Every finding on record at Homestead Post Acute

Based on observation, interview, review of the Food and Drug Administration web site, and review of the facility's documents and policy, the facility failed to store and serve food in a sanitary manager. Observations on 07/15/2025 revealed 5 of 5 nourishment refrigerator/freezers did not have a thermometer, and the freezer temperatures were not recorded. Also, observations on 07/15/2025 during the breakfast tray line revealed not all modified texture foods were listed, and the temperatures were not recorded.The findings include:Review of the facility's policy titled, Food Preparation and Service, revised 11/2022, revealed it referenced the United States Food and Drug Administration (FDA) Food Code. Per the policy, the term danger zone meant temperatures in the range, between 41 degrees Fahrenheit (F) and below 135 degrees F, that allowed the rapid growth of pathogenic microorganisms that could cause foodborne illness. The policy stated potentially hazardous food (PHF), or Time/Temperature Control for Safety (TCS) foods held in the danger zone for more than four hours or six hours (if cooked or cooled) might cause a food borne illness outbreak if consumed. Review of the web site, https://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely, revealed food that was properly handled, frozen, and stored in the freezer at zero degrees F would remain safe. It also stated while freezing did not kill most bacteria, it did stop bacteria from growing. Further review revealed, though food would be safe indefinitely at zero degrees F, quality would decrease the longer the food was in the freezer. It stated refrigerator/freezer thermometers could be purchased in the housewares section of department, appliance, culinary, and grocery stores. It stated to place one thermometer, in an easy-to-read location such as the front, both in the refrigerator and in the freezer, and to check the temperature regularly.1. Observation on 07/15/2025 at 8:00 AM and review of the facility's document Tray line Temperatures, with completed dates of 07/13/2025, 07/14/2025, and to breakfast on 07/15/2025, revealed regular texture and modified texture foods listed for lunch and dinner with temperatures recorded. However, the breakfast meal did not list or record temperatures for the modified texture foods.Review of the facility's document Refrigerator Temperature Log, dated 07/2025, for the 500, 400, 300, 200, and the 100 Unit's nourishment refrigerator temperature, revealed it should be between 36 degrees F and 41 degrees F, and the frozen foods should be frozen solid. However, the Refrigerator Temperature Log for the units did not document the freezer temperatures.2. a. Observation on 07/15/2025 at 9:43 AM of the 500 Unit nourishment refrigerator, and review of its Refrigerator Temperature Log, revealed no documentation of freezer temperatures, from 07/01/2025 through 07/15/2025. Further observation revealed no thermometer in the freezer.b. Observation on 07/15/2025 at 9:57 AM of the 300 Unit nourishment refrigerator, and review of its Refrigerator Temperature Log, revealed no documentation of freezer temperatures, from 07/01/2025 through 07/15/2025. Further observation revealed no thermometer in the freezer.c. Observation on 07/15/2025 at 9:59 AM of the 400 Unit nourishment refrigerator, and review of its Refrigerator Temperature Log, revealed no documentation of freezer temperatures, from 07/01/2025 through 07/15/2025. Further observation revealed no thermometer in the freezer.d. Observation on 07/15/2025 at 10:00 AM of the 200 Unit nourishment refrigerator, and review of its Refrigerator Temperature Log, revealed no documentation of freezer temperatures, from 07/01/2025 through 07/15/2025. Further observation revealed no thermometer in the freezer.e. Observation on 07/15/2025 at 10:07 AM of the 100 Unit nourishment refrigerator, and review of its Refrigerator Temperature Log, revealed no documentation of freezer temperatures, from 07/01/2025 through 07/15/2025. Further observation revealed no thermometer in the freezer.In an interview with the Dietary Manager on 07/16/2025 at 9:47 AM, she stated the staff did check the temperatures for all the breakfast foods. She stated she did not realize all the foods for breakfast were not documented as were the foods for lunch and supper. She stated the concern would be not all foods would be at safe temperatures. In an interview with Certified Nurse Aide (CNA) 5 on 07/16/2025 at 1:50 PM, she stated night shift passed the snacks and documented the refrigerator temperatures. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 07/17/2025 at 11:10 AM, she stated if food temperatures were not monitored, food might not be in the acceptable temperature range. She stated it was important for the nourishment freezers to have a thermometer and to have their freezer temperatures recorded. In an interview with the Administrator on 07/17/2025 at 11:53 AM, he stated if the food temperatures were not documented, then it would not be known if the food temperatures were acceptable. However, he stated the nourishment freezers did not need a thermometer because the freezer temperature could be checked by the firmness of the frozen foods.

Based on observation, interview, and review of the facility's policy, the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 treatment carts. Observation on 07/14/2025 at 2:45 PM revealed the 500-A Unit treatment cart was left unlocked and unattended. The findings include: Review of the facility's policy titled, Storage of Medications, revised November 2020, revealed compartments containing drugs and biologicals were to be locked when not in use, and unlocked carts were not to be left unattended.Observation on 07/14/2025 at 2:45 PM revealed the 500-A Unit treatment cart was left unlocked and unattended. On 07/14/2025 at 3:13 PM, the State Survey Agency (SSA) Surveyor went through the cart with the Nurse Manger of the area, Licensed Practical Nurse (LPN) 1. Items in the unlocked cart were one double antibiotic ointment for Resident (R) 82; one triple antibiotic ointment for R83; two [NAME] and castor oil wound dressings, one for R26 and one for R124; one medi-honey for R84; one triple antibiotic ointment with pain relief for R34; one miconazole nitrate antifungal vaginal cream for R72; three Desitin ointments, one each for R80, R67, and R124; two Venelex wound dressings, one for R134 (discharged ) and one for R1; diclofenac gel, one for R34; one hydrocortisone cream for R26; and one Occusoft lid scrub for R67.During an interview with Licensed Practical Nurse (LPN) 1 on 07/14/2025 at 3:17 PM, she stated, The importance is to make sure the residents don't get into the cart. It could potentially harm the resident if they got into the cart. LPN1 stated, I am not sure what the policy says about locking the medication cart.During an interview with LPN3 on 07/16/2025 at 8:12 AM, he stated staff kept the carts locked to prevent anyone getting into the medications and ingesting them, and to prevent loss. He stated it was the facility's policy to keep the carts locked when unattended.During an interview with Registered Nurse (RN) 2 on 07/16/2025 at 8:12 AM, he stated it was important to keep the carts locked to prevent residents' access to harmful items and medications. RN2 stated it was the facility's policy to keep the carts locked when not in use.During an interview with the Director of Nursing (DON) on 07/17/2025 at 10:45 AM, she stated, The main reason we keep the carts locked is patient safety. We have a policy that states to keep carts locked when unattended. We have addressed this and reeducated staff last night.During an interview with the Administrator on 07/17/2025 at 11:58 AM, he stated, The issue is really patient safety; we do not want a resident ingesting something that is harmful. We do have a policy in place that carts are to be kept locked when not in use.

Based on observation, interview, record review, and review of the facility's policy and protocol, it was determined the facility failed to protect residents from infection for 1 of 3 sampled residents who had an indwelling urinary catheter, Resident (R) 84.Observation on 07/14/2025 at 4:05 PM revealed R84's indwelling urinary catheter bag was dragging on the floor under the resident's wheelchair. The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, policy revision not dated, revealed the infection prevention control program provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. Review of the facility's Catheter Care Protocol, not dated, revealed the catheter tubing and drainage bag were kept off the floor. Review of R84's admission Record revealed the facility originally admitted the resident on 01/13/2017 with diagnoses to include multiple sclerosis, diabetes with diabetic nephropathy, and transient cerebral ischemic attack. Review of R84's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/07/2025, revealed the facility assessed R84 to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating the resident had moderate cognitive impairment. Review of R84's Medication Administration Record [MAR], for June 2025, revealed R84 was started on an antibiotic for a urinary tract infection on 06/13/2025 which continued until 06/19/2025.Observation on 07/14/2025 at 4:05 PM revealed R84's indwelling urinary catheter bag dragging on the floor under the wheelchair. During an interview with Licensed Practical Nurse (LPN) 4 at the time of the observation, she stated the policy stated the urinary drainage bag should be off the floor and covered. She stated that was important to prevent bacteria from entering the resident. She stated R84's catheter bag was on the floor because the wheelchair was too low. She then moved the catheter bag off the floor. During an interview with Certified Nurse Aide (CNA) 1 on 07/14/2025 at 4:13 PM, she stated she got R84 up at 11:00 AM today. She stated she thought the bag was off the floor. She stated she had received education in infection control. She stated the catheter bag might have slipped. During an interview with LPN1/Nurse Manager on 07/14/2025 at 4:21 PM, she stated she did not notice that R84's catheter bag was on the floor. She stated she had received training in infection control. She stated she was trained about three months ago, and the training involved urinary catheters. She stated the training went over catheter care and the importance of keeping the catheter clean to prevent organisms from going into the bladder. During an interview with the Director of Nursing (DON) on 07/16/2025 at 9:18 AM, she stated the urinary catheter bags were to be kept off the floor to prevent infection. She stated staff was educated on that and infection control. She stated she expected staff to keep catheter bags off the floor to prevent infection.During an interview with the Administrator on 07/16/2025 at 1:24 PM, he stated he expected staff to follow the infection control policies. He stated he assured staff was trained in infection control to prevent the spread of infection.

Based on interview, record review, review of the facility's job descriptions for the Infection Preventionist and the Maintenance Director, and review of the facility's policy, the facility failed to establish written standards, policies, and procedures by having a documented water management program based on nationally accepted standards for all residents (census 122). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 12/2023, revealed the infection prevention and control program (IPCP) addressed the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment, and the program was reviewed annually and updated as necessary. Further review revealed the coordination and oversight of the IPCP was the responsibility of the Infection Preventionist (IP). It stated policies and procedures were the cornerstone of the IPCP, reflected the current infection prevention and control standards of practice, and followed established general and disease-specific guidelines, such as those of the Centers for Disease Control and Prevention (CDC). Review of the Job Description for the Infection Preventionist, revised date 10/2020, identified the purpose of the position was to plan, organize, develop, coordinate, and direct the facility's IPCP and its activities in accordance with current federal, state, and local standards, guidelines and regulations that governed such programs. Further review identified duties and responsibilities that included interpreting, reviewing, and modifying infection control and prevention policies and procedures as necessary. Review of the Job Description for the Maintenance Director, dated 09/2018, identified the purpose of the job was to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility. Further review revealed essential duties included developing, maintaining, and implementing infection control and universal precautions policies and procedures to assure a sanitary environment was maintained at all times and aseptic and isolation techniques were followed by all maintenance personnel. Review of the facility's Water Management Binder, revealed the cover page read water management program free chlorine levels maintained 0.4-0.6 contact water company if not in range, and contained two pages with heading water chlorine testing (PPM) [parts per million], and a copy of the CDC document Developing a water management program to reduce Legionella growth & spread in buildings-A practical guide to implementing industry standards, dated 06/05/2017, Version 1.1. There was also a handwritten notation on the front cover, updated reviewed QA committee 1/2024, initialed by the facility's Administrator. Review of the two pages water chlorine testing (PPM) identified nine columns; date, initials, supply, station A, station B, station C, station D, 500 Hall, and kitchen. Further review revealed that the column dated 03/14/2024 for the 500 Hall had a reading of 0.61; the column dated 07/17/2024 for station D had a reading of 0.61; and the column dated 08/20/2024 for the kitchen had a reading of 0.61. However, there was no documentation of notification to the water company or actions, if any, that were taken. Further review of the binder revealed it did not contain information on the facility's specific water system, water flow diagram, measures to prevent growth of waterborne pathogens, testing protocols, acceptable ranges, and interventions taken when controls were not met. Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign in sheet, dated 01/09/2024, revealed it was signed by the Medical Director, Administrator, Director of Nursing (DON), QA/Infection Preventionist (IP), Director of Rehab, Social Services Assistant, Medical Records, and Staff Development/IP. Review of the form Quality Assurance Committee Meeting, Administrator report (may be utilized as QA minutes), dated 01/09/2024, identified the section labeled V. Water management program for prevention of an outbreak for Legionnaire's Disease (LD): circled Yes and below that stated develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of LD. Program evaluation and testing annually. In an interview with the Maintenance Assistant on 09/19/2024 at 11:16 AM, he stated he was the former Maintenance Director at the facility, retired last year, and was re-hired to train the new Maintenance Director. He stated he had worked in maintenance for [AGE] years and had never heard of Legionella before this date. When asked about the facility's water testing process, he stated he checked water temperatures. When asked if the facility had a water management program or policy, he stated not to his knowledge. When asked if the facility had a water flow diagram identifying cut offs, dead legs, and possible areas of stagnated water, he stated to his knowledge there was not one. In another interview on 09/19/2024 at 11:37 AM, the Maintenance Assistant returned to the State Survey Agency (SSA) Surveyor and stated he had determined since the earlier interview that the Administrator was in charge of the water testing and had the water management program information. He also provided the SSA Surveyor with a facility map of the resident rooms with hand drawn lines labeled with water line, tank, and flow. Review of the map revealed there was no description of street locations where water entered the facility and connected to the municipal water supply or where waste water was discarded. The Maintenance Assistant also provided a paper of temperature log sheet to the SSA Surveyor with room numbers, corresponding temperatures, and signed and dated by the previous Maintenance Director on 08/13/2024, 08/21/2024, and 08/26/2024. In an interview with the Maintenance Director on 09/09/2024 at 11:20 AM, he stated he had been in that position for three (3) days, and prior to that had worked as an assistant to the previous Maintenance Director and the housekeeping department. He stated to date he had not received any education or training on the water maintenance program or testing procedures for Legionella. In an interview with the Staff Development (SD)/Infection Preventionist backup on 09/20/2024 at 9:40 AM, she stated as the backup to the IP nurse she did new hire orientation and yearly education of employees covering hand hygiene, donning (putting on) and doffing (removing) personal protective equipment (PPE), transmission-based precaution education, new employee immunization, and assisted with other duties as assigned. In a follow up interview with the SD/Infection Preventionist backup on 09/20/2024 at 2:19 PM, she stated she did work with maintenance since she also ordered nursing supplies. She stated to her knowledge the facility had a water management program, and two machines that were tested weekly for chlorine levels, which had to stay in a certain range. She stated she did not know the ranges, but results had never been out of range. She stated she had never personally performed the testing, did not know how it was performed, and had not visualized a water flow diagram of the facility. In an interview with the IP nurse on 09/20/2024 at 9:21 AM, she stated she had worked in that role for the past eight years. She stated she did not have any involvement in the water management program but had spoken to the Administrator and was assured by him that the facility did have a water management program and had conducted testing. She stated any questions pertaining to water flow diagrams or policies on water management would have to be directed to the Administrator, who was currently overseeing that program. She stated in her eight years at the facility there had not been any cases of Legionella. However, she stated, in the event a case did occur, she would be responsible to conduct the review, report, track, surveil, and educate staff. In an interview with the DON on 09/20/2024 at 3:21 PM, she stated she had general knowledge of the IPCP but did not have direct involvement in the activities. The DON stated to her knowledge there was a water management and testing program, but she could not speak to any specifics of the policy or procedures that were monitored by the IP nurse and her back up, the SD/IP nurse. The DON stated there had been a recent turn over in the maintenance department, and any further questions regarding the water management program needed to be directed to the Administrator. In an interview with the Administrator on 09/20/2024 at 9:50 AM, he stated last year the facility Maintenance Director retired, the facility filled the position, and as of last week, a change was made in the role, and a new Maintenance Director had been in the position for three (3) days. He stated the Maintenance Director that retired was asked to come back to train the newly appointed Maintenance Director, and he had assumed responsibility of the water management program until the new Maintenance Director could be trained. The Administrator stated the facility currently had a water management program that measured chlorine levels and water temperatures, which the QAPI committee updated and reviewed in 01/2024. When asked to provide a facility specific assessment of areas where opportunistic waterborne pathogens could grow and spread, flow diagrams, the facility's measures to prevent growth, testing protocols, acceptable ranges, monitoring of control measures, and established ways to intervene when control limits were not met, he stated he could not provide those documents that were specific to the facility.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive, resident-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents investigated for trauma-informed care, Resident (R) 85. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed the facility was to develop and implement a person-centered care plan for each resident that included measurable objectives to meet the residents physical and psychosocial needs. Further review revealed the care plan was to include trauma-informed services, and interventions were chosen after data gathering and careful consideration of the relationship between the resident's problem areas and their causes. Review of R85's Admission Record revealed the facility admitted R85 on 11/01/2021 with diagnoses including sequelae of cerebral infarction (after-effects of a stroke), post-traumatic stress disorder (PTSD), insomnia, and recurrent depressive disorders. Review of R85's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed the facility assessed R85's cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the facility included PTSD in the list of R85's active diagnoses. Continued review revealed the facility assessed R85's mood with a Personal Health Questionnaire (PHQ)-9 (depression screening tool) score of 12 out of 27, indicating moderate depression symptoms. Review of R85's Care Plan, dated 09/17/2024, revealed the facility failed to include the resident's history of traumatic life events as one of the resident's focus areas. Further review revealed the facility failed to include interventions to mitigate potential triggers related to R85's diagnosis of PTSD. Review of R85's Psychiatric Progress Note, dated 07/03/2024, revealed R85 reported to Licensed Clinical Social Worker (LCSW) 1 that her father killed her baby brother when she was approximately four years old. Further review revealed LCSW1 wrote that she provided a copy of this note to the clinicians caring for R85's comorbid conditions. In an interview on 09/20/2024 at 2:12 PM, the Unit Manager (UM) for the 100 Hall stated she did not know if trauma informed care and interventions to mitigate triggers should be included on a care plan if the resident had a PTSD diagnosis. Per interview, the UM stated she did not see trauma interventions on R85's care plan, but she would continue to research. In additional interview on 09/20/2024 at 3:16 PM, the UM stated she determined trauma care needs should have been on R85's care plan but had not been included prior to the interview. In an interview on 09/19/2024 at 2:18 PM, the Social Services Assistant (SSA) stated he was not working at the facility when R85 was admitted . Per interview, the SSAs role in developing the comprehensive care plan was to conduct a social services history assessment, which included asking the resident about their history of traumatic life events. He further stated residents were not always willing to talk about trauma from their pasts but might disclose it to staff later. The SSA stated the interdisciplinary team should add trauma information to a care plan once a resident disclosed it. In an interview on 09/20/2024 at 3:00 PM, the Social Services Director (SSD) stated he was not familiar with the long-term care residents, including R85, as he was new to the facility and had spent much of his time coordinating discharge care needs for short term rehabilitation residents. The SSD stated his department passed along information regarding mood and cognitive assessments, but it was primarily the role of the Minimum Data Set Coordinator (MDSC) to develop comprehensive care plans, including sections dealing with mental health and psychosocial needs. In an interview on 09/20/2024 at 12:58 PM, Minimum Data Set Nurse (MDSN) 1 stated she did not work at the facility at the time R85 was admitted to the facility. She further stated her process for comprehensive assessments was to review the resident's diagnoses on admission, as well as information from social services, such as a depression screening, to develop a comprehensive care plan. MDSN1 stated she reviewed consult notes quarterly to determine if the resident had new psychiatric needs. Per interview, MDSN1 did not know why the facility failed to develop a trauma care plan for R85 when the resident had an active diagnosis of PTSD. In an interview on 09/20/2024 at 1:16 PM, the MDSC stated the facility's process for developing a comprehensive care plan included looking at the admission diagnoses and ensuring resident needs related to those diagnoses were addressed in the care plan. She stated she included psychosocial needs on care plans, but she had never seen a resident's care plan address specific trauma triggers. The MDSC stated identifying a history of trauma and trauma triggers was the role of the social services department. Additionally, the MDSC stated she did not believe information about trauma and triggers should be included on the care plans because that was personal information. Per interview, the MDSC stated she could not describe what negative effect re-traumatization might have on a resident. In an interview on 09/20/2024 at 3:19 PM, the Director of Nursing (DON) stated her expectations for care plans were for trauma triggers to be included to promote the resident's quality of life by mitigating triggers where possible. She further stated the care plan was a communication tool to be used to make staff aware of a resident's triggers so they would know how to approach the resident. The DON stated the facility had a lot of staff turnover in the social services department in the past, which had likely contributed to the facility's failure to include R85's PTSD care needs in the original care plan. Per interview, the DON was not able to describe how the facility failed to identify trauma needs during quarterly care plan reviews. In an interview on 09/20/2024 at 4:01 PM, the Administrator stated he expected psychiatric needs, including trauma-informed care, to be included in resident care plans. He further stated he could not describe how the facility failed to include trauma informed care on R85's care plan.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure that residents who were trauma survivors received trauma-informed care, including accounting for the resident's experiences in order to eliminate or mitigate triggers that may have caused re-traumatization of the resident for 1 of 3 residents sampled for trauma informed care, Resident (R) 85. The findings include: Review of the facility's policy titled, Behavioral Assessment, Intervention, and Monitoring, revised 03/2019, revealed the facility expected to provide residents with services to attain or maintain their highest level of mental and psychosocial function. Further review revealed the interdisciplinary team was to thoroughly assess each resident for a history of mental disorders, behavioral symptoms, including sleep disturbances, for underlying causes and to address any modifiable factors. Review of R85's Admission Record revealed the facility admitted R85 on 11/01/2021 with diagnoses including sequelae of cerebral infarction (after-effects of a stroke), post-traumatic stress disorder (PTSD), insomnia, and recurrent depressive disorders. Review of R85's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed the facility assessed R85's cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the facility included PTSD in the list of R85's active diagnoses. Continued review revealed the facility assessed R85's mood with a Personal Health Questionnaire (PHQ)-9 (depression screening tool) score of 12 out of 27, indicating moderate depression symptoms. Review of R85's Care Plan, dated 09/17/2024, revealed the facility failed to include the resident's history of traumatic life events as one of the resident's focus areas. Further review revealed the facility failed to include interventions to mitigate potential triggers related to R85's diagnosis of PTSD. Review of R85's Psychiatric Progress Note, dated 07/03/2024, revealed R85 reported to Licensed Clinical Social Worker (LCSW) 1 that her father killed her baby brother when R85 was approximately four years old. Further review revealed LCSW1 wrote that she provided a copy of this note to the clinicians caring for R85's comorbid conditions. Review of R85's Psychiatric Progress Note, dated 09/11/2024, revealed R85 reported to LCSW1 that she saw her father shoot her baby brother while trying to kill her mother when R85 was approximately four years old. Per review, R85 reported trying to fix her brother and that she never will forget it. Observation on 09/17/2024 at 11:17 AM revealed R85 lying in bed with the curtains drawn and a blanket pulled over her face. Observation on 09/19/2024 at 10:44 AM revealed R85 in bed with the curtains drawn. Further observation revealed R85 was sleeping but woke up when Licensed Practical Nurse (LPN) 2 came in to administer her medication. In an interview on 09/19/2024 at 10:44 AM, R85 pointed to a photograph on the wall, explaining that was her mother and baby brother. R85 further stated she witnessed her father shoot and kill her baby brother when she was four years old. In continued interview, R85 stated she often had trouble sleeping at night because staff members slammed doors and made a lot of noise, which startled her. Per interview, R85 stated she had never considered if the trauma from her childhood made her more sensitive to noises such as slamming doors, but she did report she had always been a nervous person since that incident. In an interview on 09/20/2024 at 1:48 PM, State Registered Nurse Aide (SRNA) 5 stated she noticed R85's social withdrawal and depression symptoms worsened for days at a time if the resident had a disagreement with her granddaughter. SRNA5 further stated she did not know details about R85's family history but knew the resident had problems with her family in the past. In an interview on 09/20/2024 at 2:12 PM, the Unit Manager for the 100 Hall could not describe how she expected staff to care for residents with a history of trauma. Per interview, she did not know what R85's history of trauma was, nor could she describe ways staff assessed for and mitigated the resident's trauma triggers. In an interview on 09/19/2024 at 2:18 PM, the Social Services Assistant (SSA) stated he was not aware of R85's history of trauma, although he had spoken with her many times about her depression. He stated the interdisciplinary team reviewed progress notes from the psychiatric nurse practitioner, so he was not able to determine why the facility had not done further investigation into the care R85 needed related to her history of domestic violence as disclosed to the psychiatric nurse practitioner. The SSA stated R85 had a history of difficulty getting along with roommates because she was annoyed by the television being on and preferred a dark room with the curtains drawn. Additionally, the SSA stated R85 had strained family relationships at times, including with her granddaughter, who was her Power of Attorney (POA). In an interview on 09/20/2024 at 3:00 PM, the Social Services Director (SSD) stated he was not familiar with the long-term care residents, including R85, as he was new to the facility and had spent much of his time coordinating discharge care needs for short term rehabilitation residents. He further stated he did not know what the role of social services would be in caring for a resident with PTSD beyond performing a trauma history screening on admission. The SSD stated if a resident scored higher than a 10 on a PHQ-9, he would expect further investigation into the cause and interventions to address the resident's psychosocial needs. In an interview on 09/20/2024 at 3:19 PM, the Director of Nursing (DON) stated she had not been aware of R85's trauma history. She further stated she did not know how the facility had failed to assess the resident for the root cause of her PTSD and potential triggers. The DON stated her expectations for providing trauma informed care were for staff to be aware if a resident had a history of being exposed to violence, because something like loud noises could cause them to self-isolate. Per interview, the DON stated mitigating triggers would promote a resident's quality of life by allowing them to increase their socialization. In an interview on 09/20/2024 at 4:01 PM, the Administrator stated he believed the interdisciplinary team did everything they could to identify a resident's history of trauma and providing care that was psychosocially supportive. Per interview, he was not able to identify how the process of identifying R85's history of trauma and potential triggers had failed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure grievances presented by the Family Council involving resident care were addressed in writing. Review of the Family Council meeting minutes and responses provided by the facility revealed multiple instances of actions taken to address grievances that had not been presented to the Family Council. The findings include: Review of the facility's policy titled, Grievances/Complaints, Filing, not dated, revealed any resident, family member, or appointed resident representative could file a grievance concerning care or treatment or lack thereof, or any other concerns regarding his or her stay at the facility. The policy stated all grievances stemming from resident or family groups concerning issues of resident care would be considered, and actions on such issues would be responded to in writing, including a rationale for the response. Finally, the policy stated the person filing the grievance or complaint would be informed verbally and in writing of the findings and actions to be taken to correct any identified problems. Review of an email (electronic mail) sent to the Administrator by the Family Council President (FCP), dated 06/15/2022, regarding a 06/11/2022 Family Council Meeting, revealed the FCP identified several grievances involving resident care. These grievances included: (1) family