respiratory aerosols treatments for COVID-19 and the facility instructed staff to be on a heightened alert for COVID-19 respiratory symptoms. Resident #1 presented over a three (3) day period with low-grade fevers and a low oxygen level while on oxygen. Furthermore, on the morning of the fourth day, Resident #1 presented with a Change of Condition (CoC) and the complaint of difficulty with breathing. A staff's assessment reported oxygen saturations of between seventy (70) and eighty (80) percent (percentage) on oxygen at 7:30 AM on 06/01/2020. Staff did not administer respiratory treatments, left the resident in the room without supervision, and the resident continued to decline. At 9:53 AM, staff sent a text message to the Nurse Practitioner (NP) with the first notification of Resident #1's complaint of Shortness of Breath (SOB) after another staff assessed Resident #1's oxygen level at fifty-six (56) % and now in respiratory distress. The NP did not respond and arrived later to the floor. The NP's assessment revealed an oxygen saturation of fifty-four (54) % on oxygen and in respiratory distress. The facility activated 911, and the resident was transported to an emergency room (ER) with the admission recorded at 10:59 AM, three and a half (3.5) hours after the identified CoC. The ER diagnosed Resident #1 with Respiratory Failure and Pneumonia with [CONDITION(S)] with a venous oxygen saturation level of seventy-one point seven (71.7) percent. The findings include: The facility failed to provide a policy of Respiratory Care and Services upon request. The facility failed to provide a policy for Re-Assessment of a Resident. Review of the policy Departmental (Respiratory Therapy) Prevention of Infection, dated 11/2011, revealed therapy services documentation included date, time, type of therapy, and staff who completed the respiratory therapy. In addition, all assessment data obtained or refusals of care which included why and what was done when the resident refused by the person who recorded the information. Review of COVID-19 Resident Policy, undated, revealed the facility initiated the policy for early detection and effective triage of a potentially infectious resident. The facility monitored residents for fever and respiratory symptoms every shift. In addition, the facility monitored residents throughout the shift for potential symptoms of a respiratory infection. Review of the policy Change in a Resident's Condition or Status, dated 5/2017, revealed notification of the provider occurred promptly when the resident's condition changed. A significant change included a decline to which the change in condition will not resolve without intervention by staff and clinical measures. Staff notification information to the provider included detailed observations and findings, which the staff documented on a Situation-Background-Assessment-Recommendation (SBAR) communication form. Further review revealed staff documented information of the residents' change of condition in the residents' record. Review of the facility document Communication/How to Notify Provider, undated, revealed when staff identified a CoC requiring attention; the staff contacted the provider on the phone. The Urgent Needs included in a list on the document, which the facility determined warranted a call to the provider, included a CoC. Review of the facility COVID-19 Preparedness Checklist, undated, revealed the facility completed plans for the training and education of staff to help the providers understand the implications of prevention and control measures for COVID-19. The facility education plan included to educate staff on the Signs and Symptoms (S/S) of the COVID-19 virus and how to monitor residents for respiratory illnesses. The facility's education and training plan included education to staff for infection control measures to prevent the spread of COVID-19. Review of the Centers for Disease Control and Prevention (CDC), dated 5/13/2020, revealed adults with medical conditions for lung diseases remained at a high risk for the development of serious complications. The CDC list for symptoms to monitor included a fever of unknown origin and shortness of breath. Furthermore, emergency warning signs for COVID-19 included trouble breathing to which the person needed to seek or transfer to emergent medical services. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 03/15/19 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the physician ordered a [CONDITION(S)] (a supportive respiratory system) every night for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as not having shortness of Breath under Section J. The facility assessed Resident #1's cognition with the Brief Interview for Mental Status (BIMS) exam and scored the resident with twelve (12) out of a possible fifteen (15) total score and determined the resident as able to convey his/her needs and cognitively intact. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician ordered PRN medications for episodes of SOB, which included a rescue inhaler of [MEDICATION(S)] (used to treat breathing issues) every four (4) hours. In addition, a second PRN medication included [MEDICATION(S)]-[MEDICATION(S)] inhaled (used for wheezing, difficulty breathing, chest tightness, and coughing) through a nebulizer (a treatment which mists the medication to allow inhalation) every 4 hour for SOB. Further review revealed the PO did not include bedside and self-administrative orders for medications by Resident #1. Interview with the Lead Care Coordinator (LCC), on 06/08/2020 at 1:10 PM, revealed facility staff reported a resident presented with wheezing on 06/01/2020 at about 10:00 AM. The LCC stated the NP arrived to the floor and went to the resident's room. The LCC stated the NP reported the resident's low oxygen saturations in the fifties (50's). The LCC stated Emergency Medical Services (EMS) arrived and the resident left the faciity on a stretcher with the EMS staff providing respiratory support to the resident. Review of the clinical record, oxygen saturation summary, revealed Registered Nurse (RN) #2 recorded Resident #1's saturation of eighty-nine (89) % while on oxygen on 05/30/2020 at 3:04 AM and 3:32 AM. Review of recorded levels from 01/01/2020 to 05/29/2020 revealed Resident #1's documented oxygen levels were between ninety-two (92) to ninety-eight (98) % with and without oxygen. Further review revealed staff did not document interventions or care provided to Resident #1 for the oxygen below ninety (90) % in a progress note; nor record administration of ordered PRN medications on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #2, on 06/10/2020 at 9:19 AM, revealed RN #2 assessed Resident #1's oxygen level on 05/30/2020 at 3:04 AM and 3:32 AM for the COVID-19 shift assessment. RN #2 stated he acquired the second reading to re-evaluate the first low reading as the resident wore oxygen with the first reading. RN #2 stated he did not complete a further assessment to Resident #1 when the second reading remained below ninety (90). Additionally, RN #2 stated he did not administer or offer ordered PRN medications. RN #2 stated staff responsibilities included resident assessments, providing treatments, documenting each, and report to the next shift. Interview with LPN #2, on 6/11/2020 at 3:22 PM, revealed he provided care to Resident #1 on the weekend of 05/30/2020 to 05/31/2020. LPN #2 stated he performed blood draws for serum laboratory levels on 05/30/2020 instead of 06/01/2020 as ordered because of a reported low-grade fever. LPN #2 stated the labs came back unremarkable and the NP did not order further tests. LPN #2 stated he did not receive report in the AM of 05/30/2020 regarding the resident's oxygen saturation of eighty-nine (89) percent. LPN #2 stated the resident's normal oxygen levels as mid-nineties (90's). He stated if RN #1 relayed a low oxygen level, and the return of the low-grade fever on 05/31/2020 he would have called the NP. However, he stated report at the change of shift from night to day provided limited information because staff wanted to get out and home to sleep. Furthermore, LPN #2 stated when the resident presented with the fever again; he did not complete a thorough assessment of the resident including lung sounds, and general status. He further stated the TAR instructions included to notify the provider of two (2) or more symptoms. LPN #2 stated he did not consider the symptoms possibly COVID-19 related Interview with LPN #1, on 06/09/2020 at 2:36 PM, revealed Resident #1 requested assistance from the LPN around 9:30 AM on 06/01/2020. The LPN stated Resident #1 stated the RN did not come back to the room after completion of medication pass and that upon entry into the resident's room he observed the resident to be in respiratory distress because he/she breathed heavily, wheezing was audible without a stethoscope, and the resident sweated profusely. The LPN stated the resident wore oxygen and he obtained an oxygen saturation level in the fifties (50's). The LPN stated he attempted to locate the rescue inhaler, could not find the inhaler, and attempted to find a nebulizer machine unsuccessfully. The LPN stated after the failed attempts to find a machine himself, the NP arrived to the floor sometime after 10:00 AM and he immediately asked the NP to see Resident #1. The LPN stated the NP assessed the resident and requested 911 activation. The LPN stated responsibilities of the nurse providing resident care included detailed documentation. The LPN stated he did not notify a provider or the Unit Manager (UM) of his assessment and findings at the time of the initial observation. Review of the Registered Nurse (RN) Position Summary, dated 8/2019, revealed essential responsibilities included assessment and documentation of residents' condition and nursing needs, to accurately and promptly implement orders, provide report, record observations, and assist or activate emergency measures for sudden adverse developments with a resident. Review of the clinical progress noted, dated 06/01/2020 at 7:43 AM, revealed RN #1 documented the administration of the residents ordered insulin. Review revealed the presence of RN #1 at the resident's bedside with the resident's initial report of breathing difficulties and need for respiratory care. Interview with RN #1, on 06/09/2020 at 12:04 PM, revealed the RN cared for Resident #1 on 06/01/2020 for day shift. The RN stated she did not know the resident presented with low levels of oxygen, low-grade fevers or had labs recently drawn. The RN stated the resident activated the call bell as she arrived to the room and complained of not being able to breathe. The RN stated the time was around 7:30 AM and during medication pass. The RN stated she assessed the resident oxygen level while the resident wore oxygen and noted the level between seventy (70) to eighty (80) percent. The RN stated the resident kept [MEDICATION(S)] and [MEDICATION(S)] inhalers in the room but she was only able to locate the box for the inhaler, but not the actual inhaler. The RN stated she looked at the list of medications for the resident and the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated she attempted to look for the resident's nebulizer in the room and could not find it and did not ask about an Emergency Drug Box for the facility. The RN stated she notified the Unit Manager (UM) of the resident's complaint. However, she did not notify the UM of the need for a nebulizer machine nor her inability to locate the resident's rescue inhaler. The RN stated she continued with medication pass and assisted taking residents to the desk for COVID-19 screening. The RN stated the NP came to the unit, requested the resident go to the ER, and ordered a nebulizer treatment before the resident left. The RN stated she did not complete a treatment because she could not find the machine. RN #1 stated she did not know about SBAR forms. The RN stated the nurses' responsibilities included complete documentation of events with a resident, and providing care as ordered. Review of RN #1's text message, dated 6/01/2020 at 9:53 AM, revealed RN #1 texted to the NP that Resident #1 had SOB. The RN stated the facility provided one and half days (1 ½) of orientation four (4) weeks ago when she started. Review of Resident #1's ER admission record, dated 6/01/2020 at 10:59 AM, revealed the ER room received the resident in respiratory distress with oxygen levels on arrival in the seventies (70's) per transport staff. The resident received immediate [CONDITION(S)] (continuous air pressure) and labs. The ER physician diagnosed the resident with Respiratory Failure, Pneumonia, and [CONDITION(S)]. The resident COVID-19 screen returned with positive results. Interview with the UM #1, on 06/10/2020 at 9:05 AM, revealed RN #1 notified her Resident #1 complained of SOB about 8:30 AM. The UM stated she did not assess the resident or inquire for relevant information. The UM stated she left the unit to check on another area, returned and discussed the resident treatment orders with the RN. The UM stated the RN thought the resident had orders for respiratory treatments but neither checked PO's. The UM stated she instructed the RN to notify the NP but did not follow-up. The UM stated the resident went to the ER per the NP request when the NP arrived to the unit. The UM stated staff did not report the lack of equipment to provide treatments. The UM stated when a respiratory CoC occurred she expected staff to complete a full assessment, notify the provider immediately, follow orders, provide treatments, and stay with the resident to monitor for distress. The UM stated she expected staff to complete detailed documentation and a SBAR on the event with the provided care and resident's response. The UM stated if staff delayed care and services to a with resident breathing issues the resident's breathing could become impaired and the resident could experience a body system shut down. In addition, the UM stated the Intra-Department Team (IDT) reviewed the residents chart and events on 6/02/2020 with the clinical team. The UM stated the IDT did not identify issues with care before transfer and staff documentation. However, the UM stated the IDT team did not interview staff to obtain details of the events on shift, and did not review the clinical chart. Interview with the NP, on 6/10/2020 at 9:47 AM, revealed facility staff did not call to report a respiratory CoC for Resident #1 but sent one (1) text message to her phone, which she did not notice. The NP stated she became aware of the CoC when she arrived after 10:00 AM and LPN #1 reported Resident #1 needed an immediate assessment because of respiratory distress. The NP stated she found the resident in respiratory distress, heard the resident wheezing upon entering the resident's door, and assessed his/her oxygen at fifty-six (56) % on two (2) liters of oxygen per nasal cannula. The NP stated staff did not inform her of a continued low-grade fevers or of the low oxygen levels while on oxygen. Furthermore, the NP stated staff should have called because of the unknown source of the fevers and with COVID-19 residents in the building, the resident needed further assessment. Review of the NP visit, dated 06/01/2020, revealed the NP documented Resident #1's chest assessment with wetness, crackles, and wheezes. The resident complained of thick yellow sputum, cough, and reported to the NP he/she cannot breathe. The NP documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP plan included sending the resident to the ER and an immediate nebulizer or inhaler treatment as ordered before transfer. Record review and interview revealed staff did not provide the ordered nebulizer, Interview with the Staff Development Coordinator, on 06/09/2020 at 10:39 AM, revealed all staff received education of the S/S and care of a COVID-19 resident. Education to staff included S/S, assessments, care, monitoring and reporting. She stated staff received respiratory care education for residents in the facility and the facility provided extra information on pre and post assessments, documentation, and the process of providing respiratory care and treatments. She stated she expected staff to document findings in the chart of assessment findings and interventions. She further stated normal oxygen levels included ninety (90) % to one hundred (100) %, and a low reading included 89% with or without oxygen. She stated staff responsibilities included notification of the provider with assessments, which identified condition changes. Interview with the Director of Nursing (DON), on 06/10/2020 at 2:52 PM, revealed the facility provided education for COVID-19 related S/S and care for the residents for all staff and new employees. The DON stated the facility owned nebulizer machines and is able to provide the equipment for residents who need treatments, including seventeen (17) residents who required respiratory care. The DON stated she expected nurses to respond to resident needs, report to the provider, notify nursing administration, and continually monitor the resident until transferred or stable, and complete all required documentation. The DON stated she became aware of Resident #1's condition when staff transferred the resident. The DON stated the clinical team at the IDT meeting reviewed the transfer of a resident the next day and did not identify issues in the clinical chart. The DON stated she knew the resident left in respiratory distress; however, she stated she did not have knowledge of the staff's inability to locate equipment, or medications for treatments. Additionally, the DON stated she was unaware of the clinical findings of staff, which included oxygen saturations in the fifties (50's) two (2) hours after an assessment of oxygen saturations in the seventies to eighties (70-80's) while on oxygen, and the decline of the resident's respiratory status after the initial complaint and assessment at 7:30 AM. The DON stated it concerned her to learn of the findings of the resident's course of care and response by staff and stated residents with CoC in their respiratory status usually decline quickly, which is why staff response remained important. Interview with Resident #1's Physician, on 06/12/2020 at 11:10 AM, revealed he identified the resident as a high-risk patient because of his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the resident's decline to the point of the documented findings by the NP may have been avoidable with early notification of the CoC. He stated as a provider his expectations of staff further included complete, accurate, and informative documentation, especially when in a crisis mode. Interview with the Administrator, on 06/11/2020 at 8:29 AM, revealed the facility admitted and cared for residents with respiratory diseases without previously identified issues for care and services. He stated new nurses received extensive training and the facility previously ramped up the training to ensure staff orientation received proper training by the facility. He stated the IDT clinical team did not report issues after record review of the transfer of Resident #1. He stated his expectation for staff included to provide competent care to the residents. He stated he expected the administrative team, which include himself, to have proactive responses for the continuation of quality resident care.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to develop/implement the care plan for six (6) of thirty-two (32) sampled residents (Residents #34, #57, #91, #101, #135, and #493). Interviews and record review revealed the facility failed to administer pain medication as ordered and care planned, implement falls prevention interventions as care planned, and provide respiratory services as care planned. Review of Resident #34's Medication Administration Record (MAR), dated December 2019, revealed [MEDICATION NAME] 10-325 mg was not administered on 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; or 12/16/2019 at 12:00 AM. Further review of the MAR revealed staff failed to assess the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM. Further review of Resident #101's clinical record revealed a Physicians Order, dated 09/27/2019, for [MEDICATION NAME]-APAP 10-325 mg give one (1) tablet by mouth every four (4) hours for pain. Review of Resident #101's MAR, dated October 2019, revealed a total of fourteen (14) missed doses of [MEDICATION NAME]-APAP. Continued review of the MAR, dated November 2019, revealed a total of six (6) missed doses of [MEDICATION NAME]-APAP. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person - Centered, revised December 2016, revealed a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The policy stated a comprehensive care plan for each resident would be developed within seven (7) days of completion of the required comprehensive assessment (MDS- Minimum Data Set). The policy further revealed the comprehensive, person-centered care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; and incorporate risk factors associated with identified problems. The person-centered care plan included measurable objectives and timetables that met the resident's physical, psychosocial and functional needs. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process included the resident's strength and needs and culture preferences. The IDT reviewed and updated the care plan when a resident had a significant change, when the desired outcome was not met, when a resident was readmitted to the facility from a hospital stay and quarterly, in conjunction with the required Quarterly Minimum Data Set (MDS) Assessment. 1. Review of Resident 91's clinical record revealed the facility admitted the resident on 03/18/2019 with [DIAGNOSES REDACTED]. Review of Resident #91's Comprehensive Care Plan for Fall Risk, initiated 10/16/2019, revealed the resident was at risk for falls related to Dementia with confusion, incontinence, poor communication/comprehension, and poor safety awareness. Continued review revealed the goal of the care plan was the resident would have a reduced risk for falls and fall related injury. Interventions included assist with transfers and encourage/assist resident to wear non skid footwear. However, there was no intervention related to side rail assessment/safety. Observation, on 01/06/2020 at 11:22 AM, revealed Resident #91's side rail was not secured to the bed and was partially resting on the floor. Further observation revealed the resident attempted to move his/her legs over the broken rail. Interview with Certified Nursing Assistant (CNA) #2, on 01/06/2020 at 11:36 AM, revealed the broken side rail was a safety issue and could cause an accident. Interview with CNA #4, on 01/08/2020 at 9:08 AM, revealed the broken rail was a fall and trip hazard. Interview with LPN (Licensed Practical Nurse) #4, on 01/06/2020 at 11:28 AM, revealed the side rail appeared to be broken. She stated Resident #91 could potentially fall out of bed. Interview with LPN #2, on 01/10/2020 at 4:54 PM, revealed the nurses were responsible for completion of the Side Rail Assessment Screen when a resident was admitted . LPN #2 stated she was not sure of the facility's protocol for utilizing side rails. Interview with Licensed Practical Nurse #12, on 01/10/2020 at 2:47 PM, revealed the purpose of the care plan was to communicate resident care needs. Interview with the MDS Coordinator #1, on 01/11/2020 at 10:24 AM, revealed she reviewed the clinical record and [DIAGNOSES REDACTED]. The MDS Coordinator stated the care plan communicated resident care needs. Interview with the Director of Nursing (DON), on 01/10/2020 at 5:04 PM, revealed she had not initiated any audits related to care plans. 2. Review of the facility's policy Pain Management, dated October 2018, revealed a plan of care would be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. Observation, on 01/07/2020 at 10:22 AM, revealed Resident #34 neatly groomed and seated on the bedside. Interview during the observation revealed the resident went two (2) days without pain medication because the facility let it run out. Review of the clinical record revealed the facility admitted Resident #34 on 10/28/2019 with [DIAGNOSES REDACTED]. Review of the 5-day Minimum Data Set (MDS) Assessment, dated 11/03/2019, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) and determined the resident was interviewable. Further review of the clinical record revealed a Physicians' Order, dated 11/06/2019, for [MEDICATION NAME] 10-325 mg ([MEDICATION NAME]-[MEDICATION NAME], pain medication) give one (1) tablet by mouth every four (4) hours related to Nontraumatic [DIAGNOSES REDACTED] of Unspecified Lower Extremity. Review of the Care Plan for Pain, revised 11/05/2019, revealed a goal that Resident #34 would verbalize adequate relief of pain. Interventions included administering pain medications as ordered; notifying the physician of unrelieved or worsening pain; observing and reporting changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion (ROM), withdrawal or resistance to care; observing for non-verbal pain; and providing the resident and family with information about pain and options available for pain management. Review of Resident #34's Medication Administration Record (MAR), dated December 2019, revealed [MEDICATION NAME] 10-325 mg was not administered on 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; or on 12/16/2019 at 12:00 AM. Further review of the MAR revealed staff failed to assess the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM. Review of the Progress Notes, dated 12/14/2019 at 4:49 PM, revealed Resident #34's [MEDICATION NAME] was not available. Further review of the Progress Notes revealed staff did not assess the resident's pain level, implement non-pharmacological interventions, or notify the physician to manage the resident's pain for the two (2) days the [MEDICATION NAME] was unavailable. Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed non-pharmacological pain interventions would include applying a cold/warm compress, offering fluids or diversional activities. LPN #11 stated she should have assessed Resident #38's pain level, implemented non-pharmacological intervention(s), and probably should have notified the physician for a one-time order for pain medication; however, she was sometimes swamped and did not document everything. LPN #11 further revealed the resident could be in a lot of pain if their pain medication was not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed non-pharmacological interventions to manage pain could include deep breathing, repositioning, and positive visualization. She further revealed pain assessments and interventions should be documented in the progress notes. According to LPN #12, Resident #34 was very upset about not having pain medication available. Interview with LPN #4, on 01/09/2020 at 10:38 AM, revealed the care plan was not implemented if the prescribed services or medications were not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the care plan communicated the resident's care needs. LPN # 12 stated Resident #34's care plan was not implemented for pain management. 3. Observation, on 01/10/2020 at 10:33 AM, revealed Resident #101 seated at the bedside. Interview during observation revealed the resident's pain medication was sometimes not available. Review of the clinical record revealed the facility readmitted the resident on 03/25/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Review of the Care Plan for Pain, revised 09/20/2019, revealed a goal the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included administer [MEDICATION NAME] as per orders; monitor/record/report to nurse resident's complaints of pain or requests for pain treatment; and notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. Further review of the clinical record revealed a Physicians Order, dated 09/27/2019, for [MEDICATION NAME]-APAP 10-325 mg give one (1) tablet by mouth every four (4) hours for pain. Review of the MAR, dated October 2019, revealed a total of fourteen (14) missed doses of [MEDICATION NAME]-APAP on 10/02/2019, 10/04/2019, 10/07/2019, 10/09/2019, 10/11/2019, and 10/13/2019. Review of the MAR, dated November 2019, revealed a total of six (6) missed doses of [MEDICATION NAME]-APAP on 11/20/2019, 11/21/2019, and 11/26/2019. Interview with Licensed Practical Nurse (LPN) #4, on 01/09/2020 at 10:38 AM, revealed pain could affect a resident's activities of daily living (ADL). The LPN further revealed the care plan was not implemented if the prescribed pain medication was not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the purpose of the care plan was to communicate resident needs. The LPN stated the care plan was not implemented if medications were not administered to manage the resident's pain. 4. Observation of Resident #57, on 01/07/2020 at 9:12 AM, revealed the resident had oxygen on via nasal cannula at three (3) Liters per minute (3L/min) and a BI-PAP (Bilevel Positive Airway Pressure) machine sat atop the resident's closet. Observation of Resident #57, on 01/07/2020 at 3:18 PM, revealed the resident rested in bed, eyes closed without the BI-PAP machine on for use. The equipment was atop of the bed and was not administered during the resident's naptime. Resident #57's clinical record review revealed the facility readmitted the resident, on 11/16/2019, with [DIAGNOSES REDACTED]. Resident #57's Quarterly Minimum Data Set review, dated 11/22/2019, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15) determining the resident was interviewable. The resident's functional status was determined to be extensive assistance with one (1) to two (2) staff for all activities of daily living (ADL). The facility determined the resident had shortness of breath with exertion, when sitting and at rest and received oxygen therapy. Resident #57's Minimum Data Set review dated 10/14/2019, revealed the Care Area Assessment triggered care planning for Activities of Living (ADL) function, Urinary Incontinence. Section O, Special Treatment Programs which included Oxygen and BI-PAP applications, as needed during daytime naps. Resident #57's Medication Administration Record (MAR) reviewed for September, November and January revealed nursing staff had not implemented the planned care related to administration of the BI-PAP, as planned. The order for the BI-PAP was not transcribed onto the October 2019 MAR and was not received for December of 2019. Further review revealed the resident had not received his/her showers as scheduled. Resident #57's shower sheet forms review, 11/29/2019 through 01/04/2020, revealed the resident only received six (6) of the twelve scheduled showers. Interview, on 01/07/2020 at 9:12 AM, with Resident #57, revealed he/she was supposed to wear a BI-PAP; however, the resident stated the equipment was placed on top of his/her closet. The resident stated the physician ordered for him/her to wear the equipment when he/she took a nap during the daytime and at night. Resident #57 stated he/she talked to the staff nurse, the Unit Manager and the Director of Nursing, about not getting the BI-PAP during nap times. The resident further stated, he/she had filed grievances with the facility about the BI-PAP, not receiving timely brief changes and not getting his/her showers as scheduled. Resident #57 stated because of the situation and as a last resort, in order to obtain the care and services, he/she filed a complaint with the State (State Survey Agency). Interview, on 01/10/2020 at 3:47 PM with CNA #10, revealed at times a lack of staff affected the residents care needs. She stated at times she could not provide the showers, or knew who was receiving a shower because of a lack of effective communication. CNA #12 stated Resident #57 was supposed to get a bed bath; however, she was not always sure who received a shower/bed bath and there was not always enough staff to provide it. She stated the resident sat in his/her soiled and wet brief at least twice a week when she came on shift and the resident had a right to complain. CNA #12 stated when there was a lack of staff, especially on the weekends, there were more falls and residents did not get the care. The CNA stated if staff followed the care plan and the policy there would not be as many complaints. Interview, on 01/10/2020 at 4:03 PM, with LPN #2 revealed she knew Resident #57 had a PRN BI-PAP order. However, she did not follow the policy or the order. Continued interview at 4:10 PM, revealed the facility did not have enough staff and there was a lack of oversight by facility leadership with reordering medications and at times there was only on pill left in the narcotic box. She further stated there was definitely an issue with the shower schedule for CNA's who did not know which resident got a shower and on what shift the showers should be provided. She stated the ADL policy was not followed and residents complained often about this. 5. Resident #135's thirty (30) day Minimum Data Set (MDS) review, dated 09/19/2019, revealed the facility assessed Resident #135 with a Brief Interview for Mental Status score of four out of fifteen (4/15) and determined the resident was cognitively severely impaired. The resident required total assistance with one (1) staff for bed mobility and surface to surface transfers. The facility assessed the resident had two (2) or more injury falls. Resident #135's Quarterly MDS review, dated 12/26/2019, revealed the facility assessed Resident #135 with a BIMS score of five out of fifteen (5/15), determining the resident was cognitively severely impaired. The resident required extensive assistance with two (2) staff for bed mobility and surface to surface transfers. The facility determined the resident had one (1) non-injury fall during this period. Resident #135's Comprehensive Care Plan review revealed a revised goal date of 12/27/2019, and the facility determined the resident was at risk for falls related to his/her gait/balance problems, incontinence and psychoactive drug use, vision/hearing problems and impaired cognition. The goal for the resident was to be free of falls through the next review on 04/20/2020. Interventions included to encourage the resident to lay down after lunch and as needed (PRN), keep his/her remote and call light within reach and encourage him/her to use it, prompt response to all requests for assistance, appropriate footwear and non-skid socks when ambulating or mobilizing in wheel chair. In addition, the facility planned to review information on past falls and attempt to determine the cause of falls, record possible root causes and educate the resident/family/caregivers/IDT as to the causes. However, interview with the Director of Nursing (DON) on, 01/10/2020 at 12:36 PM, revealed she could not locate the fall evaluation, post fall investigation, root cause, or the Interdisciplinary Team meetings (IDT) notes for Resident #135's falls, on 08/24/2019, on 09/01/2019, 09/06/19 and 11/07/2019. Resident #135's medical record review revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview, on 01/10/2020 at 3:41 PM with CNA #10, revealed Resident #135 was confused and yelled out and really did not know what he/she needed, did not always know what the call light was used for and it was hard to know at times what the resident needed. However, she stated since the resident had many falls she thought staff had not checked adequately on him/her. CNA #10 stated staff needed to check on the resident when he/she yelled out. Interview, on 01/10/2020 at 2:59 PM, with CNA #11 revealed Resident #135 understood at times, and at times he/she did not understand. She stated the resident required monitoring and supervision and he/she fell because staff had not checked on the resident often enough. Interview, on 01/11/2020 at 10:24 AM, with MDS Coordinator #1, revealed it was not normal for Resident #135 to have frequent falls. However, she stated, with the resident's cognition it was hard to prevent the resident from getting up and somebody would have to stand right by his/her bed. She stated the facility was to keep residents as safe as possible. However, the resident was one you provided care for (him/her) and two (2) minutes later the resident tried to get up. She stated the care plan was updated each time a change in the resident's care occurred; and fall interventions were in place. The MDS Coordinator stated the resident's call light and non-skid socks could help prevent a fall; but one to one (1:1) supervision, one hundred (100%) of the time, would help more. MDS Coordinator #1 stated the care plan did not have interventions related to monitoring, although the facility had tried to put interventions in place. She further stated, when a patient fell the IDT team met, and as part of the IDT team, she reviewed Nurse's Notes and the care plan and put interventions in place. However, MDS Coordinator #1 stated, the DON followed up on the root cause for falls. Interview, on 01/11/2020 at 12:24 PM, with the Director of Nursing, revealed she could not locate the Post Fall/Trauma documentation for Resident #135, the IDT Notes or the root cause of the resident's falls. She stated she was not sure that the floor-nursing staff had received any training because the forms the facility was currently using came out around November. She stated she believed the forms she had reviewed were complete; however, if she felt information was missing she reached out to staff. 6. Resident #493's physician's orders [REDACTED].> 92% PRN as related to [MEDICAL CONDITION] via nasal cannula. Resident #493's Admission Summary Note review, dated 01/01/2020 at 3:39 PM, revealed the facility admitted the resident around 2:00 PM. The note stated at the time of admission, the resident's lungs sounds were diminished, and his/her oxygen saturation was ninety-five percent (95%) on room air. In addition, the resident appeared to get Short of Air (SOA) with ambulation and the nurse reviewed all medications with the physician. Resident #493's MDS review, dated 01/06/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (13/15) determining the resident was interviewable. Further review revealed the resident had shortness of breath with exertion and was on oxygen therapy and received antianxiety medications. Review of Resident #493's Baseline Care Plan revealed the resident received oxygen therapy and, as needed (PRN) and [MEDICAL CONDITION] medications. Review of Resident #493's Pharmacy Delivery Manifest, dated 01/02/2020 at 12:44 PM, revealed Resident #493's medications, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 50 mg and Alpazaoalm ([MEDICATION NAME]) 2 mg, had arrived at the facility. Review of Resident #493's Progress Note, dated 01/02/2020 at 12:45 PM, revealed the resident got his/her [MEDICATION NAME] 2 mg administered, for the first time since his/her admission, on 01/01/2020 at approximately 2:00 PM. However, the resident had remained without his/her ordered medications for twenty-two hours and twenty-five (22 hrs 25m) minutes. Interview, on 01/06/2020 at 10:57 AM, with Resident #493 revealed the physician ordered [MEDICATION NAME] and [MEDICATION NAME] and he/she had not received these medication for thirty-six (36) hours. The resident further stated he/she made this concern known to the nurse at the desk and also told LPN #11 about his/her frustration. Resident #493 stated LPN #11 informed him/her the medications should arrive in about four (4) hours. However, at 10:00 PM, the medications had not arrived from the pharmacy. The resident stated, he/she, felt extreme anxiety, as he/she suffered from Congestive Obstructive [MEDICAL CONDITION] Disease. Interview, on 01/11/2020 at 12:29 PM with the Director of Nursing (DON) revealed she discussed with the IDT what interventions were in place at the time of the fall and, if there was a need to put any additional interventions in place. She stated, after the IDT met the MDS Coordinator revised the care plan. The DON further stated, that during the weekend she directed staff to call her with any falls and she provided staff with direction to provide the care. She stated if the care plan was not revised then residents would not receive the resident specific care. Continued interview with the DON revealed she expected the staff to provide brief changes every two to three (2-3) hours when they made rounds. She stated, she expected nursing staff to document when they provided care, such as [MEDICAL CONDITION] administration. The DON stated she had identified omissions in the medical records and was looking to identify a trend. Interview, on 01/10/2020 at 4:55 PM, with the Administrator revealed he expected interventions related to falls to be in place, root cause analysis should be conducted, and they should review medications and find out if there was a trend at a certain time of day.

Based on interview, record review and policy review it was determined the facility failed to revise the plan of care to include dietary supplement recommendations in order to address identified weight loss for (1) of thirty-two (32) sampled residents (Resident #107). The findings include: Review of the undated policy, Goals and Objectives, Care Plans, revealed the care plan would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The care plan goals and objectives were defined as the desired outcome for a specific resident problem. When goals and objectives were not achieved the resident's documentation in the medical record would occur as to why they were not achieved and new goals and objectives would be established. Care plans would be modified accordingly. All disciplines would have access to the information and would be able to report whether or not the desired out comes were being achieved. The goals and objectives would be reviewed and revised when the resident had a significant change in condition, when the desired outcome was not achieved, when the resident was readmitted to the facility from a hospital and at least quarterly. Review of the facility's policy for Weight Assessment and Intervention, not dated, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. Assessment information would be analyzed by the multidisciplinary team and conclusions would be made regarding resident's target weight range, approximate calorie needs and medical condition. Review of the closed record for Resident #107, revealed the facility admitted the resident on 02/09/2009, and readmitted the resident on 10/21/2019, after a hospitalization . The resident had a history of [REDACTED]. Review of Resident #107's Nutrition/Dietary Note, made on 11/26/2019, revealed the resident's weight was 104.1 pounds. The Dietary Note stated the resident had a significant weight change of 10.3 percent in thirty (30) days and a 10.3 percent weight loss in the last three months and 11.8 percent in six months. Further review revealed a recommendation for eight ounces of Nepro (a supplement), every day between meals, to provide additional Kilocalories and Protein. However, the supplement did not get transferred to the plan of care, nor to the Treatment or Medication Administration Record [REDACTED] Further review of the Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six (6) months. Review of Resident #107's physician's orders [REDACTED]. On 01/10/2020 at 12:20 PM, interview with Certified Medication Technician (CMT) #1, revealed she did not know Resident #107 had experienced a weight loss. CMT #1 stated if the resident had an order for [REDACTED]. CMT #1 stated if the staff did not revise the plan of care then the recommended supplements would not be administered to address the identified weight loss and the resident could experience a decline. Interview with Licensed Practical Nurse (LPN) #15, on 01/11/2020 at 10:38 AM and 1:03 PM, revealed Resident #107 was a diabetic and small in stature. However, due to her being agency staff, she could not remember much more about the resident. LPN #15 stated the Interdisciplinary team revised resident care plans routinely. She stated the facility did not bring it to her attention the resident had a significant weight loss or additional supplements were recommended. Continued interview revealed there was nothing was on the MAR indicated [REDACTED]. LPN #15 stated if staff did not provide the recommended supplements the resident could experience a decline. Interview on 01/11/2020 at 12:55 PM, with the Director of Nursing (DON), revealed she had not identified that Resident #107's plan of care was not revised to reflect the recommended supplement of Nepro for the resident. She stated if the facility did not revise care plans to ensure the recommended dietary supplements were placed on the plan of care, residents could experience a decline. Interview with the Administrator, on 01/11/2020 at 2:03 PM, revealed he expected staff to revise care plans with dietary recommendations after a resident was identified with weight loss. He stated he was new to his role and was still in the process of evaluating the facility's system issues.

Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were provided medications in a timely manner for one (1) of thirty-two (32) sampled residents (Resident #493). The findings include: Review of the facility's policy, Administering Medications, dated April 2019, revealed medications were to be administered in a safe and timely manner, and as prescribed. Continued review revealed medications were only to be administered by licensed persons, or as permitted by the state, to prepare, administer and document the medication administration. According to the policy, medications were administered in accordance with the prescriber's orders to include the required time frame, and for the optimal therapeutic effect of the medication. Further review revealed this was performed to honor the resident's choices and preferences, consistent with his/her care plan. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering it was to initial the Medication Administration Record (MAR) in the space provided for the drug. Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the facility's environment and staff's behaviors were directed towards assisting residents in maintaining and/or achieving independent function, dignity and well-being. Review of Resident #493's clinical record revealed the facility readmitted the resident on 01/01/2019 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #493 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was interviewable. Further review revealed Resident #493 was assessed to have shortness of breath with exertion and was on oxygen therapy, and received antianxiety medications. Review of Resident 493's Physician order [REDACTED]. In addition, further review of the physician's orders [REDACTED].>) 92% related to [MEDICAL CONDITION] diagnosis. Review of the facility's Admission Summary Note for Resident #493, dated 01/01/2020 at 3:39 PM, revealed the resident was admitted at approximately 2:00 PM to the facility. Continued review revealed at the time of admission the resident's lungs sounds were diminished and his/her O2 level was 95% on room air. Further review revealed Resident #493 appeared to have shortness of air (SOA) with ambulation at times. In addition, the Admission Summary Note revealed the nurse had reviewed all the resident's medications with the Physician. Review of the Pharmacy Delivery Manifest, dated 01/02/2020 timed 12:44 PM, revealed the following medications were delivered to the facility for Resident #493: [MEDICATION NAME] 100 mg, [MEDICATION NAME] 50 mg and [MEDICATION NAME] (generic medication for [MEDICATION NAME]) 2 mg. Review of facility's Progress Note for Resident #493, dated 01/02/2020 at 12:45 PM, revealed the resident received his/her [MEDICATION NAME] 2 mg, for the first time since his/her admission on 01/01/2020 at 2:00 PM. Review of the facility's Medication Administration Record (MAR) for Resident #493 revealed the physician's orders [REDACTED]. However, record review revealed the Physician ordered all the medications on 01/01/2020. Review of the Inventory [MEDICATION NAME] Report, printed date of 11/13/2019 at 3:57 PM, revealed no documented evidence the facility had Resident #493's ordered [MEDICATION NAME] and [MEDICATION NAME] medications in their stock inventory available for use for the resident. Interview with Resident #493, on 01/06/2020 at 10:57 AM, revealed he/she had been to the facility for strengthening after a hospital stay. Per interview, the resident stated he/she had not received his/her medications, [MEDICATION NAME] and [MEDICATION NAME] for about thirty-six (36) hours after admission. According to Resident #493, I asked the nurse and was told my medications would be here within four (4) hours, but then it was already 10:00 PM. After I asked several more times the nurse told me the pharmacy was located about four (4) hours away. Continued interview revealed the resident stated, I felt extreme anxiety, had not received my breathing therapy although having [MEDICAL CONDITION]. All I could do was to take deep breaths, inhale and exhale. Thankfully, the hospital had loaded me up with steroids. Resident #493 further stated, I had chest pains and I told myself I had to control it mentally, when in reality it was physical. I paced around and wondered when my medications would arrive. Interview with Certified Nursing Assistant (CNA) #3, on 01/10/2020 at 11:49 AM, revealed Resident #493 had been primarily concerned about all his/her medications, but mostly the as needed (PRN) medication regarding the delayed delivery. Further interview revealed CNA #3 stated some other residents had voiced the same concern to her before. Interview with Licensed Practical Nurse (LPN) #2, on 01/10/2020 at 4:03 PM, revealed the facility had an issue with medication delivery. Per interview, in respect to medication delivery, she stated medications usually got to the facility; however, the issue was nobody oversaw the reordering/ordering of medications. Interview with LPN #11, on 01/10/2020 at 12:18 PM and again at 12:27 PM, revealed the facility had ordered the medications. According to LPN #11, residents were not getting their medications on time (at the facility). She stated when the Pharmacy had staff then they sent the medications over. LPN #11 stated she believed this affected the residents. Interview with the Assistant Director of Nursing (ADON), on 01/11/2020 at 1:16 PM, revealed the facility had trouble with nurses following up on physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 01/11/2020 at 12:43 PM, revealed she had identified some concerns on medication reordering and educated nurses on how to follow up on medications. Interview with the Administrator, on 01/10/2020 at 5:02 PM, revealed he was not a clinician; however, the nurse should have tried to get Resident #493's medication STAT (immediately). According to the Administrator, if the medication had been available in the Emergency Drug Kit, then the nurses should have gotten it out of there. He stated not getting the medication timely made Resident #493 anxious and as a result the facility failed to provide quality of care.

Based on interview, record review and policy review it was determined the facility failed to ensure residents with an identified weight loss were monitored for further weight loss and that supplements were provided as recommended for one (1) of thirty-two (32) sampled residents (Resident #107). Review of the December 2019 physician's orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the facility's electronic Weight Log, revealed Resident #107 weighed 116 pounds on 10/03/2019, and 102 pounds, on 10/24/2019. Further review revealed this was a 14 pound weight loss. Continued review of the log revealed staff did not weight the resident per the physician's orders [REDACTED]. No weights were documented for January 2020. Review of Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six months. The dietitian recommended eight ounces of Glucerna two times a day. Review of Medication Administration Record [REDACTED]. The findings include: Review of the facility's policy for Weight Assessment and Intervention, not dated, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The nursing staff would measure resident weights on admission, the next day, and weekly for two (2) weeks thereafter. If no weight concerns were noted at this point, weights would be measured monthly. Weights would be recorded in each unit's Weight Record or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment would be retaken the next day for confirmation. The threshold for significant unplanned and undesired weight loss would be based on the following criteria. For a one month time frame a 5% weight loss was significant and a greater than 5% weight loss was severe. For a three month time frame a 7.5% weight loss was significant and a greater than 7.5% weigh loss was severe. During a six months time frame a 10% weight loss was significant and greater than 10% was severe. Assessment information would be analyzed by the multidisciplinary team and conclusions would be made regarding resident's target weight range, approximate calorie needs, and medical condition etc. The team and the physician would identify conditions and medications that may be causing weight loss. Review of Resident #107's closed record revealed the facility initially admitted the resident on 02/09/2009, and readmitted the resident on 10/21/2019, after a hospitalization . The resident had a history of [REDACTED]. Review of the December 2019 physician's orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the facility's electronic Weight Log, revealed Resident #107 weighed 116 pounds on 10/03/2019, and was 102 pounds, on 10/24/2019; which was a 14 pound weight loss. Continued review of the log revealed staff did not weight the resident per the physician order [REDACTED]. No weights were documented for January 2020. Review of the Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six months. The resident's diet was a mechanical soft modified diabetic diet with thin liquids. The Dietitian recommended eight ounces of Glucerna two times a day. Review of the Medication Administration Record [REDACTED]. Review of Resident #107's Nutrition/Dietary Note, made on 11/26/2019, revealed the resident's weight was 104.1 pounds. The Dietary Note stated the resident had a significant weight change of 10.3 percent in thirty days; a 10.3 percent weight loss in the last three months; a 11.8 percent in the six months and recommendations were made for eight ounces of Nepro (a supplement), every day between meals, to provide additional Kilocalories and Protein. However, the supplement did not get transferred to the plan of care nor to the Treatment or Medication Administration Record [REDACTED] Interview with Certified Medication Technician (CMT) #1, on 01/10/2020 at 12:20 PM, revealed she was agency staff and did not know Resident #107 had experienced a weight loss. She stated her role as a CMT was to remind the Certified Nursing Assistants (CNA) to weigh residents. She stated she did not document resident's weights because the nurse documented the weights obtained. CMT #1 also stated if the resident had orders for supplements they would be on the MAR/TAR. She stated she could not remember administering supplements to the resident. CMT #1 stated if the staff did not monitor residents' weights or administer supplements per the physician's orders [REDACTED]. Interview, on 01/11/2020 at 10:38 AM and 1:03 PM, with Licensed Practical Nurse (LPN) #15, revealed Resident #107 was diabetic, small in stature and sat in a wheelchair. However, due to her being agency staff, she could not remember much more about the resident. She stated the facility did not bring it to her attention the resident had a significant weight loss or that the resident was not being weighed as ordered. LPN #15 stated nothing was on the MAR indicated [REDACTED]. LPN #15 stated she also did not review the plan of care, she just depended on the MAR indicated [REDACTED]. She stated if staff did not weigh the resident or provide supplements as ordered they could contribute to a decline. Interview with the Director of Nursing (DON), on 01/11/2020 at 12:55 PM, revealed she had identified staff were not routinely obtaining weights as ordered. The DON stated she recently assumed her role and had not yet fixed the system issues related to monitoring residents with identified weight loss. She stated the facility tried to pull staff aside at the time they identified non-compliance with physician orders [REDACTED]. The DON stated she had not identified Resident #107's weight loss, nor did she remember a discussion in the morning meeting about the staff not weighing the resident or providing the supplements as ordered. She stated if the facility did not assess or monitor residents for weight loss, residents could experience a decline. Interview with the Administrator, on 01/11/2020 at 2:03 PM, revealed he expected staff to follow facility policy and physician orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure effective pain management for two (2) of thirty-two (32) sampled residents (Residents #34 and #101). The facility failed to have an effective system to ensure pain medications were available when needed. A total of nine (9) missed doses of pain medication for the resident experiencing chronic pain. The findings include: Review of the facility's policy, Pain Management, dated October 2018, revealed the purpose of the policy was for each resident to be assessed for pain, and to maintain the resident as free from pain as possible. The policy revealed the physician would be notified of unrelieved or worsening pain in a resident. According to the policy, residents receiving routine pain medication were to be assessed each shift by the Charge Nurse during rounds and/or during medication pass. Per the policy, the reason for administration, and effectiveness of the pain medication were to be documented on the Medication Administration Record (MAR), or on the facility's specific Pain Management Flow Sheet. 1. Observation on 01/07/2019 at 10:22 AM, revealed Resident #34 neatly groomed and seated on the bedside in no apparent distress. Interview during the observation revealed Resident #34 stated he/she needed pain medication for his/her back and neck pain. According to the resident, he/she had been without his/her pain medication for two (2) days because the facility let it run out. Review of the clinical record for Resident #34 revealed the facility admitted the resident on 10/28/2019 with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set (MDS) Assessment, dated 11/03/2019, revealed the facility assessed Resident #34 with a Brief Interview for Mental Status (BIMS) total score of twelve (12) out of fifteen (15), indicating the resident was not severely cognitively impaired and therefore was interviewable. Review of Resident #34's History & Physical (H&P) dated 10/24/2019, revealed a Chief Complaint of Intractable Back Pain (severe, constant, relentless and debilitating pain that is not curable). Further review of the H&P revealed an Magnetic Resonance Imaging (MRI), performed prior to admission, showed significant disc disease of the resident's lumbar spine. Review of the facility's physician's orders [REDACTED]. Review of the facility's MAR for Resident #34 dated December 2019, revealed no documented evidence the resident's [MEDICATION NAME] 10-325 mg was administered on the following dates: 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; and 12/16/2019 at 12:00 AM. A total of nine (9) missed doses of pain medication for the resident experiencing chronic pain. Further review of the MAR revealed no documented evidence staff had assessed the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM, a period of thirty-six (36) hours. Review of the facility's Progress Note dated 12/14/2019 at 4:49 PM, revealed Resident #34's [MEDICATION NAME] pain medication was not available to administer. The Note stated the nurse had notified the Pharmacy and would continue to monitor the resident. Review of the Progress Note dated 12/15/2019 at 4:02 PM,{twenty-four (24) hours after the medication was documented to have been unavailable for administration}, revealed the nurse had notified the Physician to get a prescription for Resident #34's [MEDICATION NAME] pain medication. Review of Progress Note, dated 12/16/2019 at 3:39 AM{approximately thirty-six (36) hours after the medication had not been available for administration}, revealed the nurse had obtained a one-time order to administer [MEDICATION NAME] to Resident #34 from the facility's Emergency Drug Kit (EDK) box. Further review of the Progress Notes revealed no documented evidence staff had assessed Resident #34's pain level, implemented any non-pharmacological interventions, or had notified the Physician in order to manage the resident's pain for the thirty-six (36) hours his/her prescribed [MEDICATION NAME] had been unavailable. Interview with Licensed Practical Nurse (LPN) #2 on 01/08/2020 at 10:02 AM, revealed the facility had problems getting medications from the pharmacy and stated there were lots of issues getting residents' narcotic pain medication ever since the facility switched pharmacies. She further revealed there were also issues with delivery of stat medication orders. LPN #2 stated the pharmacy was located out of town and sometimes a resident could miss two (2) doses before the medication was delivered to the facility. According to LPN #2, [MEDICATION NAME] was not available in the emergency drug kit (EDK). Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed the facility had issues with timely delivery of medications since the pharmacy changed in September 2019. LPN #11 stated the nurse was responsible for notifying the physician if a medication was not available and request a one-time order to pull the controlled pain medication from the EDK as needed; however, she did not know why she did not notify Resident #34's physician. The nurse did not contact the physician to pull from the EDK until the medication arrived from the pharmacy. According to LPN #11, non-pharmacological pain interventions would include applying a cold/warm compress, offering fluids or diversional activities. Continued interview revealed LPN #11 should have assessed Resident #34's pain level, and implemented some non-pharmacological intervention(s). Per interview, she probably should have notified the Physician for a one-time order for pain medication as the resident was out of medication. However, she was sometimes swamped and did not document everything. Further interview revealed a resident could have been in a lot of pain if their pain medication was not administered accordingly. Interview with LPN #10, on 01/09/2020 at 11:07 AM, revealed nurses were responsible for ordering medication in the facility's electronic MAR (eMAR) and for notifying the physician for a new prescription for controlled medications. She further stated the nurse was responsible for obtaining a physician's orders [REDACTED]. LPN #10 stated she was not aware of any issues related to the availability of Resident #34's pain medication. Interview with LPN #12 on 01/10/2020 at 2:47 PM, revealed the facility had problems receiving medication orders from the Pharmacy. According to LPN #12, the pharmacy did not notify the facility whenever a new prescription was needed for refills. The LPN stated nurses were responsible for pulling medications from the EDK and/or notifying the Physician for a prescription if a medication was not available. Continued interview with LPN #12 revealed non-pharmacological interventions to use for residents' pain management could include deep breathing, repositioning, and positive visualization. She further stated pain assessments and interventions should be documented in the Progress Notes. According to LPN #12, Resident #34's was very upset about not having pain medication available. 2. Observation, on 01/10/2020 at 10:33 AM, revealed Resident #101 seated at the bedside. Interview during observation revealed the resident sometimes went without pain medication for days because it was not available. Review of the clinical record revealed the facility readmitted the resident on 03/25/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of the MAR, dated October 2019, revealed a total of fourteen (14) missed doses of [MEDICATION NAME]-APAP on 10/02/2019, 10/04/2019, 10/07/2019, 10/09/2019, 10/11/2019, and 10/13/2019. Review of the MAR, dated November 2019, revealed a total of six (6) missed doses of [MEDICATION NAME]-APAP on 11/20/2019, 11/21/2019, and 11/26/2019. Interview with Licensed Practical Nurse (LPN) #4, on 01/09/2020 at 10:38 AM, revealed the facility had issues getting medication delivered from the pharmacy. She stated sometimes the pharmacy needed a new prescription and Resident #101 would run out of pain medication. According to LPN #4, nurses were responsible for notifying the physician and pulling the narcotic from the Emergency Drug Kit (EDK) as needed. The nurse stated pain could affect a resident's activities of daily living (ADL). Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed there were constant issues with delivery of medications and stated she reported the issues to the former Administrator and the pharmacy representative. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the facility had problems with delivery of medications. She stated staff were not aware the pharmacy needed a new prescription until they called to find out why the medication was not delivered. Interview with LPN #15, on 01/11/2020 at 10:34 AM, revealed nurses were responsible for notifying the physician to request a one-time order to remove a narcotic from the EDK if a pain medication was not available. She stated it was important to manage pain because pain could affect the resident's mood, behavior, socialization, and mobility. Interview with the Regional Director of Customer Success for the pharmacy used by the facility, on 01/11/2020 at 12:52 PM, revealed he was not aware of any recent issues related to orders or delivery of medications. Interview, on 01/11/2020 at 12:29 PM with the Director of Nursing (DON) revealed she had recently assumed the role as DON and had identified omissions in the medical records and was evaluating to identify a trend to put a corrective action plan in place. Interview, on 01/10/2020 at 4:55 PM, with the Administrator revealed he expected medications to be administered as ordered and the facility was still in the process of finding out if there was a trend at a certain time of day related to medication administration and availability issues. Interview with the Medical Director, on 01/11/2020 on 2:42 PM, revealed he was working with the pharmacy to resolve an issue with faxed prescriptions. The Medical Director stated he was not aware of any persistent issues with delivery of medications.

Based on observation, interview, record review, and review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to implement the plan of care for three (3) of twenty-five (25) sampled residents, Resident #54, #65, and #71. Resident #54 did not receive weighted utensils for meals and Resident #71 was not monitored for safe smoking practices. Resident #65 had a surgical wound and care planned to receive treatment and care as ordered; however, documentation revealed staff did not provide the treatment and care and the resident's wound worsened requiring antibiotic treatment and further surgical intervention. The findings include: The facility did not provide a policy related to Care Plans. Review of the CMS RAI Manual 3.0, Chapter 4, dated (MONTH) (YEAR), revealed the comprehensive care plan was an interdisciplinary tool and must include measurable objectives and time frames. The care plan must describe services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arrange must be consistent with each resident's written plan of care. 1. Review of the clinical record revealed the facility readmitted Resident #54 on 03/14/18, with [DIAGNOSES REDACTED]. Review of the Physician Orders, dated (MONTH) (YEAR), revealed Resident #54 had an order for [REDACTED]. Review of the Care Plan, dated 03/01/16, revealed the resident was at nutritional risk with a goal for the resident to be without further significant weight change through the next review. Interventions included providing adaptive equipment as ordered. Observation, on 10/16/18 at 9:37 AM, revealed Resident #54 seated on the side of the bed eating his/her cereal with a weighted fork, there were no other utensils available on the breakfast tray. Observation, on 10/16/18 at 1:00 PM, revealed Resident #54 tearing steak with his/her fingers. Interview during observation with the resident revealed he/she needed a knife to cut the steak; however, there was not a knife available on the tray. Review of the resident's tray card revealed meals should be served with weighted utensils. Interview, on 10/18/18 at 10:44 AM, with Licensed Practical Nurse (LPN) #5 revealed the purpose of the care plan was to ensure residents care needs were met. She stated Resident #54 was supposed to have weighted utensils with meals and staff was responsible for checking tray cards to make sure adaptive utensils were on the tray. The LPN stated she gave Resident #54 a plastic spoon one day instead of a weighted spoon because she was busy. Interview, on 10/20/18 at 10:23 AM, with Dietary Aide #2 revealed adaptive equipment improved a resident's ability to eat and all dietary staff was responsible for ensuring adaptive equipment was provided on meal trays. The Aide stated staff stationed at the end of the tray line was responsible for verifying the correct utensils were on the tray prior to loading the tray onto the cart. Interview, on 10/20/18 at 12:41 PM, with Assistant Director of Nursing Services (ADNS) #1 revealed she was not aware of any issues related to missing adaptive equipment on meal trays and she monitored when she was on the floor. The ADNS stated staff was responsible for notifying the dietary department for the required utensils so the resident could eat and drink. Interview with the Director of Nursing Services (DNS), on 10/20/18 at 5:47 PM, revealed she was not aware of any concerns related to adaptive equipment or care plans. 2. Record review revealed the facility readmitted Resident #65 on 09/09/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15) and determined the resident was cognitively impaired. Review of the hospital Discharge Summary for Resident #65, dated 09/08/18, revealed a right above the knee (AKA) amputation was performed on 09/04/18 due to gangrene of the right foot. Review of the facility's Wound Assessment, dated 09/10/18, revealed Resident #65 had a surgical incision related to right AKA. The incision was closed, healing, and the staples were intact. Interview with Resident #65, on 10/18/18 at 9:48 AM, revealed his/her wound dressing was not changed daily. Observation revealed a dressing, dated 10/18/18, on the resident's right AKA stump. Review of Physician Orders, dated 09/10/18, for Resident #65 revealed a treatment order to cleanse the right surgical stump incision with soap and water, dry well, and cover with border gauze daily. Review of Resident #65's Care Plan, dated 09/09/18, revealed the resident had a surgical wound to his/her right AKA site related to a new amputation. Interventions included incision care as ordered by the physician and treatment as ordered. Review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed the treatment order on the TAR; however, staff did not document the treatment was completed for twelve (12) of nineteen (19) days. The facility did not provide paper TAR documentation completed by agency nurses. Further review of Resident #65's Wound Assessment, dated 09/19/18, revealed the surgical site was dry, no redness or drainage, and the skin was intact with staples. Review of a Wound Assessment, dated 09/28/18, revealed the incision had deteriorated, the site looked dark and scabbed with redness outside the incision. Review of the Nurses' Notes, dated 10/01/18, revealed the right stump incision site had some bogginess and was a little red with some darker skin. The wound nurse scheduled an appointment with the surgeon for 10/02/18 related to deterioration of the incision site. Review of the surgeon's Visit Note, dated 10/02/18, revealed the surgeon ordered an oral antibiotic (Bactrim double strength) and an antibiotic ([MEDICATION NAME]) ointment to be applied to the incision daily, and rescheduled the resident for follow up on 10/16/18. Review of a Physician Order, dated 10/05/18, revealed an order for [REDACTED]. Review of Resident #65's Medication Administration Record [REDACTED]. The facility did not provide paper MAR indicated [REDACTED] Review of a Wound Care Assessment, dated 10/05/18, revealed the right stump incision line had some eschar (dead matter cast off from the surface of the skin. The tissue could be hard, black or brown, and leathery in texture.) Review of Physician Orders, dated 10/12/18, revealed a change in the treatment order to cleanse the right stump incision with normal saline, apply Santyl ointment (removes dead tissue from wounds) with 4 x 4 gauze, and cover with a border gauze daily and as needed. Review of the TAR, dated (MONTH) (YEAR), revealed no documentation the treatment was completed on three (3) of four (4) days. The facility did not provide paper TAR documentation completed by agency nurses. Further review of the Nurses' Notes, dated 09/10/18 through 10/16/18, revealed no documentation the resident refused his/her treatments or medication. Review of the surgeon's Follow-up Visit Note, dated 10/16/18, revealed there was an area of necrosis (the death of most or all of the cells in an organ or tissue due to disease or injury) without infection of the medial stump. The surgeon recommended surgical debridement (removal of dead, damaged, or infected tissue) of the stump with postoperative admission for wound care. The surgeon scheduled the resident for right above the knee debridement on 10/22/18. Interview, on 10/18/18 at 3:59 PM, with the Wound Care Nurse revealed she monitored Resident #65's surgical incision weekly to ensure the treatment was in place and she assessed for healing progress. She stated the incision site became soft and boggy and she scheduled an earlier post-op appointment with the surgeon. According to the nurse, a resident's assigned nurse was responsible for completing prescribed treatments. Interview with LPN #5, on 10/18/18 at 10:44 AM, revealed the purpose of the care plan was to ensure resident care needs were met. She stated it was the responsibility of the resident's assigned nurse to ensure wound care and treatments were completed according to the care plan to prevent infections. Interview with LPN #4, on 10/19/18 at 1:54 PM, revealed dressing changes should be documented in the TAR and in the nurses' notes to show the care plan interventions were followed to meet the goal. He stated if the care was not documented, then it was not done and the care plan was not followed. Interview with Assistant Director of Nursing Services (ADNS) #2, on 10/20/18 at 5:09 PM, revealed staff was to follow resident care plans. Interview with the DNS, on 10/20/18 at 5:47 PM, revealed staff was to follow the care plan to ensure proper care for residents. Interview with the Administrator, on 10/20/18 at 6:46 PM, revealed care plans guided residents' care. She revealed there could be a negative outcome or adverse reaction for residents because of not following physician orders. 3. Review of the facility's policy, Safe Smoking, dated 11/01/16, revealed the purpose of the policy was to maximize the facility's ability to provide a safe environment for all residents who smoked. Staff would monitor or obtain fire-igniting material (matches/lighters) at the nurses' station or other designated location. Review of the facility's Smoking Rules revealed during supervised smoking time, the resident would be handed cigarettes and lighter. All resident cigarettes would be secured at the reception desk. Residents would not be allowed to keep any smoking items such as cigarettes and lighters with them outside of the designated smoking time, and resident's must be able to provide their own funds for cigarettes. Observation, on 10/17/18 at 1:30 PM, revealed Resident #71 sitting in a wheelchair and smoking a cigarette in the outside smoking area. The resident placed a pack of cigarettes into his/her bag and held a lighter in his/her hand and put the lighter into his/her bag when the smoke break was over. Activities Staff Member #1 was supervising the residents during the smoke break. Review of Resident #71's clinical record revealed the facility admitted the resident on 05/02/13. Current [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Review of Resident #71's Care Plan, dated on 01/13/16, revealed the resident had the potential for injury related to smoking with interventions for the resident to be aware his/her room might be inspected for lighters and cigarettes, which were not allowed; maintain appropriate level of supervision as determined by the smoking assessment; keep lighter at nurses' station; smoke only in designated smoking areas; and redirect the resident when inappropriate smoking habits were observed. Continued record review revealed Resident #71 signed the facility's Smoking Rules agreement on 05/22/18, which agreed to the rules. Interview, on 10/17/18 at 1:30 PM, with Activities Staff Member #1 revealed she did not see the cigarettes and lighter Resident #71 kept in his/her bag. She stated the facility assessed the resident as a safe smoker and he/she had been educated in regards to the smoking rules, which included not having any smoking materials in his/her possession outside of the supervised smoking area. Interview, on 10/17/18 at 4:55 PM, with the Social Services Coordinator revealed she spoke to Resident #71 about having cigarettes and a lighter, as staff confirmed the resident had cigarettes and a lighter in his/her bag. She stated the resident was care planned for smoking and staff should observe residents closely whenever they smoked. Interview with the DNS, on 10/20/18 at 6:37 PM, revealed resident care plans guided proper care of the residents and staff was to follow the plans. She stated the facility did not allow residents to keep smoking materials in their possession. Interview with the Administrator, on 10/20/18 at 6:37 PM, revealed staff was expected to follow care plans in order to give proper care to the residents. She stated residents could go outside and smoke with staff supervision at certain times.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide wound care according to physician orders [REDACTED].#65. The resident had a right above the knee amputation with physician orders [REDACTED]. The findings include: Review of the facility's policy, Skin Care Guideline, dated (MONTH) (YEAR), revealed the purpose of the policy was to provide a system for evaluation of skin to identify risk and identify individual interventions to address the risk. When an open area was identified, evaluation of the wound should be documented in the electronic medical record including location, size, exudate/if present, pain/if present, appearance of wound bed, including evidence of healing. The wound should be reassessed and interventions reevaluated and revised when progress was not noted within fourteen (14) days. If there was any deterioration of the wound status, comprehensive reevaluation should be initiated and the physician and/or resident representative notified. Review of the facility's policy, Specific Medication Administration Procedures, revealed after administration, the nurse should return to the cart and document administration in the Treatment Administration Record (TAR). If a resident refused a medication, document the refusal in the TAR. Review of the clinical record revealed the facility readmitted Resident #65 on 09/09/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15) and determined the resident cognitively impaired. Review of the hospital Discharge Summary, dated 09/08/18, revealed a right above the knee (AKA) amputation was performed on 09/04/18 related to gangrene of the right foot. Review of the facility's Wound Assessment for Resident #65, dated 09/10/18, revealed a surgical incision related to right AKA. The incision was closed and healing with staples intact. Review of Resident #65's Physician Orders, dated 09/10/18, revealed a treatment order to cleanse the right surgical stump incision with soap and water, dry well, and cover with border gauze daily. Interviews with Resident #65, on 10/17/18 at 2:11 PM and 10/18/18 at 9:48 AM, revealed he/she was recently hospitalized for [REDACTED]. Observation revealed a foam dressing, dated 10/18/18, on the right amputation stump. Review of the TAR, dated (MONTH) (YEAR), revealed the physician ordered treatment on the TAR. The nurses did not document the treatment as given for twelve (12) of nineteen (19) days. The facility did not provide paper TAR documentation completed by agency nurses. Review of Resident #65's Wound Assessment, dated 09/19/18, revealed the surgical site was dry and had no redness or drainage. In addition, the skin was intact with staples. Further review of Wound Assessments, dated 09/28/18, revealed the incision had deteriorated. The surgical site looked dark and scabbed with redness noted outside the incision. Review of Physician Orders, dated 09/28/18, revealed the physician changed the treatment order to cleanse the right stump incision with normal saline, dry, and apply [MEDICATION NAME] along the incision line. Nursing staff was to monitor the surgical incision to the right stump for increased redness every shift for three (3) days. Continued review of the TAR revealed a check mark under 09/28/18, 09/29/18, and 09/30/18, indicating nursing staff completed an assessment of Resident #65's wound. However, the TAR did not provide evidence the wound had improved or deteriorated. In addition, review of the nursing documentation for 09/28/18, 09/29/18, and 09/30/18, revealed no assessment or description to whether the surgical wound showed improvement or had continued to deteriorate. Review of the Nurses' Notes, dated 10/01/18, revealed the wound nurse scheduled an appointment with the surgeon for 10/02/18, related to deterioration of the incision site. The note revealed the right stump incision site continued with some bogginess and was a little red with some darker skin. According to the note, the redness had improved since the last assessment on 09/28/18. Review of the surgeon's Post-Op Visit Note, dated 10/02/18, revealed the right AKA was a little red and likely related to an irritation from the staples. The surgeon ordered an oral antibiotic (Bactrim double strength), an antibiotic ([MEDICATION NAME]) ointment to be applied to the incision daily, and rescheduled the resident for follow up on 10/16/18. Review of Physician Orders, dated 10/05/18, revealed an order for [REDACTED]. Review of Resident #65's Medication Administration Record [REDACTED]. The facility did not provide paper MAR indicated [REDACTED] Review of a Wound Assessment, dated 10/05/18, revealed the right stump incision line had some soft eschar (dead matter cast off from the surface of the skin that could be hard, black or brown, and leathery in texture.) Review of Physician Orders, dated 10/12/18, revealed the physician changed the treatment order to cleanse the right stump incision with normal saline, apply Santyl ointment (removes dead tissue from wounds) with 4 X 4 gauze, and cover with a border gauze daily and as needed. Review of the TAR, dated (MONTH) (YEAR), revealed staff did not document the treatment was completed for three (3) of four (4) days. The facility did not provide paper TAR documentation completed by agency staff. Further review of the Nurses' Notes, dated 09/10/18 through 10/16/18, revealed no documentation indicating the resident refused his/her treatments or medication. Review of the surgeon's Follow-up Office Visit Note, dated 10/16/18, revealed there was a continuous area of necrosis (death of most or all of the cells in an organ or tissue due to disease or injury) without infection of the medial stump. The surgeon recommended surgical debridement of the stump with postoperative admission for wound care. The surgeon scheduled right above the knee debridement on 10/22/18. Interview with Licensed Practical Nurse (LPN) #5, on 10/18/18 at 10:44 AM, revealed it was the responsibility of the resident's assigned nurse to ensure wound care and treatments were completed according to the physician order. She stated the nurse should document in the nurses' note and the TAR if a treatment was not completed or the resident refused. The nurse revealed it was important to follow the physician order [REDACTED]. Interview with LPN #4, on 10/19/18 at 1:54 PM, revealed the purpose of cleansing an incision site with soap and water was to prevent infection of the site. He stated dressing changes should be documented in the TAR and in the nurses' notes and include the appearance of the wound, presence of any drainage, and presence of any pain. LPN #4 revealed it was important to ensure complete documentation of care to monitor wound healing and ensure continuity of care. He stated if it was not documented, then it was not done. According to LPN #4, if a nurse and Certified Medication Technician (CMT) were assigned to the hall, the nurse was responsible for completing resident treatments for the hall. Interview with the Wound Care Nurse, on 10/18/18 at 3:59 PM, revealed the residents' assigned nurse was responsible for completing prescribed treatments. The nurse stated she monitored Resident #65's surgical incision weekly to ensure the treatment was in place and assessed for healing progress. She revealed she also notified the physician as needed for potential changes of treatment orders. The nurse stated she had concerns with the appearance and drainage of the incision site, but had not identified any concerns with the prescribed treatment/dressing changes. The Wound Nurse stated the incision site became soft and boggy and she scheduled an earlier post-op appointment with the surgeon. According to the Wound Nurse, staff should sign off the treatment in the TAR and document any abnormal changes with the wound in the nurses' notes. The nurse stated nursing staff had not reported any concerns related to the wound. Interview with Assistant Director of Nursing Services (ADNS) #1, on 10/20/18 at 12:41 PM, revealed agency nurses did not have access to the electronic MAR/TAR and therefore were required to document on a paper MAR/TAR. She stated she was responsible for reconciling the paper TAR to the electronic TAR, but was not able to reconcile all of them because she had multiple responsibilities and not enough time. She stated it was important to reconcile the documentation to ensure all care was provided for the resident because if staff did not perform wound care, the wound could deteriorate, which could lead to infection. Interview with ADNS #2, on 10/20/18 at 5:07 PM, revealed a complete and accurate MAR/TAR should not have any omissions. According to the ADNS, anything going on with the resident should be documented in the record and not documented meant it was not done. She stated if wound treatments were not done according to the physician order, it lessened the quality of care. The resident's wound could worsen and the resident could become septic. Interview with the Director of Nursing Services (DNS), on 10/20/18 at 5:47 PM, revealed resident refusal of a medication or treatment should be documented in the MAR/TAR, or nurses' note, and the physician/family notified. The DNS revealed there was a potential for resident harm if treatment was not provided according to the physician orders. Interview with the Physician, on 10/20/18 at 11:58 AM, revealed he was not aware of any concerns related to Resident #65's prescribed dressing changes. The Physician stated the incision appeared to be healing and he was not aware of any changes in the progress. He stated it was important to perform wound treatment to promote healing. The MD stated there was a potential for no improvement and/or worsening of the wound if the treatment was not administered according to the orders. Interview with the Administrator, on 10/20/18 at 6:46 PM, revealed if care was not documented then it did not happen, because there was no proof care was given. She stated staff should follow physician orders [REDACTED]. She revealed there could be a negative outcome or adverse reaction for the resident because of not following physician orders. The Administrator further revealed a negative outcome was considered poor quality of care.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to protect two (2) of six (6) sampled residents, Resident #1 and #3, from abuse. Per record review and staff interview, the facility was aware Resident #2 displayed inappropriate sexually acting out behaviors at the time of admission to the secured unit on 12/16/17; however, the facility failed to implement interventions related to Resident #2's potential behavior. On 04/05/18, Licensed Practical Nurse (LPN) #1 found Resident #1 unclothed from the waist down, laying on his/her stomach with Resident #2 on top of him/her, who was also unclothed from the waist down. In addition, Resident #2 admitted to have sucked on Resident #1's breast; however, staff determined sexual abuse did not occur and did not send Resident #1 out for an examination. The Administrator and Director of Nursing Services (DNS) stated due to Resident #1's cognitive impairment, he/she was unable to give consent to sexual behavior; however, Resident #1 was not abused because human instinct was his/her consent. On 04/11/18, the facility moved Resident #2 from the secured unit to an unlocked unit. On 04/15/18, Resident #2 was found on another floor in Resident #3's room. Resident #3 yelled for help and staff entered the room. Resident #2 was observed massaging self in the crotch area with his/her pants down past his/her buttocks. Interview with the DNS revealed there was no abuse because sexual contact had not occurred. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/23/18, and determined to exist on 04/05/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 04/27/18, alleging removal of the IJ on 04/27/18. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility failed to maintain one-to-one supervision per the A[NAME] for two (2) hours on 04/29/18. Interview with staff on 05/01/18, revealed one-to-one staffing could not be provided during this two (2) hour period due to staffing issues; however, one-to-one supervision resumed on 04/29/18 and continued with no breaks in supervision. Therefore, the SSA determined the IJ was not removed until 04/30/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Abuse, dated (MONTH) (YEAR), revealed the facility was to take appropriate steps to prevent the occurrence of abuse. The Director of Nursing Services (DNS) was responsible to direct a thorough investigation of each alleged violation and report the results of the investigation to State Agencies as required by state and federal law. Based on the facility findings of the investigation, the facility was to start corrective actions to prevent the recurrence of the abuse. Sexual abuse was defined as harassment, coercion, assault, and non-consensual sexual contact of any type with a resident. Review of Resident #2's clinical record revealed the facility admitted the resident on 12/16/17, with multiple diagnoses, which included Dementia. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident did not exhibit physical (including abusing others sexually), verbal, or other behaviors. Review of Resident #2's Nursing Note, dated 04/05/18 at 6:02 PM, revealed the DNS made a late entry that Resident #2 was observed with his/her pants around his/her knees over another resident. There were no observation of semen, discharge, or fluid, and Resident #2 was redirected. Review of a Resident Incident Report, dated 04/06/18, revealed on 04/05/18 staff found the Resident #1 on the floor on his/her abdomen with pants around his/her knees, and (Resident #2), with pants around knees, was over Resident #1. There was no erection, no semen, discharge or fluids noted, and no bruising or redness assessed. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/06/15, with multiple diagnoses, which included Dementia, [MEDICAL CONDITION] Disorder, and [MEDICAL CONDITION]. Review of the Quarterly MDS, dated [DATE], revealed the facility did not assess the resident with a BIMS due to the resident was rarely/never understood. Interview with LPN #1, on 04/19/18 at 3:55 PM, revealed he worked on 04/05/18 on the Memory Care Unit (MCU- locked unit) with Certified Nursing Assistant (CNA) #3 and he and the CNA were taking residents to the dining hall to eat. LPN #1 stated he found Resident #1 and #2 at 6:00 PM in room [ROOM NUMBER] (adjacent to Resident #2's room), on the floor. He saw two (2) sets of legs on the floor between the wall and bed and Resident #2 was laying on top of Resident #1 and both residents had their pants pulled down to their ankles. He stated he called Resident #2 by name and the resident got up off Resident #1, and Resident #2's penis was not erect. According to LPN #1, he assessed Resident #1 and his/her lip was bleeding. He stated he sent Resident #2 out of the room to the dining hall and he walked Resident #1 to the activity area and had CNA #3 sit with Resident #1 and instructed CNA #3 to keep constant observation of Resident #2. LPN #1 stated he called the Assistant Director of Nursing Services (ADNS) and reported the incident between the residents. Interview with CNA #3, on 04/20/18 at 4:25 PM, revealed she and LPN #1 worked on 04/05/18 on the MCU. She stated LPN #1 informed her he found Resident #2 on top of Resident #1 in a room and both residents were naked from the waist down. She stated LPN #1 assigned her to stay with Resident #1, who had a bloody lip, and instructed her to visually supervise Resident #2 while LPN #1 went to obtain the supervisors' phone numbers. Interview with ADNS #1, on 04/19/18 at 5:45 PM, revealed LPN #1 reported Resident #2 was found on top of Resident #1 and both residents' pants were pulled down to their ankles. She stated the DNS directed her to assess Resident #1 and the resident was not emotional; however, the resident was nonverbal. The ADNS stated Resident #1 could not give sexual consent because the resident was very confused. ADNS #1 stated Resident #1's skin was intact and she assessed the resident's buttocks for trauma but did not complete an internal vaginal or rectal exam. According to the ADNS, she and the nursing staff were not certified in sexual assault assessments. She stated she reported her findings to the DNS, and the DNS did not instruct her to send Resident #1 out for an exam, but did instruct her to send Resident #2 to the emergency room (ER) for a mental health exam. Continued interview, on 04/20/18 at 6:45 PM, revealed LPN #1 was present with the DNS when Resident #2 was interviewed and verbalized Resident #1 pulled up his/her shirt, and he/she sucked on Resident #1's breasts. Interview with the DNS, on 04/19/18 at 5:00 PM, revealed she and LPN #1 attempted to interview Resident #1 but Resident #1 was not responsive to questions. The ADNS completed a head to toe exam on Resident #1 when she arrived to the facility and found no trauma. Interview with the Medical Director (MD), on 04/23/18 at 10:27 AM, revealed the facility notified him by phone and reported the 04/05/18 incident regarding Resident #2 and #1 found undressed from the waist down and Resident #2 was on top Resident #1 while on the floor. He stated the facility reported an exam was conducted on Resident #1, with no trauma or fluids found between Resident #1's legs; therefore, he/she had not been penetrated. He further stated Resident #2 was sent to the ER for a mental health evaluation and placed on constant supervision, which continued upon return from the ER. Continued interview with the DNS, on 04/19/18 at 5:00 PM, revealed she and LPN #1 interviewed Resident #2 and he/she stated Resident #1 came to his/her room but was unable to remember any events. She stated she instructed LPN #1 to re-enact events and timed it as three (3) minutes and thirteen (13) seconds between when LPN #1 last saw the residents to when the residents were found. Per interview, the DNS determined Resident #2 had not had time to penetrate Resident #1 so Resident #1 was not sent out for an exam. She stated the Medical Director, Guardian, and family of the residents were notified. Further interview revealed since it was determined Resident #2 had not penetrated Resident #1, the DNS concluded the incident was not abuse. She further stated Resident #1 could not verbalize consent for sexual relationships but it was human instinct, which could be considered consent. She stated Resident #2 was sent out to the ER and returned with no significant findings and placed on one-on-one supervision immediately. Interview with Resident #2, on 04/24/18 at 9:30 AM, revealed the resident was unable to recall the events of 04/05/18. Interview with the Administrator, on 04/19/18 at 4:30 PM, revealed the incident on 04/05/18 was not assessed as an abuse incident because Resident #2 had not penetrated Resident #1. She stated LPN #1 reported Resident #2's penis was not erect and fluids were not found on Resident #1. She stated LPN #1 reported an assessment was completed at the time of the incident and there were no signs or symptoms of penetration. She further stated Resident #1 was unable to give verbal consent for sexual relations, but natural human instinct could be considered as consent. The Administrator stated she felt the facility had protected residents from Resident #2. Interview with Resident #2's Family Member #1, on 04/23/18 at 10:58 AM, revealed the family informed the facility before admission of Resident #2's sexual behavior history. She stated Resident #2 made comments toward women, tended to go overboard with the comments, and the comments were sexual in nature. She stated the DNS, Admission Supervisor, and Social Services expressed the facility was able to handle the behaviors to ensure the safety of Resident #2 as well as other residents. She further stated Resident #2 told the facility he/she could not help the sexual urges and behaviors on multiple occasions. Interview with Social Services #1, on 04/24/18 at 10:15 AM, revealed Resident #2's family informed the facility of the resident's sexual behaviors before admission to the facility. She stated Resident #2's sexual comments and behaviors to staff were reported and discussed with Administration in the morning meetings. Review of Resident #2's clinical record revealed three (3) documented incidents of inappropriate sexual comments and/or behaviors prior to the incident on 04/05/18. Review of Resident #2's Nursing Note, dated 01/03/18, revealed Resident #2 became inappropriate and stated to a CNA she looked tired and if she fell asleep, he/she was going to get in her ass. Further review revealed this was reported the Assistant Director of Nursing Services (ADNS). Review of Resident #2's Nursing Note, dated 02/28/18, revealed Resident #2 walked behind a CNA who was bent over and rubbed his/her genitals on the CNA's buttocks. The resident was redirected by staff. Review of Resident #2's Nursing Note, dated 03/24/18, revealed the resident made an inappropriate remark to kitchen staff. However, review of Resident #2's Care Plan revealed no interventions related to monitoring for sexual behaviors as reported by the family, or as noted in the nursing notes, from the time of admission on 12/16/17 through 04/05/18. Further review of Resident #2's clinical record revealed the resident continued to exhibit inappropriate sexual behavior. Nursing Notes, dated 04/07/18, revealed the resident stated he/she wanted to touch and grab staffs' buttocks and it was noted the ADNS and DNS were notified. Review of a Nursing Note, dated 4/10/18, revealed the resident had made gestures for the nurse to come to his/her bedside so he/she could touch him/her. However, review of the resident's care plan revealed the facility failed to address these continued behaviors. In addition, continued review of Resident #2's clinical record revealed a Facility Incident Timeline, with a post date of 04/20/18, stating on 04/11/18, Resident #2 was moved from the MCU to 1B (an open unit) and placed on close supervision. The Incident Timeline stated the resident had no further episodes of inappropriate sexual behaviors. Even though record review revealed documentation, on 04/07/18 and on 04/10/18, the resident continued to have episodes of inappropriate sexual behavior. Further review of the Facility Incident Timeline revealed the resident was medically evaluated and received medication changes to assist with suppression of sexual behavior urges. Interview with the MD, on 04/23/18 at 10:27 AM, revealed the facility evaluated Resident #2's BIMS and found the resident was not appropriate for the MCU and he approved Resident #2's move to 1B with close supervision on 04/11/15. Interview with the DNS, on 04/19/18 at 5:00 PM, revealed Resident #2 was not exhibiting signs of aggression and was deemed safe to move out of the MCU and placed on close supervision. She stated close supervision meant staff was to keep the resident in their line of the sight. However, record review revealed Resident #2 had a second event on 04/15/18, with Resident #3. Review of a Nursing Note, dated 04/15/18, revealed Resident #2 was on the second floor in another resident's room (Resident #3) and pulled his/her pants down. The resident (Resident #3) began to yell which alerted staff to his/her room. Resident #2 was returned to his/her unit. Review of Resident #3's clinical record revealed the facility admitted the resident on 10/07/15, with multiple diagnoses, which included [DIAGNOSES REDACTED]. The facility assessed the resident on 02/22/18 with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Interview with Resident #3, on 04/23/18 at 8:05 AM, revealed on 04/15/18, in the evening, Resident #2 was in his/her room twice within fifteen (15) minutes. Resident #3 stated Resident #2 had his/her hand on self, massaging the crotch area. Resident #3 further stated Resident #2's pants were down past his/her buttocks. Resident #3 stated he/she felt threatened and yelled for help and staff entered the room. Resident #3 stated he/she also felt vulnerable, scared, intimidated and unsafe in the facility. Resident #3 further stated the facility's Administration came across as not concerned because staff had not assessed his/her emotional or physical wellbeing. Per interview, the resident had requested to speak to the Administrator; however, the resident was sent to Social Services instead. Resident #3 further stated he/she was previously raped and was not sleeping well because he/she continued to feel fearful. Review of Resident #3's Nursing Notes, dated 04/15/18 through 04/19/2018, revealed no documentation of the 04/15/18 event. Interview with LPN #4, on 04/24/28 at 4:10 PM, revealed he worked on the second floor on 04/15/18, and heard Resident #3 yell for help. Resident #2 was in the resident's room and Resident #3 was visibly upset. He stated Resident #3 stated Resident #2 exposed himself/herself and had been in his/her room twice over a fifteen (15) minute period. He stated Resident #2 was unable to answer any questions. LPN #4 stated Resident #2's unit nurse was not aware he/she was off the unit. Interview with LPN #3, 04/24/18 at 3:28 PM, revealed Resident #2 returned to the facility after [MEDICAL TREATMENT] on 04/15/18 and returned to his/her room. She stated LPN #4 notified her by phone Resident #2 was on the second floor and had been in Residents #3's room. LPN #3 stated she was not aware Resident #2 was not on his/her unit. Interview with CNA #4, on 04/24/18 at 3:10 PM, revealed he worked on 04/15/18 and was not aware Resident #2 was off the unit until he/she was returned by staff. He stated he was informed Resident #2 was to be closely supervised but when staff provided care to a resident, it was difficult to adequately monitor other residents. Interview with CNA #1, on 04/21/18 at 12:15 PM, revealed he worked on 1B when Resident #2 was moved from MCU. He stated he was not informed of Resident #2's previous sexual behaviors and did not know Resident #2 was to be closely supervised. Interview revealed Resident #2 ambulated throughout the entire facility after he/she was moved off the MCU. Interview with CNA #7, on 04/24/18 at 1:50 PM, revealed she was not informed Resident #2 was to be monitored for behaviors while on 1B. She further stated she was not informed Resident #2 had been in a previous incident with a resident on the MCU, and therefore she had not monitored the resident on the unit. Continued interview with Resident #2's Family Member #1, on 04/23/18 at 10:58 AM, revealed the facility notified the family of Resident #2's move to 1B, after the resident was moved. The family questioned the appropriateness of the move due to the fact the Resident #2's behavior was worse and he/she had already been caught with another resident. She stated Resident #2 should not have been moved out of the MCU with decreased supervision because he/she wandered all over the facility and was not watched by staff. Interview with the Administrator, on 04/19/18 at 4:30 PM, revealed Resident #2 was not physical and had not attempted to touch Resident #3, so no abuse had occurred. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/05/18, Resident #1 was assessed by Assistant Director of Nursing Services (ADNS) #1 and was determined to be without injury. The Physician, Nurse Practitioner, and State Guardian were notified and no orders were received. Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation on 04/06/18. 2. On 04/15/18, the facility placed Resident #2 on one-to-one supervision after the incident with Resident #3. Resident #2 was sent to the hospital for an evaluation on 04/15/18 and was returned to the facility. Resident #2's care plan was revised on 04/18/18, to address behaviors with interventions to protect other residents. 3. On 04/20/18 to 04/26/18, the ADNSs, Health Information Manager (HIM), Workforce Manager (WFM), and Minimum Data Set (MDS) Coordinators conducted skin assessments on all residents to check for injuries. The assessments did not reveal undocumented injuries. In additions, Social Services (SS) and the Senior Director of Clinical Operations (SDCO) interviewed residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above and inquired if they had been touched inappropriately by another resident or if had witnessed other residents being touched inappropriately. The interviews did not reveal any findings. 4. On 04/20/18 through 04/26/18, the Administrator, Business Office Manager, Activity Director, Maintenance Director, Director of Therapy, Director of Clinical Education, Housekeeping Supervisor, Dietary Manager, HR/Payroll Manager, Admissions Coordinator, Director of Nursing Services, Regional Director of Clinical Operations, Regional Director of Nursing Management Services, and the Senior Director of Clinical Operations (SCDO) conducted staff interviews to identify inappropriate resident behaviors or observation of abuse in the facility. A team member interview tool was developed by the SDCO. Upon completion of the interviews, the facility determined staff had not observed inappropriate behaviors or observed abuse in the facility. 5. The Regional Director of Clinical Operations educated the Administrator on abuse, investigating, and reporting abuse on 04/20/18. The Administrator educated the department leaders: the Director of Nursing Services (DNS), ADNS, SS, Director of Clinical Education, MDS Coordinators, Dietary Services Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, Admissions Coordinator, Business Office Manager, Therapy Manager, HR/Payroll Manager, and Workforce Manager on abuse, investigating, and reporting abuse on 04/20/18. The department leaders then educated staff in their respective departments on 04/20/18 through 04/26/18, with a post-test completed. The facility would conduct a minimum of ten (10) staff interviews weekly, using the Team Member Abuse QAPI (Quality Assurance and Performance Improvement) Questionnaire, for eight (8) weeks, then five (5) per week for eight (8) weeks to ensure understanding and competency and reviewed by the QAPI team. 6. The Regional Director of Clinical Operations provided education to clinical leadership, which consisted of the DNS, ADNS, and the Director of Clinical Education on 04/24/18, regarding documentation, notification, treatment, investigating of injuries of unknown source, and updating resident care plans when altercation/abuse occurred. The clinical leadership then educated licensed staff on 04/24/18 through 04/26/18. 7. The SS monitored Resident #1 and Resident #3 on 04/24/18 through 04/26/18 for mood and behaviors with no adverse findings noted. In addition, a skin assessment was performed on 04/24/18, on Resident #3 with no adverse findings. 8. On 04/24/18, an impromptu QAPI meeting was held with the Administrator, DNS, and Medical Director to review the actions, education, and audits effective 04/24/18. The findings of the audits and actions taken after 04/24/18, would be reviewed at the monthly QAPI meeting. The QAPI team includes the Medical Director, Administrator, DNS, and at least three (3) other department leaders. 9. On 04/25/18 and 04/26/18, the Senior Director of Clinical Operations, the DNS, HIM, and MDS Coordinators reviewed all residents' most recent History and Physical and/or Psychiatric Visit Consult Notes for histories of sexually acting out behaviors to ensure care plans addressed the behaviors. New admissions and readmission History and Physicals would be reviewed for sexual behaviors during the clinical start up meetings and the care plans would be reviewed to ensure interventions were in place. In addition, current care plans, of residents who had new or worsening behaviors, were updated with interventions during the meetings. The clinical start up members included the DNS, ADNS, SS, HIM, and the MDS Coordinators. The DNS or ADNS would review the clinical start up meeting minutes to ensure compliance with behavior identification and care planning five (5) times a week for twelve (12) weeks then weekly. The findings would be reviewed with the QAPI team. 10. The Regional Vice President (RVP) reviewed the pattern for scheduling sufficient staff on 04/26/18. The RVP educated the Administrator and DNS on staff coverage, which included utilization of staffing software that would send shift coverage needed notifications to all team members. When nursing staff called in, the unit nurse would make calls to cover the shift and notified Nursing Administration if coverage could not be obtained. If Nursing Administration had to be used to cover shifts, the Administrator would notify the RVP and/or Regional Director of Clinical Operations. The Administrator educated Nursing Administration on 04/16/18. Audits would be completed for adequate staff levels using a staffing tool five (5) times a week for one (1) month, then weekly for two (2) months. The findings would be reviewed with the QAPI team. The SSA validated the facility implemented the following actions: 1. Interview with the ADNS #1, on 04/19/18 at 5:45 PM, revealed she assessed Resident #1 for injury on 04/05/18 at 7:30 PM, which included a full skin assessment, range of motion and cognitive knowledge of the incident and no issues were noted. Interview with the Physician, on 04/23/18 at 10:27 AM, revealed the DNS notified him of the incident between Resident #1 and Resident #2. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the DNS notified her of the incident between Resident #1 and Resident #2. She further stated she and the MD discussed the incident and an evaluation was completed of both residents on 04/09/18. The NP stated there were no changes to both residents assessment from the previous evaluations. Interview with Resident #1's State Guardian, on 04/23/18 at 10:35 AM, revealed the facility notified the Guardian of the incident with Resident #2 by phone and by fax. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/18 at 3:55 PM, revealed Resident #2 was placed on one-to-one supervision after the interview with the DNS on 04/05/18 at approximately 7:00 PM. Interview with the DNS, on 04/1918 at 5:00 PM, revealed after Resident #2 was interviewed, the DNS placed him/her on one-to-one supervision with a Certified Nursing Assistant (CNA) on 04/05/18. Review of Resident #1's clinical record revealed a skin assessment was documented on 04/05/18 and the skin was noted as intact. Review of Resident #2's clinical record revealed the resident was sent to the hospital for evaluation on 04/06/18. 2. Observation of Resident #2, on 04/19/18, 04/20/18, 04/21/18, 04/23/18, 04/24/18, 04/30/18, 05/01/18, and 05/02/18, revealed a male CNA was providing one-to-one supervision of resident. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed Resident #2 did not have one-on-one supervision on 04/29/18 from 7:00 AM till he was assigned to sit with the resident around 9:00 AM to 9:30 AM. He stated the CNA called out who was assigned to sit Resident #2 and the Administrator was on the floor interviewing staff when she became aware of the situation and assigned him to sit with Resident #2. Interview with CNA #11, on 05/01/18 at 1:50 PM, revealed Resident #2 was not supervised on 04/29/18 from 7:00 AM until sometime around 9:00 AM, when the Administrator placed the LPN on duty at the resident's bedside. Interview with the Administrator, on 05/01/18 at 2:15 PM, revealed while interviewing staff on 04/29/18 for abuse, she found Resident #2 was without one-on-one supervision around 9:00-9:30 AM. She stated she immediately assigned the male LPN to Resident #2's bedside. She stated Resident #2 was without supervision as stated in the Allegation of Compliance (A[NAME]). Due to the lack of one-to-one supervision of Resident #2 on 04/29/18, from 7:00 AM to approximately 9:00 AM, the Immediate Jeopardy removal date was deemed 04/30/18. Interview with SS #1, on 05/02/18 at 11: 10 AM, revealed the care plan was reviewed and updated for sexual behaviors. Review of Resident #2's Care Plan revealed the plan was updated on 04/18/18 to include inappropriate sexual behaviors with monitoring, reporting, and redirection, administration of ordered medications for sexual urges, one-to-one supervision, and evaluations by Social Services as needed. 3. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed skin assessments on the MCU and there were no identified issues of unknown injuries. Interview with the WFM, on 05/01/18 at 9:20 AM, revealed she completed skin assessments for residents. She stated she was unable to identify concerns of abuse through injury of unknown source. Interview with MDS Coordinator #2, on 05/02/18 at 10:25 AM, revealed she completed skin assessments for residents not interviewable. She stated she was unable to identify injury of unknown sources. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she identified residents with BIMS greater than eight (8) for the abuse interviews. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and no concerns were identified. Interview of SS #2, on 05/02/18 at 4:50 PM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and did not identify concerns. Record review revealed the facility conducted skin assessments on all residents on 04/24/18 through 04/26/18. Record review revealed all residents identified with the BIMS greater than eight (8) were interviewed about abuse on 04/24/18 through 04/26/18, by SS #1 and SS #2. 4. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed an abuse interview tool for staff. Interview with the Director of Clinical Education (DCE), on 05/01/18 at 3:00 PM, revealed she completed staff interviews for observations and or knowledge of abuse. She stated staff had not identified abuse. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she completed staff interviews for observation or knowledge of abuse. She stated she was unable to identify abuse. Interview with ADNS #2, on 05/02/18 at 10:25 PM, revealed she interviewed staff for observations on inappropriate behaviors or observed abuse in the facility. She stated she did not identify abuse through staff interviews. Interview with the Therapy Director, on 05/02/18 at 11:30 AM, revealed she interviewed therapy staff for abuse in the facility and abuse was not identified. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was interviewed by the supervisor on whether he had observed inappropriate touching or other signs of abuse, which he reported that he had not. Record review revealed staff was interviewed from 04/20/18 through 04/26/18 utilizing the Team Member Interview Tool. Review of active employment lists revealed all staff members were interviewed for abuse. 5. Interview with the Senior Vice President (SVP), on 05/01/18 at 3:50 PM, revealed she educated the Administrator regarding abuse, investigating, and reporting abuse on 04/20/18. She stated the Administrator took a post-test. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was educated on abuse, investigating, and reporting abuse by the Senior Vice President. Record review revealed on 04/20/18, the SVP educated the Administrator on abuse. The Administrator completed an Abuse post-test, dated 04/20/18, with a score of 100%. Interview with CNA #12, on 04/30/18 at 2:35 PM, revealed she completed an in-service on abuse, completed a post-test, and was interviewed by Administration on her knowledge of abuse on several occasions. Interview with the CNA #16, on 04/30/18 at 3:30 PM, revealed he received education by the Staff Educator on abuse, reporting, and who to notify. He stated he was required to take a post-test on abuse. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed she was educated on abuse, reporting, and investigations. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on abuse, assessments, documentation, and reporting abuse and he was required to complete a post-test. He further stated he was interviewed by Administration, sometimes twice a day. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed he was educated by the Therapy Director on abuse and was required to take a post-test. Interview with the Certified Medication Technician (CMT), on 05/01/18 at 3:30 PM, revealed she was in-serviced on abuse and when/how to report abuse by the Staff Educator. She stated she was required to complete a post-test. She stated she missed one (1) question and was immediately re-educated. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she was educated on abuse by the Administrator, and she educated staff on abuse. Interview with the Dietary Director, on 05/02/18 at 9:30 AM, revealed he attended the in-service for abuse on 04/20/18, and