members that called the facility after 5:00 PM often had those calls go unanswered; and (2) some staff that worked with Resident #7 were (still) deactivating the call light prior to addressing the reason the call light was activated. Review of an email response, dated 07/08/2022, from the Administrator (designated as the facility's liaison by the Family Council) to the FCP about the 06/15/2022 email, revealed some concerns that were brought up at the June 2022 Family Council Meeting were addressed in his response. However, the concern for calls going unanswered after 5:00 PM was not addressed, nor was the concern regarding staff turning off Resident #7's call light without addressing the resident's needs. In the email, the Administrator encouraged specific resident care concerns be brought to the attention of staff. Review of an email sent to the Administrator by the FCP, dated 10/14/2022, regarding a 10/08/2022 Family Council Meeting, revealed the FCP identified several grievances involving resident care. These grievances included: (1) phone calls that were not answered after 5:00 PM, Monday through Friday; (2) phone calls on the weekends were even more difficult to get a response than during the week; (3) staff members stated they were not allowed to change residents during meal service until meal trays were delivered and picked up; and (4) call lights were deactivated without the resident's needs being addressed It was noted these issues were more prevalent on weekends. Review of an email response, dated 11/11/2022, from the Administrator to the FCP, related to the 10/14/2022 email, revealed that some concerns brought up at the by October 2022 Family Council Meeting were addressed in his response. However, the concern for phone calls not being answered after 5:00 PM on week days or on weekends was only partially addressed. Further review revealed the Administrator noted the facility was searching for a part-time receptionist to cover some of the times mentioned. No response was provided regarding the staff members' statements that they were not allowed to change residents during meal service or that call lights were deactivated before the residents' needs were addressed. Review of an email from the FCP to the Administrator, dated 02/22/2023, regarding a 02/11/2023 Family Council Meeting, revealed the FCP identified several grievances involving resident care. These grievances included lack of supplies, specifically Depends (a brand of adult disposable briefs), which was especially a concern on evenings and weekends. Review of an email response, dated 03/10/2023, from the Administrator to the FCP about the 02/22/2023 email from the FCP, revealed although some concerns brought up by the February 2023 Family Council Meeting were addressed in the response, the concern for lack of supplies, specifically Depends, was not addressed. Review of an email from the FCP to the Administrator, dated 05/25/2023, regarding a 05/13/2023 Family Council Meeting, revealed the FCP identified several grievances involving resident care, that included residents continuing to be told by staff members they could not provide incontinence (change their brief, assist with toileting) care during meal times. Review of an email response, dated 06/08/2023, from the Administrator to the FCP related to the 05/25/2023 email, revealed some concerns brought up by the May 2023 Family Council Meeting were addressed. However, the ongoing concern of staff members telling residents they could not change them during meal times was not addressed. In an interview with the FCP on 08/16/2023 at 9:50 AM, and again on 08/22/2023 at 1:14 PM, he/she stated the Family Council met monthly usually on the second Thursday of every month, and averaged thirteen (13) to fourteen (14) members. The FCP stated the concerns regarding staff deactivating call lights without providing the residents' needed care, as well as concerns of staff members telling residents they could not change them during meal service, continued to be ongoing issues. Further, the FCP stated not being able to reach facility staff by phone after 5:00 PM was not uncommon. The FCP stated not all grievances brought up in the Family Council meetings were acknowledged by the Administrator, and the FCP was rarely provided information on the facility's findings or steps staff had taken to address the Family Council's concerns. In an interview, on 08/20/2023 at 4:17 PM, with the Ombudsman, she stated the FCP had a legitimate concern regarding grievances brought up in Family Council meetings not being addressed by the Administrator. She stated the FCP and the Administrator saw things differently, with the Administrator wanting to ensure issues were addressed at the individual resident level. Whereas, she stated, the FCP wanted things addressed at the facility level. She stated the response was always in writing back to the FCP; however, sometimes the response was not specific enough to really target the grievance. For example, she stated, the grievance of staff members telling residents they could not give them assistance with toileting at meal time had a response of staff educated on answering call lights. Regarding concerns brought up over supplies, to include Depends, she stated that was brought up earlier this year in the Family Council meetings. The Ombudsman stated supplies were available, but historically agency staff had not always known where to find supplies if they were not on the unit. In an interview with the Administrator on 08/18/2023 at 1:36 PM, and again on 08/23/2023 at 9:34 AM, he stated the purpose of the Family Council was to discuss things that could improve the quality of life of residents in the facility. He stated the Family Council could offer recommendations, express concerns, and should address positive things like planning activities and things for residents. The Administrator stated the FCP sent him emails with what was discussed in Family Council meetings, which included some concerns that appeared to be resident specific. However, he stated the FCP refused to provide resident names. He stated he encouraged resident specific complaints to be addressed on an individual basis, and he did not share that information in emails. During further interview, he stated the FCP shared emails with the public at large, and he did not feel it was appropriate to share that information. The Administrator acknowledged he had not responded in writing to all concerns brought up in Family Council meetings, but had ensured audits were put in place as well as staff education when concerns were identified. He stated for general concerns brought up in the Family Council meetings, he shared that the facility did education and audits. The Administrator stated when concerns were brought up in Family Council meetings that should be resident specific, but there were no residents' names. He stated the facility was limited in what they could do to address said concerns.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of Lippincott's (2019) Nursing Procedures, (8th ed.) and review of the facility's policies, it was determined 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 and control the development and transmission of communicable diseases, including COVID-19. The facility also failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for two (2) of seventeen (17) sampled residents (Residents #11 and #15). 1. Observation of Certified Nurse Aides (CNA) #3 and #4, on 12/06/2021, and Physical Therapy staff, on 12/07/2021, revealed they wore face masks incorrectly or failed to wear face masks at all. 2. Observation of Kentucky Medication Aide (KMA) #1, on 12/06/2021, revealed she failed to perform hand hygiene and don (put on) gloves before administering eye drops to a resident. The findings include: Review of the facility's policy titled, Coronavirus Disease (COVID-19) Prevention and Control, revised August 2021, revealed facility leadership and clinical staff should maintain measures to protect the health and safety of residents and staff during the current Coronavirus Disease (COVID-19) outbreak. Further review revealed infection prevention and control (IPC) measures were based on established guidelines governing all infectious diseases. An IPC program aimed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Per the policy, standard precautions were utilized when caring for all residents, and current CDC guidelines were followed for IPC of residents diagnosed with COVID-19. Review of the facility's policy, Infection Prevention and Control Program, revised June 2021, revealed the Infection Preventionist (IP) would coordinate and oversee the IPC program. The policy stated the facility would ensure that staff would adhere to proper techniques and procedures, and the facility would provide PPE and check for its proper use. Furthermore, the facility would follow established general and disease-specific guidelines and practices of the CDC to help prevent, detect, and investigate infections in the facility. Review of the facility's policy, Handwashing/Hand Hygiene, revised 08/2019, revealed the facility considered hand hygiene as the primary means to prevent the spread of disease and infection. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient (resident), after touching a patient or the patient's immediate environment, and before preparing or handling medications. Furthermore, the policy stated all personnel shall follow hand washing/hand hygiene procedures to help prevent the development and transmission of communicable diseases and infection. Review of the CDC's guideline, Clean Hands Count for Healthcare Providers, revised 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. Review of the CDC's guideline, Interim IPC Recommendations for Healthcare Providers During the Coronavirus Disease (COVID-19) Pandemic, updated 09/10/2021, revealed facilities must implement source control, which referred to the use of respirators or well-fitting facemasks to cover a person's nose and mouth to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Review of Lippincott's (2019) Nursing Procedures (8th ed.), revealed to ensure the installation of eye drop fluids remained sterile and to reduce the transmission of infection to the resident, perform hand hygiene, and don (put on) clean gloves. Next, administer the prescribed ophthalmic solution. Per the manual, do not touch the eyeball, eyelids, or eyelashes with your hand. Finally, remove your gloves and perform hand hygiene. Review of the facility's policy titled, Administering Medications, dated April 2019, revealed the purpose of the policy was to ensure medications were administered safely. Further review revealed staff would follow established facility IPC procedures, such as hand hygiene and the use of gloves, for the administration of medications, as applicable. Per the policy, the Director of Nursing (DON) supervised and directed all personnel who administered medications. 1. Observation of Certified Nurse Aides (CNA) #3 and #4, on 12/06/2021 at 10:00 PM, revealed CNA #4 was wearing her surgical mask below her chin. CNA #3 had her mask below her nose while each provided care to Resident #15. Interview with CNA #3, on 12/06/2021 at approximately 10:00 PM, revealed that personal protective equipment (PPE) should be donned before providing care to residents. Additionally, she stated all staff was instructed to doff (take off) PPE before exiting a room, and proper hand hygiene was required of all staff before and after resident care. According to CNA #3, she did not realize that her surgical mask had slipped below her nose. She stated, at times, it was loose, and she would adjust the mask. She proceeded to adjust her mask to fit over the nose. Interview with CNA #4, on 12/06/2021 at approximately 10:00 PM, revealed she got hot while wearing a mask and was unaware she did not have her mask on correctly. She stated that masks were to be worn in the facility unless the employee was on a break and socially distanced from other staff or during meal breaks. CNA #4 stated she had received training and education on IPC practices and was aware of the facility's policy for infection control and COVID-19. Interview with CNA #8, on 12/09/2021 at 2:05 PM, revealed surgical masks should always be worn over the nose and chin. She stated staff could remove masks if in the breakroom or while on a meal break. Further, she stated it was important that staff followed the facility's policies and procedures to prevent the spread of disease and to keep residents and staff safe. Interview with Licensed Practical Nurse (LPN) #3, on 12/09/2021 at 2:26 PM, revealed masks were to be appropriately worn over the nose and chin. LPN #3 stated following IPC procedures were important to help stop the spread of disease and infection. Interview with LPN #4, on 12/09/2021 at 2:38 PM, revealed all staff must wear their masks over the nose and chin unless on a meal break. LPN #4 stated following IPC procedures were important for resident and staff safety. Continued observation of staff in the PT Department, on 12/07/2021 at 10:20 AM and 1:05 PM, revealed two (2) PT staff members were not wearing masks. There were no residents in the department at the time. Staff then put on masks when they saw the State Survey Agency (SSA) Surveyor walk by the window. Both staff members had left the building and were unavailable for interview. Interview with the Director of Rehabilitation, on 12/09/2021 at 3:25 PM, revealed it was his expectation that PT staff always wear surgical masks while in the facility. Per the interview, the Director stated he monitored staff and addressed non-compliance of IPC practices or failure to follow facility policy with staff immediately. He stated following policy and procedures was essential to prevent the spread of infection and for the safety of all residents and staff. 2. Observation of KMA #1 performing Resident #11's medication administration, on 12/06/2021 at 9:45 AM, revealed KMA #1 failed to perform hand hygiene and don (put on) gloves before administering Resident #11's eye drop instillation. Review of Resident #11's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with KMA #1, on 12/07/2021 at approximately 9:45 AM, revealed she used alcohol-based hand rub (ABHR) before entering Resident #11's room, but she did not use it immediately before administering the eye drops. She stated she did not wear gloves while performing the eye drop medication administration, but gloves should be worn according to policy and nursing standards. She stated she received IPC training upon hire and received periodic in-services related to IPC procedures. KMA #1 stated correct PPE use was essential to prevent infection transmission to residents. Interview with CNA #7, on 12/09/2021 at 1:37 PM, revealed PPE must be donned prior to providing care to residents. In addition, she stated proper hand hygiene was required of all staff before and after resident care. Furthermore, CNA #7 stated that following IPC procedures was important to help stop infections. Interview with Licensed Practical Nurse/Staffing Coordinator #2, on 12/09/2021 at 1:51 PM, revealed each employee received education on IPC and COVID-19 upon hire and throughout the year through training and in-services. Further interview revealed surgical masks should be worn appropriately, over the nose and mouth, while in the facility. Additionally, LPN #2 stated staff should use the appropriate PPE according to the type of care provided to the resident. In addition, she stated employees were only allowed to remove masks while eating. Per the interview, she stated PPE must be donned before care, and hand hygiene was performed before, after, and during care. LPN #2 stated that following IPC policies and procedures was essential to prevent the spread of infection and the safety of residents and staff. Interview with CNA #9, on 12/09/2021 at 2:19 PM, revealed surgical masks should always be worn over the nose and chin. She stated staff could remove masks if they were in the breakroom or while on a meal break. Furthermore, she noted that staff observed each other and reminded their peers regarding hand hygiene and PPE compliance. She stated she received education upon hire and by in-services. CNA #9 stated it was important that staff follow policies and procedures to prevent infection. Interview with the IP, on 12/09/2021 at 3:50 PM, revealed the facility followed national, state, and county IPC guidelines. She stated she expected staff to use proper hand hygiene techniques routinely, before and after resident care, before and after medication administration, and during medication administration, if applicable. She stated it was her expectation that all nursing staff followed IPC guidelines to decrease the chance of the spread of infections and for the safety of residents and staff. Interview with Director of Nursing (DON), on 12/09/2021 at 4:19 PM, revealed it was her expectation that all staff followed the CDC's IPC regulations and standards. Furthermore, it was her expectation that nursing staff used the proper infection control precautions and evidence-based standards of care when administering medications, such as in the Lippincott manual, used as a reference. The DON stated that she had provided one-to-one (1:1) education with KMA #1 regarding the use of appropriate PPE and correct IPC procedures while administering eye drops. Additionally, the DON stated following the correct IPC policies and procedures was vital for the safety of the residents and staff. Interview with the Administrator, on 12/09/2021 at 4:35 PM, revealed he expected IPC guidelines to be maintained by each staff member, always, while in the facility. The Administrator stated it was important to do this for the safety of residents and staff and to decrease the potential spread of disease and infection.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to implement a person-centered comprehensive care plan (CCP) to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The facility failed to follow the care plans for incontinence care, with individualized person-centered interventions for two (2) of seventeen (17) sampled Residents (Residents #1 and #12). The findings include: Review of the facility's Resident Rights Policy, not dated, revealed the resident had the right to be treated with dignity and respect including: the right to reside and receive services in the facility with reasonable accommodation of the resident's needs and preferences. Further record revealed the resident had the right to make choices about aspects of his/her life in the facility that were significant to him/her. Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised December 2016, revealed a comprehensive, person centered care plan included measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs and was developed and implemented for each resident. Per policy, care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Further review of the policy revealed the comprehensive, person centered care plan would include measurable objectives and time frames; 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. Additionally, the policy revealed identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident, were the endpoint of an interdisciplinary process. 1. Review of Resident #1's Admission Record revealed the facility admitted the resident on 05/04/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed as occasionally incontinent of bowel and bladder. Furthermore, the facility had assessed Resident #1 as requiring total dependence with two (2) person physical assistance for bathing; extensive assistance with two (2) person physical assistance for bed mobility, transfers, and toilet use; and required extensive assistance with one (1) person physical assistance for personal hygiene. Review of Resident #1's Comprehensive Care Plan (CCP), reviewed on 12/01/2021, revealed a Self-Care Deficit. The facility assessed the resident to require extensive assistance with all ADL's (Activities of Daily Living) related to Cerebral Infarction, Right [CONDITION(S)] and [CONDITION(S)], Contracture of Right Hand, Muscle Weakness, [CONDITION(S)], and mood. Goals included: resident will maintain current level of functions in Activities of Daily Living participation in daily care tasks. Interventions included: AM and PM care, and toileting with urinal with assist of one (1); bed mobility and bathing with assist of two (2). Continued review revealed Resident #1 was at risk for Urinary Tract Infections and Constipation related to needing assistance with toileting and frequent incontinent episodes of bowel and bladder. Goals included: the resident will have toileting/incontinence needs met. Interventions included: offer assist with toileting with Certified Nurse Aide (CNA) rounds; assist as needed upon the resident's request; staff will assist with transfers and toileting as per ADL care plan, and resident required check and change, as needed. Interview with Resident #1 on 12/09/2021 at 1:42 PM, revealed on 12/02/2021 he/she used the call light around 8:00 PM, because he/she had an incontinent episode. Resident #1 stated Registered Nurse (RN) #1 came into the room, informed him/her that he was busy with giving out pills, and would send a CNA to change him/her. Resident #1 stated RN #1 turned the call light off. At the time of the incident, Resident #1 stated he/she was on the phone with his/her brother, and he/she told his/her brother that the nurse left. According to Resident #1, CNA #6 provided care, but he/she had to wait until his/her brother came to the facility over two (2) hours later. Continued interview with Resident #1, revealed that on 12/04/2021, during his/her lunch meal, he/she had an incontinent bowel and bladder episode. Resident #1 stated he/she used the call light, at 11:55 AM, and it took staff a long time to answer it. He/she further stated when CNA #13 came in, she turned off the call light and told him/her that she would be back after she was finished passing trays and feeding residents. The resident could not identify the female staff member. He/she further stated he/she waited about two (2) hours, and when the aide did not return after lunch to provide care, he/she pressed the call light. When staff did not answer the light, he/she yelled for the nurse (LPN #6). He/she stated, It was about 1:55 PM when the nurse cleaned me up. Additional interview revealed Resident #1 stated he/she had no appetite to eat lunch, because he/she was left to sit in a soiled brief. Interview with FM #1, on 12/09/2021 at 11:40 AM, revealed that his sibling, Resident #1, was left in a wet and soiled brief for over two (2) hours on 12/02/2021 while he was on the phone him/her. According to FM #1, the resident used the call light, and the nurse (RN #1) came in the room and told the resident that he was busy and could not change him/her. FM #1 stated the nurse proceeded to turn off the light and leave the room. Continued interview revealed on 12/04/2021, a similar incident occurred when his sibling had to wait through lunch to be changed after wetting himself/herself and having a bowel movement. Interview with LPN #6, on 12/09/2021 at 11:50 AM revealed that she was working during the day on 12/04/2021. She stated while sitting at the nurses' station, after lunch trays were passed, she heard Resident #1 yell her name. She stated his/her call light was not on at the time she heard the resident call out for help. LPN #6 stated she went into the room and asked Resident #1 what was wrong. The LPN stated Resident #1 told her that he/she had used the call light during lunch and the aide came in and turned off the call light and left the room. LPN #6 asked Resident #1 what he/she needed. According to LPN #6, the resident stated he/she had waited all through lunch to be changed. LPN #6 stated she changed the resident's brief, which she stated was wet, with a small bowel movement. LPN #6 stated that the bowel movement was fresh and did not appear as if Resident #1 had been laying in a soiled brief for long. When asked what the process was for answering lights during lunch, LPN #6 stated between passing trays, call lights were answered. However, if a resident needed incontinence care, We go ahead and finish the trays and feeders, and then go back and answer lights. 2. Review of Resident #12's Admission Record revealed the facility readmitted the resident on 10/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Quarterly MDS, dated [DATE], revealed the resident had a BIMS' score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was always incontinent and the facility had assessed Resident #12 as requiring extensive assistance with two (2) person physical assistance for transfers and toilet use; and required extensive assistance with one (1) for personal hygiene. Resident #12 required total dependence with one (1) person physical assistance for bathing. Review of Resident #12's CCP, reviewed on 12/01/2021, revealed a Self-Care Deficit as assist to total dependence of ADL's related to weakness, [CONDITION(S)], and Stiff Man Syndrome. Goals included: the resident would continue to eat with assistance through next review. Interventions included: incontinence care, AM and PM care, dressing, bed mobility, toileting, and bathing with assist of one (1); transfers with assist of two (2). Continued review revealed Resident #12 was incontinent of bowel and bladder and at risk for complications due to need for assistance. Goals included: the resident will have toileting/incontinence needs met, and resident required check and change with CNA rounds. Interventions included: bowel and bladder assessments quarterly to assess for changes in continence; labs; skin assessments weekly; observe, document, and notify physician of symptoms of a Urinary Tract Infection. Interview with Resident #12, on 12/06/2021 at 9:50 PM, revealed he/she was assisted by staff to his/her wheelchair after breakfast. Resident #12 stated if he/she had an incontinent episode after the staff transferred him/her to the wheelchair, the resident was told he/she had to wait to be changed until after lunch. He/she stated that this was not a one-time occurrence, as he/she has had to wait on multiple occasions for assistance after he/she was incontinent of bowel and bladder. He/she stated the staff will come into his/her room and turn off the call light, and state they will be back with help. However, Resident #12 stated they do not come back as they say they will, and he/she must continue to use the call light. Interview with Resident #13, on 12/07/2021 at 9:10 AM, revealed he/she was Resident #12's roommate. Resident #13 stated he/she has witnessed Resident #12 sitting for long periods in his/her wheelchair through lunch. Review of Resident #13's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Interview with the Quality Assurance Nurse (QA) on 12/08/2021 at 3:50 PM, revealed the CCP should be developed/revised with specific information on how to take care of each resident. She further stated nursing was responsible for CCP implementation. Interview with the Director of Nursing (DON), on 12/07/2021 at 9:40 AM, revealed the facility functioned as a team and each discipline worked to update the CCP. The DON stated the CCP was developed and updated by the MDS Nurse and nursing staff. She stated the CCP was a working document and was to reflect the resident's current status. Additionally, she stated the CCP gave direction to the staff for providing individualized care to residents. She stated changes in condition were discussed at care plan meeting and each team member contributed to developing an individualized care plan. Per interview, the interdisciplinary team, consisted of the DON, MDS Coordinator, nurses, and the clinical departments reviewed residents. Interview with the DON, on 12/08/2021 at 10:45 AM, revealed staff complete check and change rounds before any meal service. She stated that once the trays were delivered to the units and staff begin to pass trays, the priority was to feed residents in need of assistance and supervision. She stated staff will answer the lights, and let the resident know that someone will be back when all these residents were fed. Continued interview revealed when meals were finished, the staff would go back and answer lights and provide incontinence care. She stated, If you are eating lunch and have a brief on, it will wick it away. The DON further stated staff would probably change a resident who had a bowel movement. Additionally, the DON stated, You can't leave food, even if someone has had a BM. When asked how long a resident might have to wait to be changed during a meal service, the DON replied that it depends on the situation. If staff were feeding a resident, they do that first and then attend to the resident who needed to be changed as promptly as they could. Furthermore, the DON stated that the CNAs could ask the Unit Managers, Activities, and Restorative for help. When asked what happens on evening shifts when extra staff was not available to help, she stated the resident would be changed as soon as staff could get to them. Interview with the DON, on 12/09/2021 at 4:19 PM, revealed it was her expectation that the CCP should provide care to meet the resident's individualized needs. Furthermore, it was her expectation that the MDS Coordinator and nurses developed and updated the CPP. All nursing staff was responsible to ensure the CPP was implemented. Interview with Administrator, on 12/09/2021 at 4:35 PM, revealed it was his expectation that nursing staff develop, update, and follow the CCP to provide individualized care to meet the resident's needs.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for two (2) out of seventeen (17) sampled residents (Residents #1 and #12). Interview with residents and family members revealed call bells were not answered at times for over an hour. Also, Resident #1, Family Member (FM) #1, and Resident #12 complained of having to wait during meal services to be changed and receive incontinence care. Interviews with staff revealed residents wait for incontinence care until the meal service was ended. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed the resident had the right to be treated with dignity and respect including: the right to reside and receive services in the facility with reasonable accommodation of the resident's needs and preferences. In addition, the policy stated the resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Review of the facility's policy titled, Care Plans, Comprehensive Person Centered revised December 2016, revealed the comprehensive, person centered care plan, required for all residents, would include measurable objectives and time frames; 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. Additionally, the policy revealed identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident were the endpoint of this interdisciplinary process. 