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure abuse allegations were investigated for two (2) of six (6) sampled residents, Resident #1 and #3. On 04/05/18, Licensed Practical Nurse (LPN) #1 reported to Assistant Director of Nursing Services (ADNS) #1 that he found Resident #2 on top of Resident #1, on the floor. Both residents' pants and brief were down to their ankles and Resident #2's genitals were uncovered while on top of Resident #1. In addition, Resident #2 admitted to have sucked on Resident #1's breast. LPN #1 assessed Resident #1 and determined no trauma and no bodily fluids were on the resident's back or buttock area and informed the Director of Nursing Services (DNS) and Administrator of his findings. The DNS interviewed LPN #1; however, did not interview the Certified Nursing Assistant (CNA) working at the time nor assessed or interviewed other residents on the unit. On 04/15/18, Resident #3 informed the facility Resident #2 was in his/her room and massaged his/her crotch and had exposed self while in the room. The DNS was informed; however, staff interviews, statements, and resident statements and assessments were not completed. The facility's failure to have an effective system in place to ensure abuse allegations were thoroughly investigated, has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/23/18, and determined to exist on 04/05/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 04/27/18, alleging removal of the IJ on 04/27/18. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility failed to maintain one-to-one supervision per the A[NAME] for two (2) hours on 04/29/18. Interview with staff on 05/01/18, revealed one-to-one staffing could not be provided during this two (2) hour period due to staffing issues; however, one-to-one supervision resumed on 04/29/18 and continued with no breaks in supervision. Therefore, the SSA determined the IJ was not removed until 04/30/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Abuse, dated (MONTH) (YEAR), revealed the DNS was responsible to direct a thorough investigation of each allegation of abuse and report the results of the investigation to the State Agencies as required by State and Federal law. Sexual abuse was defined as harassment, coercion, assault, and non-consensual sexual contact of any type with a resident. Further review revealed the Administrator and DNS was to investigate any allegation of abuse. Based on the facility findings of the investigation, the facility was to start corrective actions to prevent the recurrence of the abuse. The investigation was to include interviews of staff, visitors, and residents who might have knowledge of the incident. Further review revealed Federal law required the facility to have evidence of the investigation of the incident. Review of a Resident Incident Report, dated 04/06/18, revealed on 04/05/18, staff found Resident #1 on the floor on his/her abdomen with pants around his/her knees, a male (Resident #2), with pants around the knees was over Resident #1. There was no erection, no semen, discharge or fluids noted, no bruising or redness. Further review of the 04/06/18 Resident Incident Report, revealed Memory Care Unit (MCU) residents' previous skin assessments were reviewed by ADNS #1; however, there were no new skin assessments completed after the incident on 04/05/18. The facility investigation file included a written statement by LPN #1; however, no other documentation, such as resident interviews or other staff interviews, was provided. Review of LPN #1's written statement, dated 04/05/18 at 8:45 PM, revealed Resident #2 was found lying on top of Resident #1 between a bed and wall of a resident's room. LPN #1 observed both residents' pants were pulled down and Resident #2 was on top of Resident #1 and Resident #2's penis was exposed but not erect. Resident #2 was removed and he/she stated Resident #1 liked it and called Resident #1 by name. LPN #1 noted Resident #1 was on his/her abdomen, no blood or semen or signs of trauma were found on the residents back or buttocks. Resident #1's lip was swollen and blood was observed. LPN #1 assessed Resident #1, assisted redressing, notified the CNA, and had her sit with Resident #1 while Resident #2 was in the dining room in the line of site of the CNA. Interview with LPN #1, on 04/19/18 at 3:55 PM, revealed he was not trained to perform sexual assault exams. He stated he reported the incident to ADNS #1 by telephone and to the DNS when she arrived to the MCU. He stated he was present when Resident #2 was interviewed by the DNS and the resident verbalized Resident #1 came into his/her room, pulled up his/her shirt and exposed his/her breasts, and Resident #2 sucked on Resident #1's breasts. He stated the DNS instructed him to write a statement, which he did; however, he was not interviewed by anyone at the facility, and had not received in-services on abuse. Interview with CNA #3, on 04/20/18 at 4:25 PM, revealed she worked on 04/05/18 from 3:00 PM to 11:00 PM on the MCU and was aware of the incident between Resident #1 and #2. She stated the DNS and ADNS #1 arrived to the unit while she was with Resident #1 and neither requested a written statement from her, and she was not interviewed about the incident. She further stated she went to ADNS #1 on another day and inquired about the facility needing a written statement or interview for the incident but was ignored by the ADNS. She further stated Administration acted like nothing happened. Interview with ADNS #1, on 04/19/18 at 5:45 PM, revealed the DNS directed her to assess Resident #1, which revealed the resident was not emotional, however Resident #1 was non-verbal. ADNS #1 stated Resident #1's skin was intact and assessed the resident's buttocks for trauma but had not completed an internal vaginal or rectal exam. She stated Resident #1 was not sent to the emergency room (ER) for an exam because the DNS made the determination, based on LPN #1 report of findings and her interviews, that Resident #1 was not abused. She stated she and the nursing staff were not certified in sexual assault assessments. She further stated she took direction from the DNS because she was not trained on investigations. Continued interview with ADNS #1, on 04/20/18 at 6:45 PM, revealed she was present with the DNS when Resident #2 was interviewed and the resident verbalized Resident #1 pulled up his/her shirt and Resident #2 sucked on Resident #1's breasts. She further stated she was not instructed to interview, obtain staff statements, or to monitor Resident #1 for emotional trauma after the incident. Interview with the DNS, on 04/19/18 at 5:00 PM, revealed she and LPN #1 went to Resident #1's room and attempted to interview Resident #1 unsuccessfully. She stated she and LPN #1 met with Resident #2 and the resident was unable to recall any event of the day. She stated ADNS #1 was instructed to review the most up to date skin assessments on all residents; however, these were past skin evaluations and not completed on 04/05/18. The DNS stated residents on the MCU were not assessed or interviewed, interviews with staff were not completed, Resident #1 was not sent out for an exam, and abuse in-services were not conducted. She stated she determined Resident #1 was not abused by Resident #2 because LPN #1 did not find trauma during the skin assessment and did not find bodily fluids on the backside of Resident #1. The DNS determined three (3) minutes and eight (8) seconds was the length of time between visual observation of Resident #2, and Resident #2 was unable to penetrate Resident #1 in that amount of time. She stated Resident #1 could not verbalize consent for sexual relationships but human instinct could be considered consent. Interview with Social Services #1, on 04/24/18 at 10:15 AM, revealed she was not instructed to interview residents regarding the 04/05/18 MCU incident. Interview with the Administrator, on 04/19/18 at 4:30 PM, revealed the incident on 04/05/18 was not assessed as an abuse incident because Resident #1 was not penetrated by Resident #2 and LPN #1 reported Resident #2's penis was not erect, body fluids were not on Resident #1, and therefore concluded penetration was not possible. She further stated Resident #1 was unable to give verbal consent for sexual relations; however, natural human instinct was considered as possible consent. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the Medical Director instructed her to evaluate Resident #1 and #2 on 04/06/18. She stated the assessments were not completed until 04/09/18, because that was the next date she was scheduled in the facility. She stated she assessed Resident #1's heart and lungs, a general exam, and did not complete a vaginal exam. The Practitioner stated the LPN reported he had not found trauma to Resident #1 and the resident was at his/her baseline emotionally. She stated she also assessed Resident #2 and he/she appeared confused and she completed a general exam. She stated she had not completed a genital exam for trauma, scratches, or wounds, which might have occurred if Resident #2 fought back. She stated she did not observe any skin issues; however, she did not undress the resident. Continued review of Resident #2's Nursing Note, dated 04/15/18 at 5:31 PM, revealed LPN #4 documented the resident was on the second floor and entered another resident's (Resident #3) room, pulled his/her pants down, would not leave the room after repeated requests by the resident and the resident started to yell for help. Review of a facility investigation for the 04/15/18 incident with Resident #2 and #3, not dated, revealed the DNS' undated written statement that a resident entered Resident #3's room and pulled down his/her pants and was redirected by staff. Resident #2 was placed on constant supervision and the physician was notified. Social Services #1's written statement, dated 04/19/18, revealed she spoke with Resident #3 on 04/16/18, and the resident reported another resident was in his/her room on Sunday, would not take redirection to leave, and Resident #3 began to yell for help. Interview with Resident #3, on 04/23/18 at 8:05 AM, revealed he/she requested to see the Administrator; however, she never came to speak to him/her. Resident #3 stated Social Services #1 came to the room, listened to his/her concerns, and came back several days later to see how he/she was feeling. Resident #3 stated he/she was not assessed, interviewed, and was not assessed by a provider. Resident #3 stated he/she felt the facility pushed the incident under the rug. Resident #3 revealed he/she had been raped in his/her youth and this incident made him/her feel vulnerable, scared, and intimidated. Interview with LPN #4, on 04/24/18 on 4:10 PM, revealed he was the nurse on the second floor on 04/15/18, and heard Resident #3 yell for help, and when he arrived to the room Resident #3 reported Resident #2 had exposed himself/herself. He stated he escorted Resident #2 to his/her room on the first floor and reported what Resident #3 said happened to LPN #3, who was also the weekend supervisor. He further stated he was not instructed to assess Resident #3 or other residents on the floor, nor was he asked to write a statement. LPN #4 revealed he attempted to interview Resident #2; however, the resident would not answer his questions. Interview with LPN #3, on 04/24/18 at 3:28 PM, revealed staff reported to her on 04/15/18, Resident #2 was found in Resident #3's room and the resident had exposed himself/herself. She stated she notified the DNS who instructed her to restart Resident #2 on constant supervision. She stated she was not instructed to obtain staff statements, conduct further interviews with staff, or complete resident interviews or assessments. She stated she was also the weekend supervisor and had been on the unit to assist with staffing needs for the facility. Interview with CNA #7, on 04/24/18 at 1:50 PM, revealed she worked on the second floor on 04/15/18. She stated she was not instructed to write a statement and she was not interviewed by Administration. Interview with CNA #5, on 04/24/18 at 3:20 PM, revealed he worked the second floor on 04/15/18, and was not interviewed or instructed to write a statement concerning Resident #2 going into Resident #3's room. Continued interview with ADNS #1, on 04/19/18 at 5:45 PM, revealed on 04/15/18, Resident #2 was found on the second floor in Resident #3's room and the resident reported Resident #2 exposed his/her genitals to him/her. She stated the facility deemed abuse had not occurred because Resident #3 was not physically touched by Resident #2 and as far as she knew, an investigation was not initiated or completed. Continued interview with the DNS, on 04/19/18 at 5:00 PM, revealed Resident #2 was moved off the MCU on 04/11/18, to an open unit and placed on close supervision. She stated on 04/15/18, staff found Resident #2 in Resident #3's room and Resident #3 stated Resident #2 exposed himself/herself. She stated Resident #2 was not abusive toward Resident #3 because Resident #2 did not touch the resident and the incident was not investigated. Interview with Social Services #1, on 04/24/18 at 10:15 AM, revealed she was asked to interview Resident #3 on 04/16/18, regarding the allegation of being exposed to by Resident #2. She stated she spoke to Resident #3 on two (2) occasions, four (4) days apart, and Resident #3's story remained the same. She further stated she did not provide written documentation of the two (2) interviews but reported the interviews to the Administrator. She stated that after the surveyor entered the facility on 04/19/18, she was instructed to start interviews with residents regarding abuse. Continued interview with the Administrator, on 04/19/18 at 4:30 PM, revealed on 04/15/18, Resident #3 reported Resident #2 exposed himself/herself in Resident #3's room. She stated Resident #2 was not physical and had not attempted to touch Resident #3 so there was no abuse and the incident was not investigated. Interview with the Staff Educator, on 04/24/18 on 2:42 PM, revealed she educated new staff and in-serviced regular staff on abuse as needed. She stated she was not instructed to re-educate for the 04/05/18 and 04/15/18 incidents between Resident #1 and #2 and Resident #3 and #2. She stated the facility was to thoroughly investigate any abuse allegation as well as any abuse witnessed by staff. She stated the Administrator and DNS had not followed the abuse regulations and the two (2) incidents were not investigated. Further interview with the DNS, on 04/24/18 on 4:10 PM, revealed as the DNS, she was expected to be familiar with abuse regulations and the investigation process. She stated she was to be the lead investigator on all abuse allegations and was to follow the abuse pathways during an investigation. The DNS stated she needed to reread the definition of abuse to see if a resident had to have trauma or had to be touched, for abuse to be considered. She stated she ensured staff followed the abuse policy and regulations and stated all staff was knowledgeable on abuse. She further stated she was knowledgeable regarding the regulations of abuse and on how to conduct a proper investigation. Further interview with the Administrator, on 04/24/18 mat 4:30 PM, revealed she was to oversee and ensure investigations were thorough and complete. She stated she felt the facility had completed investigations for both incidents with Resident #2 and felt the facility took care of all residents involved. Interview with the Medical Director, on 04/25/18 at 1:45 PM, revealed the facility reported the incidents on 04/05/18 and 04/15/18. He stated he had Resident #2 sent out both times for a mental health exam with no significant findings. He stated he and the Administrator spoke about each case and the terms of abuse, and it could have gone either way, as whether it was abuse or not. Interview with the Regional Vice President, on 05/01/18 at 3:50 PM, revealed she made the supportive decision not to investigate and report the 04/05/18 incident to the authorities based on the information the Administrator had relayed; however, she stated she was not told both residents were naked. She stated communication was poor concerning what had occurred on the unit. She further stated she was unsure why the incident on 04/15/18, with Resident #2 and #3 was not fully investigated. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/05/18, Resident #1 was assessed by Assistant Director of Nursing Services (ADNS) #1 and was determined to be without injury. The Physician, Nurse Practitioner, and State Guardian were notified and no orders were received. Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation on 04/06/18. 2. On 04/15/18, the facility placed Resident #2 on one-to-one supervision after the incident with Resident #3. Resident #2 was sent to the hospital for an evaluation on 04/15/18 and was returned to the facility. Resident #2's care plan was revised on 04/18/18, to address behaviors with interventions to protect other residents. 3. On 04/20/18 to 04/26/18, the ADNSs, Health Information Manager (HIM), Workforce Manager (WFM), and Minimum Data Set (MDS) Coordinators conducted skin assessments on all residents to check for injuries. The assessments did not reveal undocumented injuries. In additions, Social Services (SS) and the Senior Director of Clinical Operations (SDCO) interviewed residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above and inquired if they had been touched inappropriately by another resident or if had witnessed other residents being touched inappropriately. The interviews did not reveal any findings. 4. On 04/20/18 through 04/26/18, the Administrator, Business Office Manager, Activity Director, Maintenance Director, Director of Therapy, Director of Clinical Education, Housekeeping Supervisor, Dietary Manager, HR/Payroll Manager, Admissions Coordinator, Director of Nursing Services, Regional Director of Clinical Operations, Regional Director of Nursing Management Services, and the Senior Director of Clinical Operations (SCDO) conducted staff interviews to identify inappropriate resident behaviors or observation of abuse in the facility. A team member interview tool was developed by the SDCO. Upon completion of the interviews, the facility determined staff had not observed inappropriate behaviors or observed abuse in the facility. 5. The Regional Director of Clinical Operations educated the Administrator on abuse, investigating, and reporting abuse on 04/20/18. The Administrator educated the department leaders: the Director of Nursing Services (DNS), ADNS, SS, Director of Clinical Education, MDS Coordinators, Dietary Services Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, Admissions Coordinator, Business Office Manager, Therapy Manager, HR/Payroll Manager, and Workforce Manager on abuse, investigating, and reporting abuse on 04/20/18. The department leaders then educated staff in their respective departments on 04/20/18 through 04/26/18, with a post-test completed. The facility would conduct a minimum of ten (10) staff interviews weekly, using the Team Member Abuse QAPI (Quality Assurance and Performance Improvement) Questionnaire, for eight (8) weeks, then five (5) per week for eight (8) weeks to ensure understanding and competency and reviewed by the QAPI team. 6. The Regional Director of Clinical Operations provided education to clinical leadership, which consisted of the DNS, ADNS, and the Director of Clinical Education on 04/24/18, regarding documentation, notification, treatment, investigating of injuries of unknown source, and updating resident care plans when altercation/abuse occurred. The clinical leadership then educated licensed staff on 04/24/18 through 04/26/18. 7. The SS monitored Resident #1 and Resident #3 on 04/24/18 through 04/26/18 for mood and behaviors with no adverse findings noted. In addition, a skin assessment was performed on 04/24/18, on Resident #3 with no adverse findings. 8. On 04/24/18, an impromptu QAPI meeting was held with the Administrator, DNS, and Medical Director to review the actions, education, and audits effective 04/24/18. The findings of the audits and actions taken after 04/24/18, would be reviewed at the monthly QAPI meeting. The QAPI team includes the Medical Director, Administrator, DNS, and at least three (3) other department leaders. 9. On 04/25/18 and 04/26/18, the Senior Director of Clinical Operations, the DNS, HIM, and MDS Coordinators reviewed all residents' most recent History and Physical and/or Psychiatric Visit Consult Notes for histories of sexually acting out behaviors to ensure care plans addressed the behaviors. New admissions and readmission History and Physicals would be reviewed for sexual behaviors during the clinical start up meetings and the care plans would be reviewed to ensure interventions were in place. In addition, current care plans, of residents who had new or worsening behaviors, were updated with interventions during the meetings. The clinical start up members included the DNS, ADNS, SS, HIM, and the MDS Coordinators. The DNS or ADNS would review the clinical start up meeting minutes to ensure compliance with behavior identification and care planning five (5) times a week for twelve (12) weeks then weekly. The findings would be reviewed with the QAPI team. 10. The Regional Vice President (RVP) reviewed the pattern for scheduling sufficient staff on 04/26/18. The RVP educated the Administrator and DNS on staff coverage, which included utilization of staffing software that would send shift coverage needed notifications to all team members. When nursing staff called in, the unit nurse would make calls to cover the shift and notified Nursing Administration if coverage could not be obtained. If Nursing Administration had to be used to cover shifts, the Administrator would notify the RVP and/or Regional Director of Clinical Operations. The Administrator educated Nursing Administration on 04/16/18. Audits would be completed for adequate staff levels using a staffing tool five (5) times a week for one (1) month, then weekly for two (2) months. The findings would be reviewed with the QAPI team. The SSA validated the facility implemented the following actions: 1. Interview with the ADNS #1, on 04/19/18 at 5:45 PM, revealed she assessed Resident #1 for injury on 04/05/18 at 7:30 PM, which included a full skin assessment, range of motion and cognitive knowledge of the incident and no issues were noted. Interview with the Physician, on 04/23/18 at 10:27 AM, revealed the DNS notified him of the incident between Resident #1 and Resident #2. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the DNS notified her of the incident between Resident #1 and Resident #2. She further stated she and the MD discussed the incident and an evaluation was completed of both residents on 04/09/18. The NP stated there were no changes to both residents assessment from the previous evaluations. Interview with Resident #1's State Guardian, on 04/23/18 at 10:35 AM, revealed the facility notified the Guardian of the incident with Resident #2 by phone and by fax. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/18 at 3:55 PM, revealed Resident #2 was placed on one-to-one supervision after the interview with the DNS on 04/05/18 at approximately 7:00 PM. Interview with the DNS, on 04/1918 at 5:00 PM, revealed after Resident #2 was interviewed, the DNS placed him/her on one-to-one supervision with a Certified Nursing Assistant (CNA) on 04/05/18. Review of Resident #1's clinical record revealed a skin assessment was documented on 04/05/18 and the skin was noted as intact. Review of Resident #2's clinical record revealed the resident was sent to the hospital for evaluation on 04/06/18. 2. Observation of Resident #2, on 04/19/18, 04/20/18, 04/21/18, 04/23/18, 04/24/18, 04/30/18, 05/01/18, and 05/02/18, revealed a male CNA was providing one-to-one supervision of resident. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed Resident #2 did not have one-on-one supervision on 04/29/18 from 7:00 AM till he was assigned to sit with the resident around 9:00 AM to 9:30 AM. He stated the CNA called out who was assigned to sit Resident #2 and the Administrator was on the floor interviewing staff when she became aware of the situation and assigned him to sit with Resident #2. Interview with CNA #11, on 05/01/18 at 1:50 PM, revealed Resident #2 was not supervised on 04/29/18 from 7:00 AM until sometime around 9:00 AM, when the Administrator placed the LPN on duty at the resident's bedside. Interview with the Administrator, on 05/01/18 at 2:15 PM, revealed while interviewing staff on 04/29/18 for abuse, she found Resident #2 was without one-on-one supervision around 9:00-9:30 AM. She stated she immediately assigned the male LPN to Resident #2's bedside. She stated Resident #2 was without supervision as stated in the Allegation of Compliance (A[NAME]). Due to the lack of one-to-one supervision of Resident #2 on 04/29/18, from 7:00 AM to approximately 9:00 AM, the Immediate Jeopardy removal date was deemed 04/30/18. Interview with SS #1, on 05/02/18 at 11: 10 AM, revealed the care plan was reviewed and updated for sexual behaviors. Review of Resident #2's Care Plan revealed the plan was updated on 04/18/18 to include inappropriate sexual behaviors with monitoring, reporting, and redirection, administration of ordered medications for sexual urges, one-to-one supervision, and evaluations by Social Services as needed. 3. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed skin assessments on the MCU and there were no identified issues of unknown injuries. Interview with the WFM, on 05/01/18 at 9:20 AM, revealed she completed skin assessments for residents. She stated she was unable to identify concerns of abuse through injury of unknown source. Interview with MDS Coordinator #2, on 05/02/18 at 10:25 AM, revealed she completed skin assessments for residents not interviewable. She stated she was unable to identify injury of unknown sources. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she identified residents with BIMS greater than eight (8) for the abuse interviews. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and no concerns were identified. Interview of SS #2, on 05/02/18 at 4:50 PM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and did not identify concerns. Record review revealed the facility conducted skin assessments on all residents on 04/24/18 through 04/26/18. Record review revealed all residents identified with the BIMS greater than eight (8) were interviewed about abuse on 04/24/18 through 04/26/18, by SS #1 and SS #2. 4. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed an abuse interview tool for staff. Interview with the Director of Clinical Education (DCE), on 05/01/18 at 3:00 PM, revealed she completed staff interviews for observations and or knowledge of abuse. She stated staff had not identified abuse. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she completed staff interviews for observation or knowledge of abuse. She stated she was unable to identify abuse. Interview with ADNS #2, on 05/02/18 at 10:25 PM, revealed she interviewed staff for observations on inappropriate behaviors or observed abuse in the facility. She stated she did not identify abuse through staff interviews. Interview with the Therapy Director, on 05/02/18 at 11:30 AM, revealed she interviewed therapy staff for abuse in the facility and abuse was not identified. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was interviewed by the supervisor on whether he had observed inappropriate touching or other signs of abuse, which he reported that he had not. Record review revealed staff was interviewed from 04/20/18 through 04/26/18 utilizing the Team Member Interview Tool. Review of active employment lists revealed all staff members were interviewed for abuse. 5. Interview with the Senior Vice President (SVP), on 05/01/18 at 3:50 PM, revealed she educated the Administrator regarding abuse, investigating, and reporting abuse on 04/20/18. She stated the Administrator took a post-test. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was educated on abuse, investigating, and reporting abuse by the Senior Vice President. Record review revealed on 04/20/18, the SVP educated the Administrator on abuse. The Administrator completed an Abuse post-test, dated 04/20/18, with a score of 100%. Interview with CNA #12, on 04/30/18 at 2:35 PM, revealed she completed an in-service on abuse, completed a post-test, and was interviewed by Administration on her knowledge of abuse on several occasions. Interview with the CNA #16, on 04/30/18 at 3:30 PM, revealed he received education by the Staff Educator on abuse, reporting, and who to notify. He stated he was required to take a post-test on abuse. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed she was educated on abuse, reporting, and investigations. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on abuse, assessments, documentation, and reporting abuse and he was required to complete a post-test. He further stated he was interviewed by Administration, sometimes twice a day. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed he was educated by the Therapy Director on abuse and was required to take a post-test. Interview with the Certified Medication Technician (CMT), on 05/01/18 at 3:30 PM, revealed she was in-serviced on abuse and when/how to report abuse by the Staff Educator. She stated she was required to complete a post-test. She stated she missed one (1) question and was immediately re-educated. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she was educated on abuse by the Administrator, and she educated staff on abuse. Interview with the Dietary Director, on 05/02/18 at 9:30 AM, revealed he attended the in-service for abuse on 04/20/18, and completed the post-test. He further stated he was required to provide in-services to all dietary staff on abuse and they were required to complete and pass the abuse post-test. He stated he completed all dietary staffs' in-service and post-test. Interview with the Kitchen Cook, on 05/02/18 at 9:35 AM, revealed he was in-serviced on abuse by the Dietary Director. He stated he was required to complete and pass an abuse post-test. Interview with the Admissions Director, on 05/02/18 at 10:02 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. Interview with MDS Coordinator #1, on 05/02/18 at 10:10 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. She stated she completed random abuse interviews with staff. Interview with the Environmental Supervisor, on 05/02/18 at 9:49 AM, revealed he was trained by the Administrator on abuse and he trained his sta (TRUNCATED)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to have an effective system to ensure care plans were revised for three (3) of six (6) sampled residents, Resident #1, #2, and #3. Per record review and staff interview, Resident #2 was admitted to the facility on [DATE] with known inappropriate sexual behaviors displayed; however, the care plan did not reflect the problem with interventions to address the behavior. Resident #2 displayed inappropriate sexual behaviors toward staff after admission; however, the facility failed to revise the care plan to address the behaviors. On 04/05/18, staff found Resident #2 on top of Resident #1 on the Memory Care Unit (MCU) while both residents were naked. On 04/15/18, Resident #3 reported to staff Resident #2 exposed self and massaged his/her crotch area while in the resident's room. The facility did not revise Resident #2's care plan to address the behavior and did not revise Resident #1 and #3's care plans to monitor for possible effects from the events. The facility's failure to have an effective system in place to ensure resident care plans were updated for treatment of [REDACTED]. Immediate Jeopardy (IJ) was identified on 04/23/18, and determined to exist on 04/05/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 04/27/18, alleging removal of the IJ on 04/27/18. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility failed to maintain one-to-one supervision per the A[NAME] for two (2) hours on 04/29/18. Interview with staff on 05/01/18, revealed one-to-one staffing could not be provided during this two (2) hour period due to staffing issues; however, one-to-one supervision resumed on 04/29/18 and continued with no breaks in supervision. Therefore, the SSA determined the IJ was not removed until 04/30/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: The facility did not provide a policy related to care plans. Review of the RAI 3.0 User's Manual, Version 1.15, dated (MONTH) (YEAR), Chapter 4, pages 4-8 to 4-11, revealed the comprehensive care plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident received. Review of a Resident Incident Report, dated 04/06/18, revealed on 04/05/18, staff found Resident #1 on the floor on his/her abdomen with pants around his/her knees, a male (Resident #2), with pants around the knees was over Resident #1. There was no erection, no semen, discharge or fluids noted, no bruising or redness. Review of Resident #2's clinical record revealed the facility admitted the resident on 12/16/17, with multiple diagnoses, which included Dementia. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident did not exhibit physical (including abusing others sexually), verbal, or other behaviors. The resident resided on the MCU until 04/11/18. Interview with Resident #2's Family Member #1, on 04/23/18 at 10:58 AM, revealed the family informed the facility before admission of Resident #2's sexual behavior history. Interview with Social Services #1, on 04/24/18 at 10:15 AM, revealed Resident #2's family informed the facility of the resident's sexual behaviors before admission to the facility. She further stated she had oversight for the Memory Care Unit and Resident #2 was not care planned for his/her behaviors. Review of Resident #2's clinical record revealed three (3) documented incidents of inappropriate sexual comments and/or behaviors prior to the incident on 04/05/18. Review of Resident #2's Nursing Note, dated 01/03/18, revealed Resident #2 became inappropriate and stated to a Certified Nursing Assistant (CNA) she looked tired and if she fell asleep, he/she was going to get in her ass. Further review revealed this was reported the Assistant Director of Nursing Services (ADNS). Review of Resident #2's Nursing Note, dated 02/28/18, revealed Resident #2 walked behind a CNA who was bent over and rubbed his/her genitals on the CNA's buttocks. The resident was redirected by staff. Review of Resident #2's Nursing Note, dated 03/24/18, revealed the resident made an inappropriate remark to kitchen staff. However, review of Resident #2's Care Plan revealed no interventions related to monitoring for sexual behaviors as reported by the family, or as noted in the nursing notes, from the time of admission on 12/16/17 through 04/05/18. Review of Resident #2's Physician order [REDACTED]. On 3/20/18, [MEDICATION NAME] 10 mg daily was ordered for sexual behaviors, and increased to 20 mg on 04/05/18. On 04/06/18, [MEDICATION NAME] 400 mg daily was ordered for sexual urges. However, review of Resident #2's Care Plan revealed the facility failed to revise the plan of care after the physician orders [REDACTED]. Further review of Residents #2's Nursing Notes, dated 04/07/18, revealed the resident stated he/she wanted to touch and grab staffs' buttocks and the ADNS and the Director of Nursing Services (DNS) were notified. On 4/10/18, the resident made gestures for the nurse to come to his/her bedside so he/she could touch the nurse. However, continued review of Resident #2's Care Plan revealed it was not revised after the behaviors noted in the 04/07/18 and 04/10/18 nursing notes. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/06/15, with multiple diagnoses, which included Dementia, [MEDICAL CONDITION] Disorder, and [MEDICAL CONDITION]. The MDS, dated [DATE], revealed the facility was unable to conduct a BIMS due to the resident was rarely/never understood. Through staff assessment, the facility determined the resident's cognitive skills for daily decision-making were severely impaired. The resident resided on the MCU. Review of Resident #1's Care Plan, dated 02/11/16, revealed the plan was not revised after the incident on 04/05/18. Interview with Licensed Practical Nurse (LPN) #1, on 04/23/18 at 11:35 PM, revealed staff reported resident changes to the respective department for revision of the care plans. He stated staff documented the changes or needs in a communication book, which was reviewed by the MDS Coordinator. He stated he was somewhat knowledgeable how to access care plans on the computer; however, they were not available in the residents' chart. Interview with CNA #3, on 04/20/18 at 4:25 PM, revealed she worked as needed for the facility and was not provided care guides for the residents. She stated she was not aware Resident #2 was to be monitored for behaviors prior to 04/05/18. Continued interview with Social Services (SS) #1, on 04/24/18 at 10:15 AM, revealed Resident #2 was not care planned for his/her behaviors. She stated she had oversight of the MCU residents and was unable to access the computer care plan program and complete care plans for behaviors. SS #1 further stated she had never completed a care plan for behaviors during her employment with the facility and was not knowledgeable how to complete or revise a care plan for residents using the computer program. She stated the previous MDS Coordinator completed all portions of the care plans for residents. She also stated ADNS #1 started behavior monitoring for Resident #2 when staff reported sexual behaviors. She further stated when the sexual behaviors continued, the DNS instructed staff was to continue monitoring Resident #2. Interview with ADNS #1, on 04/19/18 at 5:45 PM, revealed Resident #2 had a history of [REDACTED]. She stated she discussed Resident #2's behaviors with the Administrator and the DNS during the daily morning meetings prior to the 04/05/18 incident with Resident #1; however, they were not concerned. ADNS #1 revealed she placed Resident #2 on behavior monitoring because she was concerned for staff and residents. She stated she verbally instructed the nurses to monitor Resident #2 for behaviors and the information was passed along to other staff, as the facility did not use any type of behavior monitoring sheet. Continued interview on 04/20/18 at 6:45 PM, revealed the Interdisciplinary Team (IDT) met on 04/05/18 and discussed Resident #2's care plan and Resident #2's behaviors in detail; however, the care plan was not revised. She stated Resident #2 was moved to an open unit on 04/11/18, and was to be on close supervision by staff. Continued review of Resident #2's Nursing Notes, dated 04/15/18, revealed the resident was on the second floor in another resident's room (Resident #3) and pulled his/her pants down. The resident (Resident #3) began to yell which alerted staff to his/her room. Resident #2 was returned to his/her unit. Further review of Resident #2's Care Plan revealed it was not revised for close supervision when he/she moved to the open unit. Review of Resident #3's clinical record revealed the facility admitted the resident on 10/07/15, with [DIAGNOSES REDACTED]. The facility assessed the resident on 02/22/18, with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable Interview with Resident #3, on 04/23/18 at 8:05 AM, revealed he/she felt vulnerable, scared, and intimidated. Resident #3 further stated he/she was previously raped and not sleeping well because he/she continued to feel fearful. Review of Resident #3's Care Plan, dated 10/16/15, revealed the plan was not revised after the 04/15/18 incident with Resident #2. Interview with CNA #1, on 04/21/18 at 12:15 PM, revealed when Resident #2 was moved to the open unit, he was not informed of Resident #2's previous sexual behaviors, and he was not informed Resident #2 was to have close supervision. He further stated the CNA Care Guide was not updated when the resident was moved to the open unit. He further stated if Resident #2 was to be supervised due to known sexual behaviors; the facility was responsible to ensure all staff was aware of the incident. He stated the CNAs communicated through report guided by the care guides provided by the facility. Interview with CNA #13, on 04/30/18 at 3:30 PM, revealed the CNAs had care plans called care guides kept in a binder in the nurses' station on each unit. She stated they were used to ensure the residents were cared for as an individual. She further stated the guides were updated every couple of weeks and until the guides were updated, the CNAs wrote on the paper any resident updated needs and gave it to the next shift. She stated the paper was handed off frequently. Continued interview with ADNS #1, on 04/21/18 at 12:50 PM, revealed CNA Care Guides were updated every couple of weeks. She stated medical records updated the care guide by calling the ADNS' for updated information. She further stated the care guide for Resident #2 was not updated when he/she was moved to the open unit. She stated the CNAs were to give verbal report, which included any care needed for Resident #2, while awaiting the care guides to be updated. Interview with LPN #5, on 04/30/18 at 2:52 PM, revealed she was not able to revise care plans because she had not been trained how to access the resident care plans and how to follow the computer program provided by the facility. She further stated the facility asked staff to read a pamphlet about care planning and then sign to reflect it was read. She stated reading a pamphlet was not adequate in educating staff on care plan revision with the program in the computer. Interview with LPN #2, on 04/22/18 at 8:30 PM, revealed care plans were updated by MDS, DNS, and the ADNS. She stated staff was not allowed to revise care plans and when care plans were revised, staff was not notified. She stated any changes that were needed for the nursing and CNA care plans were reported to the supervisors and changes were completed every couple of weeks. She further stated she had a new CNA with her and had to review the CNA Care Guide and made numerous changes because most of the information was incorrect. Interview with the Health Information Manager (HIM), on 04/30/18 at 2:45 PM, revealed the MDS, SS, ADNS, and DNS were all responsible to ensure care plans were initiated or revised. She stated it was important for resident care plans to be accurate so staff could follow and provide resident centered care. Interview with the MDS Coordinator, on 04/24/18 at 10:58 AM, revealed the facility was aware at admission about Resident #2's sexual behaviors. She stated Social Services was responsible to initiate behavior care plans, and Resident #2 was not care planned for behaviors at admission, or after behaviors occurred on the unit. The Coordinator stated she was required to look seven (7) days prior for information to add during MDS review and Resident #2 had not flagged for concerning behaviors during the review period. She stated she revised the care plans with changes of conditions and with the annual and quarter reviews of the MDS. According to the MDS Coordinator, the IDT revised care plans during the morning IDT meetings. She further stated she was responsible to review care plans for residents to ensure the care plans reflected the residents' care needs. Continued Interview with the DNS, on 04/20/18 at 5:30 PM, revealed Resident #1 and #2's care plans were not revised after the 04/05/18 incident on the MCU. She stated she was unable to recall if Resident #2 and #3's care plans were revised after the 04/15/18 incident between the residents. Further interview on 04/23/18 at 1:20 PM, revealed care plan revision was to be an IDT effort. She stated the MDS Coordinator completed the initial care plan and revised the care plan with quarterly reviews. She further stated she monitored resident care plans through walking rounds on the floor, observing care, and reviewing nurses' documentation. Interview with the Administrator, on 04/23/18 at 6:00 PM, revealed the facility had issues with care plans because the facility did not have policies for care plans. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/05/18, Resident #1 was assessed by Assistant Director of Nursing Services (ADNS) #1 and was determined to be without injury. The Physician, Nurse Practitioner, and State Guardian were notified and no orders were received. Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation on 04/06/18. 2. On 04/15/18, the facility placed Resident #2 on one-to-one supervision after the incident with Resident #3. Resident #2 was sent to the hospital for an evaluation on 04/15/18 and was returned to the facility. Resident #2's care plan was revised on 04/18/18, to address behaviors with interventions to protect other residents. 3. On 04/20/18 to 04/26/18, the ADNSs, Health Information Manager (HIM), Workforce Manager (WFM), and Minimum Data Set (MDS) Coordinators conducted skin assessments on all residents to check for injuries. The assessments did not reveal undocumented injuries. In additions, Social Services (SS) and the Senior Director of Clinical Operations (SDCO) interviewed residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above and inquired if they had been touched inappropriately by another resident or if had witnessed other residents being touched inappropriately. The interviews did not reveal any findings. 4. On 04/20/18 through 04/26/18, the Administrator, Business Office Manager, Activity Director, Maintenance Director, Director of Therapy, Director of Clinical Education, Housekeeping Supervisor, Dietary Manager, HR/Payroll Manager, Admissions Coordinator, Director of Nursing Services, Regional Director of Clinical Operations, Regional Director of Nursing Management Services, and the Senior Director of Clinical Operations (SCDO) conducted staff interviews to identify inappropriate resident behaviors or observation of abuse in the facility. A team member interview tool was developed by the SDCO. Upon completion of the interviews, the facility determined staff had not observed inappropriate behaviors or observed abuse in the facility. 5. The Regional Director of Clinical Operations educated the Administrator on abuse, investigating, and reporting abuse on 04/20/18. The Administrator educated the department leaders: the Director of Nursing Services (DNS), ADNS, SS, Director of Clinical Education, MDS Coordinators, Dietary Services Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, Admissions Coordinator, Business Office Manager, Therapy Manager, HR/Payroll Manager, and Workforce Manager on abuse, investigating, and reporting abuse on 04/20/18. The department leaders then educated staff in their respective departments on 04/20/18 through 04/26/18, with a post-test completed. The facility would conduct a minimum of ten (10) staff interviews weekly, using the Team Member Abuse QAPI (Quality Assurance and Performance Improvement) Questionnaire, for eight (8) weeks, then five (5) per week for eight (8) weeks to ensure understanding and competency and reviewed by the QAPI team. 6. The Regional Director of Clinical Operations provided education to clinical leadership, which consisted of the DNS, ADNS, and the Director of Clinical Education on 04/24/18, regarding documentation, notification, treatment, investigating of injuries of unknown source, and updating resident care plans when altercation/abuse occurred. The clinical leadership then educated licensed staff on 04/24/18 through 04/26/18. 7. The SS monitored Resident #1 and Resident #3 on 04/24/18 through 04/26/18 for mood and behaviors with no adverse findings noted. In addition, a skin assessment was performed on 04/24/18, on Resident #3 with no adverse findings. 8. On 04/24/18, an impromptu QAPI meeting was held with the Administrator, DNS, and Medical Director to review the actions, education, and audits effective 04/24/18. The findings of the audits and actions taken after 04/24/18, would be reviewed at the monthly QAPI meeting. The QAPI team includes the Medical Director, Administrator, DNS, and at least three (3) other department leaders. 9. On 04/25/18 and 04/26/18, the Senior Director of Clinical Operations, the DNS, HIM, and MDS Coordinators reviewed all residents' most recent History and Physical and/or Psychiatric Visit Consult Notes for histories of sexually acting out behaviors to ensure care plans addressed the behaviors. New admissions and readmission History and Physicals would be reviewed for sexual behaviors during the clinical start up meetings and the care plans would be reviewed to ensure interventions were in place. In addition, current care plans, of residents who had new or worsening behaviors, were updated with interventions during the meetings. The clinical start up members included the DNS, ADNS, SS, HIM, and the MDS Coordinators. The DNS or ADNS would review the clinical start up meeting minutes to ensure compliance with behavior identification and care planning five (5) times a week for twelve (12) weeks then weekly. The findings would be reviewed with the QAPI team. 10. The Regional Vice President (RVP) reviewed the pattern for scheduling sufficient staff on 04/26/18. The RVP educated the Administrator and DNS on staff coverage, which included utilization of staffing software that would send shift coverage needed notifications to all team members. When nursing staff called in, the unit nurse would make calls to cover the shift and notified Nursing Administration if coverage could not be obtained. If Nursing Administration had to be used to cover shifts, the Administrator would notify the RVP and/or Regional Director of Clinical Operations. The Administrator educated Nursing Administration on 04/16/18. Audits would be completed for adequate staff levels using a staffing tool five (5) times a week for one (1) month, then weekly for two (2) months. The findings would be reviewed with the QAPI team. The SSA validated the facility implemented the following actions: 1. Interview with the ADNS #1, on 04/19/18 at 5:45 PM, revealed she assessed Resident #1 for injury on 04/05/18 at 7:30 PM, which included a full skin assessment, range of motion and cognitive knowledge of the incident and no issues were noted. Interview with the Physician, on 04/23/18 at 10:27 AM, revealed the DNS notified him of the incident between Resident #1 and Resident #2. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the DNS notified her of the incident between Resident #1 and Resident #2. She further stated she and the MD discussed the incident and an evaluation was completed of both residents on 04/09/18. The NP stated there were no changes to both residents assessment from the previous evaluations. Interview with Resident #1's State Guardian, on 04/23/18 at 10:35 AM, revealed the facility notified the Guardian of the incident with Resident #2 by phone and by fax. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/18 at 3:55 PM, revealed Resident #2 was placed on one-to-one supervision after the interview with the DNS on 04/05/18 at approximately 7:00 PM. Interview with the DNS, on 04/1918 at 5:00 PM, revealed after Resident #2 was interviewed, the DNS placed him/her on one-to-one supervision with a Certified Nursing Assistant (CNA) on 04/05/18. Review of Resident #1's clinical record revealed a skin assessment was documented on 04/05/18 and the skin was noted as intact. Review of Resident #2's clinical record revealed the resident was sent to the hospital for evaluation on 04/06/18. 2. Observation of Resident #2, on 04/19/18, 04/20/18, 04/21/18, 04/23/18, 04/24/18, 04/30/18, 05/01/18, and 05/02/18, revealed a male CNA was providing one-to-one supervision of resident. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed Resident #2 did not have one-on-one supervision on 04/29/18 from 7:00 AM till he was assigned to sit with the resident around 9:00 AM to 9:30 AM. He stated the CNA called out who was assigned to sit Resident #2 and the Administrator was on the floor interviewing staff when she became aware of the situation and assigned him to sit with Resident #2. Interview with CNA #11, on 05/01/18 at 1:50 PM, revealed Resident #2 was not supervised on 04/29/18 from 7:00 AM until sometime around 9:00 AM, when the Administrator placed the LPN on duty at the resident's bedside. Interview with the Administrator, on 05/01/18 at 2:15 PM, revealed while interviewing staff on 04/29/18 for abuse, she found Resident #2 was without one-on-one supervision around 9:00-9:30 AM. She stated she immediately assigned the male LPN to Resident #2's bedside. She stated Resident #2 was without supervision as stated in the Allegation of Compliance (A[NAME]). Due to the lack of one-to-one supervision of Resident #2 on 04/29/18, from 7:00 AM to approximately 9:00 AM, the Immediate Jeopardy removal date was deemed 04/30/18. Interview with SS #1, on 05/02/18 at 11: 10 AM, revealed the care plan was reviewed and updated for sexual behaviors. Review of Resident #2's Care Plan revealed the plan was updated on 04/18/18 to include inappropriate sexual behaviors with monitoring, reporting, and redirection, administration of ordered medications for sexual urges, one-to-one supervision, and evaluations by Social Services as needed. 3. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed skin assessments on the MCU and there were no identified issues of unknown injuries. Interview with the WFM, on 05/01/18 at 9:20 AM, revealed she completed skin assessments for residents. She stated she was unable to identify concerns of abuse through injury of unknown source. Interview with MDS Coordinator #2, on 05/02/18 at 10:25 AM, revealed she completed skin assessments for residents not interviewable. She stated she was unable to identify injury of unknown sources. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she identified residents with BIMS greater than eight (8) for the abuse interviews. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and no concerns were identified. Interview of SS #2, on 05/02/18 at 4:50 PM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and did not identify concerns. Record review revealed the facility conducted skin assessments on all residents on 04/24/18 through 04/26/18. Record review revealed all residents identified with the BIMS greater than eight (8) were interviewed about abuse on 04/24/18 through 04/26/18, by SS #1 and SS #2. 4. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed an abuse interview tool for staff. Interview with the Director of Clinical Education (DCE), on 05/01/18 at 3:00 PM, revealed she completed staff interviews for observations and or knowledge of abuse. She stated staff had not identified abuse. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she completed staff interviews for observation or knowledge of abuse. She stated she was unable to identify abuse. Interview with ADNS #2, on 05/02/18 at 10:25 PM, revealed she interviewed staff for observations on inappropriate behaviors or observed abuse in the facility. She stated she did not identify abuse through staff interviews. Interview with the Therapy Director, on 05/02/18 at 11:30 AM, revealed she interviewed therapy staff for abuse in the facility and abuse was not identified. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was interviewed by the supervisor on whether he had observed inappropriate touching or other signs of abuse, which he reported that he had not. Record review revealed staff was interviewed from 04/20/18 through 04/26/18 utilizing the Team Member Interview Tool. Review of active employment lists revealed all staff members were interviewed for abuse. 5. Interview with the Senior Vice President (SVP), on 05/01/18 at 3:50 PM, revealed she educated the Administrator regarding abuse, investigating, and reporting abuse on 04/20/18. She stated the Administrator took a post-test. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was educated on abuse, investigating, and reporting abuse by the Senior Vice President. Record review revealed on 04/20/18, the SVP educated the Administrator on abuse. The Administrator completed an Abuse post-test, dated 04/20/18, with a score of 100%. Interview with CNA #12, on 04/30/18 at 2:35 PM, revealed she completed an in-service on abuse, completed a post-test, and was interviewed by Administration on her knowledge of abuse on several occasions. Interview with the CNA #16, on 04/30/18 at 3:30 PM, revealed he received education by the Staff Educator on abuse, reporting, and who to notify. He stated he was required to take a post-test on abuse. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed she was educated on abuse, reporting, and investigations. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on abuse, assessments, documentation, and reporting abuse and he was required to complete a post-test. He further stated he was interviewed by Administration, sometimes twice a day. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed he was educated by the Therapy Director on abuse and was required to take a post-test. Interview with the Certified Medication Technician (CMT), on 05/01/18 at 3:30 PM, revealed she was in-serviced on abuse and when/how to report abuse by the Staff Educator. She stated she was required to complete a post-test. She stated she missed one (1) question and was immediately re-educated. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she was educated on abuse by the Administrator, and she educated staff on abuse. Interview with the Dietary Director, on 05/02/18 at 9:30 AM, revealed he attended the in-service for abuse on 04/20/18, and completed the post-test. He further stated he was required to provide in-services to all dietary staff on abuse and they were required to complete and pass the abuse post-test. He stated he completed all dietary staffs' in-service and post-test. Interview with the Kitchen Cook, on 05/02/18 at 9:35 AM, revealed he was in-serviced on abuse by the Dietary Director. He stated he was required to complete and pass an abuse post-test. Interview with the Admissions Director, on 05/02/18 at 10:02 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. Interview with MDS Coordinator #1, on 05/02/18 at 10:10 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. She stated she completed random abuse interviews with staff. Interview with the Environmental Supervisor, on 05/02/18 at 9:49 AM, revealed he was trained by the Administrator on abuse and he trained his staff on abuse and they were required to pass the post-test. He stated he immediately retrained staff for wrong answers and he randomly asked staff about abuse. Interview with Housekeeper #1, on 05/02/18 at 9:59 AM, revealed he received education on abuse and was required to pass a post-test. He further stated he was interviewed numerous times on his knowledge of abuse and reporting abuse. Interview with ADNS #2, on 05/02/18 at 10: 25 AM, revealed she received training by the Administrator on abuse and was required to pass a post-test. She stated she provided post-tests to staff who were educated on abuse and reeducated staff immediately if answers were wrong. She stated she was interviewing random staff for knowledge of in-services. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she was educated by the Administrator on abuse, investigations, reporting and assessment. She stated she then completed staff abuse interview with post-tests. She stated staff was given one-on-one education for any missed questions. Interview with the DNS, on 05/02/18 at 4:40 PM, revealed she received education by the Administrator on abuse, investigations, and reporting. She stated Administration was required to compete post-tests. Record review revealed on 04/20/18, the Administrator educated seventeen (17) department leaders with post-tests completed. Review of staff abuse education revealed staff received abuse training from 04/20/18 to 04/26/18 with post-tests completed. The facility completed abuse in-services to all staff members. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed staff had interviewed her numerous times on abuse. Interview with the Physical Therapist, o (TRUNCATED)