1. Review of Resident #1's medical record revealed the facility admitted the resident, on 05/04/2013, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/23/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #1 as requiring total dependence with two (2) person physical assistance for bathing; extensive assistance with two (2) person physical assistance for bed mobility, transfers, and toilet use; and required extensive physical assistance with one (1) person for personal hygiene. According to the MDS Assessment, Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's Comprehensive Care Plan (CCP), reviewed on 12/01/2021, revealed a Self-Care Deficit, as evidenced by the resident requiring extensive assistance with all activities of daily living (ADL) related to the Cerebral Infarction, Right [CONDITION(S)] and [CONDITION(S)], Contracture of Right Hand, Muscle Weakness, [CONDITION(S)], and mood. Goals included: resident would maintain current level of functions in ADL participation in daily care tasks. Interventions included: ambulation with platform walker, transfer, morning and evening care, toileting with urinal, and dressing with assist of one (1); and bed mobility and bathing with assist of two (2). Continued review revealed Resident #1 was at risk for Urinary Tract Infections and Constipation related to needing assistance with toileting and frequent incontinent episodes of bowel and bladder. Goals included: the resident would have toileting/incontinence needs met. Interventions included: offer assistance with toileting with Certified Nurse Aide (CNA) rounds; assist as needed upon the resident's request; staff would assist with transfers and toileting as per ADL care plan, and resident required check and change with CNA rounds. Observation of Resident #1, on 12/06/2021 at 9:59 PM, revealed the resident was in the bed lying on his/her left side. He/she appeared to be sleeping. The resident was clean without odor and had on a clean gown. The bed sheets and blanket were clean. There was no trash or clutter in the room. The room light was on, and the television was on with a low volume. The bedside table was up against the side of the bed, and personal items were within reach. Observation of Resident #1, on 12/06/2021 at 10:30 PM, revealed the resident was in the bed lying on his/her left side. He/she appeared to be sleeping. The State Survey Agency (SSA) Surveyor rang the call light. CNA #6 came into the room within thirty (30) seconds. Observation of Resident #1, on 12/07/2021 at 9:45 AM, revealed the resident was in the bed lying back with the head of the bed slightly elevated. He/she appeared to be sleeping as evidenced by snoring. The resident was clean and had on a clean gown. The bed sheets and blanket were clean. There was no trash or clutter in the room. The bedside table was up against the side of the bed, and personal items, including drinks, were within reach. Interview with Resident #1, on 12/09/2021 at 1:42 PM, revealed on 12/02/2021 he/she used the call light around 8:00 PM because he/she had an incontinent episode. Resident #1 stated Registered Nurse (RN) #1 came into the room, informed him/her that he was busy with giving out pills and would send a CNA to change him/her. Resident #1 stated RN #1 turned the call light off. At the time of the incident, Resident #1 stated he/she was on the phone with his/her brother, and he/she told his/her brother that the nurse left. According to Resident #1, staff did not come back into the room for over two (hours). He/she stated his/her brother (FM #1), who remained on the phone during the entire time interval, was mad that they left me wet and didn't come back like the nurse said they would. Continued interview with Resident #1, on 12/09/2021 at 1:42 PM, revealed on 12/04/2021, during his/her lunch meal, he/she had another incontinent bowel and bladder episode. Resident #1 stated he/she used the call light at 11:55 AM, and it took staff a long time to answer it. He/she further stated when an aide came in, she turned off the call light and told him/her that she would be back after she was finished passing trays and feeding residents. The resident could not identify the female staff member. He/she further stated he/she waited about two (2) hours and then began to yell for the nurse, Licensed Practical Nurse (LPN) #6, when the aide did not return. He/she stated, It was about 1:55 PM when the nurse cleaned me up. Additional interview revealed Resident #1 stated he/she had no appetite to eat lunch, because he/she was left to sit in a soiled brief. Interview with FM #1, on 12/09/2021 at 11:40 AM, revealed that his/her sibling, Resident #1, was left in a wet and soiled brief for over two (2) hours on 12/02/2021, while he/she was on the phone him/her. He stated appropriate services were not being provided to his/her sibling. According to FM #1, the resident used the call light, and the nurse (RN #1) came in the room and told the resident that he was busy and could not change him/her. FM #1 stated the nurse proceeded to turn off the light and leave the room. FM #1 further stated he/she felt that Resident #1 was being retaliated against because he/she was very vocal about the care his/her sibling received. Additionally, FM #1 revealed he/she was frustrated that the facility did not take seriously the multiple care issues he/she had brought to staff's attention, which affected residents other than his/her sibling. Interview with LPN #6, on 12/09/2021 at 11:50 AM, revealed she was working during the day on 12/04/2021. She stated while sitting at the nurses' station, after lunch trays were passed, she heard Resident #1 yell her name. She stated it was easy to hear, as Resident #1's room was near the station. She stated his/her call light was not on at the time, when she heard the resident call out for help. She stated she went into the room and asked Resident #1 what was wrong. Per the interview, Resident #1 stated that he/she had used the call light during lunch, and CNA #13 came in and turned off the call light and left the room. According to LPN #6, the resident stated he/she had waited all through lunch to be changed. LPN #6 stated she changed the resident's brief, which was wet and with a small bowel movement. LPN #6 stated that the bowel movement was fresh, and it did not appear as if Resident #1 had been laying in it for long. Telephone interview with CNA #13, on 12/09/2021 at 11:49 AM, was attempted, but there was no answer, and the voicemail feature was not available. Interview with the Director of Nursing (DON), on 12/08/2021 at 10:45 AM, revealed staff did check and change rounds before any meal service. She stated that once trays were delivered to the units and staff began to pass trays, the priority was to feed residents in need of assistance and supervision. She stated staff would answer call lights, and let the resident know that someone would be back when all residents were fed. Further, she stated when meals were finished, staff would answer lights and provide incontinence care. She stated, If you are eating lunch and have a brief on, it will wick it [urine] away. The DON further stated staff would probably change a resident who had a bowel movement (BM). Additionally, the DON stated, You can't leave food, even if someone has had a BM. She stated if staff was feeding a resident, the staff member would finish that and then attend to the resident who needed to be changed as promptly as the staff member could. Furthermore, the DON stated the CNA's could ask the Unit Managers, Activities staff, and Restorative staff for help. In addition, she stated on evening shifts when extra staff was not available to help, she stated the resident would be changed as soon as staff could get to them. 2. Review of Resident #12's medical record revealed the facility readmitted the resident, on 10/14/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Quarterly MDS Assessment, dated 11/23/2021, revealed the resident had a BIMS' score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #12 as requiring extensive assistance with two (2) person physical assistance for bed mobility, transfers, and toilet use; and required extensive assistance with one (1) person physical assistance for dressing and personal hygiene. Resident #12 required total dependence with one (1) person physical assistance for bathing. According to the MDS Assessment, Resident #12 was always incontinent of bowel and bladder. Review of Resident #12's CCP, reviewed on 12/01/2021, revealed a Self-Care Deficit, as evidenced by the resident requiring assistance to total dependence of ADL's related to weakness, [CONDITION(S)], and Stiff Man Syndrome. Goals included: the resident would continue to eat with assistance through next review. Interventions included: incontinence care, morning and evening care, dressing, bed mobility, toileting, and bathing with assist of one (1); transfers with assist of two (2). Continued review revealed Resident #12 was incontinent of bowel and bladder and at risk for complications due to need for assistance. Goals included: the resident would have toileting/incontinence needs met, and the resident required check and change with CNA rounds. Interventions included: bowel and bladder assessments quarterly to assess for changes in continence; labs; skin assessments weekly; and observe, document, and notify physician of symptoms of a Urinary Tract Infection. Observation of Resident #12, on 12/06/2021 at 9:50 PM, revealed the resident was lying in bed, watching television. Resident #12 appeared clean without odor. Resident #12's bed linens were clean, and the room was clean and tidy. Observation of staff answering call lights for Resident #13, Resident #12's roommate, on 12/07/2021 at 9:10 AM, after the SSA Surveyor rang the call light in Resident #13's room revealed CNA #12 came into the room within three (3) minutes. Interview with Resident #12, on 12/06/2021 at 9:50 PM, revealed he/she was assisted by staff to his/her wheelchair after breakfast. Resident #12 stated if he/she had an incontinent episode after the staff transferred him/her to the wheelchair, the resident was told he/she must wait to be changed until after lunch. He/she stated this was not a one-time occurrence, as he/she has had to wait on multiple occasions for assistance with incontinent care. He/she stated the staff would come into his/her room, turn off the call light, and state he/she would be back with help. However, Resident #12 stated staff did not come back, and he/she must continue to use the call light. Interview with Resident #13, on 12/07/2021 at 9:10 AM, revealed the staff would often turn off the call light and then leave the room. Resident #13 stated he/she had witnessed Resident #12 sitting for long periods in his/her wheelchair. Review of Resident #13's Quarterly MDS Assessment, dated 10/21/2021, revealed the resident had a BIMS score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Interview with CNA #12, on 12/07/2021 at 1:20 PM, who cared for Residents #12 and #13, revealed that sometimes the residents had to wait to get changed if staff was giving baths or passing trays. She stated that CNA's did check and change rounds and turned and repositioned residents every two (2) hours and as needed. She stated further that the priority during lunch was to pass trays and care for residents who needed assistance or supervision with meals. Additionally, CNA #12 stated that staff tried to answer call lights within two (2) to three (3) minutes. Interview with CNA #7, on 12/09/2021 at 1:37 PM, revealed call lights were answered as soon as staff heard them. Per the interview, CNA #7 stated staff would pass trays and answer call lights. She stated on the hall where she worked, everyone was to answer lights. She stated aides did rounds every two (2) hours and as needed on every resident. She stated incontinent residents were checked and changed, turned, and reposition during rounds. Interview with CNA #8, on 12/09/2021 at 2:05 PM, revealed she tried to answer call lights within two (2) to three (3) minutes. She stated aides did rounds every two (2) hours and as needed on every resident. Per the interview, CNA #8 stated that the priority during lunch was to pass trays and care for residents who needed assistance or supervision with meals. Interview with LPN #4, on 12/09/2021 at 2:38 PM, revealed she worked the D Unit. She stated she expected staff to answer call lights within three (3) to five (5) minutes. She stated that if staff needed assistance, or could not complete the task, he/she was to leave the call light on and explain to the resident that he/she would be back with help. Additional interview with the DON, on 12/09/2021 at 4:19 PM, revealed that it was her expectation that staff attend to a resident's request immediately if they have the ability to do so at the time. She stated further that there would be circumstances when staff could not assist the resident immediately, but they should do it timely. She stated this was important for the safety of the residents and to provide quality care. Interview with the Administrator, on 12/09/2021 at 4:35 PM, revealed his expectation of staff was that they would not leave a resident in a wet or soiled brief for an extended period of time. He stated staff should answer call lights within a reasonable amount of time and residents' needs should be met as soon as staff could gather equipment and supplies, and if needed, a second person to assist. He stated it was important for the safety, comfort, and well-being of the residents.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure residents were able to exercise their right to view the results of the facility's most recent State Survey and Plan of Correction. The facility failed to ensure residents and/or families were aware of the location of the survey results and/or the results were not easily accessible to them. Observations, on 12/06/2021 through 12/09/2021, revealed the survey results were not readily accessible to residents, family members, and legal representatives of the residents. The survey result binder was located at an entrance where visitors did not enter. In addition, Resident #1's family member/Power of Attorney (POA) voiced concern that he was unaware of the location of the survey results and had to ask staff to see a copy of the survey book. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents were entitled to exercise his/her rights and privileges as a resident of the facility and as a citizen of the United States, to the fullest extent possible without interference, coercion, discrimination, or reprisal. Observation, on 12/06/2021 at 9:00 PM, revealed the front door leading into the front lobby was no longer being used as the main entrance into the facility due to COVID-19 operational changes. The front lobby was open; however, the front entrance leading directly into the lobby was locked and visitors were directed to the back entrance where all staff and visitors entered. Continued observation revealed the back entrance did not have the survey binder containing the most recent Federal and State survey results. In addition, there was not a notice posted on the availability of the reports at the back entrance of the facility. Observation, on 12/06/2021 at 9:10 PM, revealed the Federal and State survey results were in a white binder located in the facility's front lobby, on top of the reception desk, which the residents or residents' families would not walk through that area now. Record review revealed the facility assessed Resident #10 as having a Brief Interview for Mental Status (BIMS') score of fifteen (15) out of fifteen (15), indicating intact cognition on the most recent Quarterly Minimum Data Set (MDS) Assessment, dated 09/24/2021. Interview with Resident #10, on 12/06/2021 at 10:15 PM, revealed that he/she had never examined the survey book and was unsure where it was located. Record review revealed the facility assessed Resident #12 as having a BIMS' score of thirteen (13) out of fifteen (15), which indicated the resident had intact cognition on the most recent Quarterly MDS Assessment, dated 11/19/2021. Interview with Resident #12, on 12/07/2021 at 9:10 AM, revealed that he/she was unsure where survey results were located. Record review revealed the facility assessed Resident #13 as having a BIMS' score of fourteen (14) out of fifteen (15), which indicated intact cognition on the most recent Quarterly MDS Assessment, dated 10/20/2021. Interview with Resident #13, on 12/07/2021 at 9:30 AM, revealed that he/she was unsure where the survey results were located. Interview with Resident #1's family member/POA, on 12/09/2021 at 11:24 AM, revealed he was never made aware of the survey result binder's location, nor had he ever examined the survey results. Additionally, he stated when he asked staff members for the binder, he was told it was locked in the Administrator's office. Interview with Resident #14's family, on 12/09/2021 at 1:55 PM, revealed she had never examined the survey book and was not sure where it was located. However, she stated, I could always ask someone where it is. Interview with Resident #16's family member, on 12/09/2021 at 3:21 PM, revealed she was aware that a survey book existed. She stated it used to be in the front lobby, but she was unsure where it was currently located, since visitors no longer entered through the front entrance. Interview with Certified Nurse Aide (CNA) #7, on 12/09/2021 at 1:37 PM, revealed she was unaware of the location of the survey results binder. CNA #7 stated it might be in the Administrator's office. She stated it was important for residents to know where the survey binder was located and that they had easy access to it because they had a right to be informed of survey results. Interview with Licensed Practical Nurse/Staffing Coordinator (LPN) #2, on 12/09/2021 at 1:51 PM, revealed the survey results were in the front lobby. She stated it was important for residents to know where the binder was located because they had a right to be informed of survey results. Interview with CNA #8, on 12/09/2021 at 2:05 PM, revealed she was unaware of the location of the survey results. She stated residents had a right to know what problems the surveyors found, which needed to be addressed. Interview with LPN #3, on 12/09/2021 at 2:26 PM, revealed the survey results were on the desk located in the front lobby. LPN #3 stated it was important for residents and families to know the location of the survey binder because they had a right to be informed of survey results. Interview with LPN #4, on 12/09/2021 at 2:38 PM, revealed she believed the survey binder was located on the desk in the front lobby. She stated residents had a right to be informed of survey results to ensure they knew what issues needed to be addressed in the facility. Interview with LPN/Unit Manager #5, on 12/09/2021 at 2:48 PM, revealed the survey binder was located on the desk in the front lobby. She stated residents always had access to view the survey results. Further, she stated if a resident or family member did not know where it was or had difficulty accessing the binder, they could ask a staff member. She stated it was essential to have access as residents and family members had a right to be informed of survey results to ensure they knew what issues needed to be addressed in the facility. Interview with the Director of Nursing (DON), on 12/09/2021 at 4:19 PM, revealed survey results were currently kept in the front lobby entrance. She further stated a copy of the survey results binder was not kept in the back lobby entrance, where visitors and residents entered. She also stated if a resident requested to view the survey results binder, staff would assist the resident with getting the binder. The DON stated it was her expectation the facility and staff made survey results readily available to all residents and families. Per the interview, the DON stated it was an important resident right to have full access to the most recent State and Federal survey results without having to ask staff. Interview with the Administrator, on 12/09/2021 at 4:35 PM, revealed the survey result binder was in the front lobby on the lower section of the reception desk. He stated this location was easily accessible and open to all residents and visitors, even though the main entrance had changed from the front door to the back door. He stated further that a copy of the survey results binder had not been provided at the back door entrance, and there were no signs in the back entrance reception area regarding the location of the survey binder. Per the interview, residents were made aware of the location of the survey results binder by the Activities Director and the Ombudsman. He stated staff would provide the survey results binder to residents whenever they asked to see them. The interview further revealed it was the Administrator's expectation the facility made survey results readily available to the residents. He stated it was important as the residents and the residents' families had the right to know the survey results.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents and/or their families had the right to organize and participate in a family group, with private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. The findings include: Observation of the facility, from 07/26/2021 to 08/03/2021, revealed no obvious physical notification of a Family Council's existence or meeting times and locations. Interview with Family Member (FM) #1, on 07/26/2021 at 1:13 PM, revealed that a family council had been formed for relatives of residents at the facility, with membership including himself. He further stated the Administrator had tried to block the council. FM #1 stated the founding members had done research on the regulations and determined the facility was obliged to provide a private place for the council to meet and a facility liaison, but no staff member had been named, which both the Administrator and families could agree. He further stated another member of the family council had contacted the social worker, but had not received a return call. He additionally stated the Administrator wanted the liaison to be a staff member, thought to be a Certified Nursing Assistant (CNA), and not a social worker. FM #1 stated the Administrator doesn't know I know this, but he wants to only distribute information about family council during family care meetings, but we haven't had one in at least six months. He further stated the Administrator had agreed to make roped off space available outside for the first meeting in June 2021, with chairs and a sun canopy, but the Administrator did not. FM #1 additionally reported the Ombudsman was there. FM #1 stated they were able to meet in the dining room for the July 2021 meeting, but it was not private. He stated the Administrator agreed later to provide a private place for the August meeting, but the Covid restrictions would cause limitations. Interview with Licensed Practical Nurse (LPN) #1, on 07/27/2021 at 2:25 PM, revealed she was not aware of a family council. Interview with State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #2, on 07/27/2021 at 4:39 PM, revealed he was unaware of a family council. Interview with SRNA #1, on 07/28/2021 at 4:30 PM, revealed she was not aware of any family council details. Interview with the Medical Director, on 08/03/2021 at 3:46 PM, revealed he was not aware of a family council or anything about any family members' request to form a council. He stated it was an excellent idea for providing extra support to improve the residents' quality of life. Interview with the Director of Nursing (DON), on 07/28/2021 at 2:22 PM, revealed she stated if a resident's relative wanted a family council, which was fine, there was a process and procedure to be followed, but she did not detail what those would be. She further stated that Covid was increasing, so for safety, family members could be required to wear face masks and socially distance, which limited possible locations for the meeting. Additional interview with the Director of Nursing (DON), on 07/29/2021 at 6:19 PM, revealed the Administrator was not opposed to a family council, but he needed to be sure it was safe, within guidelines, and located where it could happen inside the facility with social distancing and masking. Interview with the Activities Director, on 07/28/2021 at 3:54 PM, revealed she had worked in long-term care for about forty (40) years and maintained her CNA license, helping with patient care as needed. She reported awareness of efforts for a family council, though she was not involved in it, as a staff member or liaison. She stated the family member who had led the pursuit of a family council had wanted to do that for a while now. She stated a family council's purpose should be to help families have a voice, and that others, she had been aware of through her past experiences, have had fund raisers for extras, support for outings, and held family events. She stated the council had only recently started and met in the dining room, with the current plan being that the family council could meet next time, in August 2021, in the conference room. The Activities Director stated the family council should have a staff liaison to help facilitate logistics, otherwise everything was up to the council. Interview with the Administrator, on 07/29/2019 at 9:10 AM, revealed he had spoken with the family member who was leading the pursuit of a family council, and this occurred a week or two (2) ago. He stated the council initially met the second Saturday in July, in the dining room. The Administrator further stated that one (1) of the issues was that it was just starting, so there were kinks to work out in the process. He additionally stated he and the council still had not agreed upon a staff member to be the liaison, and he believed the family member preferred that he, the Administrator, would fulfil this duty. The Administrator stated the social services discipline would be the reasonable choice for supporting a family council and suggested the facility social services assistant be the liaison. He stated the family member rejected that out of hand. He further stated the facility had not received any minutes or any topics discussed at a meeting. The Administrator stated he had talked to the family member about the council but with no start date or specifics. The Administrator also stated the council met in the dining room, but the family member had stated it was not private enough. The Administrator stated he did not know who published the flyer. He stated the facility had the responsibility to inform and notify family members of the council, and they had done that verbally through the care conferences. Also, he stated, if there was a published announcement, there should be an agreement about what should be on the announcement between the facility and the council. Telephone interview with the Ombudsman, on 07/30/2021 at 9:30 AM, revealed the council was about to have its third meeting in August, and the second one was the second Saturday of July. She stated they asked the Administrator to publish something about the family council starting and to please let the council know where a meeting could be held. She stated the Administrator told her he would get back to her, but did not. She further stated when they arrived for the June 2021 meeting, nothing was set up, and the staff knew nothing about the meeting. She additionally stated they were then forced to meet in the parking lot. The Ombudsman stated she asked her supervisor to get involved; however, then the Administrator made arrangements for the council to meet in the dining room for July, where they did meet. She related the problem with meeting in the dining room was staff kept walking around them, in and out. She stated they all understood staff was performing work, but it was not as private as it should have been. She stated she posted flyers about the meeting, on 07/21/2021. In addition, she reported, on 07/23/2021, the Administrator called by phone to ask if she posted them. When she confirmed she had, she reported he stated he removed them because he did not like the wording and thought it was too early for flyers. The Ombudsman related the Administrator told her he would change what was on the flyers, but then stated he preferred to notify families during care plan meetings. She stated she told the Administrator notification during care plan meeting would not work due to the extended timeline, but he did not give a response to this. The Ombudsman stated there had been no further conversations with the Administrator about the family council, and she hoped the Administrator would publish some form of notification of the council meetings for residents/families. Review of the initial email from FM #1 to the Administrator, the Regional Ombudsman, and the facility's Ombudsman, dated 04/09/2021, revealed notification of the effort to start a Family Council. The email also requested the Administrator's assistance by including a flyer in monthly billing statements and/or attached to the facility's Resident and Responsible Party emails, in order to help with informing others who might be interested in the council. Review of forwarded text from the facility Ombudsman to the Administrator, dated 06/11/2021, revealed she informed the Administrator that she had received a telephone call from FM #1, on 06/10/2021, asking if everything was set up for the family council meeting on 06/12/2021. The Administrator replied he would confirm and contact her on that date. The Ombudsman also included a text to state that she never heard back from the Administrator. Review of an email from the Regional Ombudsman to the Administrator, dated 06/14/2021, informed the Administrator that she and the facility Ombudsman had been communicating with FM #1 about the start of a family council. The email further revealed that the first meeting had been held, on 06/12/2021, with the few people with whom they were able to communicate with directly. The email additionally requested that the Administrator include a flyer inside one (1) of the regularly planned mailings to families, as well as to continue to send an invitation a couple of times per year so that new family members would become aware. Additional interview with the Administrator, on 08/02/2021 at 3:10 PM, revealed he could not remember when he was first approached about the family council meeting with any detail but that he had been in contact with FM #1, who did not give any reason why he wanted to form the family council. He further stated he received a recent email from FM #1, around 07/30/2021, about another family council meeting. He stated the council had one (1) family council meeting in the dining room, in July. He further stated he did not know who posted the family council posters and who took them down. He further revealed he was not aware of the June family council meeting. Telephone interview with FM #2, on 08/03/2021 at 10:22 AM, revealed he had received an email text about visitation but did not receive a message about a family group council meeting. Interview with FM #3, on 08/03/2021 at 1:00 PM, revealed she attended the Family Council meetings in June and July. She stated they were trying to work with the Administrator, however, he would not inform other families about the meetings. She stated the Administrator did not send out flyers or send any text messages out to other families about the Family Council. She further stated he did not respond to her concerning notifying other families about the Family Council meetings.

Based on interview, record review and facility policy review, it was determined the facility failed to have an effective system in place for the availability of an on call physician and the alternate covering for the physician for one (1) of twelve (12) sampled residents (Resident #4). The facility failed to ensure pain medication was obtained timely from the Pharmacy for Resident #4 because the resident's Physician and/or Advanced Registered Nurse Practitioner (APRN) could not be contacted/and or did not respond to a request for a new prescription for a narcotic pain medication. Resident #4 went approximately twenty-two (22) hours without receiving the narcotic pain medication he/she requested, ordered for knee pain every four (4) hours as needed. The findings include: Review of the facility's policy titled, Medication Ordering and Receiving From Pharmacy, undated, revealed if new medication orders were needed before the next regular delivery, the nurse must fax and phone in the medication order to the pharmacy immediately upon receipt. Further, if the order was on Sunday, the nurse was to phone the pharmacy. Additionally, if the pharmacy did not answer, the policy instructed the nurse to follow the emergency procedure to contact the pharmacy. Further review of the policy revealed that timely delivery of new orders was required so that medication administration was not delayed and that the emergency kit was used when the resident needed a medication prior to pharmacy delivery. Review of the facility's policy titled, Emergency Pharmacy Service and Emergency Kits, undated, revealed the nurse must determine if the order could not be delayed until the scheduled pharmacy delivery, then ascertained whether the ordered medication was contained in the emergency kit by referring to the list of contents posted. Review of the facility's policy titled, Pain Assessment and Management, undated, revealed a section titled General Guidelines. Those guidelines included that the pain management program was based on a facility-wide commitment to resident comfort as well as a multidisciplinary care process including assessing the potential for pain, effectively recognizing the presence of pain, monitoring the effectiveness of interventions, asking the resident if he/she was experiencing pain and reviewing the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the eBox (emergency box) inventory sheet revealed that Oxycodone (a narcotic pain medication), five (5) milligram (mg) tablets were among the available medications. Review of Resident #4's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview with Resident #4, on [DATE] at 5:04 PM, revealed the resident was resting in bed with the call light and personal items in reach. The resident stated that his/her pain control had been inadequate the day before, on [DATE], a Sunday. He/she stated he/she had been transferred from the facility to an acute care hospital, on [DATE], for removal of a total knee replacement hardware, as well as placement of an antibiotic spacer and a wound vacuum. The resident stated he/she then returned for readmission to the facility, on [DATE], to receive intravenous (IV) antibiotics to manage the infection in the replaced knee. He/she stated a nurse, on Friday, [DATE], had told him/her the count on his/her pain medication, Oxycodone, was six (6) tablets, and it was ordered every four (4) hours as needed. He/she further reported, on the morning of [DATE], the pain medication supply was exhausted, and nobody had requested a refill. Resident #4 stated the nurse on duty had reported to him/her that she had called the doctor but that he had not responded, and the nurse on the previous shift had not requested a refill. The resident stated he/she was offered to be sent to the Emergency Department (ED), at a local hospital, for pain control; but, the resident declined because he/she did not want to get behind on antibiotic administration that was the main purpose of being in the facility. Resident #4 stated the night nurse, Licensed Practical Nurse (LPN) #13, was able to get the order for pain medication right away, by about 8:00 PM on [DATE]. Resident #4 stated it seemed like an undue hardship to be without pain medication for so long. Additional interview with Resident #4, on [DATE] at 5:25 PM, revealed his/her knee pain was rated ten out of ten (,d+[DATE]) on the morning of [DATE]. Resident #4 further stated that repositioning and ice application helped to make the knee pain more tolerable, but there were no other non-medicine interventions for pain other than the nurse offered to send him/her to the ED at about 6:30 PM, near the end of the day shift. Resident #4 stated that he/she did not specifically recall rating his/her knee pain on that day, Sunday, [DATE], and acknowledged the nurse would ask about his/her pain when in the room for other medications, but did not come in the room just specifically regarding pain. Resident #4 stated the nurse apologized and reported that she was trying to reach the Medical Director. Resident #4 stated he/she did not know the specific times contact with the Medical Director was attempted, but that getting the Oxycodone made a significant difference in pain, from a rating of ,d+[DATE] to ,d+[DATE]. He/she further stated that the knee pain never fell below a pain rating of ,d+[DATE]. Resident #4 stated, The night nurse came in at 7:00 PM and got the eBox order by about 8:00 PM. I was disappointed, anxious, angry. I felt that I was undergoing undue suffering. I felt I was being victimized by an incompetent nurse. I felt helpless. Review of Resident #4's narcotic tracking documentation confirmed that he/she had the prescription for twenty (20) tablets of Oxycodone ten (10) mg on hand, written by the acute care hospital physician, beginning on [DATE], and that by Friday, [DATE] at 1:00 PM, Resident #4 had six (6) tablets left on that prescription. According to the narcotic sheet, one (1) tablet was removed on [DATE] at 9:40 PM; on [DATE] at 6:00 AM, 10:04 AM, 5:50 PM, and 11:00 PM. Review of Resident #4's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At that point, the narcotic documentation revealed there were no more tablets on that prescription. Review of Resident #4's Progress Notes, from [DATE] at 6:17 PM, revealed LPN #7's note stating that Resident #4 was out of her Oxycodone 10 