Based on interview, record review, and facility staffing schedule review, it was determined the facility failed to have an effective system to provide adequate staffing to supervise residents on the Memory Care Unit (MCU) to ensure the safety for one (1) of six (6) sampled residents, Resident #1. Per record review and staff interview, on 04/05/18, staff found Resident #2 on top of Resident #1 on the floor; both residents were unclothed from the waist down, on the Memory Care Unit (MCU). Interview revealed the facility was aware of Resident #2's inappropriate sexual behaviors and staff was to monitor for the inappropriate behavior. However, interview and record review revealed the MCU unit was staffed with only one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA) for twenty-nine (29) residents from 3:00 PM to 11:00 PM on 04/05/18 and due to staffing, they could not supervise Resident #2. The facility's failure to have an effective system in place to ensure adequate staffing to supervise residents has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/23/18, and determined to exist on 04/05/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 04/27/18, alleging removal of the IJ on 04/27/18. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility failed to maintain one-to-one supervision per the A[NAME] for two (2) hours on 04/29/18. Interview with staff on 05/01/18, revealed one-to-one staffing could not be provided during this two (2) hour period due to staffing issues; however, one-to-one supervision resumed on 04/29/18 and continued with no breaks in supervision. Therefore, the SSA determined the IJ was not removed until 04/30/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: The facility was did not provide policies for staffing or resident supervision. Review of a Resident Incident Report, dated 04/05/18, revealed staff found Resident #1 on the floor on his/her abdomen with pants around his/her knees, and (Resident #2), with pants around knees, was over Resident #1. There was no erection, no semen, discharge or fluids noted, and no bruising or redness assessed. Interview with Assistant Director of Nursing Services (ADNS) #1, on 04/19/18 at 5:45 PM, revealed Resident #2 had a history of [REDACTED]. She stated Resident #2 verbalized he/she could not control his/her urges to make sexual comments and she placed Resident #2 on behavior monitoring because she was concerned for staff and residents. Further interview revealed Resident #2 was supposed to be on close supervision, which meant the resident was to be in the vision of staff. She stated Resident #2 was monitored on the MCU for inappropriate sexual behaviors; however, on 04/05/18, Resident #2 was found on top of Resident #1 and both residents were reported naked. Review of the facility's schedule for the MCU, identified as 1C, dated 04/05/18, revealed one (1) LPN scheduled from 6:45 AM to 7:15 PM, and one (1) CNA scheduled from 3:00 PM to 11:00 PM. Staff was identified as LPN #1 and CNA #3. Interview with CNA #3, on 04/20/18 at 4:25 PM, revealed she worked on 04/05/18 on the MCU with LPN #1. She stated she spoke to ADNS #1 over concerns about having only one (1) nurse and one (1) CNA for the unit. She stated she could not supervise the residents safely because the residents had behaviors, wandered, and had sundow[DIAGNOSES REDACTED] by dinner. She stated ADNS #1 stated the scheduler for the facility was attempting to find staff and hoped to have staff to help by 7:00 PM that night. She stated LPN #1 and herself kept the residents together in the activity room to attempt to keep them safe. She further stated during dinner, residents were not supervised because she was assisting residents and monitoring the dining room. She stated LPN #1 found Resident #2 on top of Resident #1 and the residents were unclothed from the waist down. Interview with LPN #1, on 04/23/18 at 11:35 AM, revealed he and one (1) CNA were scheduled on 04/05/18 on the MCU, which frequently occurred. He stated the unit had twenty-nine (29) residents with behavioral issues that required constant supervision, which was not possible with one (1) nurse and one (1) CNA. He further stated on 04/05/18, he attempted to ensure the safety of all the residents, but Resident #2 could not be adequately supervised and Resident #1 wandered. He stated the facility staffing level for the MCU was not safe. He stated he and the CNA were preparing residents for dinner when he found Resident #2 on top of Resident #1; both were unclothed on the floor. Interview with CNA #1, on 04/21/18 at 12:15 PM, revealed it was difficult to supervise residents when in resident rooms or passing trays. Interview with LPN #2, on 04/22/18 at 8:30 PM, revealed the MCU was often scheduled with only one (1) nurse and one (1) CNA. She stated staff was unable to supervise twenty-nine (29) cognitively impaired residents with behaviors, safely. Interview with ADNS #1, on 04/20/18 at 6:45 PM, revealed CNA #3 inquired about staffing on 04/05/18 and voiced concern in the ability to care for the residents with only two (2) staff on the unit. She stated she told the CNA the scheduler was attempting to find staff and she hoped help would be on the unit by 7:00 PM. She stated normal staffing for the MCU was two (2) to three (3) CNAs and one (1) nurse, due to the poor cognition and behaviors of the residents on the unit. She stated staff was unable to supervise residents safely with one (1) nurse and one (1) CNA on the unit. Interview with the Work Force Management Coordinator, on 04/24/18 at 11:42 AM, revealed on 04/05/18, she had attempted to find staff for the second shift on the MCU. She stated one (1) nurse and one (1) CNA was originally scheduled to work the MCU, and the lack of staffing was not a result of staff calling out. She stated two (2) CNAs were minimal for the MSU due to the poor cognition of the residents. She stated she reported to the Director of Nursing Services (DNS) the lack of staffing on the MCU and she had attempted all day to find help for the unit and the DNS voiced understanding of the minimal level of staff. The Coordinator stated one (1) nurse and one (1) CNA was unsafe staffing levels for the MCU. Interview with the DNS, on 05/02/18 at 4:45 PM, revealed when the 04/05/18 incident occurred, she had only been at the facility for two (2) weeks and was not monitoring staffing issues. She stated she did not remember if the Work Force Management Coordinator informed her about the need for staff on 04/05/18. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was new to the facility when the incident between Resident #1 and #2 occurred. She stated she knew staffing was an issue, and the goal was to decrease the number of agency staff. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/05/18, Resident #1 was assessed by Assistant Director of Nursing Services (ADNS) #1 and was determined to be without injury. The Physician, Nurse Practitioner, and State Guardian were notified and no orders were received. Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation on 04/06/18. 2. On 04/15/18, the facility placed Resident #2 on one-to-one supervision after the incident with Resident #3. Resident #2 was sent to the hospital for an evaluation on 04/15/18 and was returned to the facility. Resident #2's care plan was revised on 04/18/18, to address behaviors with interventions to protect other residents. 3. On 04/20/18 to 04/26/18, the ADNSs, Health Information Manager (HIM), Workforce Manager (WFM), and Minimum Data Set (MDS) Coordinators conducted skin assessments on all residents to check for injuries. The assessments did not reveal undocumented injuries. In additions, Social Services (SS) and the Senior Director of Clinical Operations (SDCO) interviewed residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above and inquired if they had been touched inappropriately by another resident or if had witnessed other residents being touched inappropriately. The interviews did not reveal any findings. 4. On 04/20/18 through 04/26/18, the Administrator, Business Office Manager, Activity Director, Maintenance Director, Director of Therapy, Director of Clinical Education, Housekeeping Supervisor, Dietary Manager, HR/Payroll Manager, Admissions Coordinator, Director of Nursing Services, Regional Director of Clinical Operations, Regional Director of Nursing Management Services, and the Senior Director of Clinical Operations (SCDO) conducted staff interviews to identify inappropriate resident behaviors or observation of abuse in the facility. A team member interview tool was developed by the SDCO. Upon completion of the interviews, the facility determined staff had not observed inappropriate behaviors or observed abuse in the facility. 5. The Regional Director of Clinical Operations educated the Administrator on abuse, investigating, and reporting abuse on 04/20/18. The Administrator educated the department leaders: the Director of Nursing Services (DNS), ADNS, SS, Director of Clinical Education, MDS Coordinators, Dietary Services Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, Admissions Coordinator, Business Office Manager, Therapy Manager, HR/Payroll Manager, and Workforce Manager on abuse, investigating, and reporting abuse on 04/20/18. The department leaders then educated staff in their respective departments on 04/20/18 through 04/26/18, with a post-test completed. The facility would conduct a minimum of ten (10) staff interviews weekly, using the Team Member Abuse QAPI (Quality Assurance and Performance Improvement) Questionnaire, for eight (8) weeks, then five (5) per week for eight (8) weeks to ensure understanding and competency and reviewed by the QAPI team. 6. The Regional Director of Clinical Operations provided education to clinical leadership, which consisted of the DNS, ADNS, and the Director of Clinical Education on 04/24/18, regarding documentation, notification, treatment, investigating of injuries of unknown source, and updating resident care plans when altercation/abuse occurred. The clinical leadership then educated licensed staff on 04/24/18 through 04/26/18. 7. The SS monitored Resident #1 and Resident #3 on 04/24/18 through 04/26/18 for mood and behaviors with no adverse findings noted. In addition, a skin assessment was performed on 04/24/18, on Resident #3 with no adverse findings. 8. On 04/24/18, an impromptu QAPI meeting was held with the Administrator, DNS, and Medical Director to review the actions, education, and audits effective 04/24/18. The findings of the audits and actions taken after 04/24/18, would be reviewed at the monthly QAPI meeting. The QAPI team includes the Medical Director, Administrator, DNS, and at least three (3) other department leaders. 9. On 04/25/18 and 04/26/18, the Senior Director of Clinical Operations, the DNS, HIM, and MDS Coordinators reviewed all residents' most recent History and Physical and/or Psychiatric Visit Consult Notes for histories of sexually acting out behaviors to ensure care plans addressed the behaviors. New admissions and readmission History and Physicals would be reviewed for sexual behaviors during the clinical start up meetings and the care plans would be reviewed to ensure interventions were in place. In addition, current care plans, of residents who had new or worsening behaviors, were updated with interventions during the meetings. The clinical start up members included the DNS, ADNS, SS, HIM, and the MDS Coordinators. The DNS or ADNS would review the clinical start up meeting minutes to ensure compliance with behavior identification and care planning five (5) times a week for twelve (12) weeks then weekly. The findings would be reviewed with the QAPI team. 10. The Regional Vice President (RVP) reviewed the pattern for scheduling sufficient staff on 04/26/18. The RVP educated the Administrator and DNS on staff coverage, which included utilization of staffing software that would send shift coverage needed notifications to all team members. When nursing staff called in, the unit nurse would make calls to cover the shift and notified Nursing Administration if coverage could not be obtained. If Nursing Administration had to be used to cover shifts, the Administrator would notify the RVP and/or Regional Director of Clinical Operations. The Administrator educated Nursing Administration on 04/16/18. Audits would be completed for adequate staff levels using a staffing tool five (5) times a week for one (1) month, then weekly for two (2) months. The findings would be reviewed with the QAPI team. The SSA validated the facility implemented the following actions: 1. Interview with the ADNS #1, on 04/19/18 at 5:45 PM, revealed she assessed Resident #1 for injury on 04/05/18 at 7:30 PM, which included a full skin assessment, range of motion and cognitive knowledge of the incident and no issues were noted. Interview with the Physician, on 04/23/18 at 10:27 AM, revealed the DNS notified him of the incident between Resident #1 and Resident #2. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the DNS notified her of the incident between Resident #1 and Resident #2. She further stated she and the MD discussed the incident and an evaluation was completed of both residents on 04/09/18. The NP stated there were no changes to both residents assessment from the previous evaluations. Interview with Resident #1's State Guardian, on 04/23/18 at 10:35 AM, revealed the facility notified the Guardian of the incident with Resident #2 by phone and by fax. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/18 at 3:55 PM, revealed Resident #2 was placed on one-to-one supervision after the interview with the DNS on 04/05/18 at approximately 7:00 PM. Interview with the DNS, on 04/1918 at 5:00 PM, revealed after Resident #2 was interviewed, the DNS placed him/her on one-to-one supervision with a Certified Nursing Assistant (CNA) on 04/05/18. Review of Resident #1's clinical record revealed a skin assessment was documented on 04/05/18 and the skin was noted as intact. Review of Resident #2's clinical record revealed the resident was sent to the hospital for evaluation on 04/06/18. 2. Observation of Resident #2, on 04/19/18, 04/20/18, 04/21/18, 04/23/18, 04/24/18, 04/30/18, 05/01/18, and 05/02/18, revealed a male CNA was providing one-to-one supervision of resident. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed Resident #2 did not have one-on-one supervision on 04/29/18 from 7:00 AM till he was assigned to sit with the resident around 9:00 AM to 9:30 AM. He stated the CNA called out who was assigned to sit Resident #2 and the Administrator was on the floor interviewing staff when she became aware of the situation and assigned him to sit with Resident #2. Interview with CNA #11, on 05/01/18 at 1:50 PM, revealed Resident #2 was not supervised on 04/29/18 from 7:00 AM until sometime around 9:00 AM, when the Administrator placed the LPN on duty at the resident's bedside. Interview with the Administrator, on 05/01/18 at 2:15 PM, revealed while interviewing staff on 04/29/18 for abuse, she found Resident #2 was without one-on-one supervision around 9:00-9:30 AM. She stated she immediately assigned the male LPN to Resident #2's bedside. She stated Resident #2 was without supervision as stated in the Allegation of Compliance (A[NAME]). Due to the lack of one-to-one supervision of Resident #2 on 04/29/18, from 7:00 AM to approximately 9:00 AM, the Immediate Jeopardy removal date was deemed 04/30/18. Interview with SS #1, on 05/02/18 at 11: 10 AM, revealed the care plan was reviewed and updated for sexual behaviors. Review of Resident #2's Care Plan revealed the plan was updated on 04/18/18 to include inappropriate sexual behaviors with monitoring, reporting, and redirection, administration of ordered medications for sexual urges, one-to-one supervision, and evaluations by Social Services as needed. 3. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed skin assessments on the MCU and there were no identified issues of unknown injuries. Interview with the WFM, on 05/01/18 at 9:20 AM, revealed she completed skin assessments for residents. She stated she was unable to identify concerns of abuse through injury of unknown source. Interview with MDS Coordinator #2, on 05/02/18 at 10:25 AM, revealed she completed skin assessments for residents not interviewable. She stated she was unable to identify injury of unknown sources. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she identified residents with BIMS greater than eight (8) for the abuse interviews. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and no concerns were identified. Interview of SS #2, on 05/02/18 at 4:50 PM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and did not identify concerns. Record review revealed the facility conducted skin assessments on all residents on 04/24/18 through 04/26/18. Record review revealed all residents identified with the BIMS greater than eight (8) were interviewed about abuse on 04/24/18 through 04/26/18, by SS #1 and SS #2. 4. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed an abuse interview tool for staff. Interview with the Director of Clinical Education (DCE), on 05/01/18 at 3:00 PM, revealed she completed staff interviews for observations and or knowledge of abuse. She stated staff had not identified abuse. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she completed staff interviews for observation or knowledge of abuse. She stated she was unable to identify abuse. Interview with ADNS #2, on 05/02/18 at 10:25 PM, revealed she interviewed staff for observations on inappropriate behaviors or observed abuse in the facility. She stated she did not identify abuse through staff interviews. Interview with the Therapy Director, on 05/02/18 at 11:30 AM, revealed she interviewed therapy staff for abuse in the facility and abuse was not identified. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was interviewed by the supervisor on whether he had observed inappropriate touching or other signs of abuse, which he reported that he had not. Record review revealed staff was interviewed from 04/20/18 through 04/26/18 utilizing the Team Member Interview Tool. Review of active employment lists revealed all staff members were interviewed for abuse. 5. Interview with the Senior Vice President (SVP), on 05/01/18 at 3:50 PM, revealed she educated the Administrator regarding abuse, investigating, and reporting abuse on 04/20/18. She stated the Administrator took a post-test. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was educated on abuse, investigating, and reporting abuse by the Senior Vice President. Record review revealed on 04/20/18, the SVP educated the Administrator on abuse. The Administrator completed an Abuse post-test, dated 04/20/18, with a score of 100%. Interview with CNA #12, on 04/30/18 at 2:35 PM, revealed she completed an in-service on abuse, completed a post-test, and was interviewed by Administration on her knowledge of abuse on several occasions. Interview with the CNA #16, on 04/30/18 at 3:30 PM, revealed he received education by the Staff Educator on abuse, reporting, and who to notify. He stated he was required to take a post-test on abuse. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed she was educated on abuse, reporting, and investigations. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on abuse, assessments, documentation, and reporting abuse and he was required to complete a post-test. He further stated he was interviewed by Administration, sometimes twice a day. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed he was educated by the Therapy Director on abuse and was required to take a post-test. Interview with the Certified Medication Technician (CMT), on 05/01/18 at 3:30 PM, revealed she was in-serviced on abuse and when/how to report abuse by the Staff Educator. She stated she was required to complete a post-test. She stated she missed one (1) question and was immediately re-educated. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she was educated on abuse by the Administrator, and she educated staff on abuse. Interview with the Dietary Director, on 05/02/18 at 9:30 AM, revealed he attended the in-service for abuse on 04/20/18, and completed the post-test. He further stated he was required to provide in-services to all dietary staff on abuse and they were required to complete and pass the abuse post-test. He stated he completed all dietary staffs' in-service and post-test. Interview with the Kitchen Cook, on 05/02/18 at 9:35 AM, revealed he was in-serviced on abuse by the Dietary Director. He stated he was required to complete and pass an abuse post-test. Interview with the Admissions Director, on 05/02/18 at 10:02 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. Interview with MDS Coordinator #1, on 05/02/18 at 10:10 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. She stated she completed random abuse interviews with staff. Interview with the Environmental Supervisor, on 05/02/18 at 9:49 AM, revealed he was trained by the Administrator on abuse and he trained his staff on abuse and they were required to pass the post-test. He stated he immediately retrained staff for wrong answers and he randomly asked staff about abuse. Interview with Housekeeper #1, on 05/02/18 at 9:59 AM, revealed he received education on abuse and was required to pass a post-test. He further stated he was interviewed numerous times on his knowledge of abuse and reporting abuse. Interview with ADNS #2, on 05/02/18 at 10: 25 AM, revealed she received training by the Administrator on abuse and was required to pass a post-test. She stated she provided post-tests to staff who were educated on abuse and reeducated staff immediately if answers were wrong. She stated she was interviewing random staff for knowledge of in-services. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she was educated by the Administrator on abuse, investigations, reporting and assessment. She stated she then completed staff abuse interview with post-tests. She stated staff was given one-on-one education for any missed questions. Interview with the DNS, on 05/02/18 at 4:40 PM, revealed she received education by the Administrator on abuse, investigations, and reporting. She stated Administration was required to compete post-tests. Record review revealed on 04/20/18, the Administrator educated seventeen (17) department leaders with post-tests completed. Review of staff abuse education revealed staff received abuse training from 04/20/18 to 04/26/18 with post-tests completed. The facility completed abuse in-services to all staff members. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed staff had interviewed her numerous times on abuse. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed the Director randomly interviewed him on his knowledge of abuse. Interview with the DCE, on 05/01/18 at 3:00 PM, revealed she interviewed staff at random on a daily basis on knowledge of abuse. She stated she used the abuse questionnaire to complete the question and answer session. She further stated staff was re-educated one on one with incorrect answers. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed the Abuse QAPI Questionnaire for staff interviews. The tool was to be used to identify continual education needs for staff in regards to abuse. Review of weekly abuse interviews revealed the facility completed seven (7) on 04/27/18, eleven (11) on 04/28/18, six (6) on 04/29/18, nine (9) on 04/30/18 and fifty-six (56) on 05/01/18 using the Abuse QAPI Questionnaire. 6. Interview with the Director of Staff Education, on 05/01/18 at 3:00 PM, revealed she was in-serviced and completed the post-test for assessments, investigations, and documentation of injury of unknown sources. Interview with LPN #5, on 04/30/18 at 2:52 PM, revealed she received education on care plan initiation and revision, including behaviors and skin assessments, and reporting injuries or skin alterations without a known source. She stated she was required to take a post-test for the in-service and had been interviewed by Administration numerous times on her knowledge of all in-services she had recently received. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on assessments, documentation, and reporting injury of unknown sources, and revision of care plans. He stated he had been interviewed on assessments, reporting injuries, and care planning. Interview with ADNS #2, on 05/02/18 at 10: 25 AM, revealed she received training on assessments, reporting injury, as well as investigating injuries of unknown source and care plan revision. She stated she then conducted in-services with floor staff and they were required to pass and complete a post-test. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed education on updating care plans, assessments and reporting injuries, as well as investigating an injury of unknown source. She stated she then conducted in-services with floor staff and they were required to pass and complete a post-test. Interview with the Regional Director of Clinical Operations, 05/01/18 at 4:10 PM, revealed she gathered the information for the in-service on revision of care plans and a post-test was developed for staff. Record review revealed all licensed staff was in-serviced and completed post-tests on assessment, investigation of unknown injury source, treatment and reporting, and care plan revision with post-tests completed, from 04/20/18 through 04/26/18. 7. Observation of Resident #1, on 04/30/18 at 4:00 PM, revealed the resident was engaged in activities on the unit, smiling, [MEDICATION NAME], and laughing. Observation of Resident #3, on 04/30/18 at 2:30 PM, revealed Resident #3 was resting quietly in bed, talkative, and smiling. The resident appeared calm and was not distressed. Interview revealed the Administrator and DNS interviewed him/her about the 04/15/18 incident and nursing staff completed a skin assessment. Resident #3 stated Social Services had spoken to him/her on several occasions. Interview with ADNS #2, on 05/02/18 at 10:25 AM, revealed Resident #3 had a skin assessment on 04/24/18, and no significant changes were found. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she met with Resident #3 on 04/24/18 and 04/26/18 to evaluated for changes in mood or behaviors with no changes noted. She stated the resident's care plan was updated for at risk of mood or behaviors related to the incident. In addition, she monitored Resident #1 on 04/24/18 through 04/26/18 for mood or behavior changes. She stated Resident #1 did not display unusual behaviors, mood changes, or noted cognitive changes. Record review revealed Resident #3's care plan was updated on 04/26/18, for at risk for mood or behaviors related to a sexual incident with another resident. Staff was to ensure trust and support, and to observe for changes in behavior, anxiety, depression, and [MEDICAL CONDITION]. 8. Interview with the Senior Vice President, on 05/01/18 at 3:50 PM, revealed she or a Corporate Team Member would monitor the facility weekly for compliance with all measures implemented to remove the Immediate Jeopardy. She stated the corporate team had access to the staffing software and were able to review daily. She stated the Administrator and the Nursing Administration were educated in the expectations to maintain compliance. She stated the Administrator would communicate to her any issues with compliance immediately. Interview with the Regional Director of Clinical Operations, on 05/01/18 at 4:25 PM, revealed she was to oversee abuse audit questionnaires weekly, and review staffing with the audit tool weekly with Nursing Administration. She stated she had access to the software program and would track staffing through the program. She stated she would have oversight for Nursing Administration's review of behaviors, admission review of behaviors, one-to-one supervision management, and to ensure proper assessments were conducted by staff. Interview with the Medical Director, on 05/02/18 at 2:15 PM, revealed he met with the facility's Administration during the QAPI meeting on 04/24/18 to review the Immediate Jeopardy. He stated the facility educated staff on abuse and care plans, and how to properly assess, treat, and report abuse. He stated staffing issues were a constant issue with most facilities and this facility was no exception. He further stated he would be a participant of notifications of abuse, residents who required one-to-one supervision, notified for admissions with noted behaviors, and oversite for resident safety. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed QAPI team members met on 04/24/18 to review and analysis the IJ notification. She stated the facility identified issues with the assessment, reporting, and investigation of abuse; care planning behaviors; and sufficient staffing. She stated interviews were ongoing with staff to evaluate staff knowledge of abuse. She stated care plans were to be reviewed in daily meetings to ensure updates were completed for behaviors. She stated she would be monitoring for staffing needs. She stated QAPI tools were provided to help track abuse allegations, care planning, and staffing. She further stated the RVP or RDCO would be notified of all incidents within the facility for oversite. 9. Interview with the Regional Director of Clinical Operations, on 05/01/18 at 4:10 PM, revealed she reviewed resident charts for notations by providers for sexual or inappropriate behaviors to ensure residents with behaviors had interventions in place. Interview with HIM, on 05/01/18 at 4:40 PM, revealed she reviewed resident charts for notations concerning sexual behaviors. She stated she reviewed medical visitation and assessment notes from the medical and psychological provider. Interview with MDS Coordinator #2, on 05/02/18 at 10:40 AM, revealed she evaluated residents' history and physical notations for sexual behaviors unknown to the facility to ensure care plans were updated for behaviors. Interview with the DNS, on 05/02/18 at 4:40 PM, revealed she reviewed resident charts for noted sexual behaviors. She stated she reviewed history and physical notations by the physician, admission notes, discharge records, and psychological notations. She stated when the facility was able to readmit or admit residents to the facility, the IDT would review the history of the resident for sexual behaviors. She further stated interviews with family would include inappropriate behaviors of the

Based on observation, interview, record review, review of facility job descriptions, and review of the facility's abuse policy, it was determined the facility's Administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services for (2) of six (6) sampled residents, Resident #1 and #3, to prevent the residents from abuse. Interview and record review revealed the facility admitted Resident #2 to the Memory Care Unit (MCU) on 12/16/17, with known inappropriate sexual acting out behaviors; however, the initial care plan did not reflect interventions to address the problem. On 04/05/18 at 6:00 PM, staff found Resident #2 on top of Resident #1 and both residents were naked from the waist down. The incident was not investigated as the Administrator and the Director of Nursing Services (DNS) determined no abuse occurred. Resident #1 and #2's care plans were not revised with interventions to address the incident. On 04/11/18, the facility transferred Resident #2 to an open unit on the first floor, which allowed him/her to ambulate throughout the facility. On 04/15/18, staff heard Resident #3 yell for help and found Resident #2 in Resident #3's room, on the second floor of the facility, and Resident #3 stated Resident #2 exposed himself/herself. The incident was not investigated as it was determined abuse had not occurred. Resident #3's care plan was not revised after the incident to monitor for effects from the event. (Refer to F600, F610, F657) The facility was found to have an ineffective system in place to ensure the facility administered care and services effectively to residents, which has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/23/18, and it was determined to exist on 04/05/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 04/27/18, alleging removal of the IJ on 04/27/18. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility failed to maintain one-to-one supervision per the A[NAME] for two (2) hours on 04/29/18. Interview with staff on 05/01/18, revealed one-to-one staffing could not be provided during this two (2) hour period due to staffing issues; however, one-to-one supervision resumed on 04/29/18 and continued with no breaks in supervision. Therefore, the SSA determined the IJ was not removed until 04/30/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator Position Description, dated 01/04/17, revealed the Administrator was responsible to ensure compliance with State and Federal regulations. The Administrator was to ensure quality care and services were provided to residents. Further review revealed the Administrator was to act as the compliance officer, lead an effective Quality Assurance Process Improvement (QAPI) program, and adhere to the code of conduct. Review of the DNS Position Description, undated, revealed the DNS was to ensure the facility's nursing department followed policy and procedures of the facility. The DNS was to ensure State and Federal regulations were followed to promote quality of care to residents, and was to ensure positive outcomes for residents. Review of the facility's policy, Abuse, dated (MONTH) (YEAR), revealed sexual abuse was defined as harassment, coercion, assault, and non-consensual sexual contact of any type with a resident. The facility was to take appropriate steps to prevent the occurrence of abuse. The Administrator and DNS were to investigate any allegation of abuse, any allegation of abuse was to be investigated, and the facility was to prevent further potential abuse. The DNS was responsible to direct a thorough investigation of each alleged violation and report the results of the investigation to State agencies as required by State and Federal law. The investigation was to include interviews of staff, visitors, and residents who might have knowledge of the incident. Based on the facility findings of the investigation, the facility was to start corrective actions to prevent the recurrence of the abuse. Further review revealed Federal law required the facility to have evidence of the investigation of the incident. Interview and record review during this survey revealed on 04/05/18, Licensed Practical Nurse (LPN) #1 found Resident #2 on top of Resident #1 on the floor and both residents were naked from the waist down. In addition, Resident #2 admitted to have suckled on Resident #1's breast. The DNS interviewed LPN #1; however, did not interview the Certified Nursing Assistant (CNA) working at the time, nor assessed or interviewed other residents on the unit. On 04/15/18, Resident #3 informed the facility Resident #2 was in his/her room and massaged his/her crotch and exposed himself/herself while in the room. The DNS was informed; however, staff interviews, statements, and resident statements and assessments were not completed. (Refer to F610) Interview with the DNS, on 04/19/18 at 5:00 PM, revealed she conducted an investigation on 04/05/18, and concluded with LPN #1's observations Resident #1 was not penetrated and therefore abuse had not occurred. She stated Resident #1 could not verbalize consent for sexual relationships but human instinct could be considered consent. Further interview revealed, on 04/15/18, Resident #2 was found in Resident #3's room and Resident #3 stated Resident #2 had exposed himself/herself. According to the DNS, Resident #2 had not touched Resident #3 and therefore no abuse occurred. She stated since the incidents were not deem abuse, they were not reported to the authorities or investigated. Continued interview on 04/20/18 at 5:30 PM, revealed Resident #1 and #2's care plans were not revised after the 04/05/18 incident on the MCU. She stated she was unable to recall if Resident #2 and #3's care plans were revised after the 04/15/18 incident between the residents. Interview with the Administrator, on 04/19/18 at 4:30 PM, revealed based on LPN #1's report for the 04/05/18 incident, it was determined Resident #2 did not penetrate Resident #1 and therefore no abuse occurred. She stated Resident #1 was unable to give verbal consent for sexual relations; however, she stated natural human instinct was considered as possible consent. She stated on 04/15/18, Resident #3 reported Resident #2 exposed himself/herself while in the resident's room but Resident #2 did not physically touch Resident #3 and therefore he/she was not abused. The Administrator stated neither incident was reported, as Resident #1 and #3 were not abused. Per interview, the Administrator was knowledgeable about the abuse policy and steps to take when there was an allegation of abuse; however, since the 04/05/18 and 04/15/18 incidents were not deemed abuse, thorough investigations were not completed. Continued interview on 04/23/18 at 6:00 PM, revealed the facility had issues with care plans because the facility did not have policies for care plans. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/05/18, Resident #1 was assessed by Assistant Director of Nursing Services (ADNS) #1 and was determined to be without injury. The Physician, Nurse Practitioner, and State Guardian were notified and no orders were received. Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation on 04/06/18. 2. On 04/15/18, the facility placed Resident #2 on one-to-one supervision after the incident with Resident #3. Resident #2 was sent to the hospital for an evaluation on 04/15/18 and was returned to the facility. Resident #2's care plan was revised on 04/18/18, to address behaviors with interventions to protect other residents. 3. On 04/20/18 to 04/26/18, the ADNSs, Health Information Manager (HIM), Workforce Manager (WFM), and Minimum Data Set (MDS) Coordinators conducted skin assessments on all residents to check for injuries. The assessments did not reveal undocumented injuries. In additions, Social Services (SS) and the Senior Director of Clinical Operations (SDCO) interviewed residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or above and inquired if they had been touched inappropriately by another resident or if had witnessed other residents being touched inappropriately. The interviews did not reveal any findings. 4. On 04/20/18 through 04/26/18, the Administrator, Business Office Manager, Activity Director, Maintenance Director, Director of Therapy, Director of Clinical Education, Housekeeping Supervisor, Dietary Manager, HR/Payroll Manager, Admissions Coordinator, Director of Nursing Services, Regional Director of Clinical Operations, Regional Director of Nursing Management Services, and the Senior Director of Clinical Operations (SCDO) conducted staff interviews to identify inappropriate resident behaviors or observation of abuse in the facility. A team member interview tool was developed by the SDCO. Upon completion of the interviews, the facility determined staff had not observed inappropriate behaviors or observed abuse in the facility. 5. The Regional Director of Clinical Operations educated the Administrator on abuse, investigating, and reporting abuse on 04/20/18. The Administrator educated the department leaders: the Director of Nursing Services (DNS), ADNS, SS, Director of Clinical Education, MDS Coordinators, Dietary Services Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, Admissions Coordinator, Business Office Manager, Therapy Manager, HR/Payroll Manager, and Workforce Manager on abuse, investigating, and reporting abuse on 04/20/18. The department leaders then educated staff in their respective departments on 04/20/18 through 04/26/18, with a post-test completed. The facility would conduct a minimum of ten (10) staff interviews weekly, using the Team Member Abuse QAPI (Quality Assurance and Performance Improvement) Questionnaire, for eight (8) weeks, then five (5) per week for eight (8) weeks to ensure understanding and competency and reviewed by the QAPI team. 6. The Regional Director of Clinical Operations provided education to clinical leadership, which consisted of the DNS, ADNS, and the Director of Clinical Education on 04/24/18, regarding documentation, notification, treatment, investigating of injuries of unknown source, and updating resident care plans when altercation/abuse occurred. The clinical leadership then educated licensed staff on 04/24/18 through 04/26/18. 7. The SS monitored Resident #1 and Resident #3 on 04/24/18 through 04/26/18 for mood and behaviors with no adverse findings noted. In addition, a skin assessment was performed on 04/24/18, on Resident #3 with no adverse findings. 8. On 04/24/18, an impromptu QAPI meeting was held with the Administrator, DNS, and Medical Director to review the actions, education, and audits effective 04/24/18. The findings of the audits and actions taken after 04/24/18, would be reviewed at the monthly QAPI meeting. The QAPI team includes the Medical Director, Administrator, DNS, and at least three (3) other department leaders. 9. On 04/25/18 and 04/26/18, the Senior Director of Clinical Operations, the DNS, HIM, and MDS Coordinators reviewed all residents' most recent History and Physical and/or Psychiatric Visit Consult Notes for histories of sexually acting out behaviors to ensure care plans addressed the behaviors. New admissions and readmission History and Physicals would be reviewed for sexual behaviors during the clinical start up meetings and the care plans would be reviewed to ensure interventions were in place. In addition, current care plans, of residents who had new or worsening behaviors, were updated with interventions during the meetings. The clinical start up members included the DNS, ADNS, SS, HIM, and the MDS Coordinators. The DNS or ADNS would review the clinical start up meeting minutes to ensure compliance with behavior identification and care planning five (5) times a week for twelve (12) weeks then weekly. The findings would be reviewed with the QAPI team. 10. The Regional Vice President (RVP) reviewed the pattern for scheduling sufficient staff on 04/26/18. The RVP educated the Administrator and DNS on staff coverage, which included utilization of staffing software that would send shift coverage needed notifications to all team members. When nursing staff called in, the unit nurse would make calls to cover the shift and notified Nursing Administration if coverage could not be obtained. If Nursing Administration had to be used to cover shifts, the Administrator would notify the RVP and/or Regional Director of Clinical Operations. The Administrator educated Nursing Administration on 04/16/18. Audits would be completed for adequate staff levels using a staffing tool five (5) times a week for one (1) month, then weekly for two (2) months. The findings would be reviewed with the QAPI team. The SSA validated the facility implemented the following actions: 1. Interview with the ADNS #1, on 04/19/18 at 5:45 PM, revealed she assessed Resident #1 for injury on 04/05/18 at 7:30 PM, which included a full skin assessment, range of motion and cognitive knowledge of the incident and no issues were noted. Interview with the Physician, on 04/23/18 at 10:27 AM, revealed the DNS notified him of the incident between Resident #1 and Resident #2. Interview with the Nurse Practitioner, on 04/25/18 at 1:30 PM, revealed the DNS notified her of the incident between Resident #1 and Resident #2. She further stated she and the MD discussed the incident and an evaluation was completed of both residents on 04/09/18. The NP stated there were no changes to both residents assessment from the previous evaluations. Interview with Resident #1's State Guardian, on 04/23/18 at 10:35 AM, revealed the facility notified the Guardian of the incident with Resident #2 by phone and by fax. Interview with Licensed Practical Nurse (LPN) #1, on 04/19/18 at 3:55 PM, revealed Resident #2 was placed on one-to-one supervision after the interview with the DNS on 04/05/18 at approximately 7:00 PM. Interview with the DNS, on 04/1918 at 5:00 PM, revealed after Resident #2 was interviewed, the DNS placed him/her on one-to-one supervision with a Certified Nursing Assistant (CNA) on 04/05/18. Review of Resident #1's clinical record revealed a skin assessment was documented on 04/05/18 and the skin was noted as intact. Review of Resident #2's clinical record revealed the resident was sent to the hospital for evaluation on 04/06/18. 2. Observation of Resident #2, on 04/19/18, 04/20/18, 04/21/18, 04/23/18, 04/24/18, 04/30/18, 05/01/18, and 05/02/18, revealed a male CNA was providing one-to-one supervision of resident. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed Resident #2 did not have one-on-one supervision on 04/29/18 from 7:00 AM till he was assigned to sit with the resident around 9:00 AM to 9:30 AM. He stated the CNA called out who was assigned to sit Resident #2 and the Administrator was on the floor interviewing staff when she became aware of the situation and assigned him to sit with Resident #2. Interview with CNA #11, on 05/01/18 at 1:50 PM, revealed Resident #2 was not supervised on 04/29/18 from 7:00 AM until sometime around 9:00 AM, when the Administrator placed the LPN on duty at the resident's bedside. Interview with the Administrator, on 05/01/18 at 2:15 PM, revealed while interviewing staff on 04/29/18 for abuse, she found Resident #2 was without one-on-one supervision around 9:00-9:30 AM. She stated she immediately assigned the male LPN to Resident #2's bedside. She stated Resident #2 was without supervision as stated in the Allegation of Compliance (A[NAME]). Due to the lack of one-to-one supervision of Resident #2 on 04/29/18, from 7:00 AM to approximately 9:00 AM, the Immediate Jeopardy removal date was deemed 04/30/18. Interview with SS #1, on 05/02/18 at 11: 10 AM, revealed the care plan was reviewed and updated for sexual behaviors. Review of Resident #2's Care Plan revealed the plan was updated on 04/18/18 to include inappropriate sexual behaviors with monitoring, reporting, and redirection, administration of ordered medications for sexual urges, one-to-one supervision, and evaluations by Social Services as needed. 3. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed skin assessments on the MCU and there were no identified issues of unknown injuries. Interview with the WFM, on 05/01/18 at 9:20 AM, revealed she completed skin assessments for residents. She stated she was unable to identify concerns of abuse through injury of unknown source. Interview with MDS Coordinator #2, on 05/02/18 at 10:25 AM, revealed she completed skin assessments for residents not interviewable. She stated she was unable to identify injury of unknown sources. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she identified residents with BIMS greater than eight (8) for the abuse interviews. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and no concerns were identified. Interview of SS #2, on 05/02/18 at 4:50 PM, revealed she completed abuse interviews on residents with BIMS greater than eight (8) and did not identify concerns. Record review revealed the facility conducted skin assessments on all residents on 04/24/18 through 04/26/18. Record review revealed all residents identified with the BIMS greater than eight (8) were interviewed about abuse on 04/24/18 through 04/26/18, by SS #1 and SS #2. 4. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed an abuse interview tool for staff. Interview with the Director of Clinical Education (DCE), on 05/01/18 at 3:00 PM, revealed she completed staff interviews for observations and or knowledge of abuse. She stated staff had not identified abuse. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she completed staff interviews for observation or knowledge of abuse. She stated she was unable to identify abuse. Interview with ADNS #2, on 05/02/18 at 10:25 PM, revealed she interviewed staff for observations on inappropriate behaviors or observed abuse in the facility. She stated she did not identify abuse through staff interviews. Interview with the Therapy Director, on 05/02/18 at 11:30 AM, revealed she interviewed therapy staff for abuse in the facility and abuse was not identified. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was interviewed by the supervisor on whether he had observed inappropriate touching or other signs of abuse, which he reported that he had not. Record review revealed staff was interviewed from 04/20/18 through 04/26/18 utilizing the Team Member Interview Tool. Review of active employment lists revealed all staff members were interviewed for abuse. 5. Interview with the Senior Vice President (SVP), on 05/01/18 at 3:50 PM, revealed she educated the Administrator regarding abuse, investigating, and reporting abuse on 04/20/18. She stated the Administrator took a post-test. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed she was educated on abuse, investigating, and reporting abuse by the Senior Vice President. Record review revealed on 04/20/18, the SVP educated the Administrator on abuse. The Administrator completed an Abuse post-test, dated 04/20/18, with a score of 100%. Interview with CNA #12, on 04/30/18 at 2:35 PM, revealed she completed an in-service on abuse, completed a post-test, and was interviewed by Administration on her knowledge of abuse on several occasions. Interview with the CNA #16, on 04/30/18 at 3:30 PM, revealed he received education by the Staff Educator on abuse, reporting, and who to notify. He stated he was required to take a post-test on abuse. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed she was educated on abuse, reporting, and investigations. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on abuse, assessments, documentation, and reporting abuse and he was required to complete a post-test. He further stated he was interviewed by Administration, sometimes twice a day. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed he was educated by the Therapy Director on abuse and was required to take a post-test. Interview with the Certified Medication Technician (CMT), on 05/01/18 at 3:30 PM, revealed she was in-serviced on abuse and when/how to report abuse by the Staff Educator. She stated she was required to complete a post-test. She stated she missed one (1) question and was immediately re-educated. Interview with SS #2, on 05/01/18 at 4:50 PM, revealed she was educated on abuse by the Administrator, and she educated staff on abuse. Interview with the Dietary Director, on 05/02/18 at 9:30 AM, revealed he attended the in-service for abuse on 04/20/18, and completed the post-test. He further stated he was required to provide in-services to all dietary staff on abuse and they were required to complete and pass the abuse post-test. He stated he completed all dietary staffs' in-service and post-test. Interview with the Kitchen Cook, on 05/02/18 at 9:35 AM, revealed he was in-serviced on abuse by the Dietary Director. He stated he was required to complete and pass an abuse post-test. Interview with the Admissions Director, on 05/02/18 at 10:02 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. Interview with MDS Coordinator #1, on 05/02/18 at 10:10 AM, revealed she received abuse education by the Administrator and conducted abuse education and post-test evaluations on staff. She stated she completed random abuse interviews with staff. Interview with the Environmental Supervisor, on 05/02/18 at 9:49 AM, revealed he was trained by the Administrator on abuse and he trained his staff on abuse and they were required to pass the post-test. He stated he immediately retrained staff for wrong answers and he randomly asked staff about abuse. Interview with Housekeeper #1, on 05/02/18 at 9:59 AM, revealed he received education on abuse and was required to pass a post-test. He further stated he was interviewed numerous times on his knowledge of abuse and reporting abuse. Interview with ADNS #2, on 05/02/18 at 10: 25 AM, revealed she received training by the Administrator on abuse and was required to pass a post-test. She stated she provided post-tests to staff who were educated on abuse and reeducated staff immediately if answers were wrong. She stated she was interviewing random staff for knowledge of in-services. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she was educated by the Administrator on abuse, investigations, reporting and assessment. She stated she then completed staff abuse interview with post-tests. She stated staff was given one-on-one education for any missed questions. Interview with the DNS, on 05/02/18 at 4:40 PM, revealed she received education by the Administrator on abuse, investigations, and reporting. She stated Administration was required to compete post-tests. Record review revealed on 04/20/18, the Administrator educated seventeen (17) department leaders with post-tests completed. Review of staff abuse education revealed staff received abuse training from 04/20/18 to 04/26/18 with post-tests completed. The facility completed abuse in-services to all staff members. Interview with CNA #13, on 04/30/18 at 3:40 PM, revealed staff had interviewed her numerous times on abuse. Interview with the Physical Therapist, on 05/01/18 at 1:35 PM, revealed the Director randomly interviewed him on his knowledge of abuse. Interview with the DCE, on 05/01/18 at 3:00 PM, revealed she interviewed staff at random on a daily basis on knowledge of abuse. She stated she used the abuse questionnaire to complete the question and answer session. She further stated staff was re-educated one on one with incorrect answers. Interview with the SDCO, on 05/01/18 at 4:10 PM, revealed she developed the Abuse QAPI Questionnaire for staff interviews. The tool was to be used to identify continual education needs for staff in regards to abuse. Review of weekly abuse interviews revealed the facility completed seven (7) on 04/27/18, eleven (11) on 04/28/18, six (6) on 04/29/18, nine (9) on 04/30/18 and fifty-six (56) on 05/01/18 using the Abuse QAPI Questionnaire. 6. Interview with the Director of Staff Education, on 05/01/18 at 3:00 PM, revealed she was in-serviced and completed the post-test for assessments, investigations, and documentation of injury of unknown sources. Interview with LPN #5, on 04/30/18 at 2:52 PM, revealed she received education on care plan initiation and revision, including behaviors and skin assessments, and reporting injuries or skin alterations without a known source. She stated she was required to take a post-test for the in-service and had been interviewed by Administration numerous times on her knowledge of all in-services she had recently received. Interview with LPN #6, on 05/01/18 at 10:45 AM, revealed he was educated on assessments, documentation, and reporting injury of unknown sources, and revision of care plans. He stated he had been interviewed on assessments, reporting injuries, and care planning. Interview with ADNS #2, on 05/02/18 at 10: 25 AM, revealed she received training on assessments, reporting injury, as well as investigating injuries of unknown source and care plan revision. She stated she then conducted in-services with floor staff and they were required to pass and complete a post-test. Interview with ADNS #1, on 05/02/18 at 10:45 AM, revealed she completed education on updating care plans, assessments and reporting injuries, as well as investigating an injury of unknown source. She stated she then conducted in-services with floor staff and they were required to pass and complete a post-test. Interview with the Regional Director of Clinical Operations, 05/01/18 at 4:10 PM, revealed she gathered the information for the in-service on revision of care plans and a post-test was developed for staff. Record review revealed all licensed staff was in-serviced and completed post-tests on assessment, investigation of unknown injury source, treatment and reporting, and care plan revision with post-tests completed, from 04/20/18 through 04/26/18. 7. Observation of Resident #1, on 04/30/18 at 4:00 PM, revealed the resident was engaged in activities on the unit, smiling, [MEDICATION NAME], and laughing. Observation of Resident #3, on 04/30/18 at 2:30 PM, revealed Resident #3 was resting quietly in bed, talkative, and smiling. The resident appeared calm and was not distressed. Interview revealed the Administrator and DNS interviewed him/her about the 04/15/18 incident and nursing staff completed a skin assessment. Resident #3 stated Social Services had spoken to him/her on several occasions. Interview with ADNS #2, on 05/02/18 at 10:25 AM, revealed Resident #3 had a skin assessment on 04/24/18, and no significant changes were found. Interview with SS #1, on 05/02/18 at 11:10 AM, revealed she met with Resident #3 on 04/24/18 and 04/26/18 to evaluated for changes in mood or behaviors with no changes noted. She stated the resident's care plan was updated for at risk of mood or behaviors related to the incident. In addition, she monitored Resident #1 on 04/24/18 through 04/26/18 for mood or behavior changes. She stated Resident #1 did not display unusual behaviors, mood changes, or noted cognitive changes. Record review revealed Resident #3's care plan was updated on 04/26/18, for at risk for mood or behaviors related to a sexual incident with another resident. Staff was to ensure trust and support, and to observe for changes in behavior, anxiety, depression, and [MEDICAL CONDITION]. 8. Interview with the Senior Vice President, on 05/01/18 at 3:50 PM, revealed she or a Corporate Team Member would monitor the facility weekly for compliance with all measures implemented to remove the Immediate Jeopardy. She stated the corporate team had access to the staffing software and were able to review daily. She stated the Administrator and the Nursing Administration were educated in the expectations to maintain compliance. She stated the Administrator would communicate to her any issues with compliance immediately. Interview with the Regional Director of Clinical Operations, on 05/01/18 at 4:25 PM, revealed she was to oversee abuse audit questionnaires weekly, and review staffing with the audit tool weekly with Nursing Administration. She stated she had access to the software program and would track staffing through the program. She stated she would have oversight for Nursing Administration's review of behaviors, admission review of behaviors, one-to-one supervision management, and to ensure proper assessments were conducted by staff. Interview with the Medical Director, on 05/02/18 at 2:15 PM, revealed he met with the facility's Administration during the QAPI meeting on 04/24/18 to review the Immediate Jeopardy. He stated the facility educated staff on abuse and care plans, and how to properly assess, treat, and report abuse. He stated staffing issues were a constant issue with most facilities and this facility was no exception. He further stated he would be a participant of notifications of abuse, residents who required one-to-one supervision, notified for admissions with noted behaviors, and oversite for resident safety. Interview with the Administrator, on 05/02/18 at 4:18 PM, revealed QAPI team members met on 04/24/18 to review and analysis the IJ notification. She stated the facility identified issues with the assessment, reporting, and investigation of abuse; care planning behaviors; and sufficient staffing. She stated interviews were ongoing with staff to evaluate staff knowledge of abuse. She stated care plans were to be reviewed in daily meetings to ensure updates were completed for behaviors. She stated she would be monitoring for staffing needs. She stated QAPI tools were provided to help track abuse allegations, care planning, and staffing. She further stated the RVP or RDCO would be notified of all incidents within the facility for oversite. 9. Interview with the Regional Director of Clinical Operations, on 05/01/18 at 4:10 PM, revealed she reviewed resident charts for notations by providers for sexual or inappropriate behaviors to ensure residents with behaviors had interventions in place. Interview with HIM, on 05/01/18 at 4:40 PM, revealed she reviewed resident charts for notations concerning sexual behaviors. She stated she reviewed medical visitation and assessment notes from the medical and psychological provider. Interview with MDS Coordinator #2, on 05/02/18 at 10:40 AM, revealed she evaluated residents' history and physical notations for sexual behaviors unknown to the facility to ensure care plans were updated for behaviors. Interview with the DNS, on 05/02/18 at 4:40 PM, revealed she reviewed resident charts for noted sexual behaviors. She stated she reviewed history and physical notations by the physician, admission notes, discharge records, and psychological notations. She stated when the facility was able to readmit or admit residents to the facility, the IDT would review the history of the resident for sexual behaviors. She further stated interviews with family would include inappropriate behaviors of the resident. Record review revealed the facility reviewed all residents' History and Physicals and/or Psychiatric Visit Consult Notes. Record review (TRUNCATED)