mg, and Resident #4 had asked for this medication multiple times that day. The notes further revealed LPN #7's statement that she had contacted pharmacy at 7:15 AM and their response being that they needed a current prescription. The notes additionally revealed that LPN #7 notified the on-call doctor and sent a narcotic refill request to the office, but still no response was received. The Progress Note further stated the pharmacy still did not have an updated prescription at that time. LPN #7's note reflected her asking Resident #4 if he/she would like to be sent to the hospital emergency department (ED) for a pain evaluation and that he/she stated, That is not necessary. I will just wait. Interview with Pharmacist #1, on [DATE] at 10:09 AM, revealed the pharmacy had processed an order from a physician at the hospital when Resident #4 was discharged on [DATE], for twenty (20) tablets of Oxycodone ten (10) milligrams (mg), for Resident #4's readmission. She further stated there was an emergency stat (now) order from the facility's Medical Director for seventeen (17) tablets of Oxycodone documented on [DATE]. The Pharmacist additionally stated that a staff pharmacist filled out an emergency prescription form, on [DATE] at 8:11 PM, and the pharmacy sent the emergency prescription, at 8:50 PM on [DATE]. She stated because the staff pharmacist completed an emergency prescription form indicated someone called to request, it but there was not a note of that. She further revealed the facility had Oxycodone five (5) mg tablets in their Emergency Stock Kit (eBox), and that the requesting nurse, LPN #13, was authorized to withdraw two (2) tablets of those from the eBox, at 8:46 PM on [DATE]. The Pharmacist stated the Medical Director subsequently sent an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Pharmacist #2, on [DATE] at 9:39 AM, revealed an eBox order should be the same details as the available medications, and with Resident #4's order for ten (10) mg of Oxycodone, the Physician would have to order two (2) tablets of Oxycodone five (5) mg for an emergency, rather than Oxycodone ten (10) mg, as the eBox only had Oxycodone in five (5) mg tablet strength. Review of pharmacy's notes and records relating to Resident #4's pain medication revealed the pharmacy received a refill request for his/her Oxycodone ten (10) mg prescription, on Friday, [DATE] at 10:20 PM. Since the prescription had no tablets remaining, the pharmacy sent a request for a new prescription to the Medical Director. The pharmacy records further revealed there was no communication from the facility or provider on [DATE]. The records additionally revealed the pharmacy received a call from the facility, on [DATE] at 7:16 AM, regarding the medication, and they followed up eleven (11) minutes later, at 7:27 AM, and informed the nurse that there were no tablets on the order, and also that they had reached out to the Medical Director for a new prescription. The records also stated the pharmacy received another call later, on [DATE] at 12:07 PM, from the facility stating they had reached out to the Medical Director and would be expecting a script to be sent over. The records showed the pharmacy followed up, at 12:16 PM, and reported there was still no order. The records subsequently documented the Medical Director called the pharmacy, on [DATE] at 8:20 PM, at which time, he gave the pharmacist two (2) emergency orders. The records revealed one (1) order was for two (2) tablets of Oxycodone five (5) mg to be withdrawn from the eBox and the second was a prescription for Oxycodone ten (10) mg tablets for the pharmacy to send to the facility. The pharmacy records additionally revealed that they gave authorization to the facility for the eBox withdrawal, and the new prescription was filled and sent out. Telephone interview with the Medical Director (MD), on [DATE] at 11:36 PM, revealed he did not recall any specific times when he was contacted about Resident #4, on the weekend of [DATE] through [DATE], but did remember working on the order on Sunday evening, [DATE]. The interview further revealed he was usually in the office for a bit in the mornings and afternoons on weekends, and was in and out. The MD stated if a pharmacy notification came after hours on the weekend by fax, it would not be seen until Monday morning, and the office would have hundreds of faxes by then. He additionally stated there was often a time lag for the order, on a weekday or on the weekend, as he might be in a facility and have to call back or even drive back to the office to put in an emergency order for a controlled medication. The Medical Director stated he would typically ask the nurse if the resident needed an eBox order. He further stated his hope was that a medication that was running low on volume would be noticed on a Thursday, so that an order could be managed in a non-emergent state on Friday, which was more efficient than handling the order in a rush. He also stated that his nurse was listed on the voice mail, and she could reach him as well as manage orders that her license allowed. The Medical Director stated when he was on call, the staff could call him directly on his cell phone. He stated about the circumstances of Resident #4's pain medication, that if we had it to do over again, we would have arranged for more over the weekend. I just didn't realize that we were in such an acute situation. Interview with LPN #7, on [DATE] at 7:03 PM, revealed, upon her arrival on Sunday, [DATE] at 7:00 AM, the night nurse gave report, including that Resident #4 had no more Oxycodone, and she had called pharmacy for a stat order, anticipating the resident would need it during the day. She stated the pharmacy advised the prescription was expired and needed a new order before any medication could be sent, or an access code could be issued for the eBox to obtain additional Oxycodone. She further stated she contacted the Medical Director about the order, and he responded. She additionally revealed she had informed the Medical Director of what the pharmacy required when he asked. LPN #7 stated she called the pharmacy about 1:30 PM, and they had not received the order. She also stated the resident, until that time, had not asked for Oxycodone or complained of pain. LPN #7 said, at that point, Resident #4 did ask when he/she could have Oxycodone to stay ahead of the pain. LPN #7 stated she then called the doctor again but did not receive a response. Later, she reported Resident #4 called out complaining of a migraine headache, and she administered another prescribed pain medication, [MEDICATION(S)] (a non-narcotic and used to treat migraines). She stated she subsequently called pharmacy and the Medical Director again, to determine availability of the Oxycodone. She further stated she must have called pharmacy five (5) or six (6) times throughout the day. She stated Resident #4 only stated that he/she wanted to stay ahead of the pain. LPN #7 stated he/she did not reference any pain location other than the migraine headache. She further stated that she went in Resident #4's room to update the resident on the status of the order, and offered to send him/her to the ED for pain management. She stated Resident #4 declined, stating that he/she preferred to wait for the order to come in. Additional telephone interview with LPN #7, on [DATE] at 9:01 AM, revealed the expected process was on Fridays, if the count on a particular medication was low, then those were ordered so that it did not run out over the weekend. She stated, when counting the cart at report, on the morning of [DATE], a Saturday, the pull sticker was removed from Resident #4's Oxycodone, which indicated somebody had taken it to make the order, because the pull sticker went on the refill sheet. She stated usually, if the prescription was expired, pharmacy would call to inform the nurse that a new prescription was needed or they might call the doctor directly, but stated she knew this happened, as she had taken those calls. LPN #7 also stated she would typically check to see if a needed medication was on the refill sheet, but was not aware whether the night nurse called about a refill when the resident ran out on [DATE]. Post exit interview via a return telephone call with LPN #13, on [DATE] at 7:52 AM, revealed she was working on [DATE] and [DATE] (7 PM to 7 AM shift) with Resident #4. LPN #13 stated Resident #4 first requested Oxycodone a few hours into the shift on [DATE]; at that time, she noticed there was only one (1) tablet of Oxycodone, which she administered to the resident. She stated she sent a message to the physician, asking for a call back about needing a prescription, stating sometimes he is hard to get in touch with. She stated she relayed the situation to Resident #4 and told her a call in morning to the physician would likely be more effective, since it would be during the day. She stated the resident had verbalized understanding of that. LPN #13 further revealed she also passed on the situation to the day shift nurse, LPN #7, in report, the morning of [DATE]. When returning that Sunday evening, [DATE], she reported LPN #7 was frazzled and upset because her efforts had not resulted in obtaining a new prescription for Resident #4's Oxycodone. LPN #13 stated Resident #4 was upset also, and was in a lot of pain by that point. LPN #13 stated she called the Medical Director six (6) times in a row when she first arrived and had gotten report. She reported she then left a message at pharmacy saying she needed an eBox access code, when she learned the Medical Director had contacted the pharmacy with an order, because the pharmacy contacted her directly. She stated she had given her personal number in the message because there had been such difficulty resolving the situation. When pharmacy called the facility directly, she stated, the phone rang to every unit so the staff never knew who was going to get the call or how long it would take to get the message to the right nurse. LPN #13 stated of the situation with obtaining the pain medication prescription, It shouldn't have been that hard. I just think it was a perfect storm. Interview with LPN #5, on [DATE] at 12:29 PM, revealed for unusual or immediately needed medications, the nurse would call pharmacy after faxing the order. She stated that pharmacy would deliver faxed orders if ordered with stat priority, and the deliveries of all medications arrived around 3:00 PM and about midnight. If a resident had a narcotic order, LPN #5 reported, the pharmacy required a hard or paper prescription, but could fax the hard prescription, then when the medication was delivered, the pharmacy courier would collect the hard prescription. LPN #5 stated, when reordering a resident's medication, and if the prescription was still current, the nurse could call pharmacy for authorization from them to open the eBox. In addition, she said, if the prescription was expired, she stated the staff must obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After receipt, LPN #5 stated the physician sent in the order. Further, LPN #5 stated staff tried to anticipate needs for weekends and ordered accordingly. She stated residents should never go without pain medications, and that if the resident had a current prescription, the nurse could use the eBox or call the physician for a specific order. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 3:54 PM, revealed her expectation that nursing staff would call the doctor for a one-time dose of a medication the facility had in house for pain until the resident's prescription arrived. She further stated that the physician would send a prescription by e-scribe or if on site, would write a hard prescription, and that either way worked for obtaining a request for medication from the eBox. She additionally stated that the nurse would need to call pharmacy to determine or confirm receipt of the order. Once received, the nurse could request a one-time dose from the eBox. Also, she stated she would expect if there was a prescription in process, then the nurse could request a needed dose with an eBox pull when the prescription was verified. Interview with the Director of Nursing (DON), on [DATE] at 4:48 PM, revealed her expectation that if a resident had a medication order that was unavailable, and it was in stock in the eBox, the nurse should use it. For controlled medications, she stated if the medicine was available in the eBox, and an active order existed, the pharmacist would inform the nurse if an eBox pull was possible and would give the access code. The DON stated in a case where the order was already shipped but the resident needed a dose, or if the eBox stock was not consistent with the order, then a separate one-time order was necessary. The DON additionally stated when a resident had no appropriate medications available to address a given problem, the nurse could offer to send him/her to the hospital emergency department (ED), and that was always an option for any problem the nurse could not solve independently. Without alternative interventions or if unable to reach the doctor, the DON revealed her expectation that a staff nurse would call another nurse for confirmation, call the unit manager, or call the DON for assistance. Interview with the Administrator, on [DATE] at 4:37 PM, revealed his expectation for any staff member was to do his/her best to ensure residents' needs were met. He further stated they should do whatever they could, and to use whatever tools were at his/her disposal at any given time. He additionally stated that, in the event that a staff member did not have the tools to address a particular problem, he expected that staff member to contact his/her supervisor for assistance.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide medication as ordered by the prescriber, to meet the needs of each resident for one (1) of twelve (12) sampled residents (Resident #11). The facility failed to ensure the administration of pain medication followed their policies, and as a result, Resident #11 waited approximately eight and one-half (8.5) hours to receive a dose of pain medication that he/she had requested. The findings include: Review of the facility's policy titled, Pain Assessment and Management, undated, revealed a section titled General Guidelines. Those guidelines included that the pain management program was based on a facility-wide commitment to resident comfort as well as a multidisciplinary care process including assessing the potential for pain, effectively recognizing the presence of pain, monitoring the effectiveness of interventions, asking the resident if he/she was experiencing pain and reviewing the medication administration record to determine how often the individual requested and received pain medication, and to what extent the administered medications relieved the resident's pain. Review of the facility's policy titled, Medication Ordering and Receiving From Pharmacy, undated, revealed if new medication orders were needed before the next regular delivery, the nurse must fax and phone in the medication order to the pharmacy immediately upon receipt. Further, if the order was on Sunday, the nurse was to phone the pharmacy. Additionally, if the pharmacy did not answer, the policy instructed the nurse to follow the emergency procedure to contact the pharmacy. Further review of the policy revealed that timely delivery of new orders was required so that medication administration was not delayed, and the emergency kit (eBox) was used when the resident needed a medication prior to pharmacy delivery. Review of the facility's policy titled, Emergency Pharmacy Service and Emergency Kits, undated, revealed that the nurse must determine if the order could not be delayed until the scheduled pharmacy delivery, then ascertained whether the ordered medication was contained in the emergency kit by referring to the list of contents posted. Review of the eBox inventory sheet revealed that [MEDICATION(S)]-Acetaminophen (an opioid pain reliever for moderate pain) 5-325 milligram (mg) tablets were among the available medications. Review of Resident #11's medical record revealed the facility admitted the resident on, 02/21/2021, with diagnoses that included Displaced Trimalleolar Fracture of Right Lower Leg; Diabetes Mellitus, Type 2; [CONDITION(S)] (COPD); Mixed Hyperlipidemia; Essential Hypertension; and Chronic Kidney Disease, Stage 3. Review of hospital discharge records, dated 02/21/2021, revealed that Resident #11's discharge medication orders included [MEDICATION(S)]-Acetaminophen 5-325 mg per tablet, one (1) tablet, oral, every four (4) hours as needed. Review of Resident #11's electronic Medication Administration Record (eMAR) revealed an order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) 5-325 mg with instructions to give one (1) tablet every four (4) hours by mouth as needed for pain, as of 02/21/2021 at 10:00 AM. Review of Resident #11's Baseline Care Plan, dated 02/21/2021, revealed a goal that he/she would maintain an acceptable level of pain control related to disease process or injury, with stated intervention for [MEDICATION(S)] 5-325 mg every four (4) hours as needed and Acetaminophen (Tylenol, a non-narcotic, mild pain reliever) 325 mg every four (4) hours, as needed for pain. Interview with Pharmacist #1, on 07/29/2021 at 10:09 AM, and review of Resident #11's pharmacy record, revealed the pharmacy received an order for sixteen (16) tablets of [MEDICATION(S)]-Acetaminophen 5-325 mg for Resident #11 from the discharging hospital, at 8:34 AM on 02/21/2021; this was followed by pharmacist verification, at 12:39 PM on 02/21/2021. The pharmacist stated, upon verification, orders went to the filling process, and then packed for delivery. Resident #11's order was scanned to depart the pharmacy for stat (now, immediate) delivery, at 3:30 PM on 02/21/2021, so Pharmacist #1 stated the facility should have received the medication within a couple of hours. Further interview with the pharmacist revealed nurses could request a dose from the Emergency Stock Box (eBox) as long as the pharmacy had an actual prescription on file. In that situation, she stated, nurses could request an access code to obtain the dose from the eBox. The pharmacist further stated if the pharmacy received an eBox request prior to the prescription leaving the building, then the pharmacy took action to reduce the number of tablets being sent, in order for the nurse to obtain a dose from the eBox. Further interview revealed, in this case, it was accurate to state that pain medication could have been retrieved from the eBox, between 12:39 PM and 3:30 PM on 02/21/2021. Review of the proof of delivery record revealed that the [MEDICATION(S)]-Acetaminophen 5-325 mg tablets were received by the facility, on 02/21/2021 at 7:26 PM. Review of Resident #11's eMAR revealed the first dose of the medication was administered, on 02/21/2021 at 9:06 PM. Review of the eMAR further revealed that Resident #11 had received two (2) tablets of Acetaminophen 325 mg orally, on 02/21/2021 at 12:11 PM and at 4:14 PM. Further review of the eMAR revealed a documented response of pain relief following the 12:11 PM administration occurred at 2:14 PM, noting it was ineffective with Resident 11's pain rated at 6/10. Review of the eMAR further indicated the 4:14 PM Tylenol administration response was not documented until 9:12 PM and was shown as ineffective, with a pain rating of 8/10. Review of pharmacy notes documenting transactions with the facility, on 02/21/2021, revealed the pharmacy received no communication about Resident #11. The notes further revealed that We were not alerted to any need to access the E-Kit, so no authorizations were granted. Interview with Licensed Practical Nurse (LPN) #2, on 07/28/2021 at 11:37 AM, revealed, for admission, the transferring hospital was asked for a short prescription for a narcotics order. She stated it could be a paper prescription or electronic prescribing, and paper prescriptions were faxed to pharmacy. For orders given during non-business hours, she stated, there was an on call pharmacist who responded to the request and could provide a code to access the eBox. Interview with LPN #5, on 07/28/2021 at 12:29 PM, revealed the process for a newly admitted resident's medications prior to pharmacy delivery, was to use the eBox. She stated the eBox had a stocked inventory list to detail what was available. She further stated this could be used for some narcotics and some antibiotics or other critical medications. For unusual or immediately needed medications, the nurse would call pharmacy after faxing the order. She stated that pharmacy would deliver faxed orders if ordered with stat priority, and the deliveries had all medications and arrived around 3:00 PM and about midnight. If a resident had a narcotic order, LPN #5 reported the pharmacy required a hard or paper prescription, but could fax the hard prescription, and when the medication was delivered, the pharmacy courier would collect it. She reported the nurse could call the transferring facility about orders also, and usually that facility would send the paper prescription with the resident. She stated residents should never go without pain medications, and if the resident had a prescription, the nurse could use the eBox. Interview with LPN #10 on 07/30/2021 at 12:43 PM revealed nurses had a printed guide to prompt asking for everything that was needed when receiving report from the referring facility for a new admission, which included asking for a paper prescription for a three day supply of narcotic pain medication. LPN #10 stated the nurse could ask pharmacy for a dose from the eBox, if the resident had the prescription in hand. Interviews with the 500 Unit Manager (UM), on 07/30/2021 at 1:22 PM, and the Director of Nursing (DON), on 08/02/2021 at 4:48 PM, confirmed the process for new admission orders and narcotic orders as well as eBox requests. Interview with Resident #11, on 07/31/2021 at 1:30 PM, revealed he/she stated the short time spent in the facility had been the worst time he/she had experienced because of his/her pain level. Resident #11 stated he/she had received a dose of pain medication prior to leaving the hospital, at approximately 9:30 AM on 02/21/2021. He/she further stated the pain medication made the pain bearable but did not totally relieve the pain; therefore, the resident stated he/she asked for it about thirty (30) minutes before the time he/she believed the next dose should have been available. Resident #11 stated he/she was told because it was a Sunday he/she might not get pain medicine until late that night or even the next morning. The resident further stated he/she just received regular strength Tylenol a couple of times during the day, and it might have helped a little bit, but not enough to ease the pain of a broken ankle and surgery. Subsequently, Resident #11 reported once the prescription pain medicine was available, the resident was told that he/she had to ask an hour in advance. Resident #11 stated, I couldn't do anything right for them. The resident reported the nurse eventually came around 10:00 PM, and he/she received the prescription pain medication, but he/she did not remember nursing staff asking to rate the pain after the pain medication was given. Resident #11 then stated, Going that long without pain control or about all of it, made me feel like nobody gave a [NAME]. He/she reported that later that night, one (1) of the nurses told him/her that he/she only had so many pain pills left, and he/she should start backing off of them. Resident #11 stated he/she got no sleep at all that night and did not have words for how miserable he/she was. Additional interview with Resident #11, on 08/01/2021 at 5:30 PM, per his/her call, revealed he/she did not recall any of the staff asking him/her about his/her level of pain, ever. He/she further stated the nurses did not have to ask about pain because he/she volunteered it. Resident #11 stated he/she told the nursing staff his/her pain was probably rated an 8/10, after the medicine at the hospital wore off. The resident further stated he/she considered calling 911 and reporting being held against his/her will, or if that did not work, getting down on his/her knees and crawling out of the facility. Resident #11 reported asking multiple times if the prescription pain medication had arrived and expressed the need for pain medication multiple times. Resident #11 stated, I felt like I was neglected or overlooked, like I was not a real person or didn't matter. He/she further revealed, after getting the pharmacy pain medicine, he/she was much better. Interview with the Assistant Director of Nursing (ADON), on 08/02/2021 at 3:54 PM revealed her expectation that nursing staff would call the doctor for a one-time dose of a medication the facility had in house for pain until the resident's prescription arrived. She further stated the physician would send a prescription by e-scribe or if on site, would write a hard prescription, and either way worked for obtaining a request for medication from the eBox. She additionally stated the nurse would need to call pharmacy to confirm receipt of the order. Once received, the nurse could request a one-time dose from the eBox. Also, she stated she would expect if there was a prescription in process, then the nurse could request a needed dose with an eBox pull when the prescription was verified. Interview with the Director of Nursing (DON), on 08/02/2021 at 4:48 PM, revealed her expectation that if a resident had a medication order that was unavailable, and it was in stock in the eBox, the nurse should use it. For controlled medications, she stated if the medicine was available in the eBox and an active order existed, the pharmacist would inform the nurse if an eBox pull was possible and would give the access code. The DON stated in a case where the order was already shipped but the resident needed a dose, or if the eBox stock was not consistent with the order, then a separate one-time order was necessary. The DON additionally stated when a resident had no appropriate medications available to address a given problem, the nurse could offer to send the resident to the hospital emergency department (ED) and that was always an option for any problem the nurse could not solve independently. Without alternative interventions or if unable to reach the doctor, she revealed her expectation that a staff nurse would call another nurse for confirmation, call the Unit Manager, or call the DON for assistance. Interview with the Administrator, on 08/02/2021 at 4:37 PM, revealed his expectation for any staff member was to do his/her best to ensure residents' needs were met. He further stated staff should do whatever he/she could and use whatever tools were at his/her disposal at any given time. He additionally stated, in the event that a staff member did not have the tools to address a particular problem, he expected that staff member to contact his/her supervisor for assistance.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person centered care plan interventions for one (1) of eleven (11) sampled residents (Resident #1), whom the facility assessed to exhibit wandering behavior and to be at risk for elopement. The facility admitted Resident #1, on 02/01/2014, with diagnoses, which included Alzheimer's Disease and Dementia. The facility most recently assessed Resident #1 was at risk for elopement, on 02/16/2021. The Comprehensive Person Centered Care Plan interventions, included interventions to prevent elopement. In addition, Resident #1 wore a Wanderguard bracelet (a device that activated alarms when the resident was near an exit door) to alert staff. Per documentation, Resident #1's assigned nurse, Licensed Practical Nurse (LPN) #1, last observed Resident #1, at 4:30 PM on 02/23/2021. Review of the facility's video footage revealed Resident #1 exited the facility's back door, at 4:40 PM on 02/23/2021, without staff knowledge. LPN #1 stated she heard door alarms, at approximately 4:30 PM to 4:40 PM, and responded to the alarms. LPN #1 stated she noted Resident #1 was not in the facility, between 5:00 PM and 5:30 PM on 02/23/2021. However, according to Resident #1's Comprehensive Care Plan (CCP) staff was to perform every fifteen (15) minute resident location checks and to thoroughly investigate the source of the alarms. LPN #1 failed to check on the resident at 4:45 PM. Staff found Resident #1 approximately eight (8) hours later in a wooded area, off facility property, approximately three hundred fifty-six (356) yards from the back door he/she had exited. Resident #1 was transferred to the hospital and admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to have an effective system in place to ensure each resident's comprehensive person centered care plan interventions were implemented to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/26/2021 and was determined to exist on 02/23/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 03/04/2021, with the facility alleging removal of the Immediate Jeopardy on 03/03/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/03/2021, prior to exit on 03/11/2021, with the 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, Care Plans, Comprehensive Person Centered, undated, revealed a comprehensive, person centered care plan included measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs and was developed and implemented for each resident. Per policy, care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Per policy, the comprehensive, person centered care plan would include measurable objectives and time frames; 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. Further review of the policy revealed identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident, were the endpoint of an interdisciplinary process. Review of the facility's policy titled, Responding to Egress/Wanderguard Alarms, undated, revealed staff was to respond immediately to egress and Wanderguard alarms. Continued review of the policy revealed the facility's procedure for responding to Egress/Wanderguard alarms included any staff who heard an alarm was to respond immediately, whether the egress/door alarm or the Wanderguard alarm. In addition, the policy stated staff would determine what triggered the alarms. Per policy, staff was to check inside and outside of the facility to determine the source. Furthermore, the policy stated if the source was unable to be determined, a facility head count would be initiated to confirm all residents were accounted for. Review of Resident #1's medical record revealed the facility admitted Resident #1, on 02/01/2014, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 02/08/2021, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severely impaired cognition. Further review revealed the facility assessed Resident #1 to have limited mobility and required the assistance of one (1) staff with activities of daily living (ADL's). Further review revealed the resident would have access to a walker or wheelchair for long distances, but could ambulate with or without a walker. Review of Resident #1's Comprehensive Care Plan (CCP) revealed the resident was last assessed, on 02/16/2021, and had a focus area of elopement risk. The goal was the resident would not wander from the facility unattended through the next review. Further review of the CCP revealed interventions for elopement prevention included Resident #1 was to wear a bracelet (Wanderguard) at all times; the nurse was to observe/document the resident's location every fifteen (15) minutes; and, staff was to check door alarms promptly to ensure safety of the resident. Review of Resident #1's Initial Investigation Report, dated 02/23/2021, revealed Resident #1 was last seen in the facility, on 02/23/2021 at 4:30 PM, by Licensed Practical Nurse (LPN) #1, as she had last documented on the resident's fifteen (15) minute observation checklist at 4:30 PM. Continued review revealed LPN #1 was working on Unit C (where the resident's room was located) at the time of the elopement, on the 3:00 PM to 11:00 PM shift on 02/23/2021. The report stated LPN #1 heard the alarms go off on Unit C, Door #5 (the door the resident used to exit the facility) when she was completing the medication administration. Continued review of the investigation report revealed when LPN #1 got to the door, she did not see anyone, and she silenced the alarms by placing a code in both keypads, located on either side of the door. Per the report, LPN #1 poked her head out of the door and looked both ways but did not see anyone and walked back to Unit C. Record review revealed videos from the investigation noted Resident #1 exited the facility at 4:40 PM through Unit C, Door #5. According to the report, Resident #1 exited through an alarmed door that was functioning properly because both the door alarm and the Wanderguard alarm sounded. The report concluded the alarms were silenced by a staff member who did not conduct a proper resident verification search. Interview with Licensed Practical Nurse (LPN) #1, on 02/26/2021 at 9:25 AM, revealed she had worked at the facility since August 2020. LPN #1 stated she observed Resident #1 lying in bed when observing for fifteen (15) minute checks; however, per the fifteen (15) minute observation sheet, the last physical check off on Resident #1 was at 4:30 PM. LPN #1 stated she had given Resident #1 Tylenol (a pain reliever) at 4:17 PM for pain. Continued interview with LPN #1 on 02/26/2021 at 9:25 AM, revealed she helped deliver meal trays, around 5:00 PM to 5:30 PM, and was unable to locate Resident #1 at that time. LPN #1 stated she heard the door alarms sound from Door #5 (door the resident exited), around 4:30 PM, and went to examine the area. The LPN stated she went to the door, turned off the alarm on the right side of the door (the egress alarm) by putting in the code and then turned off the alarm on the left side of the door (the Wanderguard alarm) by putting in the code. Further, LPN #1 stated she observed the area and held the door open while she looked outside the facility and reported that she did not see anyone around the area. However, per the care plan, the nurse was to observe/document the resident's location every fifteen (15) minutes; and, staff was to check door alarms promptly to ensure safety of the resident Continued interview on 02/26/2021 at 9:25 AM, with LPN #1 revealed Resident #1 was not identified