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Manual and the facility's policy and procedures, it was determined the facility failed to have an effective system to review and revise care plans to ensure interventions were in place for three (3) of twelve (12) sampled residents, Residents #1, #2, and #3. The facility assessed Resident #1 at risk for elopement and wandering and put interventions in place to ensure the resident's safety. On 10/21/16, Resident #1 eloped from the facility without staff knowledge and was found off the facility's grounds walking down the sidewalk. The facility's investigation determined the resident took the elevator to the lobby where Receptionist #2 keyed in the alarm code to the front door and allowed the resident to exit the building. The resident was returned to the facility uninjured. The facility failed to revise the resident's care plan to mitigate the risk of future elopements. In addition, The facility failed to revise the care plan for Resident #2 to ensure the resident's safety and well-being inside and outside the facility. The facility did not revise the care plan to allow the resident to sit supervised on the facility's front porch. The facility also failed to revise the care plan for Resident #3 after an attempted elopement. The facility's failure to revise the plan of care for residents placed those residents in a situation for risk of serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 11/04/16 and was determined to exist on 10/21/16. The facility was notified of the IJ on 11/04/16. An Acceptable Allegation of Compliance was received on 11/09/16, which alleged removal of the IJ on 11/07/16. The State Survey Agency validated the IJ was removed on 11/07/16, as alleged, and the Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Care System Guideline, Elopement, revised 2015, revealed the facility established a process that identified risk and interventions to mitigate the occurrence of elopements. When an elopement occurred, after the facility located and returned the resident to the facility, the facility would complete a thorough evaluation of the resident's physical condition and psychosocial wellbeing. Further review revealed the facility would establish the cause of the elopement and address with an appropriate plan to prevent reoccurrence. In addition, the facility reviewed all other residents identified at risk for elopement to ensure current interventions were in place to prevent elopement. Interview with the Director of Clinical Operations, on 11/11/16 at 2:00 PM, revealed the facility used the Resident Assessment Instrument (RAI) Manual 3.0, as the policy for updating care plans. She stated the RAI manual provided nursing with the only instruction on when to complete various types of resident assessments. Review of the RAI Manual 3.0, revealed the facility reviewed and updated care plans with each quarterly, annual, or other Minimum Data Set (MDS) assessment to ensure the continuance or revision of the existing care plan based on the need of each resident. Additionally, the facility also evaluated the appropriateness of the care plan on an on-going basis, and modified the care plan when appropriate. The RAI Manual stated the facility made changes to the care plan as needed in accordance with professional standards of practice. The facility oriented care plans towards preventing avoidable declines in functioning, managing risk factors, and respecting the resident's right to decline treatment. The facility assessed behavior symptoms in order to determine whether and why behavior was problematic, and to identify underlying causes. The behavior Care Area Assessments (CAA) focuses on potentially problematic behaviors, such as wandering. 1. Review of the clinical record for Resident #1, revealed the facility admitted the resident on 04/22/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/16, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #1's Risk of Elopement Review, dated 06/20/16, revealed the facility completed an Admission Elopement Evaluation. The evaluation determined the resident was at risk for elopement due to cognitive impairment, diagnoses, and ability to ambulate independently without a walker or wheelchair. Review of Resident #1's Care Plan for Alzheimer's, dated 08/20/16, revealed the facility placed the resident on the secured unit related to the medical [DIAGNOSES REDACTED]. The interventions included staff to cue the resident for safety and provide supervision. Staff was to observe the resident for exit seeking behavior, and if observed, redirect the resident and notify the supervisor. Review of Resident #1's Care Plan for Elopement, dated 09/09/16, revealed the facility identified the resident was at risk for elopement and wandering. The facility put interventions in place to ensure resident safety that included: placing the resident in areas where frequent observations were possible on the secure unit; placement of a wander guard bracelet on the resident that sounded an alarm when the resident approached an exit door and checking the placement and functioning of the device every shift; alerting staff to the resident's behavior of wandering; and, providing the resident with diversional activities. Further review revealed the care plan stated staff would stay with the resident if he/she wandered away from the unit, and gently persuade the resident to walk back to the designated area with them. Staff was to observe and document the resident's behavior as needed. Review of the facility's investigation, dated 10/21/16, revealed Resident #1 eloped from the facility on 10/21/16. The facility completed an investigation that stated the resident left the secured unit after following a visitor onto the elevator and was then let out of the facility by a Receptionist. The investigation stated the Activities Assistant saw the resident through a window and recognized the resident was out of the facility unsupervised. The Activities Assistant and the Business Office Manager looked for the resident but were unable to locate him/her from the facility's property. The Activities Assistant and Business Office Manager called a Code W and began searching the neighborhood for Resident #1. The staff located the resident and returned with him/her to the facility with no further incident. Interview with Licensed Practical Nurse (LPN) #3, on 11/04/16 at 1:45 PM, revealed he was the nurse working with Resident #1 at the time the resident eloped from the facility. LPN #3 stated after the elopement, staff returned the resident to the unit and the resident was very cheerful and talkative. LPN #3 stated he did not document the elopement or complete any type of assessment on Resident #1 after he/she eloped from the facility. LPN #3 stated he did not update the resident's care plans as the Interdisciplinary Team (IDT) updated care plans in the morning Clinical Start-up Meetings. Interview with Social Services #1, on 11/03/16 at 2:00 PM, revealed Social Services completed resident Elopement Assessments; however, they were not completed quarterly or with any regular frequency. She stated Social Services did not complete a new Elopement Assessment after Resident #1 eloped from the facility nor did they review or revise the resident's care plan. Interview with MDS Coordinator #1, on 11/03/16 at 2:18 PM, revealed the MDS Coordinators updated care plans in the Clinical Start-up Meetings. She stated other departments might also update care plans, such as Social Services or nursing departments. However, MDS Coordinators completed the majority of the care plan updates. She stated the IDT discussed Resident #1's elopement in the Clinical Start-up Meeting on 10/24/16, but she did not update the care plan for Resident #1 after his/her elopement from the facility because the resident already had an elopement care plan in place. However, review of the facility's policy, Care System Guideline, Elopement, revised 2015, revealed the facility would establish the cause of the elopement and address with an appropriate plan to prevent reoccurrence. Interview with the Director of Clinical Operations, on 11/01/16 at 1:30 PM, revealed the facility had not changed any of the current interventions for Resident #1 to prevent a reoccurrence of elopement. Interview with the Director of Nursing Services (DNS), on 11/03/16 at 8:30 AM, revealed the facility discussed the resident's elopement at the next morning meeting on 10/24/16, but she did not ensure the facility updated the care plan. In addition, she stated the facility had not reviewed other residents, assessed at risk for elopement, to ensure interventions were sufficient per the facility's policy. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed on 10/25/16 he reviewed the Elopement Incident Investigation of Resident #1's 10/21/16 elopement from the facility. However, he did not follow up with the IDT to ensure staff reviewed and revised the care plans during the morning start up meeting and there was no evidence the facility updated the care plans for Resident #1 after he/she eloped from the facility. 2. Review of the clinical record for Resident #2, revealed the facility admitted the resident on 06/22/16 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, completed 07/01/16, revealed the facility assessed the resident as requiring limited one (1) person physical assistance to walk. The facility assessed the resident as only able to stabilize during transfers and walking with human assistance. During the assessment, the facility conducted a BIMS examination and assessed the resident with a score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of Resident #2's Physician Orders, dated November 2016, revealed the Physician order [REDACTED]. Review of Resident #2's Risk of Elopement Review, dated 07/13/16, revealed the facility completed an elopement assessment and determined the resident was at risk for elopement and placed a resident monitoring device on the resident. The facility stated the resident was at risk due to cognitive impairment with poor decision-making skills, independent ambulation, [DIAGNOSES REDACTED]. The facility noted the resident wandered the hallway of the unit and frequently discussed wanting to go home. Review of Resident #2's Care Plan pertaining to Exit Seeking Behaviors, dated 07/12/16, revealed interventions for a Wander Guard bracelet that sounded alarms when the resident approached an exit door. Staff was to stay with the resident if he/she wandered away from the unit. Further review of Resident #2's clinical record revealed a document, dated 09/23/16, that Social Services had received permission from Resident #2's health care and financial Power Of Attorney (POA) for the resident to sign himself/herself out and sit on the front porch. Further review of Resident #2's Care Plan revealed no plan that allowed the resident to sign himself/herself out of the facility to sit on the front porch of the facility unsupervised. Review of the Release of Responsibility for Leave of Absence, dated October 2016, revealed Resident #2 signed out of the facility on five (5) occasions. Review of a piece of paper with Sign Out Sheet handwritten at the bottom, undated, revealed Resident #2 signed out of the facility on an additional six (6) occasions. Interview with Social Services #1, on 11/03/16 at 3:00 PM, revealed she had called Resident #2's POA about the resident going out of the facility due to the resident wanting to go outside. She stated that once she received permission from the resident's POA for the resident to sign out of the facility and sit on the front, she had not reviewed the resident's care plan to ensure it contained appropriate interventions for the resident's safety when he/she signed out of the facility. Interview with MDS Coordinator #1, on 11/03/16 at 2:18 PM, revealed MDS Coordinators updated care plans in the Clinical Start-up Meetings. She stated other departments might update care plans, such as Social Services or nursing departments; however, MDS Coordinators completed the majority of the care plan updates. Interview with the DNS, on 11/03/16 at 9:00 AM, revealed she had talked with the Medical Director about residents requesting to go outside and he had advised the facility to obtain a release Against Medical Advice (AMA) form for each of the residents. She stated Resident #2 was one of the residents who requested to go outside. She stated the facility obtained permission from the resident's POA for the resident to go outside and sit on the facility's front porch. The DNS stated the facility had not updated the care plan for Resident #2 to reflect the resident could sign out of the facility. Interview with the Medical Director, on 11/03/16 at 4:57 PM, revealed he had discussed with the Administrator and the DNS, the use of AMA forms for residents who could safely go out of the building unsupervised. However, it was unsafe for Resident #2 to go outside of the facility unattended due to the risk of a [MEDICAL CONDITION] and he was unaware the facility allowed Resident #2 to sign out and leave the facility unsupervised. Interview with the Administrator, on 11/02/16 at 4:45 PM, revealed the facility had Resident #2 sign a Release of Responsibility form and an AMA form so the resident could then sign himself/herself out of the facility; however, the facility had not updated the care plan for Resident #2 to include the plan for the resident to sign himself/herself out or to ensure the resident was safe. 3. Review of the facility's clinical record for Resident #3, revealed the facility admitted the resident on 12/12/13 with [DIAGNOSES REDACTED]. Review of Resident #3's Risk of Elopement Review, dated 09/01/16, revealed the facility conducted an elopement assessment and determined the resident was at risk for elopement due to impaired cognition, [DIAGNOSES REDACTED]. The facility noted the resident frequently remained near the exits stating he/she needed to go home and wandered aimlessly at times. The facility determined to place a Wander Guard bracelet on the resident. Review of Resident #3's printed November 2016 Physician order [REDACTED]. Review of Resident #3's Care Plan for Elopement, dated 12/30/13, revealed the facility developed a care plan to ensure the resident's safety from elopement due to wandering and exit seeking behaviors. The interventions included completing an Elopement Assessment quarterly and as needed. Staff was to escort the resident to activities off his/her unit to ensure the resident got to the correct destinations safely. Review of Resident #3's Significant Change MDS assessment, completed on 09/22/16, revealed the facility assessed the resident as requiring only limited assistance for walking and limited to extensive assistance to complete most ADLs. The facility assessed the resident as having unsteady balance but able to stabilize without staff assistance. During the assessment, the facility conducted a BIMS examination and assessed the resident with a score of eight (8) out of fifteen (15) and determined the resident was interviewable. Review of Resident #3's Nursing Notes, dated 08/03/16 through 11/01/16, revealed the resident had exit seeking behaviors such as pushing and trying to exit doors on 08/29/16, 09/01/16, 09/02/16, 09/06/16, 09/14/16, and 10/12/16. On 10/30/16, the resident ran out of the building behind a family exiting the facility. Staff went out, got the resident, and brought him/her back into the facility. Interview with MDS Coordinator #1, on 11/03/16 at 2:18 PM, revealed she was unaware of Resident #3's elopement attempt on 10/30/16. She stated the facility had not talked about the attempt in the morning Clinical Start-up Meeting on 10/31/16. Further interview revealed the facility did not update the care plan after Resident #3 attempted to elope from the facility. Interview with Social Services #2, on 11/02/16 at 11:15 AM, revealed she had completed Elopement Assessments for Resident #3. Social Services #2 stated Resident #3 had an increase in wandering and exit seeking behaviors and the current interventions for Resident #3 were not effective; however, she did not update the resident's care plan. Interview with the DNS, on 11/03/16 at 8:30 AM, revealed she was aware of Resident #3's attempt to elope from the facility on 10/30/16. She stated the IDT should have updated the Elopement Risk Screen in the morning Clinical Start-up Meeting on 10/31/16 after the elopement attempt. However, she was not present in the meeting on 10/31/16 and had not ensured staff reviewed and revised the care plan to reflect appropriate interventions were in place. Continued interview with the DNS, on 11/11/16 at 10:25 AM, revealed she audited charts to ensure staff accurately completed documentation. She stated that after an event, she reviewed the medical record; however, she had not checked documentation to ensure the facility had updated care plans for Resident #1 or Resident #3 after each resident's attempted elopement. She stated she had not reviewed the care plan for Resident #2 to ensure the facility recorded interventions or instructions allowing or disallowing the resident to sign out of the facility and sit on the front porch to ensure the resident's safety. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed MDS updated care plans during the morning Clinical Start-up Meetings. He stated the facility should have reviewed the care plans for Residents #1, #2, and #3 to ensure interventions were appropriate. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The MDS Coordinator reassessed Resident #1 for elopement risk on 11/05/16. The Elopement Care Plan for Resident #1 was reviewed and updated on 11/06/16 by the MDS Coordinator. 2. The Restorative Nurse, MDS Coordinator, DNS, ADNS, or the Regional Director of Clinical Operations assessed all residents in the facility for elopement risk using the Elopement Evaluation by 11/06/16. 3. Elopement Care Plans were implemented and/or updated by 11/06/16 for the twenty-three (23) residents identified as at risk for elopement by the Restorative Nurse, MDS Coordinator, DNS, ADNS, and the Regional Director of Clinical Operations. 4. An Admission Clinical Health Status was completed, including the Risk for Elopement section, for newly admitted residents and readmitted residents who were admitted to the facility after 11/06/16. The facility admitted on e (1) new resident and readmitted three (3) residents. None of the admitted residents was assessed at risk for elopement. The DNS used the Elopement Tool to discuss all admissions in the IDT morning clinical start up meeting each morning, five (5) days per week. 5. The Elopement Risk Identification book was updated on 11/06/16 by Social Services to include all residents identified at risk for elopement. The books contained each of the twenty-three (23) identified residents' name, face sheet, and picture. Updated Elopement Risk Identification books were placed at the receptionist desk and at each nurses' station on 11/06/16. 6. The code to enter the 1C secured unit via the elevator was changed on 10/21/16 by the Maintenance Director. The task of changing the elevator codes was placed on the maintenance calendar to occur quarterly, with the next code change occurring 01/09/17. 7. Signs were placed on 11/05/16 by the Regional Vice President. Signs were placed on the elevator to the 1C secured unit, on the ground floor at the elevator, and on the first (1st) floor at the elevator. The signs instructed visitors to see an employee for assistance with the elevator code and not to allow residents on the 1C secured unit to enter the elevator without staff assistance. 8. All staff received training on the Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and the security of the elevator and door codes by the Clinical Educator by 11/06/16. The New Hire Pack was updated by the to include education on the current facility Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the security of the elevator and door codes. All new hires will receive this education by the Clinical Educator or ADNS. 9. Education was provided to the Administrator and the DNS on the Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the elevator and door codes by the Regional Director of Clinical Services on 11/06/16. 10. Audits were completed by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or the Regional Vice President using the Elopement QAPI Questionnaire tool with at least five (5) employees, five (5) times per week. The Elopement QAPI Questionnaire tool included the questions: What do you do if you hear a wander guard alarm?; What is the first thing you do if a resident is missing?; What is the code that is announced when a resident is missing?. 11. Elopement drills were conducted weekly by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or Regional Vice President. All participating staff signed off that they participated in the drills. 12. The facility held a QAPI meeting on 11/06/16 to review the facility actions, the audits, admissions, and newly identified residents at risk for elopement. Findings of audits and actions taken after 11/06/16 will be reviewed at the monthly QAPI meeting by the QAPI team. The QAPI team included the Medical Director, Administrator, DNS, and at least three (3) other departmental leaders. The State Survey Agency validated the facility's actions as follows: 1. Review of the Elopement Care Plan for Resident #1, dated 09/09/16, revealed the facility reviewed and updated the care plan on 11/06/16. Review of the Elopement Evaluation tool for Resident #1, dated 11/05/16, revealed the facility re-assessed Resident #1 for risk for elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations and updated the care plan for Resident #1. 2. Review of the Elopement Evaluation, dated November 2016, revealed the facility conducted an elopement assessment with every resident in the facility on 11/05/16 and 11/06/16. The facility assessed twenty-three (23) residents at risk of elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations on one hundred percent (100%) of the residents in the facility. 3. Review of the facility's care plans for the twenty-three (23) identified residents at risk for elopement, revealed the facility updated and implemented elopement care plans for each of the identified residents by 11/06/16. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility updated the care plans for each resident assessed as at risk for elopement. 4. Review of the facility's census, 11/09/16, revealed the facility admitted on e new resident and readmitted three (3) additional residents. Review of the Admission Clinical Health Status for each of the new/readmitted residents, dated 11/07/16 and 11/08/16, revealed the facility conducted the Risk for Elopement section in each resident's Admission Clinical Health Status. The facility identified none of the admitted residents were at risk for elopement. Review of the facility's Elopement Tool, dated 11/07/16 and 11/08/16, revealed the facility discussed admissions in the Clinical Start Up Meeting to determine if each admission resident was at risk for elopement. Interview with the DNS, on 11/11/16 at 10:15 AM, revealed she discussed admitted residents in the Clinical Start Up meeting each morning. Meeting attendants discussed the Admission Clinical Health Status to ensure the Risk for Elopement section of the form was complete and accurate. The DNS stated she documented the conversation on the Elopement Tool. 5. Review of the Elopement Risk Identification book, updated 11/06/16, revealed the facility updated the book to include all residents identified at risk for elopement, regardless if the resident wore a Wander Guard. The books contained residents by name, picture, and face sheet. The books were located at the receptionist desk and at each nurses' station. Interview with DNS, on 11/11/16 at 10:15 AM, revealed the facility updated the Elopement Risk Identification book to reflect all residents identified as at risk for elopement. She stated residents, regardless of if they wore a Wander Guard, were represented in the book with a picture and cover sheet. 6. Observation of the code pad on the elevator revealed the facility changed the code to access the 1C secured unit. Review of the maintenance calendar, 2017, revealed the facility placed the task of changing the elevator codes on the calendar to occur quarterly, starting 01/09/17. 7. Observation, on 11/10/16, revealed the facility placed signs on the secured unit at the elevator on the ground floor, and on the 1st floor. The signs gave instruction to not allow residents residing on the memory care unit onto the elevator without staff assistance and instruction for visitors to see an employee for assistance with the elevator code. 8. Review of the facility provided education, posttests, and employee roster, revealed the facility provided education to all staff who had worked pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and elevator and door codes, by the Clinical Educator by 11/06/16. All staff passed all post-tests. Interviews with Receptionist #2, CNA#7, CNA #8, LPN #6, LPN #7, Housekeeping, and Dietary Aide, on 11/11/16, revealed the facility provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. The education included post tests. Interview with the Director of Clinical Education, on 11/11/16 at 9:30 AM, revealed she provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. She stated she received education on those systems from the Clinical Director of Operations prior to providing education to staff. She stated she provided the education to all staff who worked prior to 11/06/16. Additionally, the Director of Clinical Education stated any employee who had not received the education due to not yet working would not be allowed to work until they first received the education. Review of the New Hire Pack, undated, revealed the facility added education to new hires using current facility elopement guidelines, Elopement Care System Guidelines. The New Hire Pack also included education to new employees pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, and elevator and door codes. 9. Interview with the Clinical Director of Operation, on 11/11/16 at 11:52 AM, revealed she provided education to the Administrator and the DNS on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. Review of the education logs, 11/06/16, revealed the DNS and Administrator also received education with all facility staff. 10. Review of the QAPI Questionnaire Tools, completed between 11/06/16 and 11/09/16, revealed the facility leadership team conducted interviews with at least five (5) employees each day. The questions on the Questionnaire Tool included: What do you do if you hear a wander guard alarm? What is the first thing you do if a resident is missing? What is the code that is announced when a resident is missing? Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the facility was holding daily QAPI meetings to ensure continued compliance. He stated the Medical Director was either physically present or present via telephone for each of the daily QAPI meetings. The Administrator stated that he and the DSN completed at least five (5) QAPI Questionnaire Tool interviews with staff each day. 11. Review of the Patient/Resident Elopement Drill Worksheets, dated between 11/06/16 and 11/09/16, revealed the facility conducted elopement drills daily and ensured all participating staff signed off on the drills. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed he conducted daily elopement drills to ensure all staff knew what to do in case of elopement. He stated the facility would ask a resident to participate in the drill and hide the resident. The facility would call a Code W and facility staff conducted searches of the facility and facility grounds with each drill. Interview with LPN #6 and CNA #4, on 11/11/16, revealed the facility conducted elopement drills daily. They each stated the facility called a Code W over the loud speaker and staff begin searching for the missing individual named in the announcement in the facility and on the facility grounds. 12. Review of the Daily Focused QAPI Meeting sheets, dated 11/06/16 through 11/09/16, revealed the facility held QAPI meetings daily. The meetings included the Medical Director and reviewed actions and audits, as well as admissions and newly identified residents at risk for elopement. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the Administrator was holding QAPI meetings daily to discuss the elopement plan. He stated the Medical Director had attended every meeting either in person or via telephone. Interview with the DNS, on 11/11/16 ay 10:15 AM, revealed the facility held QAPI meetings each day. She stated she attended the QAPI meetings and the QAPI team discussed the ongoing inservices, drills, admissions, assessments, and other facility elopement initiatives.

Based on observation, interview, and record review and review of the Resident Assessment Instrument (RAI) Manual and the facility's policy and procedures, it was determined the facility failed to have an effective system in place to ensure staff implemented the care plan interventions for three (3) of twelve (12) sampled residents, Residents #1, #2, and #3. The facility assessed Resident #1 as a risk for elopement and wandering, put interventions in place to ensure the resident's safety, and applied a Wander Guard on the resident. Interventions included to provide the resident with supervision and redirect the resident if staff observed exit-seeking behavior. On 10/21/16 at 3:00 PM, Licensed Practical Nurse (LPN) #3 observed Resident #1 seated in his/her room, upset, and stating he/she needed to go home. LPN #3 did not provide supervision or redirectional activities per the care plan and walked into the closed medication room leaving the resident unsupervised. Resident #1 eloped from the facility without staff knowledge and was found off the facility's grounds, at approximately 4:00 PM, walking down the sidewalk. The facility's investigation determined the resident took the elevator to the lobby where Receptionist #2 keyed in the alarm code to the front door and allowed the resident to exit the building. The recorded weather conditions on 10/21/16 at 2:31 PM, included a high of sixty-two (62) degrees Fahrenheit with cloudy skies. In addition, the care plan for Resident #2 stated the facility provided supervision when the resident wandered the facility; however, the resident went outside unsupervised. Resident #3 was care planned for staff to accompany the resident when off the unit; however, the resident wandered the facility and near facility exit doors unaccompanied. The facility's failure to follow the plan of care for residents placed those residents in a situation for risk of serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 11/04/16 and was determined to exist on 10/21/16. The facility was notified of the IJ on 11/04/16. An Acceptable Allegation of Compliance was received on 11/09/16, which alleged removal of the IJ on 11/07/16. The State Survey Agency validated the IJ was removed on 11/07/16, as alleged, and the scope and severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Clinical Operations, on 11/11/16 at 2:00 PM, revealed the facility used the Resident Assessment Instrument (RAI) Manual, Version 3.0, as the policy for updating and following care plans. Review of the RAI Manual, Version 3.0, revealed the purpose of the care plan was to serve as an interdisciplinary communication tool. The care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The services the facility provided or arranged must be consistent with each resident's written plan of care. Review of the facility's policy, Care System Guideline, Elopement, Revised 2015, revealed the facility established a process that identified risk and interventions to mitigate the occurrence of elopements. The facility assessed residents for elopement risk using the tool in the Clinical Health Status upon admission or re-admission to the facility. If the facility determined a risk for elopement, the facility established an individualized plan to mitigate risk. The facility documented interventions on the care plan and initiated the interventions. 1. Review of the facility's clinical record for Resident #1, revealed the facility admitted the resident on 04/22/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/16, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #1's Risk of Elopement Review, dated 06/20/16, revealed the facility completed an Admission Elopement Evaluation and determined the resident was at risk for elopement due to cognitive impairment, diagnoses, and the ability to ambulate independently without a walker or wheelchair. Review of Resident #1's Care Plan for Alzheimer's, dated 08/20/16, revealed the facility placed the resident on the secured unit related to a medical [DIAGNOSES REDACTED]. The facility provided interventions that included staff cued the resident for safety and provided the resident with supervision. Staff observed the resident for exit seeking behavior, and if observed, redirected the resident and notified the supervisor. Review of Resident #1's Care Plan for Elopement, dated 09/09/16, revealed the facility put interventions in place to ensure resident safety that included: placing the resident in areas where frequent observation was possible; placement of a Wander Guard bracelet that sounded an alarm when the resident approached an exit door and checking for placement and functioning of the device every shift; alerting staff to the resident's wandering behavior; and providing the resident with diversional activities. The care plan additionally stated staff would stay with the resident if he/she wandered away from the unit and gently persuade the resident to walk back to the designated area with them. Staff was to observe and document the resident's behavior as needed. Review of the facility's Investigation, dated 10/21/16, revealed Resident #1 eloped from the facility on 10/21/16. The resident followed a visitor onto the elevator and went down to the front lobby. The receptionist opened the door for the resident and the resident exited the building. Interview with Certified Nursing Assistant (CNA) #4, on 11/02/16 at 3:35 PM, revealed she worked on Resident #1's unit when he/she eloped from the facility. She stated she talked with Resident #1 at approximately 3:00 PM and the resident asked her if he/she could go downstairs and go outside. She told the resident she would talk with the nurse, LPN #3, about it and reported it to the nurse and then left the floor to assist another CNA in providing care for another resident. Interview with LPN #3, on 11/04/16 at 1:45 PM, revealed he was Resident #1's nurse when the resident eloped from the facility. He stated the CNA reported to him that Resident #1 was talking about going home. He stated he went and talked with the resident and the resident was calm. He stated he then walked down the hallway and into the medication room. He stated staff was not present in the resident common area or in the hallway of the unit when he went into the medication room. LPN #3 stated the facility did not provide supervision for Resident #1 at the time he/she eloped from the locked unit. Interview with MDS #1, on 11/03/16 at 2:18 PM, revealed MDS reviewed and updated care plans in the Clinical Start-up Meetings. She stated the Interdisciplinary Team (IDT) discussed Resident #1's elopement in the Clinical Start-up Meeting on 10/24/16. She stated the facility did not provide supervision while the resident experienced exit-seeking behaviors, per the care plan. Interview with the Director of Nursing Services (DNS), on 11/03/16 at 8:30 AM, revealed the facility discussed the resident's elopement at the next morning meeting on 10/24/16, but did not review the care plan to ensure the facility had followed all interventions and that all necessary interventions were in place. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed he reviewed the Elopement Incident Investigation after Resident #1 eloped from the facility on 10/21/16. The Administrator stated he did not follow up with the IDT to ensure staff reviewed the care plan to determine if staff had followed care plan interventions. 2. Review of the facility's clinical record for Resident #2, revealed the facility admitted the resident on 06/22/16 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, completed 07/01/16, revealed the facility assessed the resident as requiring limited one (1) person physical assistance to walk. The facility assessed the resident as only able to stabilize during transfers and walking with human assistance. During the assessment, the facility conducted a BIMS examination and assessed the resident with a score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of Resident #2's Care Plan for Exit Seeking Behaviors, dated 07/12/16, revealed an intervention to place a monitoring device on the resident that sounded alarms when the resident left the building. Staff was to stay with the resident if he/she wandered away from the unit and converse with the resident and gently persuade him/her to walk back to designated areas with them. Review of Resident #2's Risk of Elopement Review, dated 07/13/16, revealed the facility completed an elopement assessment and determined the resident was at risk for elopement and placed a monitoring device on the resident. The facility stated the resident was at risk due to cognitive impairment with poor decision-making skills, independent ambulation, and [DIAGNOSES REDACTED]. The facility noted the resident wandered the hallway of the unit and frequently discussed wanting to go home. Further review of Resident #2's medical record revealed a document dated 09/23/16, that stated the POA gave approval for Resident #2 to sign himself/herself out to sit on the facility's front porch. The document was typed on an 8.5'' x 11.0'' sheet of paper with Social Services #2's name typed at the bottom. Interview with Social Services #1, on 11/03/16 at 3:00 PM, revealed Resident #2 had voiced a desire to go outside. She was unsure why the facility needed permission from the resident's POA to go outside because the resident had a BIMS of a 10, but she called Resident #2's POA and the POA gave permission for the resident to sign himself/herself out of the facility to sit on the front porch. However, review of the resident's care plan for Exit Seeking Behaviors revealed staff was to stay with the resident if he/she wandered from the unit. Review of the Release of Responsibility for Leave of Absence, dated October 2016, revealed Resident #2 signed out of the facility on five (5) occasions. The dates of sign out were 10/04/16 at 11:40 AM, 10/05/16 at 1:30 PM, 10/07/16 at 1:10 PM, and 10/08/16 at 1:30 PM, and one (1) undated and untimed occasion. There were no dates, times, or signature for when the resident returned to the facility. Review of a piece of paper with Sign Out Sheet handwritten at the bottom, undated, revealed Resident #2 signed out of the facility an additional six (6) times. One (1) signature was not dated or timed. Interview with Director of Nursing Services (DNS), on 11/03/16 at 9:00 AM, revealed it was not typical facility practice to allow residents with a Wander Guard to leave the building unaccompanied and she did not believe the facility should allow any resident with a Wander Guard to go out of the facility without supervision. The DNS stated the facility had placed a Wander Guard bracelet on the resident due to exit seeking behaviors, such as pushing on exit doors and talking about wanting to go home. The resident had a history of [REDACTED]. However, she stated the facility obtained permission from the resident's POA for the resident to go outside and sit on the facility's front porch. The DNS further stated the facility could not ensure the resident would stay on the porch when he/she signed out of the facility, as the facility had not provided supervision when the resident signed out per the resident's care plan. 3. Review of the facility's clinical record for Resident #3, revealed the facility admitted the resident on 12/12/13 with [DIAGNOSES REDACTED]. Review of Resident #3's Care Plan for Elopement, initiated on 12/30/13, revealed interventions that included providing supervision. Staff was to escort the Resident #3 to off unit activities and ensure the resident arrived to the correct destinations safely. The facility placed a picture of the resident in the elopement binder. Review of Resident #3's Physician Orders, dated November 2016, revealed on 09/01/16, the physician ordered the facility to place a Wander Guard on the resident's ankle and check placement of the Wander Guard every shift. Review of Resident #3's Significant Change MDS assessment, completed on 09/22/16, revealed the facility assessed the resident as requiring only limited assistance for walking and limited to extensive assistance to complete most ADLs. The facility assessed the resident as having unsteady balance but able to stabilize without staff assistance. During the assessment, the facility conducted a BIMS examination and assessed the resident with a score of eight (8) out of fifteen (15) and determined the resident was interviewable. Review of Resident #3's Nursing Notes, from 08/03/16 through 11/01/16, revealed on 08/29/16, nursing staff heard the wander guard alarm sound and discovered Resident #3 pushing on the door and stating he/she was leaving to live with their family member. On 09/01/16, the resident was walking around inside the facility attempting to find exit doors. On 09/02/16, the resident left the unit and went to the lobby area and attempted to leave the building. On 09/06/16, the facility documented the resident had continued multiple attempts to exit the facility. On 10/30/16, the resident ran out of the building behind a family who was exiting. Staff went out after the resident and was able to redirect him/her back into the facility. Interview with CNA #5, on 11/03/16 at 2:36 PM, revealed CNAs were aware of residents who wore a Wander Guard because it was on the CNA Assignment Sheet. She stated Resident #3 wore a Wander Guard due to wandering behaviors to ensure he/she did not get out of the facility. The Wander Guard bracelet would set off an alarm at the facility exits if the resident tried to go out the door. CNA #5 stated Resident #3 was able to go anywhere in the facility unsupervised. She stated she was unaware of any interventions stating staff was to escort the resident to off unit activities. Interview with MDS Coordinator #1, on 11/03/16 at 2:18 PM, revealed staff did not follow elopement interventions when staff did not escort or redirect the resident when he/she left the unit. Continued interview with the DNS, on 11/11/16 at 10:25 AM, revealed the DNS supervised staff to ensure staff followed care plan interventions for residents by completing rounds. The DNS could not state how often she completed the rounds. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed the facility had no evidence they reviewed Resident #3's Care Plan after the elopement attempts to ensure staff had followed care plan interventions. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The MDS Coordinator reassessed Resident #1 for elopement risk on 11/05/16. The Elopement Care Plan for Resident #1 was reviewed and updated on 11/06/16 by the MDS Coordinator. 2. The Restorative Nurse, MDS Coordinator, DNS, ADNS, or the Regional Director of Clinical Operations assessed all residents in the facility for elopement risk using the Elopement Evaluation by 11/06/16. 3. Elopement Care Plans were implemented and/or updated by 11/06/16 for the twenty-three (23) residents identified as at risk for elopement by the Restorative Nurse, MDS Coordinator, DNS, ADNS, and the Regional Director of Clinical Operations. 4. An Admission Clinical Health Status was completed, including the Risk for Elopement section, for newly admitted residents and readmitted residents who were admitted to the facility after 11/06/16. The facility admitted on e (1) new resident and readmitted three (3) residents. None of the admitted residents was assessed at risk for elopement. The DNS used the Elopement Tool to discuss all admissions in the IDT morning clinical start up meeting each morning, five (5) days per week. 5. The Elopement Risk Identification book was updated on 11/06/16 by Social Services to include all residents identified at risk for elopement. The books contained each of the twenty-three (23) identified residents' name, face sheet, and picture. Updated Elopement Risk Identification books were placed at the receptionist desk and at each nurses' station on 11/06/16. 6. The code to enter the 1C secured unit via the elevator was changed on 10/21/16 by the Maintenance Director. The task of changing the elevator codes was placed on the maintenance calendar to occur quarterly, with the next code change occurring 01/09/17. 7. Signs were placed on 11/05/16 by the Regional Vice President. Signs were placed on the elevator to the 1C secured unit, on the ground floor at the elevator, and on the first (1st) floor at the elevator. The signs instructed visitors to see an employee for assistance with the elevator code and not to allow residents on the 1C secured unit to enter the elevator without staff assistance. 8. All staff received training on the Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and the security of the elevator and door codes by the Clinical Educator by 11/06/16. The New Hire Pack was updated by the to include education on the current facility Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the security of the elevator and door codes. All new hires will receive this education by the Clinical Educator or ADNS. 9. Education was provided to the Administrator and the DNS on the Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the elevator and door codes by the Regional Director of Clinical Services on 11/06/16. 10. Audits were completed by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or the Regional Vice President using the Elopement QAPI Questionnaire tool with at least five (5) employees, five (5) times per week. The Elopement QAPI Questionnaire tool included the questions: What do you do if you hear a wander guard alarm?; What is the first thing you do if a resident is missing?; What is the code that is announced when a resident is missing?. 11. Elopement drills were conducted weekly by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or Regional Vice President. All participating staff signed off that they participated in the drills. 12. The facility held a QAPI meeting on 11/06/16 to review the facility actions, the audits, admissions, and newly identified residents at risk for elopement. Findings of audits and actions taken after 11/06/16 will be reviewed at the monthly QAPI meeting by the QAPI team. The QAPI team included the Medical Director, Administrator, DNS, and at least three (3) other departmental leaders. The State Survey Agency validated the facility's actions as follows: 1. Review of the Elopement Care Plan for Resident #1, dated 09/09/16, revealed the facility reviewed and updated the care plan on 11/06/16. Review of the Elopement Evaluation tool for Resident #1, dated 11/05/16, revealed the facility re-assessed Resident #1 for risk for elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations and updated the care plan for Resident #1. 2. Review of the Elopement Evaluation, dated November 2016, revealed the facility conducted an elopement assessment with every resident in the facility on 11/05/16 and 11/06/16. The facility assessed twenty-three (23) residents at risk of elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations on one hundred percent (100%) of the residents in the facility. 3. Review of the facility's care plans for the twenty-three (23) identified residents at risk for elopement, revealed the facility updated and implemented elopement care plans for each of the identified residents by 11/06/16. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility updated the care plans for each resident assessed as at risk for elopement. 4. Review of the facility's census, 11/09/16, revealed the facility admitted on e new resident and readmitted three (3) additional residents. Review of the Admission Clinical Health Status for each of the new/readmitted residents, dated 11/07/16 and 11/08/16, revealed the facility conducted the Risk for Elopement section in each resident's Admission Clinical Health Status. The facility identified none of the admitted residents were at risk for elopement. Review of the facility's Elopement Tool, dated 11/07/16 and 11/08/16, revealed the facility discussed admissions in the Clinical Start Up Meeting to determine if each admission resident was at risk for elopement. Interview with the DNS, on 11/11/16 at 10:15 AM, revealed she discussed admitted residents in the Clinical Start Up meeting each morning. Meeting attendants discussed the Admission Clinical Health Status to ensure the Risk for Elopement section of the form was complete and accurate. The DNS stated she documented the conversation on the Elopement Tool. 5. Review of the Elopement Risk Identification book, updated 11/06/16, revealed the facility updated the book to include all residents identified at risk for elopement, regardless if the resident wore a Wander Guard. The books contained residents by name, picture, and face sheet. The books were located at the receptionist desk and at each nurses' station. Interview with DNS, on 11/11/16 at 10:15 AM, revealed the facility updated the Elopement Risk Identification book to reflect all residents identified as at risk for elopement. She stated residents, regardless of if they wore a Wander Guard, were represented in the book with a picture and cover sheet. 6. Observation of the code pad on the elevator revealed the facility changed the code to access the 1C secured unit. Review of the maintenance calendar, 2017, revealed the facility placed the task of changing the elevator codes on the calendar to occur quarterly, starting 01/09/17. 7. Observation, on 11/10/16, revealed the facility placed signs on the secured unit at the elevator on the ground floor, and on the 1st floor. The signs gave instruction to not allow residents residing on the memory care unit onto the elevator without staff assistance and instruction for visitors to see an employee for assistance with the elevator code. 8. Review of the facility provided education, posttests, and employee roster, revealed the facility provided education to all staff who had worked pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and elevator and door codes, by the Clinical Educator by 11/06/16. All staff passed all post-tests. Interviews with Receptionist #2, CNA#7, CNA #8, LPN #6, LPN #7, Housekeeping, and Dietary Aide, on 11/11/16, revealed the facility provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. The education included post tests. Interview with the Director of Clinical Education, on 11/11/16 at 9:30 AM, revealed she provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. She stated she received education on those systems from the Clinical Director of Operations prior to providing education to staff. She stated she provided the education to all staff who worked prior to 11/06/16. Additionally, the Director of Clinical Education stated any employee who had not received the education due to not yet working would be allowed to work until they first received the education. Review of the New Hire Pack, undated, revealed the facility added education to new hires using current facility elopement guidelines, Elopement Care System Guidelines. The New Hire Pack also included education to new employees pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, and elevator and door codes. 9. Interview with the Clinical Director of Operation, on 11/11/16 at 11:52 AM, revealed she provided education to the Administrator and the DNS on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. Review of the education logs, 11/06/16, revealed the DNS and Administrator also received education with all facility staff. 10. Review of the QAPI Questionnaire Tools, completed between 11/06/16 and 11/09/16, revealed the facility leadership team conducted interviews with at least five (5) employees each day. The questions on the Questionnaire Tool included: What do you do if you hear a wander guard alarm? What is the first thing you do if a resident is missing? What is the code that is announced when a resident is missing? Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the facility was holding daily QAPI meetings to ensure continued compliance. He stated the Medical Director was either physically present or present via telephone for each of the daily QAPI meetings. The Administrator stated that he and the DSN completed at least five (5) QAPI Questionnaire Tool interviews with staff each day. 11. Review of the Patient/Resident Elopement Drill Worksheets, dated between 11/06/16 and 11/09/16, revealed the facility conducted elopement drills daily and ensured all participating staff signed off on the drills. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed he conducted daily elopement drills to ensure all staff knew what to do in case of elopement. He stated the facility would ask a resident to participate in the drill and hide the resident. The facility would call a Code W and facility staff conducted searches of the facility and facility grounds with each drill. Interview with LPN #6 and CNA #4, on 11/11/16, revealed the facility conducted elopement drills daily. They each stated the facility called a Code W over the loud speaker and staff begin searching for the missing individual named in the announcement in the facility and on the facility grounds. 12. Review of the Daily Focused QAPI Meeting sheets, dated 11/06/16 through 11/09/16, revealed the facility held QAPI meetings daily. The meetings included the Medical Director and reviewed actions and audits, as well as admissions and newly identified residents at risk for elopement. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the Administrator was holding QAPI meetings daily to discuss the elopement plan. He stated the Medical Director had attended every meeting either in person or via telephone. Interview with the DNS, on 11/11/16 ay 10:15 AM, revealed the facility held QAPI meetings each day. She stated she attended the QAPI meetings and the QAPI team discussed the ongoing inservices, drills, admissions, assessments, and other facility elopement initiatives.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure residents received adequate supervision to prevent an incident of elopement for three (3) of twelve (12) sampled residents, Residents #1, #2, and #3. On 10/21/16, Resident #1 eloped from the facility without staff knowledge. The resident was found, at approximately 4:00 PM, off the facility's grounds walking down the sidewalk. At 3:00 PM, Licensed Practical Nurse (LPN) #3 observed Resident #1 seated in his/her room, upset, and stating he/she needed to go home. LPN #3 did not provide supervision or redirectional activities per the care plan and walked into the closed medication room. No other staff was available on the unit at the time. The facility's investigation determined the resident took the elevator to the lobby where Receptionist #2 keyed in the alarm code to the front door and allowed the resident to exit the building. The recorded weather conditions on 10/21/16 at 2:31 PM, included a high of sixty-two (62) degrees Fahrenheit with cloudy skies. The resident was returned to the facility uninjured. Additionally, the facility failed to provide supervision to mitigate the risk of elopement for Residents #2 and #3. The facility assessed Resident #2 as at risk for elopement; however, allowed the resident to sign himself/herself out of the facility and sit on the front porch unsupervised on eleven (11) occasions. Resident #3 was care planned for supervision when he/she went off the unit; however, the facility allowed the resident to wander the building unsupervised and he/she attempted to elope from the facility on 10/30/16. The facility's failure to have an effective system in place to ensure staff provided adequate supervision of residents has placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) with Substandard Quality of Care was identified on 11/04/16 and was determined to exist on 10/21/16. The facility was notified of the IJ on 11/04/16. An Acceptable Allegation of Compliance (AOC) was received on 11/09/16, which alleged removal of the IJ on 11/07/16. The State Survey Agency validated the IJ was removed on 11/07/16, as alleged, and the scope and severity was lowered to an D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Care System Guideline, Elopement, revised 2015, revealed the facility established a process that identified risk and interventions to mitigate the occurrence of elopements. The facility assessed residents for elopement risk using the Clinical Health Status upon admission or re-admission to the facility. If the facility determined a resident was at risk for elopement, the facility established an individualized care plan and documented interventions to prevent elopement. The facility placed elopement interventions on the Direct Care Giver Card and initiated the interventions. The facility maintained a central binder system and placed a photograph and information about each resident assessed as at risk of elopement. If the facility chose to place a Wander Guard bracelet alarm on a resident, the facility established a plan for monitoring the function of the bracelet alarm. When an elopement occurred, the facility alerted all staff to search the building and grounds as soon as the facility discovered a resident was missing. If the resident was not quickly located in the building or on the grounds, the facility designated a point person to notify the Administrator and Director of Nursing Services (DNS), to notify the guardian or family member, and to notify the police. After locating the resident, the facility completed a thorough evaluation of the resident's physical condition and psychosocial wellbeing. The facility notified the family and physician of the return. The facility established the cause of the elopement and addressed the cause with an appropriate plan to prevent reoccurrence. The facility documented the resident's condition, notifications, and times of actions. The facility reviewed all other residents identified at risk for elopement to ensure current interventions were in place to prevent elopement. The facility's Quality Assurance reviewed patterns or trends in elopements or elopement risks. Review of the facility's New Hire Pack, undated, revealed the facility provided training to new employees pertaining to elopement using the policy, Elopement from Designated Area of Facility, dated 08/01/12. The policy did not discuss prevention, assessment prior to or after an elopement, or quality improvement measures. The New Hire Pack did not contain the elopement policy, Care System Guideline, Elopement, revised 2015. Interview with the Director of Clinical Operations, on 11/11/16 at 2:00 PM, revealed the facility did not use the policy titled, Elopement from Designated Area of Facility, as the policy followed for elopement. However, this was included in new employee orientation. Further interview revealed the facility used the policy, Care System Guideline, Elopement, revised 2015, to provide guidance on managing elopement. She stated she did not know why the facility educated new employees using an outdated policy. Review of the facility's Elopement Risk Identification book, updated 10/27/16, revealed the facility identified and placed pictures and information pertaining to seven (7) residents in the book. The book contained documentation stating each resident wore a Wander Guard. The binder contained a photograph of each resident, the face sheet, a list of diagnoses, and a Risk of Elopement Review for each of the seven (7) residents. 1. Observation of Resident #1, on 11/01/16 at 10:10 AM, revealed the resident ambulated independently. The resident appeared neat and clean and his/her affect was appropriate. The resident talked about needing to leave the facility to go home. Resident #1 stated he/she thought he/she was at the racetrack. The resident stated he/she left the facility the other day to go for a walk to visit his/her mother. Resident #1 stated he/she walked to his/her mother's home nearly every morning. The resident had a Wander Guard bracelet on his/her ankle. Review of the facility's clinical record for Resident #1, revealed the facility admitted the resident on 04/22/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/16, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #1's Risk of Elopement Review, dated 06/20/16, revealed the facility completed an Admission elopement evaluation on 06/20/16. The facility determined the resident was at risk for elopement due to cognitive impairment, diagnosis, and ability to ambulate independently without a walker or wheelchair. The facility stated the resident had a history of [REDACTED]. The facility stated the resident verbally expressed the desire to go home and frequently sat near the exits. Based on the findings of the assessment, the facility initiated elopement interventions including placing an updated evaluation in the Elopement Risk Identification books and placing a Wander Guard bracelet on the resident. The facility also documented having informed staff of the resident's wander risk. Review of the Physician orders [REDACTED]. The facility was to check the placement of the Wander Guard every shift, two (2) times per day. Review of Resident #1's Care Plan for Alzheimer's, with a Problem Onset date of 08/20/16, revealed the facility placed the resident on the secured unit related to a medical [DIAGNOSES REDACTED]. Interventions included staff cued the resident for safety and provided the resident with supervision. Staff observed the resident for exit seeking behavior, and if observed, redirected the resident and notified the supervisor. Review of Resident #1's Care Plan for Elopement, with a Problem Onset date of 09/09/16, revealed the facility identified the resident was at risk for elopement and wandering. The facility put interventions in place to ensure the resident's safety. The interventions included: placing the resident in areas where frequent observations were possible on the secure unit; placement of a Wander Guard bracelet on the resident that sounded an alarm when the resident approached an exit door, and checking the placement and functioning of the device every shift; alerting staff to the resident's wandering behavior; and providing the resident with diversional activities. The care plan additionally stated staff would stay with the resident if he/she wandered away from the unit, and gently persuade the resident to walk back to the designated area with them. Staff was to observe and document the resident's behavior as needed. Review of the Direct Caregiver Card for Resident #1, undated, revealed the resident's card stated Wander Guard on the care sheet under the section titled Other Special Needs. No other care planned interventions or instructions pertaining to elopement risk were present on the card. Review of the facility's investigation, dated 10/21/16, revealed on 10/21/16, the Activities Assistant reported Resident #1 was outside the facility at approximately 4:00 PM. Resident #1 was described as ambulating independently but not interviewable and did not have the capacity to make informed decisions. Resident #1 followed a visitor onto the elevator and off the secured unit. The report stated the resident dressed nicely and looked like a visitor to the new Receptionist. The Receptionist observed Resident #1 walking on the facility grounds until the Activities Assistant entered the lobby asking about the resident. The Receptionist pointed the resident out to the Activities Assistant. The facility called a Code W and the Activities Assistant and the Business Office Manager approached the resident and easily redirected him/her back to the facility. The investigation summary stated staff members kept the resident within vision for the entire incident. However, review of the portion of the employees' written statements of the investigation revealed the facility did not have visual contact with the resident throughout the incident. Review of the written statements of the Activities Assistant and the Business Office Manager stated they ran out the door after Resident #1, but when they arrived at the intersection at the corner of the facility, they looked in every direction and could not locate the resident. At that point, the Business Office Manager returned to the facility and called the Code W while the Activities Assistant ran to the right of the facility. Then, both staff members ran straight down the street on which the facility was located. Approximately one (1) block from the facility, they observed the resident walking approximately one (1) block farther down the road. When staff caught up with the resident, the resident stated he/she was walking home. They returned to the facility with no further incident. Continued observation of Resident #1, on 11/01/16 at 10:10 AM, revealed the resident resided on the first floor, above the ground floor of the facility, on the secure unit, 1C. The secure unit had two (2) exits, an elevator and a doorway. The elevator was across the hallway from the door and was located next to the common area. Each of the unit exits had a keypad that required a code to open. Observations of the facility and facility grounds with the Activities Assistant, on 11/02/16 at 9:20 AM, revealed the layout of the facility and the route Resident #1 took after he/she eloped from the facility on 10/21/16. On the ground floor, the elevator was located behind and around the corner from the reception area. To exit the reception area, there was one set of double doors. The doors could be opened either with a code keyed into the keypad at the door, or if an employee pressed a door release button located at the reception desk. The facility was located on the corner of a two (2)-way busy street and a one (1)-way street. Interview with the Maintenance Director, on 11/02/16 at 3:00 PM, revealed the alarms on the exit doors in the facility were Wander Guard alarms. Doors did not alarm when held open too long or when pressed on. He stated all the doors stayed locked and facility staff could only open the doors using a badge or key code. He stated the doors did not open after any amount of delay; they would remain locked. Interview with Receptionist #2, on 11/01/16 at 3:40 PM, revealed he unknowingly let Resident #1 out of the facility's front door. Receptionist #2 stated he had worked for the facility for a few weeks at the time of the incident. He stated he attended a one (1) day orientation and an additional few days of shadowing the lead Receptionist, Receptionist #1. During the orientation, Receptionist #2 received training on the Wander Guard system and elopement book; however, he did not remember much of the training pertaining to wandering residents due to having received a large amount of information at one time during the orientation. Receptionist #2 stated Resident #1 approached the lobby and said, Have a good day and Receptionist #2 pushed the button to release the front door. When the resident got close to the front door, an alarm sounded. The receptionist stated he got up and keyed in the code to turn off the alarm and unlock the door. He stated he thought the alarm had gone off for a different reason because the week prior the alarm had gone off when residents and families were entering and exiting the building. Once the resident exited the building, the Activities Assistant came to the lobby and asked if he had let Resident #1 out of the facility. The receptionist told the Activities assistant that he had let the resident out and pointed the direction Resident #1 took to the Activity Assistant and Business Office Manager. A few minutes later, staff returned to the facility with the resident. Interview with the Activities Assistant, on 11/02/16 at 9:20 AM, revealed he observed Resident #1 through a window and the resident was out of the facility unsupervised. He stated he was in the smoking room on the ground floor of the facility located across the dining room, hallway, and through two (2) locked doors. He stated he was letting a resident out of the smoking room doors and happened to look across the hallway, across the dining room, and out a window in time to see a person wearing a hat he thought looked like Resident #1's hat. He stated he ran to the dining room and had to stand on a chair to see out an adjacent window, when he identified that Resident #1 was out of the facility. He called another staff to stay with residents in the smoking room and ran to the reception area where he confirmed with the Receptionist that Resident #1 was out of the facility unsupervised. He stated he called the resident's unit, but staff did not answer the phone so he ran down the hallway to look for the Administrator. The Administrator's door and the door to Social Services offices were closed. He then ran back to the reception area, and the Business Office Manager met him there. He stated they both ran out to the location the Activities Assistant observed the resident, looked in every direction, and did not see the resident. He instructed the Business Office Manager to go back in the building to call a Code W. The Activities Assistant then ran to the right, down one of the streets in search of the resident. He stated he did not find the resident and returned to the last point of observation outside of the facility. The Business Office Manager met him at that location and they ran straight down the street away from the facility. Approximately one (1) block from the facility, he observed the resident, identifiable by his/her hat, turning a corner approximately one (1) block further up the street. He stated he began shouting the resident's name and the resident came back around the corner and waved at them. The employees reached the resident and the resident told them he/she was looking for a pay phone to call home. He further stated it was cold that day and he told the resident it was too cold to walk that far. The resident agreed with him and returned to the facility without further incident. The Activities Assistant stated the resident had decreased safety awareness and was not oriented to place. He stated the resident was at risk of serious injury or death. He stated the resident could have tried to enter another home or could have been hit by a car. He stated the resident was out of sight of any facility employee for a few minutes. The Activities Assistant stated he did not have the resident in sight at the time of elopement. The Activities Assistant reviewed the Incident Investigation and stated the summary of his statement was not accurate in that the summary left out the part of the search when staff lost the resident. The Activities Assistant stated the DNS asked him in front of everyone in the lobby if he maintained a visual on the resident the whole time and he told her No, I lost him. Interview with the Business Office Manager, on 11/01/16 at 4:00 PM, revealed she took part in the search for Resident #1. She stated she heard the Code Alarm on the front door sound. She stated one (1) to two (2) minutes after the door alarm sounded, she observed the Activities Assistant running down the hallway, then ran back. She stated the Activities Assistant told her the facility had a Code W and that he had observed a resident outside of the facility. She stated she went outside with him to the corner of the street, looked in all four (4) directions, and did not see the resident. The Business Office Manager came back into the facility and announced a Code W over the intercom system. She stated she then went back to the corner of the facility and met the Activities Assistant. They ran together down the street one (1) block and saw the resident's hat. They yelled the resident's name and the resident turned around and waved at them. When they reached the resident, the resident was calm and walked back to the facility without incident. Upon return to the facility, the nurse and the DNS were in the lobby. The nurse escorted the resident back to his/her unit. The DNS asked specifically if the resident had always been in sight of the staff and she stated she answered no. She stated the resident was at risk of being hit by a car as the cars on the street do not have to stop at the intersection, often drove fast on the neighborhood street, and the resident had a decrease in safety awareness. She stated the resident was out of the building for approximately four (4) to five (5) minutes. The Business Office Manager reviewed the facility's investigation summary of the statement she gave to the DNS and stated it was not accurate. She stated the facility's investigation omitted the fact that the resident was not in sight during the entire incident. She stated the resident was out of sight and facility staff did not know where he/she was. Interview with CNA #4, on 11/02/16 at 3:35 PM, revealed she worked on Resident #1's unit when he/she eloped from the facility on 10/21/16. She stated she talked with Resident #1 at approximately 3:00 PM and the resident asked her if he/she could go downstairs and go outside. She told the resident she would talk with the nurse, LPN #3, about it and she reported it to the nurse. Interview with LPN #3, on 11/04/16 at 1:45 PM, revealed he was Resident #1's nurse at the time the resident eloped from the facility. He stated the CNA reported to him that Resident #1 was talking about going home. He stated he went and talked with the resident and the resident was calm. LPN #3 then walked down the hallway and into the medication room. He stated no staff was present in the resident common area or in the hallway of the unit when he went into the medication room. Interview with CNA #2, on 11/01/16 at 11:00 AM, revealed she worked Resident #1's unit and she had previously observed visitors on the unit use the code to get on the elevator or to go through the door into or off the locked unit. Continued interview with the Maintenance Director, on 11/02/16 at 3:00 PM, revealed the facility had no set schedule to change the codes to the elevator, secure unit door, or stairwells. He stated he worked for the facility for ten (10) months and had not changed the codes to the stairwell because the facility had not had a problem with the stairwell. Interview with Social Services #1, on 11/03/16 at 2:00 PM, revealed Social Services completed elopement assessments on residents. Upon admission, if the intake referral or first twenty-four (24) hours of behavior indicated, then Social Service completed an elopement assessment. Social Services did not complete elopement assessments quarterly or with any regular frequency. She stated the facility did not complete elopement assessments after a resident eloped from the facility. She stated Social Services completed a new elopement assessment if, through observation of the resident and talking with staff, it was determined the resident had a new elopement risk. She stated the purpose of the elopement risk assessment was to determine what, if any, signs or symptoms of elopement risk existed. Interview with the DNS, on 11/03/16 at 8:30 AM, revealed she was in charge of the investigation into Resident #1's elopement from the facility on 10/21/16. When staff returned to the facility with the resident, she initiated the investigation. She stated she had talked with Resident #1 who stated he/she followed a person onto the elevator and rode down to the ground floor. The DNS stated the facility should have completed a new elopement risk screening in the morning start up meeting, however, she stated she was unsure if the facility completed a new elopement assessment after Resident #1 eloped from the facility. She also stated she was unsure if the facility updated the care plan after the elopement. She stated the facility did not review other residents assessed at risk for elopement to ensure interventions were sufficient. She stated Resident #1 was at risk of injury from elopement from the facility. The DNS further revealed she did not substantiate the elopement because the resident was out of the building for less than fifteen (15) minutes and had gone only a couple of blocks. She stated although staff did lose the resident for a couple of moments, she believed staff would have been able to see the resident from the facility property, and therefore she considered the resident in sight. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed he reviewed the Elopement Incident Investigation form for Resident #1's 10/21/16 elopement on 10/25/16. He stated he did not read all of the staff statements or review the clinical record for Resident #1. He stated Social Services should have completed elopement assessments quarterly, but had not instructed them to do so. The Administrator stated the Director of Clinical Operations trained the DNS on how to complete incident investigations. Interview with the Director of Clinical Operation, on 11/03/16 at 4:10 PM, revealed there was not a policy stating how often the facility completed elopement assessments; however, the facility should complete them after an elopement attempt per reference to the elopement policy. She stated she provided the facility guidance with how to complete an incident investigation. Additionally, the investigation tool guided the facility staff on each step in completing an investigation. She stated the DNS called her for guidance the day after Resident #1 eloped from the facility. 2. Review of the facility's clinical record for Resident #2, revealed the facility admitted the resident on 06/22/16 with [DIAGNOSES REDACTED]. Review of the Kentucky Power of Attorney (POA) form, dated 06/30/16, revealed Resident #2 appointed his/her relative to act on his/her behalf in financial and healthcare decisions. Review of the admission MDS assessment, completed 07/01/16, revealed the facility assessed the resident as requiring limited one (1) person physical assistance to walk. The facility assessed the resident as only able to stabilize during transfers and walking with human assistance. During the assessment, the facility conducted a BIMS examination and assessed the resident with a score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of Resident #2's printed November 2016 Physician order [REDACTED]. On 07/11/16, the physician also ordered the facility to check the function and placement of the Wander Guard each shift. Review of Resident #2's Care Plan pertaining to Exit Seeking Behaviors, dated 07/12/16, revealed the facility had developed interventions to place a monitoring device on the resident that sounded alarms when the resident left the building. The facility also had interventions to instruct staff to stay with the resident if he/she wandered away from the unit. Staff was to converse with the resident and gently persuade him/her to walk back to designated areas with them. Review of Resident #2's Risk of Elopement Review, dated 07/13/16, revealed the facility completed an elopement assessment and determined the resident was at risk for elopement and placed a Wander Guard bracelet on the resident. The facility stated the resident was at risk due to cognitive impairment with poor decision-making skills, independent ambulation, and a [DIAGNOSES REDACTED]. The facility noted the resident wandered the hallway of the unit and frequently discussed wanting to go home. However, further review of Resident #2's medical record revealed a document dated 09/23/16, that stated the resident's Power of Attorney (POA) gave approval for Resident #2 to sign himself/herself out to sit on the facility's front porch. The document was typed on an 8.5'' x 11.0'' sheet of paper with Social Services #2's name typed at the bottom. Further review of Resident #2's Care Plan revealed no plan for allowing the resident to sign himself/herself out of the facility to sit on the front porch of the facility unsupervised. Review of the Release of Responsibility for Leave of Absence, dated October 2016, revealed Resident #2 signed out of the facility on five (5) occasions. The dates of sign out were 10/04/16 at 11:40 AM, 10/05/16 at 1:30 PM, 10/07/16 at 1:10 PM, 10/08/16 at 1:30 PM, and one (1) undated and untimed occasion. The document contained no dates, times, or signature for when the resident returned to the facility. Review of a piece of paper with Sign Out Sheet handwritten at the bottom, undated, revealed Resident #2 signed out of the facility an additional six (6) times. Review of Resident #2's Nursing Notes, dated 06/23/16 through 10/18/16, revealed nursing had not documented any instances of wandering or exit seeking behaviors. The facility did report one (1) instance where the resident signed out of the facility against medical advice on 10/07/16. The note stated the resident would return later the same evening. No other notes indicated the resident left the facility. Interview with LPN #4, on 11/02/16 at 3:50 PM, revealed the resident had wandered on all floors of the facility since admission. The resident wore a Wander Guard and was allowed to sign him/herself out of the facility to sit on the front porch of the facility. The LPN stated the resident's POA gave permission for the resident to go out of the facility. Interview with Social Services #1, on 11/03/16 at 3:00 PM, revealed she called Resident #2's POA about the resident going out of the facility due to the resident wanting to go outside. The resident had a BIMS of 10 and the facility assessed the resident to have decisional capacity so she was unsure why she had to obtain permission from the resident's POA. She stated she did not review the resident's care plan to ensure it contained appropriate interventions for the resident's safety when he/she signed out of the facility. She stated Social Services completed the elopement assessment on Resident #2 and determined the resident was at risk for elopement due to exit seeking behaviors such as talking about wanting to leave the facility and pressing on exit doors. Interview with the DNS, on 11/03/16 at 8:30 AM, revealed it was facility practice not to let residents, with a Wander Guard, out of the building unaccompanied. The facility placed a Wander Guard on Resident #2 because he/she was exhibiting exit seeking behaviors, including pushing on exit doors and trying to go outside; however, the facility allowed Resident #2 to sign self out of the facility. She stated she expressed a concern with the Medical Director because some residents wanted to go outside. The DNS stated the Medical Director reviewed a list of residents who wanted to go outside but who were medically contraindicated to go out of the facility unsupervised and Resident #2 was on that list. She stated the resident had a history of [REDACTED]. Continued interview with the DNS, on 11/03/16 at 4:40 PM, revealed she was aware Resident #2 would sign out of the facility and sit on the porch unaccompanied. She stated the resident wanted to go outside and the nurse called the resident's POA. At first, the POA said no but later agreed to allow Resident #2 to sign out of the facility to sit on the front porch only. The DNS stated the facility could not ensure the resident would stay on the porch, as he/she was not accompanied. Interview with the Medical Director, on 11/03/16 at 4:57 PM, revealed he had discussed with the Administrator and the DNS, the use of AMA forms for residents who could safely go out of the building unsupervised; however, it was unsafe for Resident #2 to go outside of the facility unattended due to the risk of a seizure. The Medical Director stated he was unaware the facility allowed Resident #2 to sign out of the facility. Interview with the Administrator, on 11/02/16 at 4:45 PM, revealed the facility had an increased number of residents making requests to go outside in the last six (6) months. The Administrator stated Resident #2 suffered from seizures and had a history of [REDACTED]. Therefore, he stated the facility had Resident #2 sign a Release of Responsibility form and an AMA form. The resident could then sign him/herself out of the facility; however, the facility had not updated the care plan for Resident #2 to include the plan for the resident to sign him/herself out of the facility. Additionally, the Administrator stated the purpose of the AMA and the Release of Responsibility forms was to protect the facility if the resident did not return. 3. Review of Resident #3's clinic