as missing until meals were being served, between 5:00 PM and 5:30 PM. However, Resident #1 was scheduled to have a fifteen (15) minute location check by LPN #1 at 4:45 PM, 5:00 PM, and 5:15 PM. In addition, LPN #1 heard Door #5 alarm, at 4:30 PM, went to the door, did not see anyone outside the door, and continued to work. Per the CCP and policy, LPN # 1 was required to do a resident head count when she did not discover the source of the alarms, but she waited until she discovered Resident #1 was missing, between 5:00 PM and 5:30 PM. Interview with State Registered Nurse Aide (SRNA) #1, on 02/25/2021 at 4:23 PM, revealed the nurses performed the every fifteen (15) minute Wanderguard checks and documented them in the health record. Per interview, SRNA's would also monitor the resident, but the nurse verified and documented the every fifteen (15) minute resident location checks. SRNA #1 stated she thought Resident #1 was the only resident on Unit C who wore a Wanderguard device. Interview with SRNA #2, on 02/26/2021 at 10:22 AM, revealed the procedure for responding to the door alarm was when the alarm sounded, staff would check the alarm box at the Nurse's Station which indicated the door where the alarm was sounding. In addition, she stated staff would then go to that door to investigate the alarm. In addition, she stated the SRNA's checked daily to confirm the resident was still wearing the Wanderguard device; and the nurse signed off on the resident's location every fifteen (15) minutes, per the elopement risk resident's CCP. Interview with SRNA #3, on 02/26/2021 at 11:15 AM, revealed on 02/23/2021 from 7:00 AM to 3:00 PM, he had been Resident #1's primary aide, providing care to him/her on that day. SRNA #3 stated if an alarm sounded, staff was to check the panel (Staff Alert System) to see the alarm's location. SRNA #3 further stated the door would remain unlocked as long as it was alarming, which allowed time to visually check outside and still be able to return through the door to the inside. Moreover, he stated he would notify his nurse, and a head count of residents would be completed to verify all residents were accounted for per the resident's care plan. Interview with LPN #2, on 02/26/2021 at 10:02 AM, revealed she had worked the 7:00 AM to 3:00 PM shift, on Unit C, the day of the elopement. LPN #2 further stated, If you hear an alarm, you should respond immediately and see what caused it to alarm. She stated nurses were responsible to verify that designated residents had Wanderguard devices in place each shift and signed off on resident location checks every fifteen (15) minutes. LPN #2 stated these actions were on a resident's care plan that had elopement as a focus area. Interview with the Director of Nursing (DON), on 02/26/2021 at 1:17 PM, revealed she received a call from LPN #1, on 02/23/2021 around 5:00 PM, reporting Resident #1 was missing from the facility. The DON stated she had LPN #1 initiate a Code Green, and she came to the facility to help search for the resident. Per interview, she stated education on elopement and wandering of residents was given to all new hires and also completed annually. In addition, the training provided by the facility covered the door and Wanderguard alarms and specific codes used by the facility, including Code Green which was for elopement. In addition, she stated training on developing and implementing care plans was given at orientation and annually for nurses. Per interview, the DON stated she expected staff to respond immediately and determine who or what set off the alarms per the resident's CCP. She stated staff was expected to check outside the building, comb the area thoroughly, and verify that all residents were accounted for. The DON stated the Wanderguard alarm had a higher pitch sound than the door alarm, and LPN #1 should have been able to distinguish between them and realize if the Wanderguard alarm sounded, a resident would have probably exited the door. The DON stated LPN #1 did not follow Resident's #1's CCP when she failed to do a prompt and thorough investigation of the cause of the alarms and immediately do a resident head count when she did not determine what had triggered the alarms. Interview with the Administrator, on 02/26/2021 at 4:20 PM, revealed he was made aware of Resident #1 missing, at approximately 6:00 PM on 02/23/2021, and came to the facility immediately to facilitate the search for Resident #1. He stated he expected staff to respond immediately and find the source of the alarm activation. The Administrator stated if no one could be seen around the area, and the cause could not be determined, staff was to verify that all residents were accounted for in the facility by means of a physical head count for the residents' safety, per policy and the resident's care plan. The Administrator stated he believed facility staff knew what the alarms were for and what to do if alarms were activated, even though LPN #1 did not follow the facility's policy or Resident #1's care plan. In addition, he stated all staff were to follow the facility's policies and the residents' care plans at all times when providing care. The facility provided an acceptable credible Allegation of Compliance (AoC), on 03/04/2021, which alleged removal of the Immediate Jeopardy, on 03/03/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/23/2021, immediately after notification of Resident #1's disappearance, nursing staff performed a headcount of all residents. Staff accounted for all the other residents. 2. On 02/24/2021, at approximately 12:30 AM, facility staff found Resident #1 in a wooded area adjacent to the facility. Resident #1 was immediately assessed and sent to a local hospital for evaluation and admission. When Resident #1 returned to the facility, he/she would be placed on one-to-one (1:1) supervision along with wearing the Wanderguard bracelet. A new elopement assessment would be completed. Any new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's State Guardian was notified of the incident. 3. On 02/24/2021, at 9:30 AM, an Ad Hoc QA Committee meeting was held regarding the elopement incident with the Administrator, the DON, the Medical Director, the Regional Director of Clinical Services (RDCS), Quality Assurance/Infection Control (QA/IC) Nurse, and Social Services (SS) in attendance. The attendees established the following action items for this AoC. 4. The facility's monthly QA Committee meetings were changed to weekly meetings until the Immediate Jeopardy (IJ) was removed. The QA Committee meetings would consist of the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Staff Development Coordinator (SD), Social Services, Dietary, and Unit Managers (UM). The next QA meeting would be held on 03/02/2021. 5. On 02/24/2021, housekeeping/maintenance checked all doors for a fifteen (15) second egress and documented an audit check. All doors worked properly. 6. On 02/24/2021, housekeeping/maintenance staff checked all doors for the Wanderguard functioning properly and documented the audit, completed on 02/24/2021. All Wanderguards worked properly. The audits would be conducted daily and submitted to the weekly QA Committee meetings for review. 7. On 02/23/2021, the QA/IC Nurse checked each resident's Wanderguard to validate that it was working correctly and checked to ensure the Wanderguard devices were physically in place on residents. The QA/IC Nurse found no problems during this audit. This audit will continue weekly, by the QA/IC Nurse, to validate compliance. The QA/IC Nurse submitted the audits to the weekly QA Committee for review. 8. On 02/23/2021, the QA/IC Nurse checked to verify each Wanderguard bracelet was on the Treatment Administration Record (TAR), was checked for placement/function, and signed and dated each shift by the nurse. The audit was completed on 02/24/2021. No concerns were noted. This audit would continue weekly by the QA/IC Nurse to validate compliance and submitted to the weekly QA Committee meeting. 9. On 02/25/2021, the Interdisciplinary Team (IDT) met and developed a written procedure for staff response to Wanderguard and door alarms. The IDT included the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. In-service training on this was completed, on 02/25/2021 through 03/02/2021, by the Nursing Administrative Team. The Nursing Administrative Team included the DON, the ADON, the QA/IC Nurse, and the Assistant RDCS. The facility had one hundred two (102) nursing staff and one hundred sixty-two (162) total staff. Eighty-nine (89) nursing staff and one hundred thirty-eight (138) total staff had received the in-service education. The thirteen (13) nursing staff and eleven (11) non-nursing staff who had not received the in-service education were currently on leave. Education included: a) Abuse/neglect-All staff with post-test; b) Behavior Management-All staff with post-test; c) Injury Prevention-All staff with post-test; d) Wandering Risk/Elopement-All staff with post-test; e) Dementia; Providing care for people with Dementia and cognitive changes-All staff with post-test; f) Care plan development and revision-IDT only with no post-test; g) Care Plans-Nursing Staff only; h) Accidents policy and procedures; Safety and supervision of residents-All staff with post-test; i) To not prop open any door for any reason unless someone was there monitoring doors-All staff with post-test; j) Elopement risks and procedures-All staff with post-test; k) Do not disarm any alarms without looking to see if the resident was outside-All staff with post-test; and l) Facility alarm in-service training included: photo of egress door alarm, photo of Wanderguard system code alert-All staff with post-test. 10. The staff on-leave would be in-serviced on these policies upon return to work. Current Agency staff was in-serviced. The facility would require new agency staff to be in-serviced with either the weekend House Supervisor, Saturday and Sunday or the Human Resource (HR) Director/Staffing Coordinator, Monday through Friday. The HR Director compiled a list of all staff on leave and tracked the schedule to assure that no staff returned to work and no agency staff worked without receiving the training and passing the post-test. 11. On 02/23/2021, Social Services, for residents with Wanderguard devices, compared physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No residents were identified with inaccuracies or incomplete records. This was completed on 02/28/2021. 12. On 02/24/2021, Social Services checked all elopement risk assessments to ensure they were up to date (at least quarterly). This audit was completed on 02/28/2021. 13. On 02/24/2021 through 02/28/2021, Social Services reviewed the last thirty (30) days of all residents' medical records, Nurses' Notes, Progress Notes, eMAR notes, behavior monitoring notes, care plans, and Social Services Notes. The purpose of this review was to identify any previously unknown behaviors to ensure staff addressed appropriate interventions for supervision. Social Services updated care plans as needed. 14. Social Services audited Wander Alert Books weekly to ensure they were updated. Results will be submitted to the weekly QA Committee meetings for review. The Elopement Risk Books were located on six (6) units. Two (2) additional books were being created, and one (1) would be placed at the front door and one (1) at the back door by Social Services. Completion date 02/28/2021. 15. On 02/24/2021, Social Services completed a new Elopement Risk Assessment for one hundred eighteen (118) residents and completed it on 02/28/2021. No changes were identified for care plan revisions with these new assessments. 16. On 02/24/2021, the DON reviewed the Interdisciplinary Plan of Care (IPOC) process and decided no revisions were needed. During IPOC meetings, Monday through Friday, the IDT reviewed the 24-hour Summary and Incident Reports, including elopements, elopement attempts, falls, progress notes for behaviors, and electronic Medication Administration (eMAR) notes for behaviors. The licensed nurses updated the care plans using a three-part form, which included one (1) each for a change in condition, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plans were reviewed and revised by the IPOC Team as needed for behavior and supervision interventions during the IPOC meetings. The DON reported IPOC results to the QA Committee weekly. 17. On 02/24/2021, the Maintenance Department changed all keypad codes and will change keypad codes monthly. Staff was notified of door code changes via an internal communication system. 18. On 02/28/2021 through 03/01/2021, the QA/IC Nurse and/or the DON will conduct an elopement drill on each shift, including weekend staff, and document the drill and staff responses with signatures. Results will be submitted to the weekly QA Committee meeting on 03/02/2021. The elopement drills will be conducted monthly on each shift by the Nursing Department. The next drill will be due in March and performed by the Nurse Administrative Team. 19. On 02/24/2021, the facility requested the Wanderguard Company to check the Wanderguard system. The Wanderguard Company visited, on 02/25/2021, and checked all Wanderguard doors and systems. All were functioning correctly. 20. On 02/25/2021, the ADON added education on the Wanderguard and egress alarm systems to new hires and agency orientation, along with a post-test for validation of understanding. All in-services (12) conducted as part of this AoC were included in the new hire and agency orientation. 21. Starting 02/26/2021, the QA/IC Nurse will review the AoC plan daily for completion and compliance with the IPOC team, a subcommittee of the QA Committee. The Administrator, the DON, and the QA/IC Nurse were also members of the IPOC Committee. Then the AoC plan would be submitted weekly to the QA Committee meeting for additional oversight of compliance and completeness. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Interview with the DON, on 02/25/2021 at 3:04 PM, revealed LPN #1 notified her, around 5:30 PM on 02/23/2021, of Resident #1's disappearance. She gave instructions for LPN #1 to have each unit perform a head count of all residents in the facility. Also, she instructed LPN #1 to call a Code Green, which was an internal missing resident alert. The headcount revealed no other resident was missing. Interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed she called a Code Green, searched for Resident #1 on C and D Units, and then notified all units to search for Resident # 1 on their units. She also told them to perform a head count of all residents on their units. The headcount revealed no other missing resident. Review of Police Incident Report #2012- 310, dated 02/23/2021 at 8:09 PM, revealed a head count was conducted, and Resident #1 was not inside. 2. Review of the Division of Fire and Emergency Medical Service (EMS) Incident Report # , on 02/24/2021 at 12:52 AM, revealed Resident #1 was found in a wooded area after being missing for several hours. The resident was shivering vigorously. She denied other complaints. No obvious injury was noted. Resident #1 was transferred to the hospital. Review of Progress Notes, dated 03/03/2021 at 3:15 PM, revealed Resident #1 returned to the facility from the hospital, on 03/03/2021 at 3:00 PM, and one-to-one (1:1) staff supervision was initiated with the resident. Additional documentation at 6:51 PM stated Resident #1 continued with one-to-one (1:1) supervision, and a Wanderguard device/bracelet was on his/her left ankle. Review of Resident #1's Comprehensive Care Plan, revised 03/05/2021, revealed staff made elopement risk revisions, on 03/03/2021, to include one-to-one (1:1) supervision. Review of Elopement Assessments, dated 02/25/2021, revealed elopement assessments were conducted on all residents in the facility. Interview with the Social Services Coordinator, on 03/10/2021 at 11:00 AM, revealed she completed elopement assessments on one hundred eighteen (118) residents, beginning 02/24/2021 through 02/28/2021. Interview with LPN #2, on 03/10/2021 at 9:30 AM, revealed staff provided one-to-one (1:1) monitoring and supervision, at all times (24/7), to Resident #1, since he/she returned to the facility, on 03/03/2021. In addition, she stated Resident #1 had a Wanderguard bracelet on his/her left ankle. Continued interview revealed Resident #1 was transferred to another facility, on 03/09/2021, to evaluate increased agitation and medication management/adjustment. 3. Review of the QA Ad Hoc Meeting minutes and attendance roster, dated 02/24/2021 at 9:30 AM, revealed the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Regional Director of Clinical Services, the Social Services Coordinator, and the Social Services Director were in attendance. Resident #1's elopement and a Root Cause Analysis (RCA) were discussed. The attendees established action items for the Allegation of Compliance (AoC). Interviews, on 03/10/2021, with the Social Services Coordinator at 11:00 AM, the QA/IC Nurse at 12:00 PM, the DON at 2:19 PM, and the Administrator at 3:00 PM, revealed they all attended the QA Ad Hoc Meeting, on 02/24/2021 at 9:30 AM. Resident #1's elopement and an RCA were discussed. Action items for the AoC were established. 4. Review of the QA Meeting minutes and roster, dated 03/02/2021 and 03/09/2021, and titled AoC Weekly Meeting, Discussing the Elopement Incident and Action Items for the AoC revealed those signing the roster included the Medical Director, the Administrator, the DON, the QA/IC Nurse, the UM, Social Services, the ADON/Staff Development Coordinator (SDC), and the Dietary Manager. Interviews, on 03/10/2021, with the Social Services Coordinator at 11:00 AM, the QA/IC Nurse at 12:00 PM, the DON at 2:19 PM, and the Administrator at 3:00 PM, revealed they all attended the weekly QA Committee meetings, on 03/02/2021 and 03/09/2021. Action items for the AoC were discussed. 5. Review of Exit Door Audits, dated 02/24/2021 at 8:00 AM, signed by the Maintenance Director, revealed ten (10) exit door checks were done to include egress, battery, hardware, alarm, and the Wanderguard system. All worked properly. Interview with the Maintenance Director, on 03/10/2021 at 12:22 PM, revealed he checked all doors, on 02/24/2021, and documented the audit. No issues were found. He stated since the elopement, the door checks were done daily instead of weekly, and Housekeeping would check the Wanderguard functioning. 6. Review of the Wanderguard Daily Door Function Test, dated from 02/01/2021 to 03/09/2021, and initialed daily by the Housekeeping Supervisor, or designee, revealed they checked the Wanderguard functionality daily for ten (10) exit doors. All Wanderguards worked correctly. The audits were part of the QA report. Interview with the Housekeeping Supervisor, on 03/09/2021 at 2:30 PM, revealed he tested the Wanderguard alarm system during the week by physically placing a Wanderguard device close to each exit door to set off the alarm, validating it was working correctly. The audits were performed daily and submitted to the weekly QA meeting for review. Interview with Housekeeper #1, on 03/09/2021 at 2:45 PM, revealed she performed the test on the Wanderguard alarm system on weekends. She or her designee conducted the test every weekend. She submitted the audits to the QA meeting. 7. Review of the Wanderguard Placement Check, dated 02/23/2021, signed by the QA/IC Nurse, revealed she checked all (6) six residents' placement and function with Wanderguards and identified no issues. Interview with the QA/IC Nurse, on 03/10/2021 at 12:00 PM, revealed, on 02/23/2021, she checked all Wanderguards in the facility to validate the device was working correctly and physically in place. Staff used a small testing device that beeped when placed next to the Wanderguard bracelet, indicating it was working. She found no problems. The audits were part of the weekly QA meeting. 8. Review of the Weekly Wanderguard QA Audit, dated 02/24/2021, 03/02/2021, 03/08/2021, and 03/09/2021, revealed the QA/IC Nurse audited a check of each Wanderguard bracelet on the Treatment Administration Record (TAR) for placement and function. She identified no concerns. The audits were included in the QA reports. Review of the TAR's of nine (9) residents listed on the Wanderguard Audit revealed staff checked the device function every shift on the night shift, and day shift staff checked for placement each shift daily. Interview with the QA/IC Nurse, on 03/10/2021 at 12:00 PM, revealed she checked the Wanderguard audits to see if nurses were doing the audits for function and placement per policy and included the results in the weekly QA audit reports. 9. Review of the Interdisciplinary Team Meeting minutes, dated 02/25/2021, revealed the meeting's purpose and attendees, to include the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. Review of education provided to all staff, dated 02/24/2021 through 03/02/2021, included: Abuse/Neglect; Behavior Management; Injury Prevention; Wandering Risk/Elopement; Dementia; Care Plan Development & Revision; Accidents Policy & Procedure; Propping Open Doors; Elopement Risks & Procedures; Disarming Alarms; and Facility Alarms. Attendance rosters were attached. Interview with the Nursing Administrative Team members, on 03/10/2021, the ADON at 11:36 AM, the QA/IC Nurse at 12:00 PM, and the DON at 2:19 PM, revealed they provided education to staff 02/24/2021 through 03/02/2021. Education was ongoing. Interviews, on 03/09/2021, with LPN #7 at 2:30 PM, LPN #3 at 2:40 PM, SRNA #4 at 2:50 PM, LPN #8 at 3:00 PM, SRNA #5 at 3:15 PM, RN # 2 at 3:20 PM, LPN # 6 at 3:30 PM, Housekeeper #1 at 3:40 PM, and the Housekeeping Supervisor at 3:55 PM, revealed they received education and training provided by the QA/IC Nurse, the ADON, and the DON. Education included door alarms, behavior management, care plan development and revision, accidents, abuse/neglect, elopement, wandering, Dementia, and propping doors. An interview with SRNA #6, on 03/10/2021 at 10:24 AM, revealed she received mandatory education and training regarding elopement, alarms, COVID, care plans, abuse/neglect, behaviors, and elopement. The ADON provided the education. 10. Review of all documents and education rosters revealed a list of all staff either on Family and Medical Leave Act (FMLA), currently not working, or who had not received the required AoC education and training. The HR Manager monitored this list. Interview with the HR Director/Staffing Coordinator, on 03/10/2021 at 12:42 PM, revealed that as HR Director, she oriented all new staff that entered the facility and was respon [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, review of the facility's investigation, review of the website www.localconditions.com, review of the police department report, and review of the fire department report, 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 eleven (11) sampled residents (Resident #1), who was assessed to exhibit wandering behavior and to be at risk for elopement. The facility admitted Resident #1, on 02/01/2014, with diagnoses, which included Alzheimer's Disease and Dementia. On 02/16/2021, the facility assessed the resident to be at risk for elopement due to wandering behavior and lack of safety awareness. Resident #1 wore a Wanderguard bracelet (a device that activated alarms when the resident was near an exit door) to alert staff. Residents with Wanderguard bracelets were to be checked every fifteen (15) minutes for location. Staff last observed Resident #1, at 4:30 PM on 02/23/2021. Review of the facility's video footage revealed Resident #1 exited the facility's back door, at 4:40 PM on 02/23/2021, without staff knowledge. The resident's assigned nurse, Licensed Practical Nurse (LPN) #1, stated she heard the door alarms, at approximately 4:30 PM to 4:40 PM, and responded to the alarms. The LPN silenced the alarms, but failed to determine what triggered the alarms and failed to ensure staff accounted for Resident #1, as per the facility's policy. LPN #1 stated she noted Resident #1 was not in the facility, between 5:00 PM and 5:30 PM on 02/23/2021. Staff found Resident #1 approximately eight (8) hours later in a wooded area, off facility property, approximately three hundred fifty-six (356) yards from the back door he/she had exited. Resident #1 was transported to a local hospital per Emergency Medical Services (EMS) and was admitted to the hospital. Review of the hospital's Emergency Department record revealed the resident was diagnosed with Hypothermia (a dangerous drop in body temperature caused by prolonged exposure to cold); and Acute Kidney Injury (a condition in which the kidneys could not filter waste from the blood which developed rapidly) related to dehydration. 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) were identified on 02/26/2021 and determined to exist on 02/23/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 03/04/2021, with the facility alleging removal of the Immediate Jeopardy on 03/03/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/03/2021, prior to exit on 03/11/2021, with the 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, Wandering and Elopements, undated, revealed the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Further review of the policy revealed if a resident was identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety; and, if a resident was missing, initiate the elopement/missing resident emergency procedure. Review of the facility's policy titled, Wanderguard System, undated, revealed the Wanderguard system was used for at-risk residents for elopement. The purpose of using this system was for each resident to reach his/her highest practicable well-being in an environment that prohibited the use of restraints for discipline or convenience. The policy stated the Wanderguard bracelet would be applied to the resident's wrist or ankle and not be removed until a replacement was needed. In addition, the Wanderguard bracelets were checked for placement and functional status each shift by the charge nurse and were documented in the treatment administration record (TAR). Review of the facility's policy, Responding to Egress/Wanderguard Alarms, undated, revealed staff should immediately respond to egress and Wanderguard alarms. Per policy, upon hearing an alarm, staff members should immediately respond to the alarm sounds of both the door alarm and the Wanderguard alarm. In addition, upon responding to the alarms, staff should determine what triggered the alarms. Further review revealed staff should check inside and outside the facility to determine the source that triggered the alarms. Furthermore, if the source of the egress or Wanderguard alarm was not resolved, staff should initiate a facility resident head count. Review of Resident #1's medical record revealed the facility admitted the resident, on 02/01/2014, with diagnoses to include Dementia, Alzheimer's Disease, Unsteadiness on Feet, and Chronic Kidney Disease. Review of Resident #1's Comprehensive Care Plan (CCP), most recently reviewed by the facility on 02/16/2021, had a focus of the resident was at risk for elopement due to wandering behavior and lack of safety awareness. The goal was the resident would not wander out of the facility unattended through the next review. Further review revealed interventions included: allow the resident to wander in safe paths in the facility; attempt to divert the resident's attention when he/she became insistent on leaving; check door alarms promptly to ensure safety; elopement prevention (Wanderguard) bracelet at all times, and check placement every shift; elopement risk assessment per facility policy; elopement risk required to check the resident's location every fifteen (15) minutes; keep a picture of (Resident #1) in the Elopement Risk book; and give medications per Physician's Orders. Review of Resident #1's Comprehensive Minimum Data Set (MDS) Assessment, dated 05/08/2020, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Score (BIMS) of eight (8) out of fifteen (15), indicating moderate cognitive impairment. However, review of the most recent MDS Quarterly Assessment, dated 02/08/2021, revealed the facility assessed Resident #1 as having a BIMS' score of five (5) out of fifteen (15), indicating severe cognitive impairment. Continued review of Resident #1's Comprehensive MDS Assessment, Section E, Behavior-Wandering, dated 05/08/2020, revealed Resident #1 exhibited no wandering behavior. However, review of Section E of the most recent MDS Quarterly Assessment, dated 02/08/2021, revealed the facility assessed Resident #1 as exhibiting wandering behaviors one (1) to three (3) days per week. Review of the Physician's Orders, dated 08/27/2020, revealed an order to place a Wanderguard bracelet for safety. Review of the Resident #1's Progress Notes, on 02/23/2021, revealed no documented evidence the resident was exhibiting exit-seeking and wandering behaviors. Review of the facility's Investigation Accident/Incident Report, initiated on 02/23/2021, and signed by the Administrator on 02/24/2021, revealed Resident #1 exited the facility, at approximately 4:40 PM on 02/23/2021, from Unit C, Door #5. The Wanderguard and door alarm sounded, and it was confirmed both worked properly for Door #5. Further review revealed the nurse silenced the alarm, but did not determine the alarm source or immediately perform a thorough resident search. Continued review revealed LPN #1 notified the Director of Nursing (DON), around 5:30 PM on 02/23/2021 that Resident #1 could not be located. Review of the report revealed the DON informed the Administrator that staff had initiated a search for Resident #1 inside and outside the facility. Per the report, staff notified the resident's Guardian, the Physician, the Police, the Fire Department, and local hospitals, alerting them of the missing resident. The report stated approximately forty (40) individuals assisted in the search for the missing resident, and the media issued a Golden Alert (an alert for elderly or impaired missing persons). In addition, the report stated a helicopter and a canine unit were deployed in the search, and staff searched on foot and in vehicles. The facility's staff located Resident #1, in a wooded area left of an adjacent long-term care facility. The resident was responsive and in stable condition. Staff called 911. An ambulance arrived and transferred Resident #1 to a local hospital ED (emergency department). Review of the hospital's Emergency Department record revealed the resident was admitted to the hospital, on 02/24/2021, and diagnosed with Hypothermia (a dangerous drop in body temperature caused by prolonged exposure to cold) with a rectal temperature of 90.9 degrees Fahrenheit (normal was 97.1 to 99.2 degrees Fahrenheit); and Acute Kidney Injury (a condition in which the kidneys could not filter waste from the blood which developed rapidly) related to dehydration. Further review revealed Resident #1 also had superficial abrasions over both hands and both knees and had tenderness in his/her [MEDICATION(S)] and lumbar spine areas with palpation. Continued review revealed blood tests were performed which showed an elevated serum creatinine level of 1.21 milligrams (mg) per deciliter (d/L). In addition, per the record, Resident #1 was placed under warming blankets and then a [NAME] [NAME] blanket (a forced air warming system used to prevent hypothermia and keep patients at a normal core body temperature). Further review revealed Resident #1 stayed under the [NAME] [NAME] for four (4) hours until his/her rectal temperature improved to 97.5 degrees Fahrenheit. In addition, a Computed Tomography (CT) scan was done of the head and the spine, which were negative for acute fractures. Continued review revealed Resident #1 was initially given one (1) liter of warmed intravenous fluids (IVF) and then continued on regular IVF's. Per hospital record, Resident #1 was discharged from the hospital on 03/03/2021, after an eight (8) day stay. Review of the local weather history, via the website www.localconditions.com, revealed the temperature high, on 02/23/2021, was fifty-seven (57) degrees Fahrenheit, with a low of forty-one (41) degrees Fahrenheit, when staff found Resident #1. Review of video footage from the facility's security camera revealed Resident #1 exited the facility from a back door, on 02/23/2021 at 4:40 PM, and proceeded along a fence row toward an adjacent long-term care facility. Review of the Police Department (PD) Incident Report, dated 02/26/2021 at 11:07 AM, revealed the police received a call, on 02/23/2021 at 7:09 PM, from the facility, regarding a missing elderly person. The police were dispatched to the facility, on 02/23/2021 at 7:10 PM. Per the dispatch log, the resident was found by facility staff, on 02/24/2021 at 12:36 AM. Review of the Fire Department (FD)/EMS Report, dated 02/23/2021, revealed units responded to a report of a missing elderly long-term care (LTC) facility resident, who, according to the LTC facility staff, had been missing for approximately one (1) hour. The report stated staff was actively searching for the individual when the FD arrived, and the FD crew searched the LTC facility's surrounding area using flashlights and thermal imaging cameras. In addition, the report stated the PD used a helicopter at 9:53 PM and had requested a tracking canine (K-9). Continued review revealed at 12:30 AM on 02/24/2021, the unit was advised the resident had been located and was dispatched to where the resident had been located. The report stated Resident #1 complained of being cold; was shivering vigorously; denied other complaints; and FD personnel observed no obvious injuries. Further review revealed Resident #1 was transported to a local hospital. Observation of the elopement route, on 02/25/2021 at 11:50 AM, revealed Resident #1 exited his/her room on Unit C, turned left, passed the Nurses Station, made another left, and left the facility though Door #5 to the outside of the building. Observation of the location where staff found Resident #1 revealed a wooded area, left of an adjacent LTC facility, approximately three hundred fifty-six (356) yards, as measured by the Maintenance Director, from the door where the resident exited. Observation of all exit doors in the facility, during a facility tour, on 02/25/2021 at 11:00 AM, revealed nine (9) exit doors. Further observation revealed doors #6, #7, #8, and #9 had signage with various instructions to include: Do not use door to enter/exit per administration; If you see any resident standing next to the door, do not let them out, call for a staff member; Please make sure the door completely shuts. It would alarm until the door was properly shut. Per observation, there was no signage on doors #1, #2, #3, #4, or #5. Also, these doors were observed to have a Wanderguard alarm keypad to the left side of the door and a door alarm keypad to the right side of the door. Interview with the Maintenance Director, on 02/26/2021 at 10:30 AM, revealed he had been employed twenty-six (26) years at the facility. Continued interview revealed before the elopement, doors were checked weekly, on Mondays; but now, he checked exit doors daily. He stated checks involved reviewing the codes; looking for any obstructions around the doors; and checking the egress, hinges, screens, and backup battery. He stated all doors had a backup battery, which connected to the generator in the event of a power failure. Also, he stated housekeeping staff checked the Wanderguard device to the door alarm for proper functioning daily. In addition, the Maintenance Director revealed when the door alarm sounded, a staff member must respond immediately and punch in the code to the keypad to silence the alarm. Observation of a demonstration of functionality, by the Maintenance Director and the Housekeeping Supervisor, on 02/26/2021 at 10:40 AM, of Door #5's alarm (the door the resident exited) with the Wanderguard alarm occurred. This demonstration revealed engaging the door handle for fifteen (15) seconds or less would not open the door; however, continued engaging the door handle for another fifteen (15) seconds, for a total of thirty (30) seconds, would open the door, and the alarm would sound. Per observation, the alarm would continue to sound until a code was entered into the keypad to silence the alarm. Also, per observation, when a Wanderguard bracelet came within two (2) to three (3) feet of a Wanderguard alarm device, the alarm would sound, and entering a code into the keypad would silence the alarm. Continued observation revealed the difference between the two (2) alarms was distinguishable. The Wanderguard alarm had a louder, constant, piercing, loud sound, and the door alarm had a loud throbbing noise. Continued observation of Door #5 revealed a keypad on the left side of the door to silence the Wanderguard alarm and a keypad on the right side to silence the actual door alarm (both were on the inside of the facility). Observation of the Staff Alert System, on 02/26/2021 at 10:55 AM, revealed they were located in or close to each Nurse's Station, in a panel box with a light that would flash with audible alarm sounds, indicating which facility door was alarming. Further, per observation, staff could see, from any station, which door to respond to, even if it was not their assigned unit. Interview with Resident #2 (BIMS 15, which indicated cognitively intact), on 02/25/2021 at 12:15 PM, revealed he/she was reasonably sure the person who walked by his/her window, the evening (unsure of the exact time) of 02/23/2021, was Resident #1, but he/she could not say with total certainty. Resident #2 stated he/she was lying in bed when a person walked past his/her window hunched over, looked back, and then continued walking. The resident stated, after telling a staff member what he/she had witnessed, he/she was interviewed by a police officer. Interview with State Registered Nurse Aide (SRNA) #1, on 02/25/2021 at 4:23 PM, employed at the facility for fourteen (14) months, revealed she was working Unit C, the unit where Resident #1 resided, the evening Resident #1 exited the facility. She said she did not hear the door alarm go off, adding she was making her rounds and was either in a room with the door closed, or too far away to hear it. She stated she last saw Resident #1, on 02/23/2021 around 4:00 PM, in his/her room, sitting on the bed, fully dressed, and wearing a sweatshirt and pants but not a coat. She stated she talked to the resident, and he/she said nothing about going anywhere or wanting to go anywhere. Further interview revealed, between 5:00 PM and 5:45 PM, she was approached by LPN #1 and asked if she had seen Resident # 1 because he/she could not be located. SRNA #1 stated she began to search for Resident #1 with other staff in every room in the facility Continued interview with SRNA #1, on 02/25/2021 at 4:23 PM, revealed if the door alarm sounded, staff went to the door, looked out, and then cut the alarm off if they did not see anything. She stated she was not aware of any issue with the door alarm system. She said if you deactivated the door alarms, then reopened the door, the alarm would sound again. She stated staff on Unit C and Unit D would respond to the door alarm on either unit, and all available staff from each unit would go and check the doors. SRNA #1 stated there was a difference in the sound of the door alarm and the sound of the Wanderguard alarm; the Wanderguard alarm was much louder than the door alarm. She also stated nursing staff did not go out the doors that had egress and Wanderguard alarms because the alarms would sound; however, housekeeping staff would use them, but they would put in the codes to deactivate the alarms and the alarms would reactivate. She stated nurses performed the every fifteen (15) minute Wanderguard checks and documented them in the health record. Per interview, SRNA's would also monitor the resident, but the nurse verified and documented the every fifteen (15) minute resident location checks. SRNA #1 stated she thought Resident #1 was the only resident on Unit C who wore a Wanderguard device. Telephone interview with LPN #1, on 02/26/2021 at 9:27 AM, who had been employed at the facility since August 2020, revealed she typically reported to work between 2:30 PM and 2:45 PM. She stated she saw Resident #1, on 02/23/2021, when first reporting to work and again when administering medications, around 4:00 PM. She said when she was delivering dinner trays, around 5:00 PM or 5:30 PM, she could not find Resident #1. She stated she went to the Day Room, did not see him/her, and then started looking in all the other rooms on Unit C and Unit D but did not find the resident. Per interview, she then requested Units A, B, and 500 staff to look for Resident #1 in their areas. She stated she called the DON, between 5:00 PM and 5:30 PM, who instructed her to call a Code Green, the code for a missing resident. LPN #1 stated everyone started looking for the resident. Further interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed when she saw Resident #1, before the elopement, he/she was lying in bed, with no agitation or talk of leaving. She stated staff checked the Wanderguard placement every shift to ensure the resident was still wearing the device, and the day shift nurse checked functionality daily. She stated when the door alarm sounded for Door #5 (the door Resident #1 exited), she went to the door, turned off the alarm on the right side of the door (the egress alarm) by putting in the code. In addition, LPN #1 stated there was another alarm (the Wanderguard alarm), on the left side of the door, and she did not know the purpose of that alarm, but knew the code to silence it. Per interview, LPN #1 stated she opened the door and looked out both ways quickly, and no one was there; so, she closed the door, returned to her workstation, and continued to work. She stated she did not check to see if all residents were accounted for because she did not see anyone outside the door. However, review of the facility's policy revealed if the source of the egress or Wanderguard alarm was not resolved, staff should initiate a facility resident head count, which LPN #1 failed to do, as she did not determine what triggered the alarm. Continued interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed she was not aware that one (1) alarm on the door was for the Wanderguard device, and the other alarm was for the door. She was asked about the difference between the sound of the Wanderguard alarm and the door alarm, and LPN #1 stated there was no sound difference. She asked, Is there an alarm sound difference? Then, she added, I did not know there were two (2) different alarms on the door. I thought the door had two (2) alarms that sounded when opened. I did not know one (1) alarm was associated with the Wanderguard. In addition, she stated all available staff usually went to the door to check when the alarm sounded; however, only she went to the door this time, and SRNA #1 and an agency SRNA were also working on the unit. LPN #1 stated she was informed facility staff found the resident around 1:00 AM to 2:00 AM, in the early morning of 02/24/2021. Interview with LPN #2, on 02/26/2021 at 10:02 AM, who had been employed ten (10) years at the facility, revealed she worked day shift, on 02/23/2021, the day Resident #1 eloped. She stated when she left the facility around 4:00 PM, Resident #1 was in his/her room and sitting in a chair, where he/she had been most of the day. She stated Resident #1 could ambulate with or without a walker. In addition, she stated Resident #1 wore a Wanderguard bracelet. LPN #2 stated an alarm sounded when residents wearing a Wanderguard got too close to an exit door. Further, she stated the Wanderguard door alarm had a louder, more piercing sound than the door alarm. In addition, she stated there was a panel at each Nurses Station that flashed, indicating from which door the alarm was sounding. Per interview, if that occurred, all available staff should immediately go to the door and determine the source of the alarm. LPN #2 stated she was not aware of any issues with the door alarms malfunctioning. Interview with SRNA #2, on 02/26/2021 at 10:22 AM, employed approximately four (4) years at the facility, revealed she worked the day shift, on 02/23/2021, and had gone home when the elopement occurred. She stated, at times, Resident #1 wandered around the facility and wore a Wanderguard bracelet around the ankle at all times for safety. She stated from time to time, Resident #1 would go to the door, and staff would redirect him/her away from the door. SRNA #2 stated the procedure for responding to the door alarm was when the alarm sounded, staff would check the alarm box at the Nurses Station which indicated the door where the alarm was sounding. In addition, she stated staff would then go to that door to investigate the alarm. Continued interview revealed the door alarm and the Wanderguard alarm had two distinct tones, with the Wanderguard alarm being louder. In addition, she stated the SRNA's checked daily to confirm the resident was still wearing the Wanderguard device; and the nurse signed off on the resident's location every fifteen (15) minutes. Interview with SRNA #3, on 02/26/2021 at 11:30 AM, employed twenty (20) years at the facility, revealed Resident #1 did not want to do much the morning of the elopement, which was typical for him/her in the mornings; but, he/she became a busy bee in the afternoon and moved around more. Also, he stated he thought the resident was wearing a thick green sweatshirt and thick brown slacks that day, adding he/she liked to be warm. He also stated the procedure for responding to an alarm was to look at the alarm indicator light displayed on the panel box at the Nurse's Station to determine from which door the alarm was sounding, go immediately to that door, and look inside and outside the door. The alarm was silenced if all was okay, but if not, the nurse was informed so she could do a headcount of all residents to confirm all were in the facility. SRNA #3 stated residents were to be counted on all units, especially those residents who wander or those with a Wanderguard device. Interview with the DON, on 02/26/2021 at 1:16 PM, employed three (3) years at the facility and in her current role since August 2020, revealed staff was educated about elopements, Wanderguard, door alarms, and Code Green upon hire and annually. She stated she called the Administrator regarding the elopement around 5:30 PM. She stated she instructed the nurse to call a Code Green (missing person code), and she returned to the facility to search for the resident and initiate the investigation. Per interview, she stated when a door alarm sounded, an indicator light flashed at the Nurses Station, indicating which door was alarming. She stated this light flashed for both the Wanderguard alarm and the door alarm. The DON stated she expected staff to look at the indicator box, respond immediately to the alarming door, find the source of what/who tripped the alarm, comb the area, and find out if anyone was missing. She emphasized that staff must immediately find the source of the alarm, and do a resident head count per policy. In addition, the DON stated the alarms had two (2) distinct sounds, with the Wanderguard alarm having a higher pitch. However, per the facility's report, LPN #1 did not do a resident head count immediately, after the alarms sounded, on 02/23/2021, when she could not determine the source for triggering the alarms. Interview with the Administrator, on 02/26/2021 at 4:25 PM, employed two (2) years at the facility, revealed he expected staff to respond immediately when an alarm sounded, for both, the door alarm and the Wanderguard alarm. He stated he expected staff to find the alarm source, as only a person could set off the alarm. Per interview, if staff could not determine the source, as was the case with LPN #1 and Resident #1's elopement, the next step was to ensure and not assume everyone was accounted for, which LPN #1 did not do. He stated he expected staff, who heard the alarm, to immediately respond to keep residents safe. In addition, he stated the facility had experienced no issues with the alarm system. Continued interview revealed the facility immediately initiated the investigation of the elopement, which included placing the nurse on administrative leave. The facility provided an acceptable credible Allegation of Compliance (AoC), on 03/04/2021, which alleged removal of the Immediate Jeopardy, on 03/03/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/23/2021, immediately after notification of Resident #1's disappearance, nursing staff performed a headcount of all residents. Staff accounted for all the other residents. 2. On 02/24/2021, at approximately 12:30 AM, facility staff found Resident #1 in a wooded area adjacent to the facility. Resident #1 was immediately assessed and sent to a local hospital for evaluation and admission. When Resident #1 returned to the facility, he/she would be placed on one-to-one (1:1) supervision along with wearing the Wanderguard bracelet. A new elopement assessment would be completed. Any new Physician's Orders would be implemented. Resident #1's care plan would be updated with the additional interventions related to wandering and the elopement incident. The resident's State Guardian was notified of the incident. 3. On 02/24/2021, at 9:30 AM, an Ad Hoc QA Committee meeting was held regarding the elopement incident with the Administrator, the DON, the Medical Director, the Regional Director of Clinical Services (RDCS), Quality Assurance/Infection Control (QA/IC) Nurse, and Social Services (SS) in attendance. The attendees established the following action items for this AoC. 4. The facility's monthly QA Committee meetings were changed to weekly meetings until the Immediate Jeopardy (IJ) was removed. The QA Committee meetings would consist of the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Staff Development Coordinator (SD), Social Services, Dietary, and Unit Managers (UM). The next QA meeting would be held on 03/02/2021. 5. On 02/24/2021, housekeeping/maintenance checked all doors for a fifteen (15) second egress and documented an audit check. All doors worked properly. 6. On 02/24/2021, housekeeping/maintenance staff checked all doors for the Wanderguard functioning properly and documented the audit, completed on 02/24/2021. All Wanderguards worked properly. The audits would be conducted daily and submitted to the weekly QA Committee meetings for review. 7. On 02/23/2021, the QA/IC Nurse checked each resident's Wanderguard to validate that it was working correctly and checked to ensure the Wanderguard devices were physically in place on residents. The QA/IC Nurse found no problems during this audit. This audit will continue weekly, by the QA/IC Nurse, to validate compliance. The QA/IC Nurse submitted the audits to the weekly QA Committee for review. 8. On 02/23/2021, the QA/IC Nurse checked to verify each Wanderguard bracelet was on the Treatment Administration Record (TAR), was checked for placement/function, and signed and dated each shift by the nurse. The audit was completed on 02/24/2021. No concerns were noted. This audit would continue weekly by the QA/IC Nurse to validate compliance and submitted to the weekly QA Committee meeting. 9. On 02/25/2021, the Interdisciplinary Team (IDT) met and developed a written procedure for staff response to Wanderguard and door alarms. The IDT included the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. In-service training on this was completed, on 02/25/2021 through 03/02/2021, by the Nursing Administrative Team. The Nursing Administrative Team included the DON, the ADON, the QA/IC Nurse, and the Assistant RDCS. The facility had one hundred two (102) nursing staff and one hundred sixty-two (162) total staff. Eighty-nine (89) nursing staff and one hundred thirty-eight (138) total staff had received the in-service education. The thirteen (13) nursing staff and eleven (11) non-nursing staff who had not received the in-service education were currently on leave. Education included: a) Abuse/neglect-All staff with post-test; b) Behavior Management-All staff with post-test; c) Injury Prevention-All staff with post-test; d) Wandering Risk/Elopement-All staff with post-test; e) Dementia; Providing care for people with Dementia and cognitive changes-All staff with post-test; f) Care plan development and revision-IDT only with no post-test; g) Care Plans-Nursing Staff only; h) Accidents policy and procedures; Safety and supervision of residents-All staff with post-test; i) To not prop open any door for any reason unless someone was there monitoring doors-All staff with post-test; j) Elopement risks and procedures-All staff with post-test; k) Do not disarm any alarms without looking to see if the resident was outside-All staff with post-test; and l) Facility alarm in-service training included: photo of egress door alarm, photo of Wanderguard system code alert-All staff with post-test. 10. The staff on-leave would be in-serviced on these policies upon return to work. Current Agency staff was in-serviced. The facility would require new agency staff to be in-serviced with either the weekend House Supervisor, Saturday and Sunday or the Human Resource (HR) Director/Staffing Coordinator, Monday through Friday. The HR Director compiled a list o [TRUNCATED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person centered care plan interventions for one (1) of eleven (11) sampled residents (Resident #1), whom the facility assessed to exhibit wandering behavior and to be at risk for elopement. The facility admitted Resident #1, on 02/01/2014, with diagnoses, which included Alzheimer's Disease and Dementia. The facility most recently assessed Resident #1 was at risk for elopement, on 02/16/2021. The Comprehensive Person Centered Care Plan interventions, included interventions to prevent elopement. In addition, Resident #1 wore a Wanderguard bracelet (a device that activated alarms when the resident was near an exit door) to alert staff. Per documentation, Resident #1's assigned nurse, Licensed Practical Nurse (LPN) #1, last observed Resident #1, at 4:30 PM on 02/23/2021. Review of the facility's video footage revealed Resident #1 exited the facility's back door, at 4:40 PM on 02/23/2021, without staff knowledge. LPN #1 stated she heard door alarms, at approximately 4:30 PM to 4:40 PM, and responded to the alarms. LPN #1 stated she noted Resident #1 was not in the facility, between 5:00 PM and 5:30 PM on 02/23/2021. However, according to Resident #1's Comprehensive Care Plan (CCP) staff was to perform every fifteen (15) minute resident location checks and to thoroughly investigate the source of the alarms. LPN #1 failed to check on the resident at 4:45 PM. Staff found Resident #1 approximately eight (8) hours later in a wooded area, off facility property, approximately three hundred fifty-six (356) yards from the back door he/she had exited. Resident #1 was transferred to the hospital and admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to have an effective system in place to ensure each resident's comprehensive person centered care plan interventions were implemented to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 02/26/2021 and was determined to exist on 02/23/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 03/04/2021, with the facility alleging removal of the Immediate Jeopardy on 03/03/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/03/2021, prior to exit on 03/11/2021, with the 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, Care Plans, Comprehensive Person Centered, undated, revealed a comprehensive, person centered care plan included measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs and was developed and implemented for each resident. Per policy, care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Per policy, the comprehensive, person centered care plan would include measurable objectives and time frames; 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. Further review of the policy revealed identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident, were the endpoint of an interdisciplinary process. Review of the facility's policy titled, Responding to Egress/Wanderguard Alarms, undated, revealed staff was to respond immediately to egress and Wanderguard alarms. Continued review of the policy revealed the facility's procedure for responding to Egress/Wanderguard alarms included any staff who heard an alarm was to respond immediately, whether the egress/door alarm or the Wanderguard alarm. In addition, the policy stated staff would determine what triggered the alarms. Per policy, staff was to check inside and outside of the facility to determine the source. Furthermore, the policy stated if the source was unable to be determined, a facility head count would be initiated to confirm all residents were accounted for. Review of Resident #1's medical record revealed the facility admitted Resident #1, on 02/01/2014, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 02/08/2021, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severely impaired cognition. Further review revealed the facility assessed Resident #1 to have limited mobility and required the assistance of one (1) staff with activities of daily living (ADL's). Further review revealed the resident would have access to a walker or wheelchair for long distances, but could ambulate with or without a walker. Review of Resident #1's Comprehensive Care Plan (CCP) revealed the resident was last assessed, on 02/16/2021, and had a focus area of elopement risk. The goal was the resident would not wander from the facility unattended through the next review. Further review of the CCP revealed interventions for elopement prevention included Resident #1 was to wear a bracelet (Wanderguard) at all times; the nurse was to observe/document the resident's location every fifteen (15) minutes; and, staff was to check door alarms promptly to ensure safety of the resident. Review of Resident #1's Initial Investigation Report, dated 02/23/2021, revealed Resident #1 was last seen in the facility, on 02/23/2021 at 4:30 PM, by Licensed Practical Nurse (LPN) #1, as she had last documented on the resident's fifteen (15) minute observation checklist at 4:30 PM. Continued review revealed LPN #1 was working on Unit C (where the resident's room was located) at the time of the elopement, on the 3:00 PM to 11:00 PM shift on 02/23/2021. The report stated LPN #1 heard the alarms go off on Unit C, Door #5 (the door the resident used to exit the facility) when she was completing the medication administration. Continued review of the investigation report revealed when LPN #1 got to the door, she did not see anyone, and she silenced the alarms by placing a code in both keypads, located on either side of the door. Per the report, LPN #1 poked her head out of the door and looked both ways but did not see anyone and walked back to Unit C. Record review revealed videos from the investigation noted Resident #1 exited the facility at 4:40 PM through Unit C, Door #5. According to the report, Resident #1 exited through an alarmed door that was functioning properly because both the door alarm and the Wanderguard alarm sounded. The report concluded the alarms were silenced by a staff member who did not conduct a proper resident verification search. Interview with Licensed Practical Nurse (LPN) #1, on 02/26/2021 at 9:25 AM, revealed she had worked at the facility since August 2020. LPN #1 stated she observed Resident #1 lying in bed when observing for fifteen (15) minute checks; however, per the fifteen (15) minute observation sheet, the last physical check off on Resident #1 was at 4:30 PM. LPN #1 stated she had given Resident #1 Tylenol (a pain reliever) at 4:17 PM for pain. Continued interview with LPN #1 on 02/26/2021 at 9:25 AM, revealed she helped deliver meal trays, around 5:00 PM to 5:30 PM, and was unable to locate Resident #1 at that time. LPN #1 stated she heard the door alarms sound from Door #5 (door the resident exited), around 4:30 PM, and went to examine the area. The LPN stated she went to the door, turned off the alarm on the right side of the door (the egress alarm) by putting in the code and then turned off the alarm on the left side of the door (the Wanderguard alarm) by putting in the code. Further, LPN #1 stated she observed the area and held the door open while she looked outside the facility and reported that she did not see anyone around the area. However, per the care plan, the nurse was to observe/document the resident's location every fifteen (15) minutes; and, staff was to check door alarms promptly to ensure safety of the resident Continued interview on 02/26/2021 at 9:25 AM, with LPN #1 revealed Resident #1 was not identified as missing until meals were being served, between 5:00 PM and 5:30 PM. However, Resident #1 was scheduled to have a fifteen (15) minute location check by LPN #1 at 4:45 PM, 5:00 PM, and 5:15 PM. In addition, LPN #1 heard Door #5 alarm, at 4:30 PM, went to the door, did not see anyone outside the door, and continued to work. Per the CCP and policy, LPN # 1 was required to do a resident head count when she did not discover the source of the alarms, but she waited until she discovered Resident #1 was missing, between 5:00 PM and 5:30 PM. Interview with State Registered Nurse Aide (SRNA) #1, on 02/25/2021 at 4:23 PM, revealed the nurses performed the every fifteen (15) minute Wanderguard checks and documented them in the health record. Per interview, SRNA's would also monitor the resident, but the nurse verified and documented the every fifteen (15) minute resident location checks. SRNA #1 stated she thought Resident #1 was the only resident on Unit C who wore a Wanderguard device. Interview with SRNA #2, on 02/26/2021 at 10:22 AM, revealed the procedure for responding to the door alarm was when the alarm sounded, staff would check the alarm box at the Nurse's Station which indicated the door where the alarm was sounding. In addition, she stated staff would then go to that door to investigate the alarm. In addition, she stated the SRNA's checked daily to confirm the resident was still wearing the Wanderguard device; and the nurse signed off on the resident's location every fifteen (15) minutes, per the elopement risk resident's CCP. Interview with SRNA #3, on 02/26/2021 at 11:15 AM, revealed on 02/23/2021 from 7:00 AM to 3:00 PM, he had been Resident #1's primary aide, providing care to him/her on that day. SRNA #3 stated if an alarm sounded, staff was to check the panel (Staff Alert System) to see the alarm's location. SRNA #3 further stated the door would remain unlocked as long as it was alarming, which allowed time to visually check outside and still be able to return through the door to the inside. Moreover, he stated he would notify his nurse, and a head count of residents would be completed to verify all residents were accounted for per the resident's care plan. Interview with LPN #2, on 02/26/2021 at 10:02 AM, revealed she had worked the 7:00 AM to 3:00 PM shift, on Unit C, the day of the elopement. LPN #2 further stated, If you hear an alarm, you should respond immediately and see what caused it to alarm. She stated nurses were responsible to verify that designated residents had Wanderguard devices in place each shift and signed off on resident location checks every fifteen (15) minutes. LPN #2 stated these actions were on a resident's care plan that had elopement as a focus area. Interview with the Director of Nursing (DON), on 02/26/2021 at 1:17 PM, revealed she received a call from LPN #1, on 02/23/2021 around 5:00 PM, reporting Resident #1 was missing from the facility. The DON stated she had LPN #1 initiate a Code Green, and she came to the facility to help search for the resident. Per interview, she stated education on elopement and wandering of residents was given to all new hires and also completed annually. In addition, the training provided by the facility covered the door and Wanderguard alarms and specific codes used by the facility, including Code Green which was for elopement. In addition, she stated training on developing and implementing care plans was given at orientation and annually for nurses. Per interview, the DON stated she expected staff to respond immediately and determine who or what set off the alarms per the resident's CCP. She stated staff was expected to check outside the building, comb the area thoroughly, and verify that all residents were accounted for. The DON stated the Wanderguard alarm had a higher pitch sound than the door alarm, and LPN #1 should have been able to distinguish between them and realize if the Wanderguard alarm sounded, a resident would have probably exited the door. The DON stated LPN #1 did not follow Resident's #1's CCP when she failed to do a prompt and thorough investigation of the cause of the alarms and immediately do a resident head count when she did not determine what had triggered the alarms. Interview with the Administrator, on 02/26/2021 at 4:20 PM, revealed he was made aware of Resident #1 missing, at approximately 6:00 PM on 02/23/2021, and came to the facility immediately to facilitate the search for Resident #1. He stated he expected staff to respond immediately and find the source of the alarm activation. The Administrator stated if no one could be seen around the area, and the cause could not be determined, staff was to verify that all residents were accounted for in the facility by means of a physical head count for the residents' safety, per policy and the resident's care plan. The Administrator stated he believed facility staff knew what the alarms were for and what to do if alarms were activated, even though LPN #1 did not follow the facility's policy or Resident #1's care plan. In addition, he stated all staff were to follow the facility's policies and the residents' care plans at all times when providing care. The facility provided an acceptable credible Allegation of Compliance (AoC), on 03/04/2021, which alleged removal of the Immediate Jeopardy, on 03/03/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/23/2021, immediately after notification of Resident #1's disappearance, nursing staff performed a headcount of all residents. Staff accounted for all the other residents. 2. On 02/24/2021, at approximately 12:30 AM, facility staff found Resident #1 in a wooded area adjacent to the facility. Resident #1 was immediately assessed and sent to a local hospital for evaluation and admission. When Resident #1 returned to the facility, he/she would be placed on one-to-one (1:1) supervision along with wearing the Wanderguard bracelet. A new elopement assessment would be completed. Any new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's State Guardian was notified of the incident. 3. On 02/24/2021, at 9:30 AM, an Ad Hoc QA Committee meeting was held regarding the elopement incident with the Administrator, the DON, the Medical Director, the Regional Director of Clinical Services (RDCS), Quality Assurance/Infection Control (QA/IC) Nurse, and Social Services (SS) in attendance. The attendees established the following action items for this AoC. 4. The facility's monthly QA Committee meetings were changed to weekly meetings until the Immediate Jeopardy (IJ) was removed. The QA Committee meetings would consist of the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Staff Development Coordinator (SD), Social Services, Dietary, and Unit Managers (UM). The next QA meeting would be held on 03/02/2021. 5. On 02/24/2021, housekeeping/maintenance checked all doors for a fifteen (15) second egress and documented an audit check. All doors worked properly. 6. On 02/24/2021, housekeeping/maintenance staff checked all doors for the Wanderguard functioning properly and documented the audit, completed on 02/24/2021. All Wanderguards worked properly. The audits would be conducted daily and submitted to the weekly QA Committee meetings for review. 7. On 02/23/2021, the QA/IC Nurse checked each resident's Wanderguard to validate that it was working correctly and checked to ensure the Wanderguard devices were physically in place on residents. The QA/IC Nurse found no problems during this audit. This audit will continue weekly, by the QA/IC Nurse, to validate compliance. The QA/IC Nurse submitted the audits to the weekly QA Committee for review. 8. On 02/23/2021, the QA/IC Nurse checked to verify each Wanderguard bracelet was on the Treatment Administration Record (TAR), was checked for placement/function, and signed and dated each shift by the nurse. The audit was completed on 02/24/2021. No concerns were noted. This audit would continue weekly by the QA/IC Nurse to validate compliance and submitted to the weekly QA Committee meeting. 