Based on interview, record review, review of the Administrator's job description, and review of the facility's policy, it was determined the facility's Administration failed to have an effective system in place to ensure resources, including care plans, were used effectively and efficiently to maintain the highest practicable well-being of one (1) of twelve (12) sampled residents, Resident #1. (Refer to F280, F282 and F323) On 10/21/16, Resident #1 eloped from the facility without staff's knowledge. The resident followed a visitor onto the elevator and off the secured unit. The resident went to the lobby where Receptionist #2 keyed in the code to the front door and allowed Resident #1 to exit the building. The Administration's failure to ensure facility policies/procedures related to elopement were followed and care plan interventions were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care was identified on 11/04/16 and determined to exist on 10/21/16. The facility was notified of the IJ on 11/04/16. An Acceptable Allegation of Compliance was received on 11/09/16, which alleged removal of the IJ on 11/07/16. The State Survey Agency validated the IJ was removed on 11/07/16, as alleged, and the scope and severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Position Description for the position title Administrator, dated August 2015, revealed the facility Administrator was responsible for ensuring residents were at the center of every decision made, and was to ensure compliance with State and Federal Regulations. The Administrator ensured the quality of care and services provided to all residents met the satisfaction of the residents, family, and other service partners. The Administrator led an effective Quality Assurance and Process Improvement (QAPI) Program. Review of the facility's policy, Care System Guideline, Elopement, Revised 2015, revealed the facility established a process that identified risk and interventions to mitigate the occurrence of elopements. The facility assessed residents for elopement risk using the tool in the Clinical Health Status upon admission or re-admission to the facility. If the facility determined a risk for elopement, the facility established an individualized plan to mitigate risk. The facility documented interventions on the care plan, on the direct caregiver's care card, and initiated the interventions. The facility placed a photograph in the central system where information regarding all those identified at risk was located. If a bracelet alarm was chosen as an intervention, the facility established a plan for monitoring of the function of the bracelet alarm. When an elopement occurred, the facility alerted all staff to search the building and grounds as soon as there was an awareness of the resident missing. If the resident was not quickly located in the building or on the grounds, the facility designated a point person to notify the Administrator and Director of Nursing Services (DNS), notify the guardian or family member, and notify the police. After the facility located the resident, the facility completed a thorough evaluation of the resident's physical condition and psychosocial wellbeing. The facility notified the family and physician of the return. The facility established the cause of the elopement and addressed the cause with an appropriate plan to prevent reoccurrence. The facility documented the resident's condition, notifications, and times of actions. The facility reviewed all other residents identified at risk for elopement to ensure current interventions were in place to prevent elopement. The facility's Quality Assurance reviewed patterns or trends in elopements or elopement risks. Interview and record review revealed the facility assessed Resident #1 at risk for elopement, care planned the resident for elopement, and applied a Wander Guard to the resident. Record review revealed on 10/21/16, Resident #1 left the facility without staff knowledge. Review of the facility's investigation, dated 10/21/16, revealed Resident #1 eloped from the facility on 10/21/16. The facility completed an investigation that stated the resident left the secured unit after following a visitor onto the elevator and was then let out of the facility by a Receptionist. The investigation stated the Activities Assistant saw the resident through a window and recognized the resident was out of the facility unsupervised. The Activities Assistant and the Business Office Manager looked for the resident but were unable to locate the resident on the facility property. The Activities Assistant and Business Office Manager called a Code W and began searching the neighborhood for Resident #1. Staff located the resident and returned with him/her to the facility with no further incident. Further review of the facility's investigation, dated 10/21/16, revealed staff members kept the resident within vision for the entire incident; however, review of the portion of the employees' written statements of the investigation revealed the facility did not have visual contact with the resident throughout the incident. Interview with the Activities Assistant and the Business Office Manager and review of their written statements revealed they ran out the door after Resident #1, but when they arrived at the intersection at the corner of the facility, they looked in every direction and could not locate the resident. Interview with the Activities Assistant, on 11/02/16 at 9:20 AM, and the Business Office Manager, on 11/01/16 at 4:00 PM, revealed they stated the summary of their statements in the Incident Investigation was not accurate in that the summary left out the part of the search that staff had lost the resident. Review of the investigation summary, dated 10/21/16, revealed the form did not have a place for the person conducting the investigation to sign the form and that no one signed the form. The investigation form did contain a section to include summaries of interviews. Each Summary of Interview section contained a place for a signature acknowledging the accuracy of the summary. Review of the form revealed the DNS conducted three staff interviews with the Activities Assistant, the Business Office Manager, and Receptionist #2. None of the interview summaries were signed to acknowledge the accuracy of the summary. The investigation summary was not signed by any facility staff. Interview with the DNS, on 11/03/16 at 8:30 AM, revealed she was in charge of the investigation into Resident #1's elopement from the facility on 10/21/16. She stated that since the resident was not missing for more than fifteen (15) minutes, they did not substantiate the elopement. The DNS further revealed although staff did lose the resident for a couple of moments, she believed staff would have been able to see the resident from the facility property, and therefore she considered the resident in sight. Interview with the Administrator, on 11/03/16 at 3:00 PM, revealed he reviewed the investigation for Resident #1's elopement on 10/25/16 when he returned to the facility. However, he did not read all of the staff statements or review the clinical record for Resident #1 to ensure the investigation was complete and accurate. Interview revealed he was under the impression the resident was in sight of staff the whole time and therefore he did not consider the incident to be an actual elopement and did not take the incident to the Quality Assurance Committee. However, interview and record review revealed the resident exited the facility without staff knowledge. Continued interview with the Administrator revealed he did not provide training or instruction to the DNS pertaining to how to complete an incident investigation. Instead, he stated the DNS contacted the Director of Clinical Operations for instruction on how to complete the incident investigation for Resident #1's elopement. However, the Administrator did state he was responsible for providing supervision and oversight to the DNS. Further interview with the Administrator, on 11/11/16 at 11:05 AM, revealed he read the entire elopement incident investigation including staff statements after the initiation of the abbreviated survey. The Administrator stated he was concerned with the investigation into Resident #1's elopement due to discrepancies between the information in the facility's investigation and the information on the staff statements. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The MDS Coordinator reassessed Resident #1 for elopement risk on 11/05/16. The Elopement Care Plan for Resident #1 was reviewed and updated on 11/06/16 by the MDS Coordinator. 2. The Restorative Nurse, MDS Coordinator, DNS, ADNS, or the Regional Director of Clinical Operations assessed all residents in the facility for elopement risk using the Elopement Evaluation by 11/06/16. 3. Elopement Care Plans were implemented and/or updated by 11/06/16 for the twenty-three (23) residents identified as at risk for elopement by the Restorative Nurse, MDS Coordinator, DNS, ADNS, and the Regional Director of Clinical Operations. 4. An Admission Clinical Health Status was completed, including the Risk for Elopement section, for newly admitted residents and readmitted residents who were admitted to the facility after 11/06/16. The facility admitted on e (1) new resident and readmitted three (3) residents. None of the admitted residents was assessed at risk for elopement. The DNS used the Elopement Tool to discuss all admissions in the IDT morning clinical start up meeting each morning, five (5) days per week. 5. The Elopement Risk Identification book was updated on 11/06/16 by Social Services to include all residents identified at risk for elopement. The books contained each of the twenty-three (23) identified residents' name, face sheet, and picture. Updated Elopement Risk Identification books were placed at the receptionist desk and at each nurses' station on 11/06/16. 6. The code to enter the 1C secured unit via the elevator was changed on 10/21/16 by the Maintenance Director. The task of changing the elevator codes was placed on the maintenance calendar to occur quarterly, with the next code change occurring 01/09/17. 7. Signs were placed on 11/05/16 by the Regional Vice President. Signs were placed on the elevator to the 1C secured unit, on the ground floor at the elevator, and on the first (1st) floor at the elevator. The signs instructed visitors to see an employee for assistance with the elevator code and not to allow residents on the 1C secured unit to enter the elevator without staff assistance. 8. All staff received training on the Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and the security of the elevator and door codes by the Clinical Educator by 11/06/16. The New Hire Pack was updated by the to include education on the current facility Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the security of the elevator and door codes. All new hires will receive this education by the Clinical Educator or ADNS. 9. Education was provided to the Administrator and the DNS on the Elopement Care System Guidelines, the Wander Guard system, the Elopement Risk Identification book, and the elevator and door codes by the Regional Director of Clinical Services on 11/06/16. 10. Audits were completed by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or the Regional Vice President using the Elopement QAPI Questionnaire tool with at least five (5) employees, five (5) times per week. The Elopement QAPI Questionnaire tool included the questions: What do you do if you hear a wander guard alarm?; What is the first thing you do if a resident is missing?; What is the code that is announced when a resident is missing?. 11. Elopement drills were conducted weekly by the Administrator, DNS, ADNS, Regional Director of Clinical Operations, or Regional Vice President. All participating staff signed off that they participated in the drills. 12. The facility held a QAPI meeting on 11/06/16 to review the facility actions, the audits, admissions, and newly identified residents at risk for elopement. Findings of audits and actions taken after 11/06/16 will be reviewed at the monthly QAPI meeting by the QAPI team. The QAPI team included the Medical Director, Administrator, DNS, and at least three (3) other departmental leaders. The State Survey Agency validated the facility's actions as follows: 1. Review of the Elopement Care Plan for Resident #1, dated 09/09/16, revealed the facility reviewed and updated the care plan on 11/06/16. Review of the Elopement Evaluation tool for Resident #1, dated 11/05/16, revealed the facility re-assessed Resident #1 for risk for elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations and updated the care plan for Resident #1. 2. Review of the Elopement Evaluation, dated November 2016, revealed the facility conducted an elopement assessment with every resident in the facility on 11/05/16 and 11/06/16. The facility assessed twenty-three (23) residents at risk of elopement. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility completed Elopement Evaluations on one hundred percent (100%) of the residents in the facility. 3. Review of the facility's care plans for the twenty-three (23) identified residents at risk for elopement, revealed the facility updated and implemented elopement care plans for each of the identified residents by 11/06/16. Interview with MDS #1, on 11/11/16 at 9:00 AM, revealed the facility updated the care plans for each resident assessed as at risk for elopement. 4. Review of the facility's census, 11/09/16, revealed the facility admitted on e new resident and readmitted three (3) additional residents. Review of the Admission Clinical Health Status for each of the new/readmitted residents, dated 11/07/16 and 11/08/16, revealed the facility conducted the Risk for Elopement section in each resident's Admission Clinical Health Status. The facility identified none of the admitted residents were at risk for elopement. Review of the facility's Elopement Tool, dated 11/07/16 and 11/08/16, revealed the facility discussed admissions in the Clinical Start Up Meeting to determine if each admission resident was at risk for elopement. Interview with the DNS, on 11/11/16 at 10:15 AM, revealed she discussed admitted residents in the Clinical Start Up meeting each morning. Meeting attendants discussed the Admission Clinical Health Status to ensure the Risk for Elopement section of the form was complete and accurate. The DNS stated she documented the conversation on the Elopement Tool. 5. Review of the Elopement Risk Identification book, updated 11/06/16, revealed the facility updated the book to include all residents identified at risk for elopement, regardless if the resident wore a Wander Guard. The books contained residents by name, picture, and face sheet. The books were located at the receptionist desk and at each nurses' station. Interview with DNS, on 11/11/16 at 10:15 AM, revealed the facility updated the Elopement Risk Identification book to reflect all residents identified as at risk for elopement. She stated residents, regardless of if they wore a Wander Guard, were represented in the book with a picture and cover sheet. 6. Observation of the code pad on the elevator revealed the facility changed the code to access the 1C secured unit. Review of the maintenance calendar, 2017, revealed the facility placed the task of changing the elevator codes on the calendar to occur quarterly, starting 01/09/17. 7. Observation, on 11/10/16, revealed the facility placed signs on the secured unit at the elevator on the ground floor, and on the 1st floor. The signs gave instruction to not allow residents residing on the memory care unit onto the elevator without staff assistance and instruction for visitors to see an employee for assistance with the elevator code. 8. Review of the facility provided education, posttests, and employee roster, revealed the facility provided education to all staff who had worked pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, the Elopement Care System Guidelines, and elevator and door codes, by the Clinical Educator by 11/06/16. All staff passed all post-tests. Interviews with Receptionist #2, CNA#7, CNA #8, LPN #6, LPN #7, Housekeeping, and Dietary Aide, on 11/11/16, revealed the facility provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. The education included post tests. Interview with the Director of Clinical Education, on 11/11/16 at 9:30 AM, revealed she provided education on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. She stated she received education on those systems from the Clinical Director of Operations prior to providing education to staff. She stated she provided the education to all staff who worked prior to 11/06/16. Additionally, the Director of Clinical Education stated any employee who had not received the education due to not yet working would be allowed to work until they first received the education. Review of the New Hire Pack, undated, revealed the facility added education to new hires using current facility elopement guidelines, Elopement Care System Guidelines. The New Hire Pack also included education to new employees pertaining to the facility's Wander Guard system, the Elopement Risk Identification book, and elevator and door codes. 9. Interview with the Clinical Director of Operation, on 11/11/16 at 11:52 AM, revealed she provided education to the Administrator and the DNS on the Wander Guard system, the Elopement Risk Identification book, The Elopement Care System Guidelines, and elevator and door codes by the Clinical Educator. Review of the education logs, 11/06/16, revealed the DNS and Administrator also received education with all facility staff. 10. Review of the QAPI Questionnaire Tools, completed between 11/06/16 and 11/09/16, revealed the facility leadership team conducted interviews with at least five (5) employees each day. The questions on the Questionnaire Tool included: What do you do if you hear a wander guard alarm? What is the first thing you do if a resident is missing? What is the code that is announced when a resident is missing? Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the facility was holding daily QAPI meetings to ensure continued compliance. He stated the Medical Director was either physically present or present via telephone for each of the daily QAPI meetings. The Administrator stated that he and the DSN completed at least five (5) QAPI Questionnaire Tool interviews with staff each day. 11. Review of the Patient/Resident Elopement Drill Worksheets, dated between 11/06/16 and 11/09/16, revealed the facility conducted elopement drills daily and ensured all participating staff signed off on the drills. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed he conducted daily elopement drills to ensure all staff knew what to do in case of elopement. He stated the facility would ask a resident to participate in the drill and hide the resident. The facility would call a Code W and facility staff conducted searches of the facility and facility grounds with each drill. Interview with LPN #6 and CNA #4, on 11/11/16, revealed the facility conducted elopement drills daily. They each stated the facility called a Code W over the loud speaker and staff begin searching for the missing individual named in the announcement in the facility and on the facility grounds. 12. Review of the Daily Focused QAPI Meeting sheets, dated 11/06/16 through 11/09/16, revealed the facility held QAPI meetings daily. The meetings included the Medical Director and reviewed actions and audits, as well as admissions and newly identified residents at risk for elopement. Interview with the Administrator, on 11/11/16 at 11:04 AM, revealed the Administrator was holding QAPI meetings daily to discuss the elopement plan. He stated the Medical Director had attended every meeting either in person or via telephone. Interview with the DNS, on 11/11/16 ay 10:15 AM, revealed the facility held QAPI meetings each day. She stated she attended the QAPI meetings and the QAPI team discussed the ongoing inservices, drills, admissions, assessments, and other facility elopement initiatives.

Based on observation, interview, record review, review of a Centers' for Disease Control and Prevention document and facility policy review, it was determined the facility failed to have an effective system in place to ensure the facility was pest-free for three (3) of four (4) resident living units (Unit 1B, Unit 1C, and Unit 2B) for five (5) months prior to the Recertification Survey. Observations revealed a bug crawling on a resident's wheelchair and interviews with staff revealed sightings of mice and gnats since 12/24/14; and, as recent as 06/01/15, which affected fourteen (14) of eighty-eight (88) rooms (rooms 116, 125, 126, 127, 128, 130, 143, 148, 225, 226, 228, 229, 235, and 249). Also affected was Unit 2B's medication room, clean linen room, soiled utility room and nurse's station; and, Unit 1C's medication room, nurse's station, and soiled utility room. In addition, the pest control issues of mice and gnats affected eight (8) of thirty-two (32) sampled residents (Residents #2, #5, #6, #12, #16, #28, #30, and #32) and seventeen (17) of twenty (20) unsampled residents (Unsampled Residents A, B, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, and U). Observations, and interviews revealed the kitchen's dry storage room continued to have mice droppings. Review of the Pest Technician Service Report, dated 01/06/15, revealed the Pest Technician identified mice in the kitchen and placed four (4) RTU (container to deliver bait to kill mice) baits down and five (5) glueboard traps down in the kitchen area for mice. Review of pest control records revealed mice or other pests had been identified in the kitchen and the laundry. Resident interviews revealed sightings of mice and evidence of mice chewing on bags of chips and doughnuts. (Refer to F371) The facility's failure to have an effective system in place to ensure the facility was pest-free has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 06/04/15 and determined to exist on 01/06/15. The facility provided an acceptable Allegation of Compliance (AOC) on 06/11/15 which alleged removal of the Immediate Jeopardy on 06/10/15. The State Survey Agency verified Immediate Jeopardy was removed on 06/10/15, as alleged prior to exit on 06/18/15. The Scope and Severity was lowered to an E while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Pest Control, dated 09/01/14, revealed the facility was to maintain an effective pest control program. In addition, an on-going pest control program was to be maintained to ensure the building was kept free of insects and rodents with assistance by maintenance services, as necessary. Review of the pest control contract, CarePro Solutions, dated 02/03/14, revealed the company would provide services as needed to effectively control cockroaches, ants, rodents, or other insect infestations. Further review of the pest control contract revealed the company's treatment process would depend on feedback from Pest Sightings postings (documented on Pest Sighting Logs kept at the nursing stations) or from a primary contact person. Review of the Centers' for Disease Control and Prevention Integrated Pest Management: Conducting Urban Rodent Surveys, dated 2006, revealed a premise was considered infested as long as any active rodent signs existed. Rats and mice could contaminate food, damage structures, and carry diseases that threatened the health and quality of life, and they could cause injury (potential for bites) and death. In addition, whenever rodents find suitable food, water and harborage they become established and reproduce rapidly in premises with poor environmental quality. 1. During the Quality of Life Interview, on 06/02/15 at 3:00 PM, with Resident #5 (Room #228), who the facility assessed with [REDACTED]. Resident #5 stated there was a package of doughnuts in his/her room in a drawer which appeared to have been gnawed open. In addition, Resident #5 stated a package of chips delivered on a meal tray appeared to be gnawed open by a mouse. Resident #5 stated he/she had seen mice in his/her room on several occasions in the past few months; however, he/she did not report this to anyone. Review of the Pest Control report, dated 04/23/15, revealed glue boards were not placed in room #228 until 04/23/15. Interview with Licensed Practical Nurse (LPN) #10, on 06/03/15 at 3:14 PM, revealed he had observed a mouse in Resident #5's room (Room #228 Unit 2B) on 04/13/15 after the resident alerted him about the mouse. He stated the Maintenance Department had been contacted and indicated they would look into it the next day. He also stated a maintenance staff person had done something about the mouse in Resident #5's room (Room #228 Unit 2B) before the Pest Control Technician came to the facility on [DATE]. However, interview with the Maintenance Director, on 06/03/15 at 2:30 PM, revealed he could not remember what he had done to treat the room or if he caught any mice. LPN #10 further stated a healthcare facility should be free of pests and rodents because they could affect the cleanliness of the environment. Interview with the Director of Nursing (DON), on 06/04/15 at 4:50 PM, revealed she had heard about mice and bugs in the building for the past three (3) to four (4)months. She stated she had seen gnats several times a week for the past three (3) to four (4) months and had also seen unidentified insects in room #228, on Unit 2B. Interview with Certified Nursing Assistant (CNA) #6, on 06/03/15 at 2:10 PM, revealed she had heard mice were in the facility for several months. She stated she saw fruit flies and gnats on several occasions at Unit 2B nursing station, in the soiled utility room, and in room #228, (Resident #5 and Unsampled Resident R). Review of a Pest Service Report, dated 04/08/15, revealed the Pest Control Technician placed a mousetrap and glue boards in room #126 (Resident #30 and Unsampled Resident L) with mice as the targeted pests. Review of a Pest Service Report, dated 04/23/15, revealed the Pest Control Technician noted holes were found around electrical conduits coming through the floor of room #125 (Resident #12 and Unsampled Resident M), room #130 (Unsampled Residents B and P), room #225 (Resident #28 and Unsampled Resident Q), and room #249, which needed repaired. Further interview with CNA #6, on 06/03/15, at 10:40 AM, revealed she saw mice droppings in the 2B linen room in front of the non-working elevator doors. She was unable to specify a date. She stated she had notified her supervisor and the Maintenance Department. However, review of the Pest Control Reports revealed there was no evidence this area was treated. Interview with LPN #11, on 06/03/15 at 2:51 PM, revealed she stated she had not seen a mouse, but had heard them gnawing on trash. She further stated she had seen gnats at the nursing station and in the soiled utility room on Unit 2B. However, she did not report this to anyone. On 06/04/15, at 1:02 PM, interview with Unsampled Resident F, whom the facility assessed with [REDACTED].#226 Unit 2B), revealed the resident saw gnats and flies in the room several times a week. The resident stated he/she thought it was related to his/her roommate voiding on the floor of the bathroom. In addition, the resident stated they had seen mice in their room. Observation, on 06/03/15 at 9:49 AM, during interview with Resident #12, in room #116 on Unit 1C, revealed a black bug crawling on the resident's wheelchair wheel. The Surveyor removed the bug from Resident #12's wheelchair wheel onto the floor and collected it on a piece of clear tape. The collected bug was identified by the Pest Control Technician as a small black beetle. Telephone interview with LPN #13 (a former employee), on 06/18/15 at 11:07 AM, revealed she had seen gnats in the medication room and the soiled utility room on Unit 1C. On 06/03/15, at 5:05 PM, interview with Unsampled Resident A, whom the facility assessed with [REDACTED].#128 on Unit 1B, and Resident #2), revealed he/she saw a mouse in his/her room approximately two (2) weeks ago at about 7:00 PM. In addition, Unsampled Resident A stated he/she had seen a mouse about a week ago that ran from under his/her bed to under a dresser across the room. Unsampled Resident A stated he/she reported the mouse sighting to the nurse on the morning shift the next day. The resident stated he/she thought some residents stored too much food in their rooms and that caused the mice to be in the building. Interview, on 06/03/15 at 10:53 AM, with Unsampled Resident H, whom the facility assessed with [REDACTED].#148 on Unit 1B and Resident #6 was not interviewable), revealed Unsampled Resident H had seen gnats swarming around the container holding his/her urine hanging on the walker beside the resident's bed. In addition, Unsampled Resident H stated he saw a couple of roaches in his bedroom a few days ago and the resident killed them. However, he/she did not report it to anyone. The resident continued to state they had seen mice in their room. On 06/04/15, at 10:10 AM, interview with Unsampled Resident B (room #130 on Unit 1B), whom the facility assessed with [REDACTED]. The resident reported this to CNA #9. Unsampled Resident B stated other residents saw mice also; and, yesterday (06/03/15) the Pest Control Technician was in his/her room and drilled some holes in the room walls. In addition, the report stated mice glue boards were placed in rooms with droppings and holes in the floors. These rooms included #123 through #149 and rooms #223 through #249; mice were the targeted pests. Interview with CNA #9, on 06/15/15 at 3:16 PM, revealed she had been told by Unsampled Resident B that he/she had seen a mouse in his/her room. CNA #9 stated she told the nurse on duty and put the information on a maintenance work order on 03/31/15. She stated she saw a maintenance person put a paper trap in the room, but she was concerned because mice could carry diseases. Review of a Maintenance Work Order, dated 03/31/15, revealed CNA #9 filled the work order out which stated she saw a mouse in room (on Unit 1B) on that date. Interview with Unsampled Resident B (room #130), on 06/04/15 at 10:10 AM, revealed he/she had seen a mouse in his/her room. Review of a Mintenance Work Order, dated 04/29/15, revealed a mouse had been seen by LPN #7 in room #127 (Unsampled Residents J and K). Interview with LPN #7, on 06/03/15 at 10:10 AM, revealed she saw a mouse in Room #127 (Unsampled Residents J and K) and placed that information on a maintenance work order on 04/29/15. Interview with LPN #12, on 06/18/15 at 8:28 AM, revealed she had seen mice at the 1B nurses' station and she had put that information in the Pest Activity Log. She stated she had seen several mice around the bed of Unsampled Resident J (Room #127 Unit 1B) and had also reported this in the Pest Activity Log. She further stated she had seen the mice since January 2015. Review of the Pest Technician Service Report, dated 05/06/15 revealed the laundry was treated with a spray for roaches and room #202 for bed bugs. Interview with Housekeeper #1, on 06/04/15 at 9:49 AM, revealed he had seen gnats in the trash cans in resident rooms over the past two (2) months when the trash was not emptied timely. He also said he had seen bugs and roaches in the laundry room. 2. Review of the Pest Technician Service Report, dated 01/06/15, revealed the Pest Technician placed four (4) RTU (container to deliver bait to kill mice) baits down and five (5) glueboard traps down in the kitchen area for mice. No other areas inside the facility were treated Review of the Pest Technician Service Report, dated 02/03/15, revealed the Pest Technician placed two (2) Contrac Bait Blox and two (2) glueboard traps down in the kitchen area for mice. No other areas inside the facility were treated. Telephone interview with LPN #13 (a former employee), on 06/18/15 at 11:07 AM, revealed she had seen roaches about one (1) to two (2) inches long in the hallway by the kitchen and the dish washing room when she worked at the facility in February of 2015. She stated there were issues of uncleanliness at the facility. Review of the Pest Control Log revealed she entered the information on 05/26/15. Review of the Pest Technician Service Report, dated 03/03/15, revealed the Pest Technician placed four (4) Contrac Bait Blox and eleven (11) glueboard traps in the kitchen area for mice. No other areas in the facility were treated. Review of the Pest Technician Service Report, dated 04/08/15, revealed the Pest Technician placed one (1) Contrac Bait Blox and five (5) glueboard traps in the kitchen area for mice. On 06/04/15 at 12:42 PM, interview with Resident #16, whom the facility assessed with [REDACTED]. Resident #16 stated he/she reported the mouse to the Dining Manager and the Dining Manager told him/her it could be caused by an open loaf of bread. Resident #16 further stated what the Dining Manager told him/her did not make him/her feel any better. Interview, on 06/04/15 at 4:40 PM, with the Dietary Manager, revealed he told the Administrator, Maintenance and the Pest Technician when he started noticing the mice back in December of 2014. The Dietary Manager stated there had been problems with mice about two (2) months ago getting into the bread supply. He further stated he was not aware the mice were getting in the dry storage rice supply. The Dietary Manager stated mice carry diseases, could make the residents sick and he did not want mice in the kitchen. The Dietary Manger stated four (4) months was not a long time to have to deal with mice. Interview with the Pest Control Technician, on 06/03/15 at 2:06 PM, revealed he came to the facility monthly and inspected the outside of the building and reviewed the Pest Sighting Logs for any sightings of pests/rodents in the building. The Pest Control Technician indicated he would inspect any rooms which were on the Pest Sightings Logs and treat them if he saw any evidence of mice/pests. He stated he would place mousetraps in resident rooms or at the nurses' stations if he saw evidence of mice and he had done so for the past several months in the kitchen and throughout the facility. He indicated he would spread a chemical around the perimeter of the building which would repel ants and beetles. He further stated he could not place mouse houses (to trap mice) outside the building until two (2) months ago because his company had the mice houses on back order. He stated he was aware the facility had an active rodent problem for the past five (5) months and he had informed the Administrator in December, 2014 of the pest problem being contributed to by the uncleanliness of the facility. Interview with the Maintenance Director, on 06/03/15 at 2:30 PM, revealed he did not always see the Pest Control Technician when he came to do his monthly inspection of the facility, but he would get a written report. He stated he was aware there were mice/pests in the building for several months and he had put out mousetraps and had caught some mice (could not indicate a number) in the past several months. The Maintenance Director stated he had not informed the Administrator of an on-going pest problem in the building because he would call the Pest Control Technician to come if there were multiple sightings and the Technician had come when called in between his monthly visits. The Maintenance Director stated he was aware mice/pests could carry disease, but he did not realize the building was infested with mice or other pests. Further interview with the Pest Technician, on 06/03/15 at 2:55 PM, revealed he had spoken to the Administrator in December of 2014 about the problem with rodents. The Pest Technician stated he informed the Administrator about the housekeeping and the uncleanliness of the facility and the impact that would have on getting rid of the pests. The Pest Technician stated this was one of the worst facilities as it related to pests, insects, rodents. Interview with the Administrator, on 06/04/15 at 3:00 PM, revealed he was unaware mice had been sighted in the kitchen over the past five (5) months. The Administrator stated he just found out about mice droppings in the kitchen this past week and the health of the residents could be affected by mice in the kitchen or in the facility. He indicated he could not remember having been told by the Pest Control Technician in December, 2014 about the uncleanliness of the building contributing to a pest problem in the building. The Administrator stated the Pest Control Technician did not report his findings to him when he made a monthly inspection, but he did think the Pest Control Technician reported to the Maintenance Director. Continued interview with the Administrator, on 06/04/15 at 3:00 PM, revealed he had not had any reports by the Maintenance Director about a pest problem at the facility. The Administrator stated he did not review maintenance work orders or the Pest Sighting Logs. He stated he had been informed in February 2015 by a resident about having seen a mouse in his/her room, but he thought it was only because the resident was a hoarder and had food in his/her room on the floor. He stated food on the floors could contribute to the mice problem and he had only seen gnats on occasion. The Administrator stated he was ultimately responsible for the facility and correcting any problems at the facility. The State Survey Agency (SSA) verified the removal of Immediate Jeopardy on 06/10/15 prior to exit as follows: 1. Observation of the exterior of the facility, on 06/17/15 at 4:00 PM, with the Maintenance Director and the Administrator revealed potential rodent entry points had been repaired as outlined on the document, Summary of Building Inspection Conducted 06/05/15. Observation of the interior of the facility, on 06/17/15 at 4:30 PM, revealed no active signs of pests/rodents. Review of the Summary of Building Inspection Conducted 06/05/15, revealed an inspection was conducted of the interior and exterior of the facility for the purpose of determining if there were any active signs of pest issues. Review of the document revealed a number of potential rodent entry points were located on the exterior of the building and the document listed those entry points and how those were addressed. The document further revealed the inspection was completed on 06/05/15 and repairs were completed on 06/07/15. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Manager, on 06/17/15 at 4:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Review of an Interior Rounds Checklist form and an Exterior Rounds Checklist form, each dated 06/05/15, revealed they had been completed and signed by the Maintenance Department Director and the Administrator. Observation of the exterior of the building, on 06/17/15 at 4:00 PM, revealed new door sweeps had been installed on the loading dock doors, holes outside the break room had been filled with concrete and two old plumbing lines had been filled with pipe. Observation of the interior of the building, on 06/17/15 at 4:30 PM, revealed a hole had been filled in the dishroom, the 1C elevator room had a hole filled, the outside break room had a hole filled, a hole was filled in room #126, door sweeps were installed on two (2) utility room doors, and a new door sweep was installed at the employee entrance as alleged. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he had completed the weekly rounds monitoring forms on 06/05/15 and will continue the weekly monitoring rounds to include visual checks of interior mechanical, utility, supply rooms for potential issues and implementing interventions. He stated the results of the weekly rounds would be reviewed during the monthly Quality Assurance Performance Improvement (QAPI) meeting. 2. Review of documents titled Pest Control Questionnaire (undated) and resident census lists indicating residents' answers to the questions with a signature (when possible) revealed all interviewable residents were asked about concerns with pests. Review of Departmental Nursing Notes revealed all residents were either assessed or interviewed regarding any signs or symptoms of health problems associated with pests or uncleanliness in the facility. Interview with Resident #4, on 06/18/15 at 8:00 AM, Resident #5, on 06/18/15 at 8:20 AM, Resident #7, on 06/18/15 at 8:30 AM, Resident #10, on 06/18/15 at 8:40 AM, Resident #15, on 06/18/15 at 9:00 AM, Resident #16, on 06/18/15 at 9:20 AM, Resident #18, on 06/18/15 at 9:30 AM, Resident #20, on 06/18/15 at 9:30 AM, Resident #27, on 06/18/15 at 10:00 AM, Resident #30, Resident #31, on 06/18/15 at 10:10 AM, Resident #32 on 06/18/15 at 10:25 AM, Unsampled Resident B, on 06/18/15 at 11:00 AM, Unsampled Resident G, on 06/18/15 at 11:12 AM, Unsampled Resident J, 06/18/15 at 11:30 AM, and Unsampled Resident M, on 06/18/15 at 11:45 AM, revealed they had all been interviewed by the Director of Nursing (DON) or one of the two (2) Assistant Directors of Nursing (ADON) regarding pests or possible adverse health consequences from pests. Interview with the DON, on 06/18/15 at 10:48 AM, revealed she had participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with the Assistant ADON #1, on 06/18/15 at 9:41 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with ADON #2, on 06/18/15 at 9:38 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. 3. Review of the In-service Sign-in Sheet, dated 06/05/15, revealed the topic of the in-service was pest control logs-utilization, center leadership notification and notifying the individual department leader, review and follow up of the pest control logs and the education of team members and the review of concerns (staff) may have regarding pest control. Team member/staff education to be completed for all staff members. Review of the document further revealed it was presented by the Director of Clinical Operations and was signed by the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Director of Clinical Operations, on 06/17/15 at 3:20 PM, revealed he had trained the facility leadership to include the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Administrator, on 06/17/15 at 3:00 PM, the Clinical Educator on 06/18/15 at 9:46 AM, the DON, on 06/18/15 at 10:48 AM and the ADON #1, on 06/18/15 at 9:41 AM, and ADON #2 on 06/18/15 at 9:38 AM revealed they had attended the in-service given by Corporation Representative, Director of Clinical Operations. Review of staff In-service Sign-in sheets with comparison to the employee roster dated 06/04/15 through 06/09/15 revealed one hundred fifty-one (151) employees were educated with twenty (20) employees educated by telephone. One employee remained on Family Medical Leave Act (FMLA) and would receive the education before returning to work. The education consisted of reviewing the employee's responsibility to provide written communication when a pest issue was identified. Interview with Licensed Practical Nurse (LPN) #14, on 06/18/15 at 2:00 PM, revealed she had received an in-service on 06/06/15 about putting any pest sightings in the pest activity log. Interview with LPN #7, on 06/18/15 at 2:15 PM, revealed she had been in-serviced about pest control on 06/06/15. Interview with Certified Nursing Assistant (CNA) #3, on 06/18/15 at 2:08 PM, revealed she received an in-service on 06/06/15 about putting any pest sighting in the activity log and to notify her supervisor. Interview with a Receptionist, on 06/18/15 at 1:52 PM, revealed she had received an in-service about reporting any pest sighting on 06/05/15. Interview with the Social Services Director, on 06/18/15 at 9:59 AM, revealed she had been in-serviced on 06/05/15 about the pest control reporting. Interview with CNA #7, on 06/18/15 at 2:05 PM, revealed she had been inserviced on 06/08/15 about how to report pest sightings and to whom to report. Interview with Cook #3, on 06/18/15 at 2:17 PM, revealed he had been inserviced on 06/07/15 about how and to whom to report pest sightings. Interview with CNA #8, on 06/18/15 at 2:20 PM, revealed he had been inserviced on pest sightings in the facility on 06/08/15 regarding responsibility to log any sightings in the pest activity log and report to his supervisor. Interview with Housekeeper #3, on 06/18/15 at 2:25 PM, revealed he had been inserviced on 06/07/15 on pest sightings, where to document those sightings and to notify his supervisor of any sightings. Interview with the Activities Director, on 06/18/15 at 2:26 PM, revealed she had been inserviced on 06/07/15 on reporting of any pest sightings on the pest activity log and to notify her supervisor of any sightings. Interview with LPN #11, on 06/18/15 at 2:45 PM, revealed she had been in-serviced on 06/08/15 regarding reporting any pest sightings and notification of her supervisor if she did. Post survey interview with the DON, on 07/02/15 at 10:39 AM, revealed the staff who was telephonically inserviced on 06/05/15 to 06/08/15 were retrained upon return to work. The staff person on FMLA (CNA #14) was re-inserviced upon return to work. Post survey interviews, on 07/02/15, with CNA #14 at 11:00 AM, CNA #11 at 11:09 AM, CNA #12 at 11:25 AM, CNA #13 at 11:45 AM, and LPN #15 at 11:37 AM, revealed they had all received education over the telephone and could specify the information provided to them. They further stated the Director of Nursing discussed the education with them after they returned to work for their scheduled shifts. 4. Review of the Summary of Pest Control Service Agreement Review revealed the Administrator met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Administrator, on 06/17/15 at 5:07 PM, revealed he met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Maintenance Director, on 06/17/15 at 4:49 PM, revealed he met with the Administrator, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he met with the Administrator, the Maintenance Director, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Services Manager, on 06/17/15 at 4:00 PM; and, the President of the Pest Control Services, on 06/18/15 at 2:38 PM, revealed they met with the Administrator, the Maintenance Director, and the Pest Control Service Technician to review the pest service agreement and no changes were made on 06/05/15. 5. Review of the document, entitled Quality Assurance Review revealed a Quality Assurance Review meeting was held on 06/08/15 for the purpose of discussing the Immediate Jeopardy deficiencies that had been identified in the areas of F469, F490 and F520. Review of the Quality Assurance Review Committee sign-in sheet, dated 06/08/15, revealed it was signed by the Administer, the DON, the Social Services Director, the Maintenance Director, Environmental Services #1, Environmental Services #2, Regional Director of Housekeeping, and the Medical Director. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he reviewed the weekly rounds monitoring forms completed by the Maintenance Director on 06/05/15, he will continue to monitor them and he will take them to the monthly Quality Assurance Review Committee meeting for review. Interview with the Administrator, on 06/18/15 at 5:07 PM; the DON on 06/18/15 at 10:48 AM; the Social Services Director, on 06/18/15 at 10:00 AM; the Maintenance Director, on 06/17/15 at 4:49 PM; Environmental Services #1, on 06/18/15 at 11:00 AM; Environmental Services #2, on 06/18/15 at 11:20 AM; Regional Director of Housekeeping, on 06/18/15 at 11:40 AM; and, the Medical Director, on 06/18/15 at 11:50 AM revealed they had all attended the Quality Assurance Review Committee meeting held on 06/08/15 to discuss the Immediate Jeopardy issues. During the interview with the Administrator, on 06/18/15 at 5:07 PM, he stated he would review the overview assessment of the pest control log books to help identify any trends or patterns. If any trends/patterns were identified additional interventions will be included in the Quality Assurance Review minutes with follow up by members as needed. In addition, the pest control services monthly reports would be reviewed in the monthly Quality Assurance Review Committee meeting.