9. On 02/25/2021, the Interdisciplinary Team (IDT) met and developed a written procedure for staff response to Wanderguard and door alarms. The IDT included the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. In-service training on this was completed, on 02/25/2021 through 03/02/2021, by the Nursing Administrative Team. The Nursing Administrative Team included the DON, the ADON, the QA/IC Nurse, and the Assistant RDCS. The facility had one hundred two (102) nursing staff and one hundred sixty-two (162) total staff. Eighty-nine (89) nursing staff and one hundred thirty-eight (138) total staff had received the in-service education. The thirteen (13) nursing staff and eleven (11) non-nursing staff who had not received the in-service education were currently on leave. Education included: a) Abuse/neglect-All staff with post-test; b) Behavior Management-All staff with post-test; c) Injury Prevention-All staff with post-test; d) Wandering Risk/Elopement-All staff with post-test; e) Dementia; Providing care for people with Dementia and cognitive changes-All staff with post-test; f) Care plan development and revision-IDT only with no post-test; g) Care Plans-Nursing Staff only; h) Accidents policy and procedures; Safety and supervision of residents-All staff with post-test; i) To not prop open any door for any reason unless someone was there monitoring doors-All staff with post-test; j) Elopement risks and procedures-All staff with post-test; k) Do not disarm any alarms without looking to see if the resident was outside-All staff with post-test; and l) Facility alarm in-service training included: photo of egress door alarm, photo of Wanderguard system code alert-All staff with post-test. 10. The staff on-leave would be in-serviced on these policies upon return to work. Current Agency staff was in-serviced. The facility would require new agency staff to be in-serviced with either the weekend House Supervisor, Saturday and Sunday or the Human Resource (HR) Director/Staffing Coordinator, Monday through Friday. The HR Director compiled a list of all staff on leave and tracked the schedule to assure that no staff returned to work and no agency staff worked without receiving the training and passing the post-test. 11. On 02/23/2021, Social Services, for residents with Wanderguard devices, compared physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No residents were identified with inaccuracies or incomplete records. This was completed on 02/28/2021. 12. On 02/24/2021, Social Services checked all elopement risk assessments to ensure they were up to date (at least quarterly). This audit was completed on 02/28/2021. 13. On 02/24/2021 through 02/28/2021, Social Services reviewed the last thirty (30) days of all residents' medical records, Nurses' Notes, Progress Notes, eMAR notes, behavior monitoring notes, care plans, and Social Services Notes. The purpose of this review was to identify any previously unknown behaviors to ensure staff addressed appropriate interventions for supervision. Social Services updated care plans as needed. 14. Social Services audited Wander Alert Books weekly to ensure they were updated. Results will be submitted to the weekly QA Committee meetings for review. The Elopement Risk Books were located on six (6) units. Two (2) additional books were being created, and one (1) would be placed at the front door and one (1) at the back door by Social Services. Completion date 02/28/2021. 15. On 02/24/2021, Social Services completed a new Elopement Risk Assessment for one hundred eighteen (118) residents and completed it on 02/28/2021. No changes were identified for care plan revisions with these new assessments. 16. On 02/24/2021, the DON reviewed the Interdisciplinary Plan of Care (IPOC) process and decided no revisions were needed. During IPOC meetings, Monday through Friday, the IDT reviewed the 24-hour Summary and Incident Reports, including elopements, elopement attempts, falls, progress notes for behaviors, and electronic Medication Administration (eMAR) notes for behaviors. The licensed nurses updated the care plans using a three-part form, which included one (1) each for a change in condition, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plans were reviewed and revised by the IPOC Team as needed for behavior and supervision interventions during the IPOC meetings. The DON reported IPOC results to the QA Committee weekly. 17. On 02/24/2021, the Maintenance Department changed all keypad codes and will change keypad codes monthly. Staff was notified of door code changes via an internal communication system. 18. On 02/28/2021 through 03/01/2021, the QA/IC Nurse and/or the DON will conduct an elopement drill on each shift, including weekend staff, and document the drill and staff responses with signatures. Results will be submitted to the weekly QA Committee meeting on 03/02/2021. The elopement drills will be conducted monthly on each shift by the Nursing Department. The next drill will be due in March and performed by the Nurse Administrative Team. 19. On 02/24/2021, the facility requested the Wanderguard Company to check the Wanderguard system. The Wanderguard Company visited, on 02/25/2021, and checked all Wanderguard doors and systems. All were functioning correctly. 20. On 02/25/2021, the ADON added education on the Wanderguard and egress alarm systems to new hires and agency orientation, along with a post-test for validation of understanding. All in-services (12) conducted as part of this AoC were included in the new hire and agency orientation. 21. Starting 02/26/2021, the QA/IC Nurse will review the AoC plan daily for completion and compliance with the IPOC team, a subcommittee of the QA Committee. The Administrator, the DON, and the QA/IC Nurse were also members of the IPOC Committee. Then the AoC plan would be submitted weekly to the QA Committee meeting for additional oversight of compliance and completeness. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Interview with the DON, on 02/25/2021 at 3:04 PM, revealed LPN #1 notified her, around 5:30 PM on 02/23/2021, of Resident #1's disappearance. She gave instructions for LPN #1 to have each unit perform a head count of all residents in the facility. Also, she instructed LPN #1 to call a Code Green, which was an internal missing resident alert. The headcount revealed no other resident was missing. Interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed she called a Code Green, searched for Resident #1 on C and D Units, and then notified all units to search for Resident # 1 on their units. She also told them to perform a head count of all residents on their units. The headcount revealed no other missing resident. Review of Police Incident Report #2012- 310, dated 02/23/2021 at 8:09 PM, revealed a head count was conducted, and Resident #1 was not inside. 2. Review of the Division of Fire and Emergency Medical Service (EMS) Incident Report # , on 02/24/2021 at 12:52 AM, revealed Resident #1 was found in a wooded area after being missing for several hours. The resident was shivering vigorously. She denied other complaints. No obvious injury was noted. Resident #1 was transferred to the hospital. Review of Progress Notes, dated 03/03/2021 at 3:15 PM, revealed Resident #1 returned to the facility from the hospital, on 03/03/2021 at 3:00 PM, and one-to-one (1:1) staff supervision was initiated with the resident. Additional documentation at 6:51 PM stated Resident #1 continued with one-to-one (1:1) supervision, and a Wanderguard device/bracelet was on his/her left ankle. Review of Resident #1's Comprehensive Care Plan, revised 03/05/2021, revealed staff made elopement risk revisions, on 03/03/2021, to include one-to-one (1:1) supervision. Review of Elopement Assessments, dated 02/25/2021, revealed elopement assessments were conducted on all residents in the facility. Interview with the Social Services Coordinator, on 03/10/2021 at 11:00 AM, revealed she completed elopement assessments on one hundred eighteen (118) residents, beginning 02/24/2021 through 02/28/2021. Interview with LPN #2, on 03/10/2021 at 9:30 AM, revealed staff provided one-to-one (1:1) monitoring and supervision, at all times (24/7), to Resident #1, since he/she returned to the facility, on 03/03/2021. In addition, she stated Resident #1 had a Wanderguard bracelet on his/her left ankle. Continued interview revealed Resident #1 was transferred to another facility, on 03/09/2021, to evaluate increased agitation and medication management/adjustment. 3. Review of the QA Ad Hoc Meeting minutes and attendance roster, dated 02/24/2021 at 9:30 AM, revealed the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Regional Director of Clinical Services, the Social Services Coordinator, and the Social Services Director were in attendance. Resident #1's elopement and a Root Cause Analysis (RCA) were discussed. The attendees established action items for the Allegation of Compliance (AoC). Interviews, on 03/10/2021, with the Social Services Coordinator at 11:00 AM, the QA/IC Nurse at 12:00 PM, the DON at 2:19 PM, and the Administrator at 3:00 PM, revealed they all attended the QA Ad Hoc Meeting, on 02/24/2021 at 9:30 AM. Resident #1's elopement and an RCA were discussed. Action items for the AoC were established. 4. Review of the QA Meeting minutes and roster, dated 03/02/2021 and 03/09/2021, and titled AoC Weekly Meeting, Discussing the Elopement Incident and Action Items for the AoC revealed those signing the roster included the Medical Director, the Administrator, the DON, the QA/IC Nurse, the UM, Social Services, the ADON/Staff Development Coordinator (SDC), and the Dietary Manager. Interviews, on 03/10/2021, with the Social Services Coordinator at 11:00 AM, the QA/IC Nurse at 12:00 PM, the DON at 2:19 PM, and the Administrator at 3:00 PM, revealed they all attended the weekly QA Committee meetings, on 03/02/2021 and 03/09/2021. Action items for the AoC were discussed. 5. Review of Exit Door Audits, dated 02/24/2021 at 8:00 AM, signed by the Maintenance Director, revealed ten (10) exit door checks were done to include egress, battery, hardware, alarm, and the Wanderguard system. All worked properly. Interview with the Maintenance Director, on 03/10/2021 at 12:22 PM, revealed he checked all doors, on 02/24/2021, and documented the audit. No issues were found. He stated since the elopement, the door checks were done daily instead of weekly, and Housekeeping would check the Wanderguard functioning. 6. Review of the Wanderguard Daily Door Function Test, dated from 02/01/2021 to 03/09/2021, and initialed daily by the Housekeeping Supervisor, or designee, revealed they checked the Wanderguard functionality daily for ten (10) exit doors. All Wanderguards worked correctly. The audits were part of the QA report. Interview with the Housekeeping Supervisor, on 03/09/2021 at 2:30 PM, revealed he tested the Wanderguard alarm system during the week by physically placing a Wanderguard device close to each exit door to set off the alarm, validating it was working correctly. The audits were performed daily and submitted to the weekly QA meeting for review. Interview with Housekeeper #1, on 03/09/2021 at 2:45 PM, revealed she performed the test on the Wanderguard alarm system on weekends. She or her designee conducted the test every weekend. She submitted the audits to the QA meeting. 7. Review of the Wanderguard Placement Check, dated 02/23/2021, signed by the QA/IC Nurse, revealed she checked all (6) six residents' placement and function with Wanderguards and identified no issues. Interview with the QA/IC Nurse, on 03/10/2021 at 12:00 PM, revealed, on 02/23/2021, she checked all Wanderguards in the facility to validate the device was working correctly and physically in place. Staff used a small testing device that beeped when placed next to the Wanderguard bracelet, indicating it was working. She found no problems. The audits were part of the weekly QA meeting. 8. Review of the Weekly Wanderguard QA Audit, dated 02/24/2021, 03/02/2021, 03/08/2021, and 03/09/2021, revealed the QA/IC Nurse audited a check of each Wanderguard bracelet on the Treatment Administration Record (TAR) for placement and function. She identified no concerns. The audits were included in the QA reports. Review of the TAR's of nine (9) residents listed on the Wanderguard Audit revealed staff checked the device function every shift on the night shift, and day shift staff checked for placement each shift daily. Interview with the QA/IC Nurse, on 03/10/2021 at 12:00 PM, revealed she checked the Wanderguard audits to see if nurses were doing the audits for function and placement per policy and included the results in the weekly QA audit reports. 9. Review of the Interdisciplinary Team Meeting minutes, dated 02/25/2021, revealed the meeting's purpose and attendees, to include the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. Review of education provided to all staff, dated 02/24/2021 through 03/02/2021, included: Abuse/Neglect; Behavior Management; Injury Prevention; Wandering Risk/Elopement; Dementia; Care Plan Development & Revision; Accidents Policy & Procedure; Propping Open Doors; Elopement Risks & Procedures; Disarming Alarms; and Facility Alarms. Attendance rosters were attached. Interview with the Nursing Administrative Team members, on 03/10/2021, the ADON at 11:36 AM, the QA/IC Nurse at 12:00 PM, and the DON at 2:19 PM, revealed they provided education to staff 02/24/2021 through 03/02/2021. Education was ongoing. Interviews, on 03/09/2021, with LPN #7 at 2:30 PM, LPN #3 at 2:40 PM, SRNA #4 at 2:50 PM, LPN #8 at 3:00 PM, SRNA #5 at 3:15 PM, RN # 2 at 3:20 PM, LPN # 6 at 3:30 PM, Housekeeper #1 at 3:40 PM, and the Housekeeping Supervisor at 3:55 PM, revealed they received education and training provided by the QA/IC Nurse, the ADON, and the DON. Education included door alarms, behavior management, care plan development and revision, accidents, abuse/neglect, elopement, wandering, Dementia, and propping doors. An interview with SRNA #6, on 03/10/2021 at 10:24 AM, revealed she received mandatory education and training regarding elopement, alarms, COVID, care plans, abuse/neglect, behaviors, and elopement. The ADON provided the education. 10. Review of all documents and education rosters revealed a list of all staff either on Family and Medical Leave Act (FMLA), currently not working, or who had not received the required AoC education and training. The HR Manager monitored this list. Interview with the HR Director/Staffing Coordinator, on 03/10/2021 at 12:42 PM, revealed that as HR Director, she oriented all new staff that entered the facility and was respon [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, review of the facility's investigation, review of the website www.localconditions.com, review of the police department report, and review of the fire department report, 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 eleven (11) sampled residents (Resident #1), who was assessed to exhibit wandering behavior and to be at risk for elopement. The facility admitted Resident #1, on 02/01/2014, with diagnoses, which included Alzheimer's Disease and Dementia. On 02/16/2021, the facility assessed the resident to be at risk for elopement due to wandering behavior and lack of safety awareness. Resident #1 wore a Wanderguard bracelet (a device that activated alarms when the resident was near an exit door) to alert staff. Residents with Wanderguard bracelets were to be checked every fifteen (15) minutes for location. Staff last observed Resident #1, at 4:30 PM on 02/23/2021. Review of the facility's video footage revealed Resident #1 exited the facility's back door, at 4:40 PM on 02/23/2021, without staff knowledge. The resident's assigned nurse, Licensed Practical Nurse (LPN) #1, stated she heard the door alarms, at approximately 4:30 PM to 4:40 PM, and responded to the alarms. The LPN silenced the alarms, but failed to determine what triggered the alarms and failed to ensure staff accounted for Resident #1, as per the facility's policy. LPN #1 stated she noted Resident #1 was not in the facility, between 5:00 PM and 5:30 PM on 02/23/2021. Staff found Resident #1 approximately eight (8) hours later in a wooded area, off facility property, approximately three hundred fifty-six (356) yards from the back door he/she had exited. Resident #1 was transported to a local hospital per Emergency Medical Services (EMS) and was admitted to the hospital. Review of the hospital's Emergency Department record revealed the resident was diagnosed with Hypothermia (a dangerous drop in body temperature caused by prolonged exposure to cold); and Acute Kidney Injury (a condition in which the kidneys could not filter waste from the blood which developed rapidly) related to dehydration. 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) were identified on 02/26/2021 and determined to exist on 02/23/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 03/04/2021, with the facility alleging removal of the Immediate Jeopardy on 03/03/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/03/2021, prior to exit on 03/11/2021, with the 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, Wandering and Elopements, undated, revealed the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Further review of the policy revealed if a resident was identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety; and, if a resident was missing, initiate the elopement/missing resident emergency procedure. Review of the facility's policy titled, Wanderguard System, undated, revealed the Wanderguard system was used for at-risk residents for elopement. The purpose of using this system was for each resident to reach his/her highest practicable well-being in an environment that prohibited the use of restraints for discipline or convenience. The policy stated the Wanderguard bracelet would be applied to the resident's wrist or ankle and not be removed until a replacement was needed. In addition, the Wanderguard bracelets were checked for placement and functional status each shift by the charge nurse and were documented in the treatment administration record (TAR). Review of the facility's policy, Responding to Egress/Wanderguard Alarms, undated, revealed staff should immediately respond to egress and Wanderguard alarms. Per policy, upon hearing an alarm, staff members should immediately respond to the alarm sounds of both the door alarm and the Wanderguard alarm. In addition, upon responding to the alarms, staff should determine what triggered the alarms. Further review revealed staff should check inside and outside the facility to determine the source that triggered the alarms. Furthermore, if the source of the egress or Wanderguard alarm was not resolved, staff should initiate a facility resident head count. Review of Resident #1's medical record revealed the facility admitted the resident, on 02/01/2014, with diagnoses to include Dementia, Alzheimer's Disease, Unsteadiness on Feet, and Chronic Kidney Disease. Review of Resident #1's Comprehensive Care Plan (CCP), most recently reviewed by the facility on 02/16/2021, had a focus of the resident was at risk for elopement due to wandering behavior and lack of safety awareness. The goal was the resident would not wander out of the facility unattended through the next review. Further review revealed interventions included: allow the resident to wander in safe paths in the facility; attempt to divert the resident's attention when he/she became insistent on leaving; check door alarms promptly to ensure safety; elopement prevention (Wanderguard) bracelet at all times, and check placement every shift; elopement risk assessment per facility policy; elopement risk required to check the resident's location every fifteen (15) minutes; keep a picture of (Resident #1) in the Elopement Risk book; and give medications per Physician's Orders. Review of Resident #1's Comprehensive Minimum Data Set (MDS) Assessment, dated 05/08/2020, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Score (BIMS) of eight (8) out of fifteen (15), indicating moderate cognitive impairment. However, review of the most recent MDS Quarterly Assessment, dated 02/08/2021, revealed the facility assessed Resident #1 as having a BIMS' score of five (5) out of fifteen (15), indicating severe cognitive impairment. Continued review of Resident #1's Comprehensive MDS Assessment, Section E, Behavior-Wandering, dated 05/08/2020, revealed Resident #1 exhibited no wandering behavior. However, review of Section E of the most recent MDS Quarterly Assessment, dated 02/08/2021, revealed the facility assessed Resident #1 as exhibiting wandering behaviors one (1) to three (3) days per week. Review of the Physician's Orders, dated 08/27/2020, revealed an order to place a Wanderguard bracelet for safety. Review of the Resident #1's Progress Notes, on 02/23/2021, revealed no documented evidence the resident was exhibiting exit-seeking and wandering behaviors. Review of the facility's Investigation Accident/Incident Report, initiated on 02/23/2021, and signed by the Administrator on 02/24/2021, revealed Resident #1 exited the facility, at approximately 4:40 PM on 02/23/2021, from Unit C, Door #5. The Wanderguard and door alarm sounded, and it was confirmed both worked properly for Door #5. Further review revealed the nurse silenced the alarm, but did not determine the alarm source or immediately perform a thorough resident search. Continued review revealed LPN #1 notified the Director of Nursing (DON), around 5:30 PM on 02/23/2021 that Resident #1 could not be located. Review of the report revealed the DON informed the Administrator that staff had initiated a search for Resident #1 inside and outside the facility. Per the report, staff notified the resident's Guardian, the Physician, the Police, the Fire Department, and local hospitals, alerting them of the missing resident. The report stated approximately forty (40) individuals assisted in the search for the missing resident, and the media issued a Golden Alert (an alert for elderly or impaired missing persons). In addition, the report stated a helicopter and a canine unit were deployed in the search, and staff searched on foot and in vehicles. The facility's staff located Resident #1, in a wooded area left of an adjacent long-term care facility. The resident was responsive and in stable condition. Staff called 911. An ambulance arrived and transferred Resident #1 to a local hospital ED (emergency department). Review of the hospital's Emergency Department record revealed the resident was admitted to the hospital, on 02/24/2021, and diagnosed with Hypothermia (a dangerous drop in body temperature caused by prolonged exposure to cold) with a rectal temperature of 90.9 degrees Fahrenheit (normal was 97.1 to 99.2 degrees Fahrenheit); and Acute Kidney Injury (a condition in which the kidneys could not filter waste from the blood which developed rapidly) related to dehydration. Further review revealed Resident #1 also had superficial abrasions over both hands and both knees and had tenderness in his/her [MEDICATION(S)] and lumbar spine areas with palpation. Continued review revealed blood tests were performed which showed an elevated serum creatinine level of 1.21 milligrams (mg) per deciliter (d/L). In addition, per the record, Resident #1 was placed under warming blankets and then a [NAME] [NAME] blanket (a forced air warming system used to prevent hypothermia and keep patients at a normal core body temperature). Further review revealed Resident #1 stayed under the [NAME] [NAME] for four (4) hours until his/her rectal temperature improved to 97.5 degrees Fahrenheit. In addition, a Computed Tomography (CT) scan was done of the head and the spine, which were negative for acute fractures. Continued review revealed Resident #1 was initially given one (1) liter of warmed intravenous fluids (IVF) and then continued on regular IVF's. Per hospital record, Resident #1 was discharged from the hospital on 03/03/2021, after an eight (8) day stay. Review of the local weather history, via the website www.localconditions.com, revealed the temperature high, on 02/23/2021, was fifty-seven (57) degrees Fahrenheit, with a low of forty-one (41) degrees Fahrenheit, when staff found Resident #1. Review of video footage from the facility's security camera revealed Resident #1 exited the facility from a back door, on 02/23/2021 at 4:40 PM, and proceeded along a fence row toward an adjacent long-term care facility. Review of the Police Department (PD) Incident Report, dated 02/26/2021 at 11:07 AM, revealed the police received a call, on 02/23/2021 at 7:09 PM, from the facility, regarding a missing elderly person. The police were dispatched to the facility, on 02/23/2021 at 7:10 PM. Per the dispatch log, the resident was found by facility staff, on 02/24/2021 at 12:36 AM. Review of the Fire Department (FD)/EMS Report, dated 02/23/2021, revealed units responded to a report of a missing elderly long-term care (LTC) facility resident, who, according to the LTC facility staff, had been missing for approximately one (1) hour. The report stated staff was actively searching for the individual when the FD arrived, and the FD crew searched the LTC facility's surrounding area using flashlights and thermal imaging cameras. In addition, the report stated the PD used a helicopter at 9:53 PM and had requested a tracking canine (K-9). Continued review revealed at 12:30 AM on 02/24/2021, the unit was advised the resident had been located and was dispatched to where the resident had been located. The report stated Resident #1 complained of being cold; was shivering vigorously; denied other complaints; and FD personnel observed no obvious injuries. Further review revealed Resident #1 was transported to a local hospital. Observation of the elopement route, on 02/25/2021 at 11:50 AM, revealed Resident #1 exited his/her room on Unit C, turned left, passed the Nurses Station, made another left, and left the facility though Door #5 to the outside of the building. Observation of the location where staff found Resident #1 revealed a wooded area, left of an adjacent LTC facility, approximately three hundred fifty-six (356) yards, as measured by the Maintenance Director, from the door where the resident exited. Observation of all exit doors in the facility, during a facility tour, on 02/25/2021 at 11:00 AM, revealed nine (9) exit doors. Further observation revealed doors #6, #7, #8, and #9 had signage with various instructions to include: Do not use door to enter/exit per administration; If you see any resident standing next to the door, do not let them out, call for a staff member; Please make sure the door completely shuts. It would alarm until the door was properly shut. Per observation, there was no signage on doors #1, #2, #3, #4, or #5. Also, these doors were observed to have a Wanderguard alarm keypad to the left side of the door and a door alarm keypad to the right side of the door. Interview with the Maintenance Director, on 02/26/2021 at 10:30 AM, revealed he had been employed twenty-six (26) years at the facility. Continued interview revealed before the elopement, doors were checked weekly, on Mondays; but now, he checked exit doors daily. He stated checks involved reviewing the codes; looking for any obstructions around the doors; and checking the egress, hinges, screens, and backup battery. He stated all doors had a backup battery, which connected to the generator in the event of a power failure. Also, he stated housekeeping staff checked the Wanderguard device to the door alarm for proper functioning daily. In addition, the Maintenance Director revealed when the door alarm sounded, a staff member must respond immediately and punch in the code to the keypad to silence the alarm. Observation of a demonstration of functionality, by the Maintenance Director and the Housekeeping Supervisor, on 02/26/2021 at 10:40 AM, of Door #5's alarm (the door the resident exited) with the Wanderguard alarm occurred. This demonstration revealed engaging the door handle for fifteen (15) seconds or less would not open the door; however, continued engaging the door handle for another fifteen (15) seconds, for a total of thirty (30) seconds, would open the door, and the alarm would sound. Per observation, the alarm would continue to sound until a code was entered into the keypad to silence the alarm. Also, per observation, when a Wanderguard bracelet came within two (2) to three (3) feet of a Wanderguard alarm device, the alarm would sound, and entering a code into the keypad would silence the alarm. Continued observation revealed the difference between the two (2) alarms was distinguishable. The Wanderguard alarm had a louder, constant, piercing, loud sound, and the door alarm had a loud throbbing noise. Continued observation of Door #5 revealed a keypad on the left side of the door to silence the Wanderguard alarm and a keypad on the right side to silence the actual door alarm (both were on the inside of the facility). Observation of the Staff Alert System, on 02/26/2021 at 10:55 AM, revealed they were located in or close to each Nurse's Station, in a panel box with a light that would flash with audible alarm sounds, indicating which facility door was alarming. Further, per observation, staff could see, from any station, which door to respond to, even if it was not their assigned unit. Interview with Resident #2 (BIMS 15, which indicated cognitively intact), on 02/25/2021 at 12:15 PM, revealed he/she was reasonably sure the person who walked by his/her window, the evening (unsure of the exact time) of 02/23/2021, was Resident #1, but he/she could not say with total certainty. Resident #2 stated he/she was lying in bed when a person walked past his/her window hunched over, looked back, and then continued walking. The resident stated, after telling a staff member what he/she had witnessed, he/she was interviewed by a police officer. Interview with State Registered Nurse Aide (SRNA) #1, on 02/25/2021 at 4:23 PM, employed at the facility for fourteen (14) months, revealed she was working Unit C, the unit where Resident #1 resided, the evening Resident #1 exited the facility. She said she did not hear the door alarm go off, adding she was making her rounds and was either in a room with the door closed, or too far away to hear it. She stated she last saw Resident #1, on 02/23/2021 around 4:00 PM, in his/her room, sitting on the bed, fully dressed, and wearing a sweatshirt and pants but not a coat. She stated she talked to the resident, and he/she said nothing about going anywhere or wanting to go anywhere. Further interview revealed, between 5:00 PM and 5:45 PM, she was approached by LPN #1 and asked if she had seen Resident # 1 because he/she could not be located. SRNA #1 stated she began to search for Resident #1 with other staff in every room in the facility Continued interview with SRNA #1, on 02/25/2021 at 4:23 PM, revealed if the door alarm sounded, staff went to the door, looked out, and then cut the alarm off if they did not see anything. She stated she was not aware of any issue with the door alarm system. She said if you deactivated the door alarms, then reopened the door, the alarm would sound again. She stated staff on Unit C and Unit D would respond to the door alarm on either unit, and all available staff from each unit would go and check the doors. SRNA #1 stated there was a difference in the sound of the door alarm and the sound of the Wanderguard alarm; the Wanderguard alarm was much louder than the door alarm. She also stated nursing staff did not go out the doors that had egress and Wanderguard alarms because the alarms would sound; however, housekeeping staff would use them, but they would put in the codes to deactivate the alarms and the alarms would reactivate. She stated nurses performed the every fifteen (15) minute Wanderguard checks and documented them in the health record. Per interview, SRNA's would also monitor the resident, but the nurse verified and documented the every fifteen (15) minute resident location checks. SRNA #1 stated she thought Resident #1 was the only resident on Unit C who wore a Wanderguard device. Telephone interview with LPN #1, on 02/26/2021 at 9:27 AM, who had been employed at the facility since August 2020, revealed she typically reported to work between 2:30 PM and 2:45 PM. She stated she saw Resident #1, on 02/23/2021, when first reporting to work and again when administering medications, around 4:00 PM. She said when she was delivering dinner trays, around 5:00 PM or 5:30 PM, she could not find Resident #1. She stated she went to the Day Room, did not see him/her, and then started looking in all the other rooms on Unit C and Unit D but did not find the resident. Per interview, she then requested Units A, B, and 500 staff to look for Resident #1 in their areas. She stated she called the DON, between 5:00 PM and 5:30 PM, who instructed her to call a Code Green, the code for a missing resident. LPN #1 stated everyone started looking for the resident. Further interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed when she saw Resident #1, before the elopement, he/she was lying in bed, with no agitation or talk of leaving. She stated staff checked the Wanderguard placement every shift to ensure the resident was still wearing the device, and the day shift nurse checked functionality daily. She stated when the door alarm sounded for Door #5 (the door Resident #1 exited), she went to the door, turned off the alarm on the right side of the door (the egress alarm) by putting in the code. In addition, LPN #1 stated there was another alarm (the Wanderguard alarm), on the left side of the door, and she did not know the purpose of that alarm, but knew the code to silence it. Per interview, LPN #1 stated she opened the door and looked out both ways quickly, and no one was there; so, she closed the door, returned to her workstation, and continued to work. She stated she did not check to see if all residents were accounted for because she did not see anyone outside the door. However, review of the facility's policy revealed if the source of the egress or Wanderguard alarm was not resolved, staff should initiate a facility resident head count, which LPN #1 failed to do, as she did not determine what triggered the alarm. Continued interview with LPN #1, on 02/26/2021 at 9:27 AM, revealed she was not aware that one (1) alarm on the door was for the Wanderguard device, and the other alarm was for the door. She was asked about the difference between the sound of the Wanderguard alarm and the door alarm, and LPN #1 stated there was no sound difference. She asked, Is there an alarm sound difference? Then, she added, I did not know there were two (2) different alarms on the door. I thought the door had two (2) alarms that sounded when opened. I did not know one (1) alarm was associated with the Wanderguard. In addition, she stated all available staff usually went to the door to check when the alarm sounded; however, only she went to the door this time, and SRNA #1 and an agency SRNA were also working on the unit. LPN #1 stated she was informed facility staff found the resident around 1:00 AM to 2:00 AM, in the early morning of 02/24/2021. Interview with LPN #2, on 02/26/2021 at 10:02 AM, who had been employed ten (10) years at the facility, revealed she worked day shift, on 02/23/2021, the day Resident #1 eloped. She stated when she left the facility around 4:00 PM, Resident #1 was in his/her room and sitting in a chair, where he/she had been most of the day. She stated Resident #1 could ambulate with or without a walker. In addition, she stated Resident #1 wore a Wanderguard bracelet. LPN #2 stated an alarm sounded when residents wearing a Wanderguard got too close to an exit door. Further, she stated the Wanderguard door alarm had a louder, more piercing sound than the door alarm. In addition, she stated there was a panel at each Nurses Station that flashed, indicating from which door the alarm was sounding. Per interview, if that occurred, all available staff should immediately go to the door and determine the source of the alarm. LPN #2 stated she was not aware of any issues with the door alarms malfunctioning. Interview with SRNA #2, on 02/26/2021 at 10:22 AM, employed approximately four (4) years at the facility, revealed she worked the day shift, on 02/23/2021, and had gone home when the elopement occurred. She stated, at times, Resident #1 wandered around the facility and wore a Wanderguard bracelet around the ankle at all times for safety. She stated from time to time, Resident #1 would go to the door, and staff would redirect him/her away from the door. SRNA #2 stated the procedure for responding to the door alarm was when the alarm sounded, staff would check the alarm box at the Nurses Station which indicated the door where the alarm was sounding. In addition, she stated staff would then go to that door to investigate the alarm. Continued interview revealed the door alarm and the Wanderguard alarm had two distinct tones, with the Wanderguard alarm being louder. In addition, she stated the SRNA's checked daily to confirm the resident was still wearing the Wanderguard device; and the nurse signed off on the resident's location every fifteen (15) minutes. Interview with SRNA #3, on 02/26/2021 at 11:30 AM, employed twenty (20) years at the facility, revealed Resident #1 did not want to do much the morning of the elopement, which was typical for him/her in the mornings; but, he/she became a busy bee in the afternoon and moved around more. Also, he stated he thought the resident was wearing a thick green sweatshirt and thick brown slacks that day, adding he/she liked to be warm. He also stated the procedure for responding to an alarm was to look at the alarm indicator light displayed on the panel box at the Nurse's Station to determine from which door the alarm was sounding, go immediately to that door, and look inside and outside the door. The alarm was silenced if all was okay, but if not, the nurse was informed so she could do a headcount of all residents to confirm all were in the facility. SRNA #3 stated residents were to be counted on all units, especially those residents who wander or those with a Wanderguard device. Interview with the DON, on 02/26/2021 at 1:16 PM, employed three (3) years at the facility and in her current role since August 2020, revealed staff was educated about elopements, Wanderguard, door alarms, and Code Green upon hire and annually. She stated she called the Administrator regarding the elopement around 5:30 PM. She stated she instructed the nurse to call a Code Green (missing person code), and she returned to the facility to search for the resident and initiate the investigation. Per interview, she stated when a door alarm sounded, an indicator light flashed at the Nurses Station, indicating which door was alarming. She stated this light flashed for both the Wanderguard alarm and the door alarm. The DON stated she expected staff to look at the indicator box, respond immediately to the alarming door, find the source of what/who tripped the alarm, comb the area, and find out if anyone was missing. She emphasized that staff must immediately find the source of the alarm, and do a resident head count per policy. In addition, the DON stated the alarms had two (2) distinct sounds, with the Wanderguard alarm having a higher pitch. However, per the facility's report, LPN #1 did not do a resident head count immediately, after the alarms sounded, on 02/23/2021, when she could not determine the source for triggering the alarms. Interview with the Administrator, on 02/26/2021 at 4:25 PM, employed two (2) years at the facility, revealed he expected staff to respond immediately when an alarm sounded, for both, the door alarm and the Wanderguard alarm. He stated he expected staff to find the alarm source, as only a person could set off the alarm. Per interview, if staff could not determine the source, as was the case with LPN #1 and Resident #1's elopement, the next step was to ensure and not assume everyone was accounted for, which LPN #1 did not do. He stated he expected staff, who heard the alarm, to immediately respond to keep residents safe. In addition, he stated the facility had experienced no issues with the alarm system. Continued interview revealed the facility immediately initiated the investigation of the elopement, which included placing the nurse on administrative leave. The facility provided an acceptable credible Allegation of Compliance (AoC), on 03/04/2021, which alleged removal of the Immediate Jeopardy, on 03/03/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/23/2021, immediately after notification of Resident #1's disappearance, nursing staff performed a headcount of all residents. Staff accounted for all the other residents. 2. On 02/24/2021, at approximately 12:30 AM, facility staff found Resident #1 in a wooded area adjacent to the facility. Resident #1 was immediately assessed and sent to a local hospital for evaluation and admission. When Resident #1 returned to the facility, he/she would be placed on one-to-one (1:1) supervision along with wearing the Wanderguard bracelet. A new elopement assessment would be completed. Any new Physician's Orders would be implemented. Resident #1's care plan would be updated with the additional interventions related to wandering and the elopement incident. The resident's State Guardian was notified of the incident. 3. On 02/24/2021, at 9:30 AM, an Ad Hoc QA Committee meeting was held regarding the elopement incident with the Administrator, the DON, the Medical Director, the Regional Director of Clinical Services (RDCS), Quality Assurance/Infection Control (QA/IC) Nurse, and Social Services (SS) in attendance. The attendees established the following action items for this AoC. 4. The facility's monthly QA Committee meetings were changed to weekly meetings until the Immediate Jeopardy (IJ) was removed. The QA Committee meetings would consist of the Medical Director, the Administrator, the DON, the QA/IC Nurse, the Staff Development Coordinator (SD), Social Services, Dietary, and Unit Managers (UM). The next QA meeting would be held on 03/02/2021. 5. On 02/24/2021, housekeeping/maintenance checked all doors for a fifteen (15) second egress and documented an audit check. All doors worked properly. 6. On 02/24/2021, housekeeping/maintenance staff checked all doors for the Wanderguard functioning properly and documented the audit, completed on 02/24/2021. All Wanderguards worked properly. The audits would be conducted daily and submitted to the weekly QA Committee meetings for review. 7. On 02/23/2021, the QA/IC Nurse checked each resident's Wanderguard to validate that it was working correctly and checked to ensure the Wanderguard devices were physically in place on residents. The QA/IC Nurse found no problems during this audit. This audit will continue weekly, by the QA/IC Nurse, to validate compliance. The QA/IC Nurse submitted the audits to the weekly QA Committee for review. 8. On 02/23/2021, the QA/IC Nurse checked to verify each Wanderguard bracelet was on the Treatment Administration Record (TAR), was checked for placement/function, and signed and dated each shift by the nurse. The audit was completed on 02/24/2021. No concerns were noted. This audit would continue weekly by the QA/IC Nurse to validate compliance and submitted to the weekly QA Committee meeting. 9. On 02/25/2021, the Interdisciplinary Team (IDT) met and developed a written procedure for staff response to Wanderguard and door alarms. The IDT included the Administrator, the DON, the ADON, the QA/IC Nurse, the MDS Coordinator, Social Services, the Dietary Manager, and the Activities Director. In-service training on this was completed, on 02/25/2021 through 03/02/2021, by the Nursing Administrative Team. The Nursing Administrative Team included the DON, the ADON, the QA/IC Nurse, and the Assistant RDCS. The facility had one hundred two (102) nursing staff and one hundred sixty-two (162) total staff. Eighty-nine (89) nursing staff and one hundred thirty-eight (138) total staff had received the in-service education. The thirteen (13) nursing staff and eleven (11) non-nursing staff who had not received the in-service education were currently on leave. Education included: a) Abuse/neglect-All staff with post-test; b) Behavior Management-All staff with post-test; c) Injury Prevention-All staff with post-test; d) Wandering Risk/Elopement-All staff with post-test; e) Dementia; Providing care for people with Dementia and cognitive changes-All staff with post-test; f) Care plan development and revision-IDT only with no post-test; g) Care Plans-Nursing Staff only; h) Accidents policy and procedures; Safety and supervision of residents-All staff with post-test; i) To not prop open any door for any reason unless someone was there monitoring doors-All staff with post-test; j) Elopement risks and procedures-All staff with post-test; k) Do not disarm any alarms without looking to see if the resident was outside-All staff with post-test; and l) Facility alarm in-service training included: photo of egress door alarm, photo of Wanderguard system code alert-All staff with post-test. 10. The staff on-leave would be in-serviced on these policies upon return to work. Current Agency staff was in-serviced. The facility would require new agency staff to be in-serviced with either the weekend House Supervisor, Saturday and Sunday or the Human Resource (HR) Director/Staffing Coordinator, Monday through Friday. The HR Director compiled a list o [TRUNCATED]

Based on observation, interview, and review of the facility's policies, it was determined 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 and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observation revealed a COVID-19 unit had been set up in A Station, which was located just off the front entrance to the facility. The front entrance door was not locked and allowed entry to anyone, and there was no signage stating A Station was a COVID Unit, which required transmission-based precautions to be in effect. The findings include: Review of the facility's policy, Infection Prevention and Control Program, undated, revealed the elements of the infection prevention and control program consisted of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Further review revealed outbreak management was a process of managing affected residents and preventing the spread of the disease to other residents/individuals. Review of the facility's policy, Coronavirus Disease (COVID-19)-Identification and Management of Ill Residents, undated, revealed residents with signs and/or symptoms of COVID-19 would be identified and isolated to help control the spread of infection to other residents, staff, and visitors. Further review revealed if units were dedicated to caring for COVID-19 positive residents, the staff on these units must be able to adhere to strict infection control practices. Per policy, residents with confirmed COVID-19 were assigned to dedicated staff when possible. In addition, the policy stated residents who had a positive test must be placed on contact and droplet precautions (transmission based precautions) and staff wear recommended personal protective equipment (PPE) when caring for these residents, which according to CDC guidelines, consisted of eye protection, face mask/N95 respirator, gown, and gloves. Observation, on 01/13/2021 at 9:45 AM, revealed there was an unlocked front door to the facility, and the State Survey Agency (SSA) Surveyors entered the facility through this unlocked door which took them into an approximately two hundred (200) square foot entry room/lobby. The entry room/lobby opened into the hallway where the COVID Unit was located. The opening to the hallway was approximately fifty (50) feet from the front entry door. There were no signs on the front door, in the entry room/lobby, or in the entrance to the hallway where the COVID-19 resident rooms were located to indicate the SSA Surveyors were entering a COVID-19 unit. In addition, there were no signs posted indicating transmission-based precautions were in effect in the entry way or at the entrance to the hallway. Per observation, there was a hand written sign indicating deliveries were to enter at the back door and also signage indicating not to enter if ill. Furthermore, there was no one at the front desk. Continued observation revealed the COVID Unit was not secured and had no barrier, restrictions, or information posted, which allowed anyone to enter the COVID Unit, unknowingly. Further observation revealed two (2) staff members came to the front entry room/lobby wearing full personal protective equipment (PPE) and informed the SSA Surveyors that non-staff individuals were to enter at the back door because this area was part of a COVID Unit. Telephone interview with the Health Department Nurse (HDN), on 01/14/2021 at 4:35 PM, revealed she had collaborated with the facility's Infection Preventionist on how to separate the positive COVID residents. The HDN stated she advised the Infection Preventionist to restrict the entrance to the COVID Unit, and she had sent the floor plan to the Health Department Practitioner. The HDN stated the Health Department Practitioner advised the facility to make a secure, locked unit where no one could just walk into the area. The HDN did not mention a specific sign that needed to be posted, just that a barrier needed to be present; the barrier could be a plastic sheet or cubical divider. Interview with the Main Infection Preventionist (MIP), on 01/14/2021 at 4:56 PM, revealed on 12/22/2020, the facility received the results of positive COVID tests on multiple residents. She stated the facility then moved the positive COVID-19 residents to A Station rooms, and the entrance to the A Station was the front door, which was open during the day. The MIP stated, after 5:00 PM, the door was locked, and to enter, people had to knock for staff to open the door by entering a code on a keypad on the inside of the facility. Per interview, the MIP stated she had not been on the COVID Unit but was told there was a sign there saying it was a COVID Unit and deliveries were to go to the back entrance. She also stated there was no barrier to enter the COVID Unit because meal trays had to be delivered from another part of the facility. Interview with the Director of Nursing (DON), on 01/14/2021 at 5:44 PM, revealed a COVID outbreak occurred in December 2020, and residents that were positive for COVID were moved to A Station, which one entered through the front door. She stated there was a doorbell outside at the front entrance, and after it was rung, staff pushed an inside button to let the person in when the door was locked. In addition, the DON stated she was aware the front entrance door was unlocked during the day but always locked at night, and there was no signage related to COVID-19 in the entry room/lobby or entrance to the hallway going to the resident rooms that were COVID positive. She stated she never thought anyone would enter the front door because there was a posted sign that said deliveries were to go to the back entrance. Interview with the Administrator, on 01/14/2021 at 6:04 PM, revealed in December 2020, the lobby was moved from the front entrance to the back door and a sign was posted so people would go to the back door (the deliveries to the back sign); the facility did not post a sign stating it was a COVID Unit. The Administrator stated the front door was not locked from 9:00 AM to 5:00 PM so food could be brought in from another area in the facility. He stated this was necessary so food did not get cold and so dietary did not have to come in through another unit. The Administrator stated the door was always locked at night, and a key was required to lock the door.

Based on observation, and interview, and review of facility Policy, it was determined the facility failed to provide each resident with food that is palatable, and at a safe and appetizing temperature. Staff interview and record review revealed food temperatures from the lunch meal tray line were not immediately documented on 12/10/19. Cook #1 stated she relied on memory to document food temperatures from tray line after meal service. Further, Cook #1 stated she obtained food temperatures for tray line from the stove and not from the steam table. In addition, observation of a test tray on 12/10/19, during the noon meal service for Unit B, revealed temperatures were not at acceptable temperatures for point of service. Furthermore, observation of a test tray on 12/12/19, during the breakfast meal service for Unit C, revealed temperatures were not at acceptable temperatures for point of service. The findings include: Review of the facility's Food Preparation and Service Policy, undated, revealed previously cooked food must be reheated to an internal temperature of 165 degrees for at least fifteen (15) seconds. The policy further stated Mechanically altered hot foods prepared for a modified consistency diet will stay above 135 degrees Farenheit (F) during preparation or they must be reheated to 165 degrees F for at least fifteen seconds. In addition, steam tables are never used to reheat foods and the temperatures of foods held in steam tables will be monitored by food service staff. The Policy Statement review revealed Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. However, the Policy did not reference the acceptable temperature range of food at point of service. Observation of the kitchen on 12/10/19 at 11:10 AM, while accompanied by the Assistant Dietary Manager, revealed the kitchen staff was placing food on the steam table in preparation for meal service. The steam table food included slices of roast beef, beef gravy, roasted potatoes, mixed steamed vegetables, mechanical soft beef, mashed potatoes, pureed beef, and chicken noodle soup. Four (4) hot dogs in buns were wrapped in aluminum foil and placed on the support bars of the steam table. No temperatures were obtained once the food reached the steam table. Cold foods were located at the end of the tray line, near, but not on the steam table and included desserts and drinks. Cartons of milk were placed in two (2) picnic style coolers with ice poured over them. Food service for the unit trays began at 11:20 AM with bread or rolls placed first followed by hot foods, then cold foods. Desserts and drinks were placed on the trays last. The Assistant Dietary Manager was asked on 12/10/19 at 11:30 AM, to produce the food temperatures. Review of the temperature log dated for the week of 12/08/19 through 12/14/19, revealed no entries had been made for the lunch food temperatures on 12/10/19. Observation in the kitchen on 12/10/19 at 11:50 AM, revealed food was placed on a heated plate with an insulated bottom and cover. The food trays were then loaded onto a rolling, open sided rack cart. Further observation revealed the open sided rack was taken to Unit B by Dietary Aide #1, and placed at the nursing station at 12:03 PM. Nursing staff retrieved the trays upon arrival to the unit and placed the trays one (1) by one (1) in each resident's room. On 12/10/19 at 12:05 PM, the Surveyor asked Dietary Aide #1 to determine the temperature of a test tray for the hall on Unit B. The baked potato, and mixed vegetables which were at acceptable temperatures, but the beef slice temperature was obtained at 109 degrees F, which was not an acceptable point of service temperature. Dietary Aide #1 was questioned as to the acceptable temperature for food at point of service, and she replied that she did not know. Interview with the Assistant Food Manager, upon returning to the kitchen on 12/10/19 at 12:25 PM, revealed she was unsure why the temperatures had not been recorded prior to the lunch meal service. In this surveyor's presence, the Assistant Dietary Manager asked Cook #1 to record the food temperatures on the log for the lunch meal service. Cook #1 took the log and began to fill in temperatures without referencing any source other than her memory. Interview with Cook #1, during this observation, revealed she always took the temperatures at the stove, not at the steam table. She further stated she did not write the food temperatures down prior to serving. When asked if the temperatures were accurate from memory, she replied they may not be completely right, but would be close enough. All temperatures recorded by Cook #1 after the meal service were within acceptable range for holding temperature. A second test tray was provided on 12/12/19 at 7:35 AM, on Unit C, and temperatures were obtained by the Assistant Dietary Manager. The sausage patty temperature was obtained at 101.8 degrees Fahrenheit and the scrambled eggs temperature was obtained at 118.9 degrees, which were both below an acceptable temperature at point of service. Interview with the Assistant Dietary Manager, on 12/12/19 at 2:45 PM, revealed the food temperatures were to be obtained from the steam table right before the first meal tray was plated. Per interview, food temperatures were not to be taken from the stove. Further, the staff on the end of the line was to check the cold fruit, desserts, and milk temperatures. She stated all temperatures were to be recorded on the food temperature log. Continued interview with the Assistant Dietary Manager, revealed the safe holding temperatures of hot food was 135 degrees F and 40 degrees or less for cold foods; however, she stated the facility did not have a written policy related to food temperatures at point of service. Interview with the Director of Nursing (DON), on 12/12/19 at 3:10 PM, revealed she did not know the acceptable temperature range for food at point of service; however, she stated food should be at a palatable temperature for the residents. Further, she stated if food was not held at the proper temperatures, the result could be an outbreak of food borne illnesses. Interview with the Administrator, on 12/12/19 at 3:30 PM, revealed food temperatures should be obtained when the food was brought to the steam table and before serving. Per interview, temperatures should be recorded immediately after obtained as it was not acceptable to document temperatures from memory. He further stated the facility did not have a written policy related to food temperatures at point of service. However, he stated if foods were not served at safe temperatures the result could be food borne illness.

Based on interview, record review, review of the facility's policy and procedures it was determined the facility failed to have an effective system to ensure the Comprehensive Care Plan was developed related to residents' Advance Directives and code status for six (6) of eight (8) sampled residents (Residents #1, #2, #3, #4, #6, #7) to ensure the resident's code status was honored and Cardiopulmonary Resuscitation (CPR) was provided as requested when Resident #1 was found unresponsive on [DATE]. Resident #1 signed a document on [DATE], requesting to have CPR provided in the event of cardiac or [MEDICAL CONDITION]. However, review of Resident #1's Comprehensive Care Plan revealed no documented evidence of a care plan developed regarding the resident's requested Full Code status (a Full Code status indicates in the event of cardiac or [MEDICAL CONDITION], life-saving measures would be initiated) with interventions to address his/her code status. State Registered Nursing Assistant (SRNA) #1 found Resident #1 non-responsive on [DATE] at approximately 8:30 AM, and immediately notified Registered Nurse (RN) #1, who shook the resident and checked for a pulse and respirations. However, CPR was not initiated as the resident requested on [DATE]. Another nurse, RN #2 came to Resident #1's room as requested by SRNA #1, and was informed by RN #1 the resident was a Full Code. However, she also did not immediately initiate CPR for Resident #1, and left the room to overhead page Licensed Practical Nurse (LPN) #1/Supervisor to come to Resident #1's room. Upon entering Resident #1's room, LPN #1/Supervisor, CPR was still not initiated and she told RN #1 and RN #2 they had to start CPR. However, she failed to ensure CPR was initiated, and left Resident #1's room to verify whether CPR should be performed on a Full Code resident who was non-responsive and was told "yes" it should be done. At approximately 9:05 AM, LPN #2/MDS Nurse and RN #4/MDS Coordinator went to Resident #1's room where CPR had still not been initiated. CPR was initiated per interview at approximately 9:05 AM to 9:10 AM, (thirty-five (35) to forty (40) minutes after the resident was found unresponsive), 911 was called, and Resident #1 was transported to the hospital emergency room (ER) where the resident was pronounced deceased at 9:38 AM. The facility's failure to ensure residents' Comprehensive Care Plans were developed to include their requested code status with interventions in place to ensure their code status was honored has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], 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, "Care Plans-Comprehensive," revised [DATE], revealed an individualized Comprehensive Care Plan was developed for each resident to include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Continued review revealed each resident's Comprehensive Care Plan was designed to reflect the resident's expressed wishes regarding care and treatment goals, aid in preventing or reducing declines in the resident's functional status and/or functional levels. Further review revealed the Comprehensive Care Plan was to reflect currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #1 had requested to be a Full Code and signed a document noting this on [DATE]. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #1's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. 2. Review of Resident's #2 medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #2 as being moderately cognitively impaired, with a BIMS score of ten (10) out of fifteen (15). Continued record review revealed Resident #2 had Advance Directives dated [DATE], noting the resident did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #2's Advance Directive and/or Do Not Resuscitate (DNR) status with interventions to ensure the resident's request was honored. 3. Review of Resident's #3 medical record revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #3 as being moderately cognitively impaired, with a BIMS score of nine (9) out of fifteen (15). Continued record review revealed Resident #3 had Advance Directives dated [DATE], indicating he/she did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #3's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored. 4. Review of Resident's #4 medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #4 as being moderately cognitively impaired, with a BIMS score of twelve (12) out of fifteen (15). Continued record review revealed Resident #4 had Advance Directives dated [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #4's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. 5. Review of Resident's #6 medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #6 as being moderately cognitively impaired, with a BIMS score of ten (10) out of fifteen (15). Continued record review revealed Resident #6 had Advance Directives dated [DATE], indicating he/she did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #6's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored. 6. Review of Resident's #7 medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #7 as being severely cognitively impaired, with a BIMS score of seven (7). Continued record review revealed Resident #7 had Advance Directives dated [DATE], noting the resident did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #6's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored. Interview with RN #4/MDS Coordinator on [DATE] at 4:30 PM, revealed the Unit Manager placed residents' requested code status on the Nurse Aide Care Plans. However, residents' code status was never addressed on their Comprehensive Care Plans, although it should be a part of their care plan. Interview with LPN #2/MDS Nurse on [DATE] at 4:30 PM, revealed the facility placed residents' code status on their Comprehensive Care Plans now; however, had never addressed it on the CP prior to the survey. LPN #2/MDS Nurse stated residents' code status should be on their CP in order to honor each resident's wishes (in the event of respiratory or cardiac failure). Interview with the Director of Nursing (DON) on [DATE] at 3:25 PM and 6:05 PM, revealed residents' Advance Directives/Code Status should be care planned. Although the Nurse Supervisors put residents' code status on the nurse aide care plans, it had not been addressed on the Comprehensive Care Plans. Per interview, the facility's policy did not address requiring the Advance Directives/Code Status to be placed on residents' Comprehensive Care Plans. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) interviewed State Registered Nursing Assistant (SRNA) #1, Nursing Supervisor (NS) #1 (LPN #1/Supervisor), RN #1 and RN #2 regarding delay of the Code Blue event involving Resident #1. RN #1 and RN #2 were suspended on [DATE] pending the facility's investigation. 2. On [DATE], an initial report of the delayed Code Blue event was sent to the State Agency by the Administrator and the DON. 3. On [DATE], the DON notified Resident #1's family of the delay in initiating a Code Blue by RN #1. 4. On [DATE], the Staff Development Coordinator (SDC) initiated in-services with licensed nurses regarding immediate implementation of the facility's Code Blue Protocol for residents who had Advance Directives which indicated a Full Code status. Immediate training included face-to-face in-services with licensed staff on duty, and instruction by telephone for other licensed staff. On [DATE], the training was extended to include SRNA's and Kentucky Medication Aides (KMAs), and 100% of the nursing staff received the education. Training points included the immediate initiation of CPR, based on the physician's orders [REDACTED]. Utilized for the training was the facility's Code Blue Protocol. 5. On [DATE], the DON revised the facility's policy and procedure related to code status to include a requirement for adding each resident's code status to the care plan. 6. On [DATE], the DON developed a new system of quarterly care plan meetings with the resident and/or their Responsible Party (RP), the Social Worker, the unit nurse and the MDS nurse, to determine if any change in code status is desired by the resident. 7. On [DATE], the DON developed a Code Blue Information form to be attached to the incident report for all Code Blue events. Both forms are turned in to the DON for further investigation. The DON will submit results of all investigations to the monthly QA meetings. In addition, the DON developed a reference book for Code Blue events, and placed a book on each crash cart. 8. On [DATE], the Administrator notified the Ombudsman of the delay in initiating a Code Blue for Resident #1. The Administrator explained the corrective actions taken by the facility, and invited the Ombudsman to participate in the investigation process. 9. On [DATE], a Quality Assurance (QA) meeting was held by telephone conference. Participants included the Administrator, the DON, and the Medical Director, who was also the Attending Physician for Resident #1. The purpose of the meeting was to notify the Medical Director of the delay in providing CPR for Resident #1, and to discuss corrective actions. 10. On [DATE], an Ad Hoc QA meeting was held to establish corrective actions and monitoring to ensure future compliance related to the following: Code Blue response; residents' rights; and the facility's Abuse Policy. Attendees included the Administrator, DON, Medical Director, QA Nurse, RDCS, Regional Director of Operations (RDO), Unit Managers (UMs), and the SDC. The committee reviewed and authorized revision of the facility's current policy related to code status to include code status in each resident's Comprehensive Care Plan. In addition, the committee developed a checklist of items to be completed to ensure no other resident had the possibility of being affected by the deficient practice. Furthermore, the committee assigned individual members of the interdisciplinary team to carry out specific tasks stated on the check list, as well as, actions to ensure ongoing compliance. The committee determined the root cause of the delay in provision of CPR for Resident #1 was due to RN #1's failure to follow the facility's policy and procedure related to code status. Also, on [DATE], the regular monthly QA meeting was held and attended by the Administrator, DON, Medical Director, Social Services Director (SSD), QA Officer, Nursing Supervisor, Activities Director (AD), Director of Rehabilitation, Consultant Dietician, and the Dietary Manager Assistant. Participants confirmed the