Based on observation, interview, record review and review of the Administrator Position Description, it was determined the Administrator failed to ensure an effective system was in place to maintain a clean, pest-free environment in good repair and to maintain the highest psychosocial well-being of each resident. Five (5) months prior to the survey, the facility had identified rodents and pests in the kitchen, dining room, laundry, a medication room, a nursing station, in resident rooms and living units. Observation revealed the facility was unclean and in poor repair at the time of the survey on four (4) of four (4) living units (Units 1B, 1C, 2B, and 2C). The Administrator's failure to ensure an effective system was in place to maintain a clean, pest-free environment in good repair and to maintain the highest psychosocial well-being of each resident placed residents in a situation which has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/15 and determined to exist on 01/06/15. Refer to F253 at Substandard Quality of Care, F469 and F520. The facility provided an acceptable Allegation of Compliance (AOC) on 06/11/15 which alleged removal of the Immediate Jeopardy on 06/10/15. The State Survey Agency verified Immediate Jeopardy was removed on 06/10/15 as alleged prior to exit on 06/18/15. The Scope and Severity was lowered to an E while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator Position Description (undated) revealed the Administrator was to manage and direct day-to-day operations of the long term care facility consistent with applicable rules and regulations and company standards; plans and forecasts to ensure the ongoing success of the facility. Key responsibilities were to implement the control and effective utilization of the physical and financial resources of the facility; develop and implement policies and procedures to ensure a safe, efficient, high quality service was provided; reviewed and acted upon the reports of authorized inspecting agencies; and, recruits, selects, and retains department managers so goals of each department are accomplished. In addition, the Administrator was to ensure a Continuous Quality Improvement Program was in place with appropriate follow-up, and ensure effective communication with residents. Review of the facility's in-service (presented as the housekeeping policy), dated 01/01/00, revealed resident room walls should be spot scrubbed, both sides of the doors scrubbed, build-up on floors between rooms and hallways should be removed, and bathrooms should have all fixtures, drains and pipes cleaned with a germicide and all stains and build-up removed daily. No policy regarding cleaning of halls, storage rooms, nursing stations or common resident living areas was presented. Review of the facility's policy, Pest Control, dated 09/01/14, revealed the facility was to maintain an effective pest control program. In addition, an on-going pest control program was to be maintained to ensure the building was kept free of insects and rodents with assistance by maintenance services, as necessary. Review of the pest control contract, CarePro Solutions, dated 02/03/14, revealed the company would provide services as needed to effectively control cockroaches, ants, rodents, or other insect infestations. Further review of the pest control contract revealed the company's treatment process would depend on feedback from Pest Sightings Postings (documented on Pest Sighting Logs kept at the nursing stations) or from a primary contact person. Review of the Centers for Disease Control and Prevention, Integrated Pest Management: Conducting Urban Rodent Surveys, dated 2006, revealed a premise was considered infested as long as any active rodent signs existed. Rats and mice could contaminate food, damage structures, and carry diseases that threatened the health and quality of life, and they could cause injury (potential for bites) and death. In addition, whenever rodents find suitable food, water and harborage they become established and reproduce rapidly in premises with poor environmental quality. Observation and interview with staff and residents during the Recertification Survey, 06/18/15, revealed facility's housekeeping services had been declining since December, 2014 with the loss of multiple directors and multiple staff over the past five (5) months. In addition, interview and record review revealed pests/rodents sightings and droppings had multiplied concurrently with the decline in housekeeping services since December, 2014. Further interviews during the Extended Survey (06/15/15) revealed residents were distressed by mice and other pest sightings in their bedrooms, the hallways and in their dining room. They stated mice or other pests could bite, were frightening and could carry diseases. Interview with the Administrator, on 06/03/15 at 3:00 PM, revealed he was ultimately responsible for the facility. He stated he was aware the building was not clean, but he was unaware of maintenance concerns or pest/rodent concerns. However, he stated he should have been aware of those concerns and he should have taken those concerns to the Quality Assurance Committee. The Administrator stated he should have done something about the pest/rodent sightings in February, 2015 when a resident reported directly to him having seen a mouse in his/her bedroom. However, interview with the Pest Control Technician, on 06/03/15 at 2:06 PM, revealed he was aware the facility had an active rodent problem for the past five (5) months and had informed the Administrator in December, 2014 of the pest problem being contributed to by the uncleanliness of the facility. The Administrator further stated the residents deserved to live in a cleaner environment. The facility provided an acceptable Allegation of Compliance (AOC) on 06/11/15 and took the following immediate actions: 1. On 06/05/15 at 4:00 PM, the Administrator, Maintenance Supervisor, Pest Control Service Technician and Manager completed a four (4) hour inspection of the entire building including all resident rooms, office spaces, department spaces, and other nonresident areas to determine if there were any active signs of pest issues. On 06/05/15, an intensive tour of the exterior revealed a number of potential entry points where mice may have had opportunities to enter the building. These noted areas were addressed immediately. Of these places weather stripping the thresholds and sealing where conduit and pipe were entering the building were all addressed and sealed. This was completed on 06/07/15. The Maintenance Director will be making weekly exterior rounds monitoring for potential entry points and implementing interventions to prevent entry. Results of the weekly round audits will be reviewed during the monthly QAPI meeting. This was initiated on 06/05/15. The Maintenance Director will be making weekly visual checks of interior mechanical, utility, supply rooms for potential issues and implementing interventions. Results of the weekly rounds will be reviewed during the monthly QAPI meeting. This was initiated on 06/05/15. 2. On 06/05/15, the Director of Nursing Services (DON) and Assistant Director of Nursing Services (ADON) spoke with all interviewable residents about any of their concerns regarding pest control. The interviews completed were tracked using a resident roster. 3. The Administrator, Clinical Educator, Director of Nursing Services, and the Assistant Director of Nursing Services were educated by the Senior Director of Clinical Operations on 06/05/15 to include: completing the information in the pest control log book; notification of Maintenance or Administrator of extreme pest situations and notifying the department head of the issue. The staff education was provided by the Clinical Educator, DON, Administrator, and ADON to all staff. The education was initiated on 06/05/15 for all departments using a staff roster of employees. One hundred fifty one (151) employees were educated. There were twenty (20) employees that required telephonic education. The education was completed on 06/09/15. One employee remained on Family Medical Leave Act (FMLA) and will receive the education before starting work. The education consisted of reviewing the employees responsibility to provide written communication when a pest issue is identified. 4. The current procedures for pest control were reviewed by the Administrator, Maintenance Director, Pest Control Service Technician, Pest Control Services Manager and President of the Pest Services on 06/05/15 with no changes made. 5. An interim Quality Assessment and Assurance meeting was held on 06/08/15 to review the Center's Allegation of Compliance and interventions related to citing Immediate Jeopardy and the interventions implemented. The Administrator formulated the tracking tool on 06/05/15 for the weekly exterior/interior inspections completed by the Maintenance Director, which were also implemented on 06/05/15 and the Administrator provided the education on completing the audit tools on 06/05/15. The interim QA&A meeting held on 06/08/15 was attended by the Medical Director, Administrator, DON, Maintenance Director, representatives of Housekeeping, Social Services and Dietary. Education materials related to pest control logs were reviewed. The plan was approved by the committee. During the monthly QA&A meetings attended by the Medical Director, the members will be reviewing the pest control services monthly reports. The Administrator will review the overview assessment of the pest control log books to help identify any trends or patterns. If trends or patterns are identified additional interventions will be included in the QAPI minutes with follow up by members as needed. The State Survey Agency (SSA) verified the removal of Immediate Jeopardy on 06/10/15 prior to exit as follows: 1. Observation of the exterior of the facility, on 06/17/15 at 4:00 PM, with the Maintenance Director and the Administrator revealed potential rodent entry points had been repaired as outlined on the document, Summary of Building Inspection Conducted 06/05/15. Observation of the interior of the facility, on 06/17/15 at 4:30 PM, revealed no active signs of pests/rodents. Review of the Summary of Building Inspection Conducted 06/05/15, revealed an inspection was conducted of the interior and exterior of the facility for the purpose of determining if there were any active signs of pest issues. Review of the document revealed a number of potential rodent entry points were located on the exterior of the building and the document listed those entry points and how those were addressed. The document further revealed the inspection was completed on 06/05/15 and repairs were completed on 06/07/15. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Manager, on 06/17/15 at 4:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Review of an Interior Rounds Checklist form and an Exterior Rounds Checklist form, each dated 06/05/15, revealed they had been completed and signed by the Maintenance Department Director and the Administrator. Observation of the exterior of the building, on 06/17/15 at 4:00 PM, revealed new door sweeps had been installed on the loading dock doors, holes outside the break room had been filled with concrete and two old plumbing lines had been filled with pipe. Observation of the interior of the building, on 06/17/15 at 4:30 PM, revealed a hole had been filled in the dishroom, the 1C elevator room had a hole filled, the outside break room had a hole filled, a hole was filled in room [ROOM NUMBER], door sweeps were installed on two (2) utility room doors, and a new door sweep was installed at the employee entrance as alleged. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he had completed the weekly rounds monitoring forms on 06/05/15 and will continue the weekly monitoring rounds to include visual checks of interior mechanical, utility, supply rooms for potential issues and implementing interventions. He stated the results of the weekly rounds would be reviewed during the monthly Quality Assurance Performance Improvement (QAPI) meeting. 2. Review of documents titled Pest Control Questionnaire (undated) and resident census lists indicating residents' answers to the questions with a signature (when possible) revealed all interviewable residents were asked about concerns with pests. Review of Departmental Nursing Notes revealed all residents were either assessed or interviewed regarding any signs or symptoms of health problems associated with pests or uncleanliness in the facility. Interview with Resident #4, on 06/18/15 at 8:00 AM, Resident #5, on 06/18/15 at 8:20 AM, Resident #7, on 06/18/15 at 8:30 AM, Resident #10, on 06/18/15 at 8:40 AM, Resident #15, on 06/18/15 at 9:00 AM, Resident #16, on 06/18/15 at 9:20 AM, Resident #18, on 06/18/15 at 9:30 AM, Resident #20, on 06/18/15 at 9:30 AM, Resident #27, on 06/18/15 at 10:00 AM, Resident #30, Resident #31, on 06/18/15 at 10:10 AM, Resident #32 on 06/18/15 at 10:25 AM, Unsampled Resident B, on 06/18/15 at 11:00 AM, Unsampled Resident G, on 06/18/15 at 11:12 AM, Unsampled Resident J, 06/18/15 at 11:30 AM, and Unsampled Resident M, on 06/18/15 at 11:45 AM, revealed they had all been interviewed by the Director of Nursing (DON) or one of the two (2) Assistant Directors of Nursing (ADON) regarding pests or possible adverse health consequences from pests. Interview with the DON, on 06/18/15 at 10:48 AM, revealed she had participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with the Assistant ADON #1, on 06/18/15 at 9:41 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with ADON #2, on 06/18/15 at 9:38 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. 3. Review of the In-service Sign-in Sheet, dated 06/05/15, revealed the topic of the in-service was pest control logs-utilization, center leadership notification and notifying the individual department leader, review and follow up of the pest control logs and the education of team members and the review of concerns (staff) may have regarding pest control. Team member/staff education to be completed for all staff members. Review of the document further revealed it was presented by the Director of Clinical Operations and was signed by the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Director of Clinical Operations, on 06/17/15 at 3:20 PM, revealed he had trained the facility leadership to include the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Administrator, on 06/17/15 at 3:00 PM, the Clinical Educator on 06/18/15 at 9:46 AM, the DON, on 06/18/15 at 10:48 AM and the ADON #1, on 06/18/15 at 9:41 AM, and ADON #2 on 06/18/15 at 9:38 AM revealed they had attended the in-service given by Corporation Representative, Director of Clinical Operations. Review of staff In-service Sign-in sheets with comparison to the employee roster dated 06/04/15 through 06/09/15 revealed one hundred fifty-one (151) employees were educated with twenty (20) employees educated by telephone. One employee remained on Family Medical Leave Act (FMLA) and would receive the education before returning to work. The education consisted of reviewing the employee's responsibility to provide written communication when a pest issue was identified. Interview with Licensed Practical Nurse (LPN) #14, on 06/18/15 at 2:00 PM, revealed she had received an in-service on 06/06/15 about putting any pest sightings in the pest activity log. Interview with LPN #7, on 06/18/15 at 2:15 PM, revealed she had been in-serviced about pest control on 06/06/15. Interview with Certified Nursing Assistant (CNA) #3, on 06/18/15 at 2:08 PM, revealed she received an in-service on 06/06/15 about putting any pest sighting in the activity log and to notify her supervisor. Interview with a Receptionist, on 06/18/15 at 1:52 PM, revealed she had received an in-service about reporting any pest sighting on 06/05/15. Interview with the Social Services Director, on 06/18/15 at 9:59 AM, revealed she had been in-serviced on 06/05/15 about the pest control reporting. Interview with CNA #7, on 06/18/15 at 2:05 PM, revealed she had been inserviced on 06/08/15 about how to report pest sightings and to whom to report. Interview with Cook #3, on 06/18/15 at 2:17 PM, revealed he had been inserviced on 06/07/15 about how and to whom to report pest sightings. Interview with CNA #8, on 06/18/15 at 2:20 PM, revealed he had been inserviced on pest sightings in the facility on 06/08/15 regarding responsibility to log any sightings in the pest activity log and report to his supervisor. Interview with Housekeeper #3, on 06/18/15 at 2:25 PM, revealed he had been inserviced on 06/07/15 on pest sightings, where to document those sightings and to notify his supervisor of any sightings. Interview with the Activities Director, on 06/18/15 at 2:26 PM, revealed she had been inserviced on 06/07/15 on reporting of any pest sightings on the pest activity log and to notify her supervisor of any sightings. Interview with LPN #11, on 06/18/15 at 2:45 PM, revealed she had been in-serviced on 06/08/15 regarding reporting any pest sightings and notification of her supervisor if she did. Post survey interview with the DON, on 07/02/15 at 10:39 AM, revealed the staff who was telephonically inserviced on 06/05/15 to 06/08/15 were retrained upon return to work. The staff person on FMLA (CNA #14) was re-inserviced upon return to work. Post survey interviews, on 07/02/15, with CNA #14 at 11:00 AM, CNA #11 at 11:09 AM, CNA #12 at 11:25 AM, CNA #13 at 11:45 AM, and LPN #15 at 11:37 AM, revealed they had all received education over the telephone and could specify the information provided to them. They further stated the Director of Nursing discussed the education with them after they returned to work for their scheduled shifts. 4. Review of the Summary of Pest Control Service Agreement Review revealed the Administrator met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Administrator, on 06/17/15 at 5:07 PM, revealed he met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Maintenance Director, on 06/17/15 at 4:49 PM, revealed he met with the Administrator, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he met with the Administrator, the Maintenance Director, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Services Manager, on 06/17/15 at 4:00 PM; and, the President of the Pest Control Services, on 06/18/15 at 2:38 PM, revealed they met with the Administrator, the Maintenance Director, and the Pest Control Service Technician to review the pest service agreement and no changes were made on 06/05/15. 5. Review of the document, entitled Quality Assurance Review revealed a Quality Assurance Review meeting was held on 06/08/15 for the purpose of discussing the Immediate Jeopardy deficiencies that had been identified in the areas of F469, F490 and F520. Review of the Quality Assurance Review Committee sign-in sheet, dated 06/08/15, revealed it was signed by the Administer, the DON, the Social Services Director, the Maintenance Director, Environmental Services #1, Environmental Services #2, Regional Director of Housekeeping, and the Medical Director. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he reviewed the weekly rounds monitoring forms completed by the Maintenance Director on 06/05/15, he will continue to monitor them and he will take them to the monthly Quality Assurance Review Committee meeting for review. Interview with the Administrator, on 06/18/15 at 5:07 PM; the DON on 06/18/15 at 10:48 AM; the Social Services Director, on 06/18/15 at 10:00 AM; the Maintenance Director, on 06/17/15 at 4:49 PM; Environmental Services #1, on 06/18/15 at 11:00 AM; Environmental Services #2, on 06/18/15 at 11:20 AM; Regional Director of Housekeeping, on 06/18/15 at 11:40 AM; and, the Medical Director, on 06/18/15 at 11:50 AM revealed they had all attended the Quality Assurance Review Committee meeting held on 06/08/15 to discuss the Immediate Jeopardy issues. During the interview with the Administrator, on 06/18/15 at 5:07 PM, he stated he would review the overview assessment of the pest control log books to help identify any trends or patterns. If any trends/patterns were identified additional interventions will be included in the Quality Assurance Review minutes with follow up by members as needed. In addition, the pest control services monthly reports would be reviewed in the monthly Quality Assurance Review Committee meeting.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to identify quality deficiencies and develop and implement appropriate plans of actions by the Quality Assurance (QA) Committee to correct quality deficiencies. The facility's staff and residents had reported pests/rodents for five (5) months prior to the survey with no plans of action in place. Interviews with staff and residents revealed sightings of mice and gnats since 12/24/14; and, as recent as 06/01/15, affecting fourteen (14) of eighty-eight (84) rooms: Unit 2B medication room, clean linen room, soiled utility room and nurse's station; rooms 143, 148, 225, 226, 228, 229, 235, and 249; Unit 1B rooms 125, 126, 127, 128, and 130; and, the Unit 1C medication room, nurses station and the soiled utility room and room [ROOM NUMBER]. In addition, mice and gnats affected eight (8) of thirty-two (32) sampled residents (Resident #2, #5, #6, #12, #16, #28, #30 and #32); and, seventeen (17) of twenty (20) unsampled residents (Unsampled Resident A, B, F, G, H, J, K, L, M, N, O, P, Q, R, S, T and U). Observations, and interviews revealed the kitchen's dry storage room continued to have mice droppings after bait and traps were set in January 2015. Review of the pest control records revealed mice or other pests had been identified in the kitchen, and the laundry back to December 2014. Review of the Pest Technician Service Report, dated 01/06/15, revealed the Pest Technician placed four (4) containers of bait and five (5) glueboard traps in the kitchen area for mice. Resident interviews revealed continued sightings of mice and evidence of mice chewing on bags of chips and doughnuts. Refer to F469 and F490. In addition, the facility had an ongoing loss of housekeeping directors and housekeeping staff for eight (8) months prior to the survey with a decline in housekeeping services. Refer to F253. The facility's failure to have an effective system in place to ensure the QA Committee functioned according to their policy to identify quality deficiencies, develop plans of action, and implement the plans of action placed residents in a situation that has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/15 and was determined to exist on 01/06/15. The facility provided an acceptable Allegation of Compliance (AOC) on 06/11/15 which alleged removal of the Immediate Jeopardy on 06/10/15. The State Survey Agency verified Immediate Jeopardy was removed on 06/10/15, as alleged prior to exit on 06/18/15. The Scope and Severity was lowered to an E while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Quality Assurance and Process Improvement Meeting, dated June 2013, revealed the purpose of the Quality Assurance and Process Improvement meeting (QAPI Committee) was to identify trends and appropriately analyze data from multiple sources to improve processes supporting organizational goals. Observation and interview with staff and residents during the Recertification Survey (06/02/15) revealed the facility's housekeeping services had been declining since December 2014 with the loss of multiple directors and multiple staff over the past five (5) months. In addition, interview and record review revealed pests and rodent sightings and droppings had multiplied with the decline in housekeeping services since December 2014. Interview with the Administrator, on 06/03/15 at 3:00 PM, revealed there had been a great turnover in the laundry/housekeeping department over the past eight (8) months and the building had not been as clean. He stated he had not taken any housekeeping concerns to the QAPI Committee and he probably should have taken them to the committee. However, he stated he audited the Housekeeping Department monthly and the scores were low, but he did not want to share those documents. The Administrator stated he was not aware of pest/rodent problems in the facility, and he did not remember the Pest Technician informing him of mouse sightings or droppings in the kitchen in December 2014. However, interview with the Pest Technician, on 06/03/15 at 2:55 PM, revealed he had spoken to the Administrator in December of 2014 about the problem with rodents. The Pest Technician stated he informed the Administrator about the housekeeping and the uncleanliness of the facility and the impact that would have on getting rid of the pests. The Pest Technician stated this was one of the worst facilities as it related to pests, insects, rodents. However, the Administrator further stated he was not aware unitl a resident reported a concern to him in February of 2015 of a mouse sighting, but he thought that was because the resident was hoarding food in his/her room. He stated the facility had not done anything to clean that resident's room or provide proper storage for food in that resident's room. The Administrator stated he did not request a written or verbal report by the Pest Technician when he came to the facility monthly, but the Maintenance Director got this information. The Administrator stated he had not been notified by the Maintenance Director of any mouse concerns. He stated he had never reviewed the Pest Sightings Logs on the units. Further interview with the Administrator, on 06/03/15 at 3:00 PM, revealed he had a Maintenance Director and a Maintenance Assistant to care for the building and he was unaware of any maintenance concerns regarding the two (2) maintenance staff being unable to keep up with building repairs. He stated a Corporate Regional Director of Maintenance came to the building and inspected it on 03/25/15. The Corporate Regional Director of Maintenance gave the Administrator a written report; however, the Administrator was not willing to share that report. The Administrator stated the preventive maintenance computer program at the facility did not address maintenance issues of gouged plaster walls, painting repairs needed or splintered handrails. He stated those issues should have been identified and taken to the QA Committee. The State Survey Agency (SSA) verified the removal of Immediate Jeopardy on 06/10/15 prior to exit as follows: 1. Observation of the exterior of the facility, on 06/17/15 at 4:00 PM, with the Maintenance Director and the Administrator revealed potential rodent entry points had been repaired as outlined on the document, Summary of Building Inspection Conducted 06/05/15. Observation of the interior of the facility, on 06/17/15 at 4:30 PM, revealed no active signs of pests/rodents. Review of the Summary of Building Inspection Conducted 06/05/15, revealed an inspection was conducted of the interior and exterior of the facility for the purpose of determining if there were any active signs of pest issues. Review of the document revealed a number of potential rodent entry points were located on the exterior of the building and the document listed those entry points and how those were addressed. The document further revealed the inspection was completed on 06/05/15 and repairs were completed on 06/07/15. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Manager, on 06/17/15 at 4:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Review of an Interior Rounds Checklist form and an Exterior Rounds Checklist form, each dated 06/05/15, revealed they had been completed and signed by the Maintenance Department Director and the Administrator. Observation of the exterior of the building, on 06/17/15 at 4:00 PM, revealed new door sweeps had been installed on the loading dock doors, holes outside the break room had been filled with concrete and two old plumbing lines had been filled with pipe. Observation of the interior of the building, on 06/17/15 at 4:30 PM, revealed a hole had been filled in the dishroom, the 1C elevator room had a hole filled, the outside break room had a hole filled, a hole was filled in room [ROOM NUMBER], door sweeps were installed on two (2) utility room doors, and a new door sweep was installed at the employee entrance as alleged. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he had completed the weekly rounds monitoring forms on 06/05/15 and will continue the weekly monitoring rounds to include visual checks of interior mechanical, utility, supply rooms for potential issues and implementing interventions. He stated the results of the weekly rounds would be reviewed during the monthly Quality Assurance Performance Improvement (QAPI) meeting. 2. Review of documents titled Pest Control Questionnaire (undated) and resident census lists indicating residents' answers to the questions with a signature (when possible) revealed all interviewable residents were asked about concerns with pests. Review of Departmental Nursing Notes revealed all residents were either assessed or interviewed regarding any signs or symptoms of health problems associated with pests or uncleanliness in the facility. Interview with Resident #4, on 06/18/15 at 8:00 AM, Resident #5, on 06/18/15 at 8:20 AM, Resident #7, on 06/18/15 at 8:30 AM, Resident #10, on 06/18/15 at 8:40 AM, Resident #15, on 06/18/15 at 9:00 AM, Resident #16, on 06/18/15 at 9:20 AM, Resident #18, on 06/18/15 at 9:30 AM, Resident #20, on 06/18/15 at 9:30 AM, Resident #27, on 06/18/15 at 10:00 AM, Resident #30, Resident #31, on 06/18/15 at 10:10 AM, Resident #32 on 06/18/15 at 10:25 AM, Unsampled Resident B, on 06/18/15 at 11:00 AM, Unsampled Resident G, on 06/18/15 at 11:12 AM, Unsampled Resident J, 06/18/15 at 11:30 AM, and Unsampled Resident M, on 06/18/15 at 11:45 AM, revealed they had all been interviewed by the Director of Nursing (DON) or one of the two (2) Assistant Directors of Nursing (ADON) regarding pests or possible adverse health consequences from pests. Interview with the DON, on 06/18/15 at 10:48 AM, revealed she had participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with the Assistant ADON #1, on 06/18/15 at 9:41 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with ADON #2, on 06/18/15 at 9:38 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. 3. Review of the In-service Sign-in Sheet, dated 06/05/15, revealed the topic of the in-service was pest control logs-utilization, center leadership notification and notifying the individual department leader, review and follow up of the pest control logs and the education of team members and the review of concerns (staff) may have regarding pest control. Team member/staff education to be completed for all staff members. Review of the document further revealed it was presented by the Director of Clinical Operations and was signed by the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Director of Clinical Operations, on 06/17/15 at 3:20 PM, revealed he had trained the facility leadership to include the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Administrator, on 06/17/15 at 3:00 PM, the Clinical Educator on 06/18/15 at 9:46 AM, the DON, on 06/18/15 at 10:48 AM and the ADON #1, on 06/18/15 at 9:41 AM, and ADON #2 on 06/18/15 at 9:38 AM revealed they had attended the in-service given by Corporation Representative, Director of Clinical Operations. Review of staff In-service Sign-in sheets with comparison to the employee roster dated 06/04/15 through 06/09/15 revealed one hundred fifty-one (151) employees were educated with twenty (20) employees educated by telephone. One employee remained on Family Medical Leave Act (FMLA) and would receive the education before returning to work. The education consisted of reviewing the employee's responsibility to provide written communication when a pest issue was identified. Interview with Licensed Practical Nurse (LPN) #14, on 06/18/15 at 2:00 PM, revealed she had received an in-service on 06/06/15 about putting any pest sightings in the pest activity log. Interview with LPN #7, on 06/18/15 at 2:15 PM, revealed she had been in-serviced about pest control on 06/06/15. Interview with Certified Nursing Assistant (CNA) #3, on 06/18/15 at 2:08 PM, revealed she received an in-service on 06/06/15 about putting any pest sighting in the activity log and to notify her supervisor. Interview with a Receptionist, on 06/18/15 at 1:52 PM, revealed she had received an in-service about reporting any pest sighting on 06/05/15. Interview with the Social Services Director, on 06/18/15 at 9:59 AM, revealed she had been in-serviced on 06/05/15 about the pest control reporting. Interview with CNA #7, on 06/18/15 at 2:05 PM, revealed she had been inserviced on 06/08/15 about how to report pest sightings and to whom to report. Interview with Cook #3, on 06/18/15 at 2:17 PM, revealed he had been inserviced on 06/07/15 about how and to whom to report pest sightings. Interview with CNA #8, on 06/18/15 at 2:20 PM, revealed he had been inserviced on pest sightings in the facility on 06/08/15 regarding responsibility to log any sightings in the pest activity log and report to his supervisor. Interview with Housekeeper #3, on 06/18/15 at 2:25 PM, revealed he had been inserviced on 06/07/15 on pest sightings, where to document those sightings and to notify his supervisor of any sightings. Interview with the Activities Director, on 06/18/15 at 2:26 PM, revealed she had been inserviced on 06/07/15 on reporting of any pest sightings on the pest activity log and to notify her supervisor of any sightings. Interview with LPN #11, on 06/18/15 at 2:45 PM, revealed she had been in-serviced on 06/08/15 regarding reporting any pest sightings and notification of her supervisor if she did. Post survey interview with the DON, on 07/02/15 at 10:39 AM, revealed the staff who was telephonically inserviced on 06/05/15 to 06/08/15 were retrained upon return to work. The staff person on FMLA (CNA #14) was re-inserviced upon return to work. Post survey interviews, on 07/02/15, with CNA #14 at 11:00 AM, CNA #11 at 11:09 AM, CNA #12 at 11:25 AM, CNA #13 at 11:45 AM, and LPN #15 at 11:37 AM, revealed they had all received education over the telephone and could specify the information provided to them. They further stated the Director of Nursing discussed the education with them after they returned to work for their scheduled shifts. 4. Review of the Summary of Pest Control Service Agreement Review revealed the Administrator met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Administrator, on 06/17/15 at 5:07 PM, revealed he met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Maintenance Director, on 06/17/15 at 4:49 PM, revealed he met with the Administrator, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he met with the Administrator, the Maintenance Director, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Services Manager, on 06/17/15 at 4:00 PM; and, the President of the Pest Control Services, on 06/18/15 at 2:38 PM, revealed they met with the Administrator, the Maintenance Director, and the Pest Control Service Technician to review the pest service agreement and no changes were made on 06/05/15. 5. Review of the document, entitled Quality Assurance Review revealed a Quality Assurance Review meeting was held on 06/08/15 for the purpose of discussing the Immediate Jeopardy deficiencies that had been identified in the areas of F469, F490 and F520. Review of the Quality Assurance Review Committee sign-in sheet, dated 06/08/15, revealed it was signed by the Administer, the DON, the Social Services Director, the Maintenance Director, Environmental Services #1, Environmental Services #2, Regional Director of Housekeeping, and the Medical Director. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he reviewed the weekly rounds monitoring forms completed by the Maintenance Director on 06/05/15, he will continue to monitor them and he will take them to the monthly Quality Assurance Review Committee meeting for review. Interview with the Administrator, on 06/18/15 at 5:07 PM; the DON on 06/18/15 at 10:48 AM; the Social Services Director, on 06/18/15 at 10:00 AM; the Maintenance Director, on 06/17/15 at 4:49 PM; Environmental Services #1, on 06/18/15 at 11:00 AM; Environmental Services #2, on 06/18/15 at 11:20 AM; Regional Director of Housekeeping, on 06/18/15 at 11:40 AM; and, the Medical Director, on 06/18/15 at 11:50 AM revealed they had all attended the Quality Assurance Review Committee meeting held on 06/08/15 to discuss the Immediate Jeopardy issues. During the interview with the Administrator, on 06/18/15 at 5:07 PM, he stated he would review the overview assessment of the pest control log books to help identify any trends or patterns. If any trends/patterns were identified additional interventions will be included in the Quality Assurance Review minutes with follow up by members as needed. In addition, the pest control services monthly reports would be reviewed in the monthly Quality Assurance Review Committee meeting.

Based on observation, interview, review of the Centers' for Disease Control and Prevention document and facility policy, it was determined the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to ensure the kitchen was free of pest and mice droppings on the floor of the dry storage area; and, failed to ensure three (3) of three (3) facial beards were restrained when preparing food on the tray line. Observations on 06/02/15 and 06/03/15 revealed the dry food storage room had food, debris and mice droppings on the floor (as identified by the Pest Control Technician). Review of the Pest Technician Service Report, dated 01/06/15, revealed the Pest Technician identified mice in the kitchen and he placed four (4) RTU (container to deliver bait to kill mice) baits down and five (5) glueboard traps down in the kitchen area for mice. Although the Pest Control had been in the facility monthly after 01/06/15, the Pest Technician stated this was one of the worst facilities as it related to pests, insects, rodents. Review of pest control records dated 02/03/15, 03/03/15, 04/08/15 and 05/05/15 revealed mice or other pests continued to be identified in the kitchen. Resident interview revealed evidence of mice chewing on bags of chips that were served on the meal tray. The facility's failure to have an effective system in place to ensure the facility kitchen was free of pest has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 06/04/15 and determined to exist on 01/06/15. The facility provided an acceptable Allegation of Compliance (AOC) on 06/11/15 which alleged removal of the Immediate Jeopardy on 06/10/15. The State Survey Agency verified Immediate Jeopardy was removed on 06/10/15, as alleged prior to exit on 06/18/15. The Scope and Severity was lowered to a D while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: 1. Review of the Department Goals Policy, effective 08/01/12, revealed acceptable standards of sanitation would be maintained during all stages of food delivery, storage, preparation and service. Review of the facility's policy, Pest Control, dated 09/01/14, revealed the facility was to maintain an effective pest control program. In addition, an on-going pest control program was to be maintained to ensure the building was kept free of insects and rodents with assistance by maintenance services, as necessary. Review of the pest control contract, with CarePro Solutions, dated 02/03/14, revealed the company would provide services as needed to effectively control cockroaches, ants, rodents, or other insect infestations. Further review of the pest control contract revealed the company's treatment process would depend on feedback from the Pest Sightings Postings (documented on Pest Sighting Logs kept at the nurses' stations) or from a primary contact person. Review of the Cleaning Schedule, for 06/01/15, revealed the dry storage was not listed as an area to be cleaned daily. Review of the Centers' for Disease Control and Prevention Integrated Pest Management: Conducting Urban Rodent Surveys, dated 2006, revealed a premise was considered infested as long as any active rodent signs existed. Rats and mice could contaminate food, damage structures, and carry diseases that threatened the health and quality of life, and they could cause injury (potential for bites) and death. In addition, whenever rodents find suitable food, water and harborage they become established and reproduce rapidly in premises with poor environmental quality. Review of the Pest Technician Service Report, dated 01/06/15, revealed the Pest Technician placed four (4) RTU (container to deliver bait to kill mice) baits down and five (5) glueboard traps down in the kitchen area for mice. Review of the Pest Technician Service Report, dated 02/03/15, revealed the Pest Technician placed two (2) Contrac Bait Blox and two (2) glueboard traps down in the kitchen area for mice. Review of the Pest Technician Service Report, dated 03/03/15, revealed the Pest Technician placed four (4) Contrac Bait Blox and eleven (11) glueboard traps in the kitchen area for mice. Review of the Pest Technician Service Report, dated 04/08/15, revealed the Pest Technician placed one (1) Contrac Bait Blox and five (5) glueboard traps in the kitchen area for mice. Review of the Pest Technician Service Report, dated 05/05/15, revealed the Pest Technician placed two (2) Contrac Bait Blox and three (3) glueboard traps in the kitchen area for mice. Observation of the dry storage area in the kitchen during initial tour, on 06/02/15 at 8:25 AM, revealed debris and black and white pellets on the floor in the corner of the dry storage area which appeared to be small black mice droppings. Observation of the dry storage area in the kitchen and interview with the Pest Technician, on 06/03/15 at 2:55 PM, revealed the black pellets on the floor were mice droppings. The Technician stated he could not tell how old the droppings were; however, he had placed a mouse trap in the dry storage area about two (2) months ago. The Technician stated the mouse trap was working because he observed additional blue mouse droppings on the dry storage floor. The Technician stated that he did not see any holes in the kitchen, but the mice could come in from additional sources. Further interview with the Technician revealed the mice could bite through anything except metal. Interview with Dietary Aid #1, on 06/04/15 at 4:25 PM, revealed he had cleaned the dry storage area before and saw a mouse on Sunday or Monday morning before the survey started. He stated he had swept up rice in the dry storage room. Interview with Cook #1, on 06/04/15 at 4:04 PM, revealed there was no one responsible to clean the dry storage area at this time. She stated there was a dietary aid who had been gone for three (3) weeks to a month who would complete tasks such as stocking food items, cleaning the refrigerators, stock room and dry storage area. Cook #1 stated the dietary staff had been working short. After reviewing the cleaning schedule, Cook #1 stated the schedule needed to be more detailed to reflect the cleaning of the dry storage area. She stated she wanted to prevent mice from coming into the kitchen because they were nasty and no one wanted to eat mice poop. Cook #1 stated mice were dirty and she was scared of them. Interview with Cook #3, on 06/04/15 at 3:55 PM, revealed the person who was responsible to wash the dishes was responsible for cleaning the dry storage area. Cook #3 stated the dry storage area was a dirty area and she had seen mice as late as yesterday (06/03/15). She stated she had seen the mice mess with the rice in the dry storage area. Cook #3 stated she did not want rodents in the kitchen area because they could cause diseases. Interview with Dietary Aid #1, on 06/04/15 at 4:25 PM, revealed he had cleaned the dry storage area before and saw a mouse on Sunday 05/31/15 or Monday 06/01/15. Interview with the Dietary Manager, on 06/04/15 at 4:40 PM, revealed he had started noticing the mice back in December of 2014 and told the Administrator, Maintenance and the Pest Technician. The Dietary Manager stated there had been problems with mice about two (2) months ago getting into the bread supply. He further stated he was not aware the mice were getting in the dry storage rice supply. The Dietary Manager indicated he did not know what mouse droppings looked like so he did not know the mice were in the dry storage area. He stated he was not monitoring the Dry Storage area to ensure it was being cleaned by staff nor was the Dry Storage area on the cleaning schedule to be cleaned. The Dietary Manager stated he did not want mice in the kitchen because they carry diseases and could make the residents sick. The Dietary Manager stated he thought the mice were gone as of April 2015. However, interview with Dietary Aide #1 and Cook #3 on 06/04/15 revealed they had recently seen mice. Further interview with the Dietary Manger revealed four (4) months was not a long time to have to deal with mice. Further interview with the Pest Technician, on 06/03/15 at 2:55 PM, revealed he had spoken to the Administrator in December of 2014 about the problem with rodents. The Pest Technician stated he informed the Administrator about the housekeeping and the uncleanliness of the facility and the impact that would have on getting rid of the pests. The Pest Technician stated this was one of the worst facilities as it related to pests, insects, rodents. 2. Review of the Safety and Sanitation Policy, effective 08/01/12, revealed all dietary services personnel would wear hair nets or caps, or utilize appropriate hair restraint as designated by state law. Observation during the initial tour of the kitchen, during the breakfast meal service, on 06/02/15 at 8:20 AM, revealed Cook #2 and two (2) Dietary Aids were preparing breakfast trays, all three (3) workers were observed to have facial beards that were not restrained. Observation of the lunch meal, on 06/05/15 at 11:25 AM, revealed Cook #2 serving lunch meals from the tray line with a facial beard with no restraint. Interview with Dietary Aid #1, on 06/04/15 at 4:25 PM, revealed he was taught to wear hair restraints to prevent loose hair from falling in drinks and food. Interview with Cook #3, on 06/04/15 at 3:55 PM, revealed men were supposed to wear beard restraints to keep hair from getting into food. Cook #3 stated there were enough of the beard restraints and she had to ask the male dietary staff to wear them. Interview with the Dietary Manager, on 06/04/15 at 4:40 PM, revealed he educated the dietary staff to wear beard restraints. The Dietary Manager stated the staff wore the beard restraint just in case loose hair was to fall in the food. The State Survey Agency (SSA) verified the removal of Immediate Jeopardy on 06/10/15 prior to exit as follows: 1. Observation of the exterior of the facility, on 06/17/15 at 4:00 PM, with the Maintenance Director and the Administrator revealed potential rodent entry points had been repaired as outlined on the document, Summary of Building Inspection Conducted 06/05/15. Observation of the interior of the facility, on 06/17/15 at 4:30 PM, revealed no active signs of pests/rodents. Review of the Summary of Building Inspection Conducted 06/05/15, revealed an inspection was conducted of the interior and exterior of the facility for the purpose of determining if there were any active signs of pest issues. Review of the document revealed a number of potential rodent entry points were located on the exterior of the building and the document listed those entry points and how those were addressed. The document further revealed the inspection was completed on 06/05/15 and repairs were completed on 06/07/15. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Interview with the Pest Control Service Manager, on 06/17/15 at 4:00 PM, revealed he participated in the inspection of the interior and exterior of the facility on 06/05/15 at 4:00 PM. Review of an Interior Rounds Checklist form and an Exterior Rounds Checklist form, each dated 06/05/15, revealed they had been completed and signed by the Maintenance Department Director and the Administrator. Observation of the exterior of the building, on 06/17/15 at 4:00 PM, revealed new door sweeps had been installed on the loading dock doors, holes outside the break room had been filled with concrete and two old plumbing lines had been filled with pipe. Observation of the interior of the building, on 06/17/15 at 4:30 PM, revealed a hole had been filled in the dishroom, the 1C elevator room had a hole filled, the outside break room had a hole filled, a hole was filled in room #126, door sweeps were installed on two (2) utility room doors, and a new door sweep was installed at the employee entrance as alleged. Interview with the Maintenance Supervisor, on 06/17/15 at 4:49 PM, revealed he had completed the weekly rounds monitoring forms on 06/05/15 and will continue the weekly monitoring rounds to include visual checks of interior mechanical, utility, supply rooms for potential issues and implementing interventions. He stated the results of the weekly rounds would be reviewed during the monthly Quality Assurance Performance Improvement (QAPI) meeting. 2. Review of documents titled Pest Control Questionnaire (undated) and resident census lists indicating residents' answers to the questions with a signature (when possible) revealed all interviewable residents were asked about concerns with pests. Review of Departmental Nursing Notes revealed all residents were either assessed or interviewed regarding any signs or symptoms of health problems associated with pests or uncleanliness in the facility. Interview with Resident #4, on 06/18/15 at 8:00 AM, Resident #5, on 06/18/15 at 8:20 AM, Resident #7, on 06/18/15 at 8:30 AM, Resident #10, on 06/18/15 at 8:40 AM, Resident #15, on 06/18/15 at 9:00 AM, Resident #16, on 06/18/15 at 9:20 AM, Resident #18, on 06/18/15 at 9:30 AM, Resident #20, on 06/18/15 at 9:30 AM, Resident #27, on 06/18/15 at 10:00 AM, Resident #30, Resident #31, on 06/18/15 at 10:10 AM, Resident #32 on 06/18/15 at 10:25 AM, Unsampled Resident B, on 06/18/15 at 11:00 AM, Unsampled Resident G, on 06/18/15 at 11:12 AM, Unsampled Resident J, 06/18/15 at 11:30 AM, and Unsampled Resident M, on 06/18/15 at 11:45 AM, revealed they had all been interviewed by the Director of Nursing (DON) or one of the two (2) Assistant Directors of Nursing (ADON) regarding pests or possible adverse health consequences from pests. Interview with the DON, on 06/18/15 at 10:48 AM, revealed she had participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with the Assistant ADON #1, on 06/18/15 at 9:41 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. Interview with ADON #2, on 06/18/15 at 9:38 AM, revealed she participated in resident interviews and assessments regarding pests or possible adverse health consequences from pests. 3. Review of the In-service Sign-in Sheet, dated 06/05/15, revealed the topic of the in-service was pest control logs-utilization, center leadership notification and notifying the individual department leader, review and follow up of the pest control logs and the education of team members and the review of concerns (staff) may have regarding pest control. Team member/staff education to be completed for all staff members. Review of the document further revealed it was presented by the Director of Clinical Operations and was signed by the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Director of Clinical Operations, on 06/17/15 at 3:20 PM, revealed he had trained the facility leadership to include the Administrator, the Clinical Educator, the DON and the ADON #1 and #2. Interview with the Administrator, on 06/17/15 at 3:00 PM, the Clinical Educator on 06/18/15 at 9:46 AM, the DON, on 06/18/15 at 10:48 AM and the ADON #1, on 06/18/15 at 9:41 AM, and ADON #2 on 06/18/15 at 9:38 AM revealed they had attended the in-service given by Corporation Representative, Director of Clinical Operations. Review of staff In-service Sign-in sheets with comparison to the employee roster dated 06/04/15 through 06/09/15 revealed one hundred fifty-one (151) employees were educated with twenty (20) employees educated by telephone. One employee remained on Family Medical Leave Act (FMLA) and would receive the education before returning to work. The education consisted of reviewing the employee's responsibility to provide written communication when a pest issue was identified. Interview with Licensed Practical Nurse (LPN) #14, on 06/18/15 at 2:00 PM, revealed she had received an in-service on 06/06/15 about putting any pest sightings in the pest activity log. Interview with LPN #7, on 06/18/15 at 2:15 PM, revealed she had been in-serviced about pest control on 06/06/15. Interview with Certified Nursing Assistant (CNA) #3, on 06/18/15 at 2:08 PM, revealed she received an in-service on 06/06/15 about putting any pest sighting in the activity log and to notify her supervisor. Interview with a Receptionist, on 06/18/15 at 1:52 PM, revealed she had received an in-service about reporting any pest sighting on 06/05/15. Interview with the Social Services Director, on 06/18/15 at 9:59 AM, revealed she had been in-serviced on 06/05/15 about the pest control reporting. Interview with CNA #7, on 06/18/15 at 2:05 PM, revealed she had been inserviced on 06/08/15 about how to report pest sightings and to whom to report. Interview with Cook #3, on 06/18/15 at 2:17 PM, revealed he had been inserviced on 06/07/15 about how and to whom to report pest sightings. Interview with CNA #8, on 06/18/15 at 2:20 PM, revealed he had been inserviced on pest sightings in the facility on 06/08/15 regarding responsibility to log any sightings in the pest activity log and report to his supervisor. Interview with Housekeeper #3, on 06/18/15 at 2:25 PM, revealed he had been inserviced on 06/07/15 on pest sightings, where to document those sightings and to notify his supervisor of any sightings. Interview with the Activities Director, on 06/18/15 at 2:26 PM, revealed she had been inserviced on 06/07/15 on reporting of any pest sightings on the pest activity log and to notify her supervisor of any sightings. Interview with LPN #11, on 06/18/15 at 2:45 PM, revealed she had been in-serviced on 06/08/15 regarding reporting any pest sightings and notification of her supervisor if she did. Post survey interview with the DON, on 07/02/15 at 10:39 AM, revealed the staff who was telephonically inserviced on 06/05/15 to 06/08/15 were retrained upon return to work. The staff person on FMLA (CNA #14) was re-inserviced upon return to work. Post survey interviews, on 07/02/15, with CNA #14 at 11:00 AM, CNA #11 at 11:09 AM, CNA #12 at 11:25 AM, CNA #13 at 11:45 AM, and LPN #15 at 11:37 AM, revealed they had all received education over the telephone and could specify the information provided to them. They further stated the Director of Nursing discussed the education with them after they returned to work for their scheduled shifts. 4. Review of the Summary of Pest Control Service Agreement Review revealed the Administrator met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Administrator, on 06/17/15 at 5:07 PM, revealed he met with the Maintenance Director, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Maintenance Director, on 06/17/15 at 4:49 PM, revealed he met with the Administrator, the Pest Control Service Technician, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Service Technician, on 06/17/15 at 5:15 PM, revealed he met with the Administrator, the Maintenance Director, the Pest Control Services Manager and the President of the Pest Services to review the pest service agreement and no changes were made on 06/05/15. Interview with the Pest Control Services Manager, on 06/17/15 at 4:00 PM; and, the President of the Pest Control Services, on 06/18/15 at 2:38 PM, revealed they met with the Administrator, the Maintenance Director, and the Pest Control Service Technician to review the pest service agreement and no changes were made on 06/05/15. 5. Review of the document, entitled Quality Assurance Review revealed a Quality Assurance Review meeting was held on 06/08/15 for the purpose of discussing the Immediate Jeopardy deficiencies that had been identified in the areas of F469, F490 and F520. Review of the Quality Assurance Review Committee sign-in sheet, dated 06/08/15, revealed it was signed by the Administer, the DON, the Social Services Director, the Maintenance Director, Environmental Services #1, Environmental Services #2, Regional Director of Housekeeping, and the Medical Director. Interview with the Administrator, on 06/17/15 at 3:00 PM, revealed he reviewed the weekly rounds monitoring forms completed by the Maintenance Director on 06/05/15, he will continue to monitor them and he will take them to the monthly Quality Assurance Review Committee meeting for review. Interview with the Administrator, on 06/18/15 at 5:07 PM; the DON on 06/18/15 at 10:48 AM; the Social Services Director, on 06/18/15 at 10:00 AM; the Maintenance Director, on 06/17/15 at 4:49 PM; Environmental Services #1, on 06/18/15 at 11:00 AM; Environmental Services #2, on 06/18/15 at 11:20 AM; Regional Director of Housekeeping, on 06/18/15 at 11:40 AM; and, the Medical Director, on 06/18/15 at 11:50 AM revealed they had all attended the Quality Assurance Review Committee meeting held on 06/08/15 to discuss the Immediate Jeopardy issues. During the interview with the Administrator, on 06/18/15 at 5:07 PM, he stated he would review the overview assessment of the pest control log books to help identify any trends or patterns. If any trends/patterns were identified additional interventions will be included in the Quality Assurance Review minutes with follow up by members as needed. In addition, the pest control services monthly reports would be reviewed in the monthly Quality Assurance Review Committee meeting.

Based on observation, interview, record review, review of the facility's Minimum Data Set Coordinator position description, the facility's investigation and facility policies: Elopement Prevention; Resident Safety Checks; and Resident Individual Supervision, it was determined the facility failed to in-service and implement an intervention for elopement prevention on the comprehensive care plan for one (1) of seven (7) sampled residents, Resident #1. The intervention of "Know Whereabouts At All Times Q (every) Day" was not in-serviced to all staff caring for Resident #1, it was not listed on the Certified Nurse Aide (CNA) assignment sheet, and it was not implemented on the date of Resident #1's elopement from the 'secure' (locked) unit and the facility's property. The facility's failure to in-service and implement the comprehensive plan of care placed residents at risk for elopement which was likely to cause serious injury, harm, impairment, or death. An acceptable Allegation of Compliance (AOC) was received on 11/16/11 and the Immediate Jeopardy was removed on 11/17/11 which lowered the scope and severity to a "E" for CFR 483.20 Resident Assessment (F282), while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility policy Elopement Prevention, (undated), revealed the resident's Plan of Care should include possible causes for wandering and development of individualized, interdisciplinary interventions and goals to reduce wandering. The policy indicated these interventions should be communicated to the care giving team, the interventions should be evaluated, and the effectiveness of the interventions documented. The policy also indicated all staff should be in-serviced to assure awareness of the resident's care plan system and what steps should be taken to prevent or interrupt elopement attempts. Review of the facility policy Resident Individual Supervision (one to one supervision), (undated), revealed the decision to place a resident on one to one supervision may be determined by nursing administration, the Administrator and/or attending physician and/or the Medical Director. Review of the facility policy Resident Safety Checks (For Increased Supervision), (undated), revealed POLICY: It is the policy of this facility to initiate and perform with documentation Q15 (every 15 minute), Q30, and Q1 hour etc. checks when deemed necessary for an individual resident for safety and/or behavior reasons. PROCEDURE: The checks may be instituted for any reason that might jeopardize the safety of any resident. The checks may be instituted by nursing or administrative judgement or by physician orders. Review of the facility position description for the Minimum Data Set (MDS) Coordinator (undated) revealed this staff was to: Assist the Director of Nursing Services and relevant directors/ supervisors of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident's care plan and that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Interview with the Director of Nursing (DON), on 11/10/11 at 5:00 PM, revealed training of the comprehensive care plan interventions was the responsibility of any member of the interdisciplinary care planning team to include the MDS Coordinators and the unit manger of each unit. 1. Review of Resident #1's record revealed the facility admitted the resident on 03/24/11 with [DIAGNOSES REDACTED]. In addition, the facility assessed the resident with the ability to ambulate independently, and as requiring minimal assistance with bathing and dressing. Resident #1's record revealed nursing documentation of his/her exit-seeking behaviors on 03/24/11, 03/25/11, 03/28/11, 03/31/11, 04/03/11 and 08/20/11. Review of the comprehensive care plan for Resident #1 revealed a focus which stated the resident was at risk of elopement with the following interventions to prevent elopement: 1."Know Whereabouts At All Times Q (every) Day: and 2. Resident #1 to live on the facility's 'secured unit' (locked). Review of the facility's investigation into the elopement of Resident #1 revealed Resident #1 left the 'secure' (locked) unit and the facility unsupervised and without staff knowledge on 11/02/11. Review of the investigation also revealed Resident #1 was returned to the facility unharmed after having been found by a citizen several blocks from the facility sitting on the ground near a busy four-lane street. Interview with CNA #2 (the 'secure' (locked) unit hall monitor on 11/02/22), on 11/09/11 at 1:50 PM, revealed she did not hear an exit door alarm on the evening of Resident #1's elopement. CNA #2 also revealed she was unaware Resident #1 had eloped until she was asked to participate in a 'head count' of residents at about 8:00 PM on 11/02/11. Interview with LPN #4 (charge nurse for the 'secure' unit on the evening of 11/02/11), on 11/09/11 at 3:55 PM, revealed Resident #1 was at the nursing station about 6:00 PM on 11/02/11 to request to use a phone. She stated Resident #1 left the station toward his/her room about five (5) minutes later and LPN #4 did not know Resident #1 had left the unit until the nursing supervisor called and asked her to do a head count. Interview with CNA #7 (assigned to Resident #1 on 11/02/11 at time of elopement), on 11/09/11 at 4:28 PM, revealed she did not hear an exit door alarm on the evening of Resident #1's elopement and she was unaware the resident had eloped. CNA #7 stated she thought she had last seen Resident #1 about 6:50 PM on 11/02/11. Interview with Resident #1, on 11/07/11 at 3:00 PM, revealed the resident was alert and pleasantly confused as to his/her location, date or time of day and Resident #1 did not remember having eloped from the unit or the facility; however, further interview with Resident #1, on 11/10/11 at 10:30 AM, revealed the resident did remember an "adventure" of leaving the unit and remembered he/she got tired and sat on the ground to rest. Interview with Certified Nursing Assistant (CNA) #2, on 11/07/11 at 3:00 PM, revealed Resident #1 was on routine supervision which was every two (2) hours as standard practice for CNA's. In addition, she stated the CNA's on the 'secure' unit usually checked on their residents more often than every two hours. Interview with LPN #6, on 11/10/11 at 11:25 AM, revealed she was in charge of the 'secure' unit with four (4) CNAs (to include one {1} hall monitor) for thirty-four residents. She indicated all high risk residents were identified to staff verbally and she made sure she saw all high risk residents often (could not define often) during the shift; however, she stated was not familiar with the care plan intervention that staff was to "Know Whereabouts At All Times Q (every) Day" for Resident #1. Interview with LPN #4, on 11/09/11 at 3:55 PM, indicated she knew Resident #1 was an elopement risk but was unaware of the care plan intervention for Resident #1 to "Know Whereabouts At All Times Q (every) Day". Interview with CNA #2, on 11/09/11 at 1:50 PM, revealed she had not been trained on an intervention for Resident #1 to "Know Whereabouts At All Times Q (every) Day" and in fact was not aware of this intervention. She stated this intervention was not on the CNA assignment sheet nor was any resident listed as high risk for elopement on the CNA assignment sheet. She said she did not know how the intervention could be implemented unless the resident was on one-to-one (1:1) supervision. CNA #2 stated she was aware of some residents who were high risk for elopement either through word-of-mouth from other CNA's or from a verbal nursing report at the beginning of each shift; however, she could not name the residents on the 'secure' unit who were at risk for elopement. Interview with the Minimum Data Set (MDS) Nurse #1, on 11/10/11 at 3:40 PM, revealed he did not know exactly how the intervention of "Know Whereabouts At All Times Q (every) Day" for Resident #1 could be implemented and he could not remember who suggested the intervention for Resident #1's elopement risk. He stated the intent of the intervention was the CNA could identify the where-a-bouts of the resident if asked at random. He stated the comprehensive care plan for each resident was not viewed by each member of the interdisciplinary team during the care plan review meeting and no one in Resident #1's care plan review meeting questioned how the intervention would be implemented. MDS Nurse #1 revealed he was not aware if the CNA's had been trained on the intervention and he also stated the intervention was not implemented at the time Resident #1 eloped from the facility. He indicated it was the responsibility of the nurse unit manager to train the CNA's on care plan interventions and he did not know if these interventions were listed on the CNA assignment sheet. Interview with MDS Nurse #2, on 11/14/11 at 2:40 PM, revealed it was her understanding it was not her responsibility to in-service CNA's on the resident's comprehensive care plan. She stated the intervention "Know Whereabouts At All Times Q (every) Day" was an "unrealistic goal" and she was surprised high risk elopement was not indicated for those residents at risk on the CNA assignment sheet. Interview with LPN #2 Unit Manager, on 11/15/11 at 2:00 PM, revealed she thought it was her responsibility to update the CNA assignment sheets and she had just never put "Know Whereabouts At All Times Q (every) Day" on the CNA assignment sheets. She stated this would be impossible to do unless the resident was on 1:1 supervision. She also stated she did not indicate which residents were high risk for elopement on the CNA care plan because she thought her charge nurses were passing on the information regarding residents at high risk for elopement through the verbal nursing report at the beginning of each shift. Review of the facility investigation and interview with the Director of Nursing (DON) on 11/08/11 at 8:30 AM, who completed the investigation, revealed the facility investigation concluded the root cause of the elopement of Resident #1 was a faulty electrical system resulting in an absence of door alarms and had determined that some of the door alarms were not operational. This faulty electrical system was occurring due to ongoing facility construction. The facility had initiated direct supervision of all of the exit doors after the elopement until all of the doors were checked by the alarm company and assessed as operational on 11/03/11 (no time indicated). After the doors were determined operational on 11/01/11, the facility suspended the direct supervision of the exit doors. While the facility investigation revealed the alarm company was to increase visits to monthly to ensure operation of locked/alarmed exit doors during the construction and the nursing staff was to monitor an electrical relay box hourly to ensure there were no power disruptions to the door alarms there was no documented evidence that the facility identified that staff was not providing supervision of Resident #1 as indicated per the care plan at the time of the elopement. Furthermore there was no evidence that the facility had identified that staff was not knowledgeable and had not been trained to the resident's care plan. Additionally, the facility had not identified that all staff was not aware of all ten residents the facility had identified as an elopement risk on 11/03/11 per the elopement meeting documentation. There was no evidence the facility implemented interventions to address supervision of the residents determined at risk for elopement or effective interventions to prevent elopement recurrence while construction continued at the facility after 11/03/11. Review of the comprehensive plan of care revealed the revised care plan, dated 11/03/11, directed the staff to conduct every 15 minutes checks of Resident #1 and would be reviewed again in 48 hours. Observation of Resident #1, on 11/07/11 at 2:35 PM, revealed the resident walking in the corridor of the 'secure' unit with three (3) other residents in the hallway and one (1) staff interacting verbally with one (1) of the other residents. Observation of the secure unit revealed no staff was present monitoring the exit doors. Additionally, observation of Resident #1, on 11/10/11 at 10:25 AM, revealed the resident resting on a small couch in his/her bedroom with no staff present. Observation of the secure unit at this time revealed no staff was present monitoring the exit doors. Interview with CNA #8, on 11/10/11 at 11:40 AM revealed Resident #1 was on routine supervision at that time which to her meant observing the resident at least every two (2) hours. CNA #8 stated she would observe Resident #1 more often than that; however, could not detail how often. Interview with the Director of Nursing (DON), on 11/08/11 at 8:30 AM, on 11/10/11 at 9:00 AM and at 5:00 PM, revealed she did not know how the intervention "Know Whereabouts At All Times Q (every) Day" would be implemented unless the resident was placed on 1:1 supervision. She stated training of the comprehensive care plan interventions was the responsibility of any member of the interdisciplinary care planning team to include the MDS Coordinators and the unit manager of each unit. She further revealed that while the comprehensive care plan stated Resident #1 was to be monitored by staff every 15 minutes, these every 15 minute checks were discontinued once the alarm company assessed the doors as operational on 11/03/11. The DON stated she had not identified that staff had not provided supervision per the comprehensive care plan and had not identified that staff was unaware of the resident's care plan interventions. She indicated the lack of implementation of the care plan intervention "Know Whereabouts At All Times Q (every) Day" for Resident #1 could have contributed to the resident's elopement. Interview with the Administrator, on 11/10/11 at 5:10 PM, revealed the facility looked at safety issues weekly with the construction company foreman since the start of the facility construction project (July 5) and had a safety committee meeting weekly but this did not prevent an elopement. She stated the facility did not recognize staff was unaware of care plan interventions or any lack of resident supervision. She also stated a lack of supervision could have contributed to the elopement of Resident #1. Review of the Allegation of Compliance dated 11/16/11 and interview with the DON and Administrator, on 11/17/11 at 10:00 AM, revealed the facility took the following immediate actions in response to an elopement: 1. A resident count occurred immediately at 8:10 PM on 11/02/11. Resident #1 was initially placed on every fifteen (15) minute checks on his/her return. Resident #1's Plan of Care was updated on 11/03/11. 2. Exterior doors were checked by the LPN House Supervisor at 8:35 PM on 11/02/11. 3. On 11/2/11 at 8:30 PM until 1:30 AM on 11/03/11, an extensive meeting was held regarding resident safety. It was attended by the facility Administrator, the Maintenance Director, and the Human Resources Director. 4. Resident and facility safety was assessed. Three exit doors were placed on visual supervision from 11/02/11 at 10:30 PM to 11/03/11 at 11:00 AM when the General Alarm technician had assessed and corrected mechanical door alarm failure. All facility exterior doors have been evaluated by the alarm company and deemed secured. 5. All facility residents were re-assessed for elopement potential on 11/03/11. This action was completed by the Social Service Directors. Participating in the assessments were unit managers. Residents found with the potential for elopement were identified, assessments updated and elopement protocols followed to include Elopement Book identifiers and photos. No new elopement risks were identified. 6. All high risk elopement residents are now residing on the secured unit and all residents had been reviewed on 11/03/11 to determine risk for elopement. Care plans and elopement logs were updated as needed. Elopement logs, nurse aide assignment sheets, and care plans were updated as indicated. 7. Every one hour checks was initiated on 11/15/11 by licensed nursing staff on all residents identified as high risk for elopement for the remainder of internal construction of the roof top HVAC vent placement. 8. All high risk for elopement residents are in the Elopement Log on 11/09/11 which was located at each nurses station and at the receptionist's desk. 9. The secure unit will continue with the hall monitor programs. An additional hall monitor was added on 11/15/11 to increase supervision until internal construction is complete. One hall monitor will be located on the east wing the second on the west. 10. Each hall monitor received additional education on 11/16/11 to include supervision, responding to alarms, visualizing/checking the exit doors, and responding to residents trying to exit. 11. All non-high risk for elopement residents had every shift checks initiated on 11/15/11. 12. All staff received training beginning 11/03/11 at 1:00 AM through 11/16/11 at 11:00 PM regarding elopement risk, elopement protocols, code yellow (which indicates an elopement), expected responses, elopement logs and their purpose, and nurse aide assignment sheets which identify those who are high risk for elopement. 13. The gray relay box which indicated power disruption to the exit doors will remain on continual surveillance through out the hours of construction as well as one hour after with documentation of checks initiated on 11/14/11. Record review, on 11/16/11, of all documentation regarding the Allegation of Compliance to include staffing logs, other new or revised documentation tools, staff training records, and revised policies/procedures revealed all had been completed as alleged. Interviews, on 11/17/11, with three (3) CNA's, two (2) LPN's, the 'secure' unit Program Director, one (1) housekeeping staff, and the Maintenance Director all verified staff knowledge of new documentation tools to be utilized regarding resident head counts, how to accomplish those, and who is responsible for those duties. These staff were also knowledgeable regarding addition of a second hall monitor to the 'secure unit' and the position description of same, how to identify and respond to a missing resident and the revisions to policies/procedures related to this identified concern. Immediate Jeopardy was verified to be removed on 11/17/11 which lowered the scope and severity to a "E" at 42 CFR 483.20 Resident Assessment (F282), and while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures.

Based on observation, interview, record review, and review of facility policies: Resident Safety Checks; Resident Individual Supervision Policy; Elopement Defined; and Elopement Prevention, it was determined the facility failed to adequately supervise cognitively impaired individuals with known elopement risk for one (1) of seven (7) sampled residents, Resident #1. The facility failed to follow their policies and procedures related to resident elopement, safety checks and individual supervision. The facility failed to ensure staff was knowledgeable regarding all residents identified as elopement risk and their individualized supervision plans, and the facility failed to ensure all assistive devices used for resident safety were functional and in good repair. The facility identified Resident #1 at risk for elopement. On 11/02/11 staff was unaware Resident #1 eloped from the 'secure' (locked) unit and from the facility without supervision. Resident #1 was returned to the facility unharmed within approximately forty-five (45) minutes by a citizen after being found several blocks from the facility sitting on the ground by a busy four (4) lane street. The facility identified ten (10) residents requiring supervision due to elopement prevention who resided on the secure unit. Additionally, the facility's investigation failed to identify all causal factors of the elopement which prevented the facility from implementing effective interventions to prevent further elopement recurrence. The facility's failure to provide adequate supervision of cognitively impaired individuals with known elopement risk placed residents at risk for elopement which was likely to cause serious injury, harm, impairment, or death. An acceptable Allegation of Compliance (AOC) was received on 11/16/11 and the Immediate Jeopardy was removed on 11/17/11 which lowered the scope and severity to a "E" at 42 CF 483.25 Quality of Care (323), while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility policy Elopement Defined, (undated), revealed elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. The center will maintain a plan to prevent elopement through components that may include, but are not limited to, the following: protected list of names and photographs of those at risk for elopement; regular rounds; structured group activities; environmental modifications; staff supervision and interventions; and resident and family education. Review of the facility policy Elopement Prevention, (undated), revealed the resident's Plan of Care should include possible causes for wandering and development of individualized, interdisciplinary interventions and goals to reduce wandering. The policy indicated these interventions should be communicated to the care giving team, the interventions should be evaluated, and the effectiveness of the interventions documented. The policy also indicated all staff should be in-serviced to assure awareness of the resident's care plan system and what steps should be taken to prevent or interrupt elopement attempts. Review of the facility's position description for the Minimum Data Set (MDS) Coordinator (undated) revealed this staff was to: Assist the Director of Nursing Services and relevant directors/ supervisors of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident's care plan and that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Interview with the Director of Nursing (DON), on 11/10/11 at 5:00 PM, revealed training of the comprehensive care plan interventions was the responsibility of any member of the interdisciplinary care planning team to include the MDS Coordinators and the unit manager of each unit. Review of Resident #1's record revealed on 03/24/11, the facility admitted the resident on 03/24/11 with [DIAGNOSES REDACTED]. The facility developed a comprehensive plan of care with the following interventions: 1. "Know Whereabouts At All Times Q (every) Day" and 2. Resident #1 to live on the facility's 'secured unit' (locked). Resident #1's record revealed nursing documentation of his/her exit-seeking behaviors on 03/24/11, 03/25/11, 03/28/11, 03/31/11, 04/03/11 and 08/20/11. Observation of Resident #1, on 11/07/11 at 2:35 PM, revealed the resident walking in the corridor of the 'secure' unit with two (2) residents seated in wheelchairs in the corridor and five (5) residents seated in the alcove television area of the unit. Observation of Resident #1, on 11/10/11 at 10:25 AM, revealed the resident resting on a small couch in his/her bedroom with a call light and water within reach, appropriate, clean clothing, clean hair and skin, and a clear path to the bathroom. Interview with Resident #1, on 11/07/11 at 3:00 PM, revealed the resident was alert and pleasantly confused as to his/her location or date or time of day and Resident #1 did not remember having eloped from the unit and the facility. Further interview with Resident #1, on 11/10/11 at 10:30 AM, revealed the resident did remember an "adventure" of leaving the unit and the facility to go to St. James Court in Louisville (Resident #1 did not remember the day/date) but he/she got tired and sat on the ground to rest. Resident #1 stated he/she did not remember having been picked up by a citizen and returned to the facility. Review of the facility's investigation into the elopement of Resident #1 revealed Resident #1 left the 'secure' (locked) unit and the facility unsupervised and without staff knowledge on 11/02/11. Review of the investigation also revealed Resident #1 was returned to the facility unharmed after having been found by a citizen several blocks from the facility sitting on the ground near a busy four-lane street. The facility investigation revealed initial checks of the unit exit door and facility exit door alarms were all operative, however, a check of all exit doors approximately two (2) hours later revealed some of the door alarms were not operational. The facility had a staff placed on direct supervision of all of the exit doors after the elopement until all of the doors were checked by the alarm company and assessed as operational on 11/03/11 (no time indicated). After that assessment the direct supervision of the exit doors was suspended. The facility investigation also revealed the alarm company was to increase visits to monthly to ensure operation of locked/alarmed exit doors during the construction and the nursing staff was to monitor an electrical relay box hourly to ensure there were no power disruptions to the door alarms. However, the facility's investigation failed to identify that the facility failed to ensure staff provided appropriate supervision to Resident #1 and other residents at high risk for elopement. In addition, the facility had no interventions in place to ensure implementation of increased supervision as outlined on the comprehensive plan of care for Resident #1 and others at risk for elopement from 11/02/11 until 11/16/11. Additionally, the facility had not identified that all staff was not aware of all ten residents the facility had identified as an elopement risk on 11/03/11 per the elopement meeting documentation. There was no evidence the facility implemented interventions to address supervision of the residents determined at risk for elopement or effective interventions to prevent elopement recurrence while construction continued at the facility after 11/03/11. Interview with the Director of Nursing (DON) on 11/08/11 at 8:30 AM, who completed the investigation, revealed the facility investigation concluded the root cause of the elopement of Resident #1 was a faulty electrical system resulting in an absence of door alarms. The DON stated the focus of the immediate problem correction was to ensure the door alarms were in working order and remained in working order. Interview with CNA #2 (assigned as hall monitor on evening shift of 11/02/11), on 11/09/11 at 1:50 PM, revealed she saw Resident #1 at the unit nursing station about 6:00 PM on 11/02/11. She stated she saw Resident #1 leave the nursing station in the direction of his/her room and did not see Resident #1 again until his/her return to the facility. CNA #2 stated she did not hear an exit door alarm that evening and was unaware Resident #1 had eloped from the 'secure' unit. She also stated it was impossible to view the entire hall of rooms for thirty-four residents at all times. CNA #2 indicated she had not been in-serviced or trained on Resident #1's care plan interventions for elopement and she primarily knew which residents were at risk for elopement by word-of-mouth from other CNA's. Interview with LPN #4 (charge nurse for the 'secure' unit on the evening of 11/02/11), on 11/09/11 at 3:55 PM, revealed Resident #1 was at the nursing station about 6:00 PM to request to use a phone. She stated Resident #1 left the station toward his/her room about five (5) minutes later and LPN #4 did not know Resident #1 had left the unit until the nursing supervisor called and asked her to do a head count. LPN #4 indicated she knew Resident #1 was an elopement risk but was unaware of the care plan intervention for Resident #1 to "Know Whereabouts At All Times Q (every) Day". Interview with CNA #7 (assigned to Resident #1 on 11/02/11 evening shift), on 11/09/11 at 4:28 PM, revealed she was in the dining room of the 'secure' unit from 5:30 PM until 7:30 PM on the evening of 11/02/11 and she thought Resident #1 was on the unit for most of that time. She stated she was assigned to nine (9) other residents on the evening of 11/02/11 and they were not all in the dining room while she was there. She stated she relied on other staff to supervise her assigned residents while she was in the dining room. She further explained the one (1) hall monitor was to supervise the residents in the corridor and monitor the exit doors for loitering of residents with exit-seeking behaviors on the evening shift. She stated she did not see Resident #1 exit the unit on the evening of 11/02/11 and she did not hear any exit door alarms. Interview with the DON, on 11/07/11 at 2:40 PM, revealed Resident #1 was on routine supervision at that time which meant the resident was to be observed at least every tow hours. The DON also revealed there was no expectation that routine supervision would be documented any where and it was expected that the staff on the 'secure' unit would observe their assigned residents more frequently (no defined time) than every two (2) hours. She stated it was not documented that the staff would observe the residents more frequently than every two (2) hours, it was just known, and there was no policy regarding routine supervision. Review of the hall monitor job description revealed: "The hall monitor's was focused on safety (monitoring residents to ensure their safety), prevention (preventing residents from being involved in incidents and accidents), and documentation". Interview with CNA #3, on 11/09/11 at 4:20 PM, revealed the CNAs rotated assignment as the hall monitor. Her understanding of that job was to ensure the safety of the residents on the unit and the integrity of the exit doors by opening the doors to see if they would alarm. She stated there was a lot of traffic on the hall since the start of the construction (July 5) and a lot of confusion with all of the people coming and going. CNA #3 also revealed there was no facility rule or policy regarding supervision of the residents on the unit unless they were on every fifteen (15) minute, every thirty (30) minute, or one (1) hour checks, or one-to-one (1:1) supervision (one staff with the resident at all times). Interview with CNA #8, on 11/10/11 at 11:40 AM revealed Resident #1 was on routine supervision at that time which meant observing the resident at least every two (2) hours. CNA #8 stated she would observe Resident #1 more often than that (could not define) but would not document this anywhere. Review of the facility policy Resident Individual Supervision (one to one supervision), (undated), revealed the decision to place a resident on one to one supervision may be determined by nursing administration, the Administrator and/or attending physician and/or the Medical Director. Interview with the Director of Nursing (DON), on 11/10/11 at 9:00 AM, revealed she did not know how the intervention "Know Whereabouts At All Times Q (every) Day" would be implemented unless the resident was placed on 1:1 supervision. Review of the facility policy Resident Safety Checks (For Increased Supervision), (undated), revealed POLICY: It is the policy of this facility to initiate and perform with documentation Q15, Q30, and Q1 hour etc. checks when deemed necessary for an individual resident for safety and/or behavior reasons. PROCEDURE: The checks may be instituted for any reason that might jeopardize the safety of any resident. The checks may be instituted by nursing or administrative judgement or by physician orders. Interview with LPN #4, on 11/09/11 at 3:55 PM, indicated she knew Resident #1 was an elopement risk but was unaware of the care plan intervention for Resident #1 to "Know Whereabouts At All Times Q (every) Day". Interview with CNA #7, on 11/09/11 at 4:28 PM, revealed the intervention of "Know Whereabouts At All Times Q (every) Day" for Resident #1 was not on her assignment sheet with other care plan interventions and she was not trained on Resident #1's elopement risk interventions. She stated she received information regarding which residents were elopement risk by word-of-mouth from other staff and she did not know how the intervention of "Know Whereabouts At All Times Q (every) Day" could be implemented except by one-to-one (1:1) supervision. Interview with CNA #2, on 11/09/11 at 1:50 PM, revealed she had not been trained on an intervention for Resident #1 to "Know Whereabouts At All Times Q (every) Day" and in fact was not aware of this intervention. She stated this intervention was not on the CNA assignment sheet nor was any resident listed as high risk for elopement on the CNA assignment sheet. She said she did not know how the intervention could be implemented unless the resident was on one-to-one (1:1) supervision. CNA #2 stated she was aware of some residents who were high risk for elopement either through word-of-mouth from other CNA's or from a verbal nursing report at the beginning of each shift, however, she could not name the residents on the 'secure' unit who were at risk for elopement. Interview with LPN #6, on 11/10/11 at 11:25 AM, revealed she was in charge of the 'secure' unit with four (4) CNAs (to include one {1} hall monitor) for thirty-four residents. She stated she was not required to document any supervision of the thirty-four (34) residents in her charge unless the resident was on every fifteen (15) minute, every thirty (30) minute, every one (1) hour checks, or one-to-one (1:1) supervision (one staff with the resident at all times). She indicated all high risk residents were identified to staff verbally and she made sure she saw all high risk residents often (could not define often) during the shift. In addition, she was not required to document this supervision. She further indicated she was not familiar with the intervention for Resident #1 of "Know Whereabouts At All Times Q (every) Day". Interview with the Minimum Data Set (MDS) Nurse #1, on 11/10/11 at 3:40 PM, revealed he did not know exactly how the intervention of "Know Whereabouts At All Times Q (every) Day" for Resident #1 could be implemented and he could not remember who suggested the intervention for Resident #1's elopement risk. He stated the intent of the intervention was the CNA could identify the where-a-bouts of the resident if asked at random. He stated the comprehensive care plan for each resident was not viewed by each member of the interdisciplinary team during the care plan review meeting and no one in Resident #1's care plan review meeting questioned how the intervention would be implemented. MDS Nurse #1 revealed he was not aware if the CNA's had been trained on the intervention and he also stated the intervention was not implemented at the time Resident #1 eloped from the facility. He indicated it was the responsibility of the nurse unit manager to train the CNA's on care plan interventions and he did not know if these interventions were listed on the CNA assignment sheet. Interview with MDS Nurse #2, on 11/14/11 at 2:40 PM, revealed it was her understanding it was not her responsibility to in-service CNA's on the resident's comprehensive care plan. She stated the intervention "Know Whereabouts At All Times Q (every) Day" was an "unrealistic goal" and she was surprised high risk elopement was not indicated for those residents at risk on the CNA assignment sheet. Interview with LPN #2 Unit Manager, on 11/15/11 at 2:00 PM, revealed she thought it was her responsibility to update the CNA assignment sheets and she had just never put "Know Whereabouts At All Times Q (every) Day" on the CNA assignment sheets. She stated this would be impossible to do unless the resident was on 1:1 supervision. She also stated she did not indicate which residents were high risk for elopement on the CNA care plan because she thought her charge nurses were passing on the information regarding residents at high risk for elopement through the verbal nursing report at the beginning of each shift. Review of the revised comprehensive plan of care, dated 11/03/11, revealed the resident was placed on every fifteen (15) minutes checks by staff and was to be reassessed in forty-eight (48) hours. Interview, on 11/08/11 at 8:30 AM, with the DON revealed the alarm company came to assess the door and once it was deemed operational, the 15 minutes checks were discontinued. Continued interview with the DON, on 11/10/11 at 4:00 PM, revealed she thought the electrical failure of the door alarms was the root cause of the elopement and she thought the problem had been corrected as the facility had trained staff on elopement and responding to alarms. However, she indicated the inability of the staff to implement the elopement risk intervention for Resident #1 and the facility's lack of supervision of Resident #1 contributed to the elopement. Interview with the Administrator, on 11/10/11 at 4:35 PM, revealed the facility looked at safety weekly with the construction company foreman and had a safety committee meeting weekly but this did not prevent an elopement. She stated the lack of staff supervision contributed to the elopement of Resident #1. Review of the Allegation of Compliance dated 11/16/11 and interview with the DON and Administrator, on 11/17/11 at 10:00 AM, revealed the facility took the following immediate actions in response to an elopement: 1. A resident count occurred immediately at 8:10 PM on 11/03/011. Resident #1 was initially placed on every fifteen (15) minute checks on his/her return. Resident #1's Plan of Care was updated 11/03/11. 2. Exterior doors were checked by the LPN House Supervisor at 8:35 PM on 11/02/11. 3. On 11/2/11 at 8:30 PM until 1:30 AM on 11/03/11, an extensive meeting was held regarding resident safety. It was attended by the facility Administrator, the Maintenance Director, and the Human Resources Director. 4. Resident and facility safety was assessed. Three exit doors were placed on visual supervision from 11/02/11 at 10:30 PM to 11/03/11 at 11:00 AM when the General Alarm technician had assessed and corrected mechanical door alarm failure. All facility exterior doors have been evaluated by the alarm company and deemed secured. 5. All facility residents were re-assessed for elopement potential on 11/03/11. This action was completed by the Social Service Directors. Participating in the assessments were unit managers. Residents found with the potential for elopement were identified, assessments updated and elopement protocols followed to include Elopement Book identifiers and photos. No new elopement risks were identified. 6. All high risk elopement residents are now residing on the secured unit and all residents had been reviewed on 11/03/11 to determine risk for elopement. Care plans and elopement logs were updated as needed. Elopement logs, nurse aide assignment sheets, and care plans were updated as indicated. 7. Every one hour checks were initiated on 11/15/11 by licensed nursing staff on all residents identified as high risk for elopement for the remainder of internal construction of the roof top HVAC vent placement. 8. All high risk for elopement residents are in the Elopement Log on 11/09/11 which was located at each nurses station and at the receptionist's desk. 9. The secure unit will continue with the hall monitor programs. An additional hall monitor was added on 11/15/11 to increase supervision until internal construction is complete. One hall monitor will be located on the east wing the second on the west. 10. Each hall monitor received additional education on 11/16/11 to include supervision, responding to alarms, visualizing/checking the exit doors, and responding to residents trying to exit. 11. All non-high risk for elopement residents had every shift checks initiated on 11/15/11. 12. All staff received training beginning 11/03/11 at 1:00 AM through 11/16/11 at 11:00 PM regarding elopement risk, elopement protocols, code yellow (which indicates an elopement), expected responses, elopement logs and their purpose, and nurse aide assignment sheets which identify those who are high risk for elopement. 13. The gray relay box which indicated power disruption to the exit doors will remain on continual surveillance through out the hours of construction as well as one hour after with documentation of checks initiated on 11/14/11. Record review, on 11/16/11, of all documentation regarding the Allegation of Compliance to include staffing logs, other new or revised documentation tools, staff training records, and revised policies/procedures revealed all had been completed as alleged. Interviews, on 11/17/11, with three (3) CNA's, two (2) LPN's, the 'secure' unit Program Director, one (1) housekeeping staff, and the Maintenance Director all verified staff knowledge of new documentation tools to be utilized regarding resident head counts, how to accomplish those, and who is responsible for those duties. These staff were also knowledgeable regarding addition of a second hall monitor to the 'secure unit' and the position description of same, how to identify and respond to a missing resident and the revisions to policies/procedures related to this identified concern. Immediate Jeopardy was verified to be removed on 11/17/11 which lowered the scope and severity to a "E" at 42 CFR 483.25 Quality of Care (F323), while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures.

Based on interview, record review, and facility policy Elopement Prevention, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (1) of seven (7) sampled residents, Resident #1. The facility failed to in-service and implement comprehensive care plan interventions for Resident #1, supervise cognitively impaired individuals with known elopement risk, and identify quality deficiencies. In addition, the facility failed to develop appropriate plans of action to correct identified quality deficiencies. On 11/02/11 Resident #1 eloped from the 'secure' (locked) unit and the facility's property during a major construction project without supervision or staff knowledge and was gone from the facility for approximately forty-five (45) minutes. Resident #1 was found sitting on the ground by a four (4) lane road several blocks from the facility by a citizen and returned to the facility unharmed. The facility's failure to utilize it's resources effectively and in-service and implement the comprehensive care plan; to provide adequate supervision of cognitively impaired individuals with known elopement risk; and develop appropriate plans of action to correct identified deficiencies placed residents at risk for elopement which was likely to cause serious injury, harm, impairment, or death. An acceptable Allegation of Compliance (AOC) was received on 11/16/11 and the Immediate Jeopardy was removed on 11/17/11 which lowered the scope and severity to a "E" for 42 CFR 483.75 Administration (F490) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. Refer to F282, F323 substandard quality of care, and F520. The findings include: Review of the facility policy Elopement Prevention, (undated), revealed the resident's Plan of Care should include possible causes for wandering and development of individualized, interdisciplinary interventions and goals to reduce wandering. The policy indicated these interventions should be communicated to the care giving team, the interventions should be evaluated, and the effectiveness of the interventions documented. The policy also indicated all staff should be in-serviced to assure awareness of the resident's care plan system and what steps should be taken to prevent or interrupt elopement attempts. Review of Resident #1's record revealed the facility admitted the resident on 03/24/11 with [DIAGNOSES REDACTED]. The comprehensive plan of care directed the facility staff to prevent Resident #1's elopement from the facility by: 1. "Know Whereabouts At All Times Q (every) Day" and 2. Resident #1 to reside on the 'secured unit' (locked). Nursing documentation revealed Resident #1 displayed exit-seeking behaviors on 03/24/11, 03/25/11, 03/28/11, 03/31/11, 04/03/11 and 08/20/11. Review of the facility investigation on 11/08/11 into the elopement of Resident #1 revealed Resident #1 left the 'secure' (locked) unit and the facility unsupervised and without staff knowledge on 11/02/11. Interviews with nursing staff (CNA #2 on 11/09/11 at 1:50 PM; LPN #4 on 11/09/11 at 3:55 PM; LPN #6 on 11/10/11 at 11:25 AM; CNA #8 on 11/10/11 at 11:40 AM; MDS Nurse #1 on 11/10/11 at 3:40 PM; MDS Nurse #2 on 11/14/11 at 2:40 PM; and LPN #2 on 11/15/11 at 2:00 PM) revealed staff was not aware of all residents that the facility had identified as an elopement risk and staff had no knowledge that they were to know the whereabouts of Resident #1 at all times per the care plan. Additionally, these staff stated they had not been trained to Resident #1's care plan. Interview with nursing staff confirmed they had no trained staff regarding Resident #1's care plan. Interview with the DON, on 11/10/11 at 5:00 PM, revealed training of the comprehensive care plan interventions was the responsibility of any member of the interdisciplinary care planning team and the unit manager of each unit. The facility investigation identified the cause of the elopement was the facility's exit door alarms were not functional due to intermittent electrical surges related to the construction occurring at the facility. However, further review revealed no evidence the facility had identified lack of appropriate supervision, staff having no knowledge of the care planned supervision requirements. Additionally, the facility had not identified that all staff was not aware of all ten residents the facility had identified as an elopement risk on 11/03/11 per the elopement meeting documentation. There was no evidence the facility implemented interventions to address supervision of the residents determined at risk for elopement or effective interventions to prevent elopement recurrence while construction continued at the facility after 11/03/11. Interview with the Administrator, on 11/10/11 at 5:10 PM, revealed the facility did not recognize staff were unaware of care plan interventions. She also stated that lack of supervision and lack of implementation of the comprehensive care plan could have contributed to the elopement of Resident #1. While the facility implemented corrective action related to door alarms and having checks completed of the electrical relay box, there was no evidence the facility had implemented interventions specific to supervision of residents at risk for elopement from 11/02/11 through 11/16/11. Continued interview with the Administrator, on 11/10/11 at 5:10 PM, revealed the facility looked at safety issues weekly with the construction company foreman and had a safety committee meeting weekly but this did not prevent an elopement. The concern related to staff knowledge of care plan intervention and lack of supervision of residents identified at risk for elopement had not been identified and was not discussed as a concern with the Quality Assurance Committee. Review of the Allegation of Compliance dated 11/16/11 and interview with the DON and Administrator, on 11/17/11 at 10:00 AM, revealed the facility took the following immediate actions in response to an elopement: 1. A resident count occurred immediately at 8:10 PM on 11/02/11. Resident #1 was initially placed on every fifteen (15) minute checks on his/her return. Resident #1's Plan of Care was updated on 11/03/11. 2. Exterior doors were checked by the LPN House Supervisor at 8:35 PM on 11/02/11. 3. On 11/2/11 at 8:30 PM until 1:30 AM on 11/03/11, an extensive meeting was held regarding resident safety. It was attended by the facility Administrator, the Maintenance Director, and the Human Resources Director. 4. Resident and facility safety was assessed. Three exit doors were placed on visual supervision from 11/02/11 at 10:30 PM to 11/03/11 at 11:00 AM when the General Alarm technician had assessed and corrected mechanical door alarm failure. All facility exterior doors have been evaluated by the alarm company and deemed secured. 5. All facility residents were re-assessed for elopement potential on 11/03/11. This action was completed by the Social Service Directors. Participating in the assessments were unit managers. Residents found with the potential for elopement were identified, assessments updated and elopement protocols followed to include Elopement Book identifiers and photos. No new elopement risks were identified. 6. All high risk elopement residents are now residing on the secured unit and all residents had been reviewed on 11/03/11 to determine risk for elopement. Care plans and elopement logs were updated as needed. Elopement logs, nurse aide assignment sheets, and care plans were updated as indicated. 7. Every one hour checks were initiated on 11/15/11 to be completed by the licensed nursing staff on all residents identified as high risk for elopement for the remainder of internal construction of the roof top HVA vent placement. 8. All high risk for elopement residents are in the Elopement Log, as of 11/09/11, which was located at each nurses station and at the receptionist's desk. 9. The secure unit will continue with the hall monitor programs. An additional hall monitor was added on 11/15/11 to increase supervision until internal construction is complete. One hall monitor will be located on the east wing the second on the west. 10. Each hall monitor received additional education on 11/16/11 to include supervision, responding to alarms, visualizing/checking the exit doors, and responding to residents trying to exit. 11. All non-high risk for elopement residents had every shift checks initiated on 11/15/11. 12. All staff received training beginning 11/03/11 at 1:00 AM through 11/16/11 at 11:00 PM regarding elopement risk, elopement protocols, code yellow (which indicates an elopement), expected responses, elopement logs and their purpose, and nurse aide assignment sheets which identify those who are high risk for elopement. 13. The gray relay box which indicated power disruption to the exit doors will remain on continual surveillance, initiated 11/14/11, through out the hours of construction as well as one hour after. Record review, on 11/16/11, of all documentation regarding the Allegation of Compliance to include staffing logs, other new or revised documentation tools, staff training records, and revised policies/procedures revealed all had been completed as alleged. Observations of the residents on the secured unit, on 11/16/11 10:00 AM, wanderguards were in place, staff were visible on the units interacting with the residents in activities or in the hallway. The residents were dressed appropriately for the season. Interviews, on 11/17/11, with three (3) CNA's, two (2) LPN's, the 'secure' unit Program Director, one (1) housekeeping staff, and the Maintenance Director all verified staff knowledge of new documentation tools to be utilized regarding resident head counts, how to accomplish those, and who is responsible for those duties. These staff were also knowledgeable regarding addition of a second hall monitor to the 'secure unit' and the position description of same, how to identify and respond to a missing resident and the revisions to policies/procedures related to this identified concern. Immediate Jeopardy was verified to be removed on 11/17/11 which lowered the scope and severity to a "E" at 42 CF 483.75 Administration (490) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures.

Based on interview, record review, and facility policy Quality Assurance and Assessment Program and observation, it was determined the facility failed to identify issues for which quality assessment and assurance activities were necessary; and failed to develop and implement appropriate plans of action to correct identified quality deficiencies for one (1) of seven (7) sampled residents, Resident #1. The facility assessed Resident #1 as high risk for elopement requiring staff to know the resident's whereabouts at all times everyday. On 11/02/11, during major facility construction, Resident #1 successfully eloped from the 'secure' (locked) unit and the facility's property without staff supervision or knowledge. A citizen found Resident #1 sitting on the ground by a busy four (4) lane street several blocks from the facility. The facility's investigation failed to identify all causal factors of the elopement which prevented the facility from initiating corrective measures related to all causal factors. The facility identified 10 (ten) residents who were cognitively impaired and requiring supervision due to elopement risk. The facility's failure to identify issues for quality assessment and assurance, failure to in-service and implement appropriate plans of action to correct identified quality deficiencies, and failure to provide adequate supervision of cognitively impaired individuals with known elopement risk placed residents at risk for elopement which was likely to cause serious injury, harm, impairment, or death. An acceptable Allegation of Compliance (AOC) was received on 11/16/11 and the Immediate Jeopardy was removed on 11/17/11 which lowered the scope and severity to a "E" for 42 CFR 483.75 Administration (F520) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. Refer to F282, F323 substandard quality of care, and F490. The findings include: Review of the facility's policy, Quality Assurance and Assessment (QAA) Program, revealed STANDARD 1. The QAA sets expectations, develops plans, and implements procedures to assess and improve the quality of the facility's governance, management, clinical, and support processes. The policy also revealed PROCEDURES 5. . . .situations in which an evaluation of the performance of care is indicated are readily identified. Review of Resident #1's record revealed the facility admitted the resident on 03/24/11 with [DIAGNOSES REDACTED]. The comprehensive plan of care directed the facility staff to prevent Resident #1's elopement from the facility by: 1. "Know Whereabouts At All Times Q (every) Day" and 2. Resident #1 to reside on the 'secured unit' (locked). Nursing documentation revealed Resident #1 displayed exit-seeking behaviors on 03/24/11, 03/25/11, 03/28/11, 03/31/11, 04/03/11 and 08/20/11. Review of the facility investigation on 11/08/11 into the elopement of Resident #1 revealed Resident #1 left the 'secure' (locked) unit and the facility unsupervised and without staff knowledge on 11/02/11. Review of the investigation also revealed Resident #1 was returned to the facility unharmed after having been found by a citizen several blocks from the facility sitting on the ground near a busy four-lane street. The facility investigation revealed initial checks of the unit exit door and facility exit door alarms were all operative; however, a check of those doors approximately two (2) hours later revealed some of the alarms were not operational. The facility had a staff placed on direct supervision of all of the exit doors after the elopement until all of the doors were checked by the alarm company and assessed as operational on 11/03/11. After the assessment on 11/02/11, the facility suspended direct supervision of the exit doors. The facility investigation also revealed the alarm company was to increase visits to ensure operation of locked/alarmed exit doors to monthly during the construction and the nursing staff was to monitor an electrical relay box to ensure there were no power disruptions to the door alarms. However, further review of the facility's investigation revealed the facility did not identify all causal factors of the elopement. There was no documented evidence that the facility had identified that staff had not provided supervision, knowing the whereabouts of Resident #1 at all times everyday, per the comprehensive care plan. Additionally, the investigation did not identify that staff was not knowledgeable of the care plan intervention for supervision or that staff had not been trained on the care plan intervention. In addition, the facility could provide no evidence of the implementation of interventions related to ensuring adequate supervision to prevent the recurrence of elopements for Resident #1 or other residents of the facility who had been identified as an elopement risk, per the care plan from 11/02/11 until 11/16/11. Additionally, the facility had not identified that all staff was not aware of all ten residents the facility had identified as an elopement risk on 11/03/11 per the elopement meeting documentation. There was no evidence the facility implemented interventions to address supervision of the residents determined at risk for elopement or effective interventions to prevent elopement recurrence while construction continued at the facility after 11/03/11. Interview with the Director of Nursing (DON) on 11/08/11 at 8:30 AM, who completed the investigation, revealed the facility investigation concluded the root cause of the elopement of Resident #1 was a faulty electrical system resulting in an absence of door alarms. Further interview with the DON, on 11/10/11 at 9:00 AM and 5:00 PM, revealed she had not identified that staff had not provided supervision per the comprehensive care plan and had not identified that staff was unaware of the resident's care plan interventions. She indicated the lack of implementation of the care plan intervention "Know Whereabouts At All Times Q (every) Day" for Resident #1 could have contributed to the resident's elopement. Interview with the Administrator, on 11/10/11 at 5:10 PM, revealed the facility looked at safety issues weekly with the construction company foreman and had a safety committee meeting weekly but this did not prevent an elopement. She stated the facility had not recognized staff was unaware of care plan interventions and this concern was not discussed in the Quality Assurance Committee. She also stated she understood that lack of supervision and lack of implementation of the comprehensive care plan could have contributed to the elopement of Resident #1. Interview with the Medical Director, on 11/16/11 at 10:45 AM, revealed she attended the QAA Committee meetings at least quarterly and she attended care plan meetings almost every week. She stated she did not realize implementation of the comprehensive plans of care was a concern in regards to the residents at high risk for elopement. Review of the Allegation of Compliance dated 11/16/11 and interview with the DON and Administrator, on 11/17/11 at 10:00 AM, revealed the facility took the following immediate actions in response to an elopement: 1. A resident count occurred immediately at 8:10 PM on 11/02/11. Resident #1 was initially placed on every fifteen (15) minute checks on his/her return. Resident #1's Plan of Care was updated on 11/03/11. 2. Exterior doors were checked by the LPN House Supervisor at 8:35 PM on 11/02/11. 3. On 11/2/11 at 8:30 PM until 1:30 AM on 11/03/11, an extensive meeting was held regarding resident safety. It was attended by the facility Administrator, the Maintenance Director, and the Human Resources Director. 4. Resident and facility safety was assessed. Three exit doors were placed on visual supervision from 11/02/11 at 10:30 PM to 11/03/11 at 11:00 AM when the General Alarm technician had assessed and corrected mechanical door alarm failure. All facility exterior doors have been evaluated by the alarm company and deemed secured. 5. All facility residents were re-assessed for elopement potential on 11/03/11. This action was completed by the Social Service Directors. Participating in the assessments were unit managers. Residents found with the potential for elopement were identified, assessments updated and elopement protocols followed to include Elopement Book identifiers and photos. No new elopement risks were identified. 6. All high risk elopement residents are now residing on the secured unit and all residents had been reviewed on 11/03/11 to determine risk for elopement. Care plans and elopement logs were updated as needed. Elopement logs, nurse aide assignment sheets, and care plans were updated as indicated. 7. Every one hour checks were initiated 11/15/11 by licensed nursing staff on all residents identified as high risk for elopement for the remainder of internal construction of the roof top HVA vent placement. 8. All high risk for elopement residents are in the Elopement Log 11/09/11 which was located at each nurses station and at the receptionist's desk. 9. The secure unit will continue with the hall monitor programs. An additional hall monitor was added on 11/15/11 to increase supervision until internal construction is complete. One hall monitor will be located on the east wing the second on the west. 10. Each hall monitor received additional education on 11/16/11 to include supervision, responding to alarms, visualizing/checking the exit doors, and responding to residents trying to exit. 11. All non-high risk for elopement residents had every shift checks initiated 11/15/11. 12. All staff received training beginning 11/03/11 at 1:00 AM through 11/16/11 at 11:00 PM regarding elopement risk, elopement protocols, code yellow (which indicates an elopement), expected responses, elopement logs and their purpose, and nurse aide assignment sheets which identify those who are high risk for elopement. 13. The gray relay box which indicated power disruption to the exit doors will remain on continual surveillance as through out the hours of construction as well as one hour after with documentation of checks to begin on 11/14/11. Record review, on 11/16/11, of all documentation regarding the Allegation of Compliance to include staffing logs, other new or revised documentation tools, staff training records, and revised policies/procedures verified all had been completed as alleged. Observations of the residents on the secured unit, on 11/16/11 10:00 AM, wanderguards were in place, staff were visible on the units interacting with the residents in activities or in the hallway. The residents were dressed appropriately for the season. Interviews, on 11/17/11, with three (3) CNA's, two (2) LPN's, the 'secure' unit Program Director, one (1) housekeeping staff, and the Maintenance Director all verified staff knowledge of new documentation tools to be utilized regarding resident head counts, how to accomplish those, and who is responsible for those duties. The staff was knowledgeable regarding the addition of a second hall monitor to the 'secure unit', the position description, and how to identify and respond to a missing resident and the revisions to policies/procedures related to this identified concern. Immediate Jeopardy was verified removed on 11/17/11 which lowered the scope and severity to a "E" at 42 CFR 483.75 Administration (F520) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures.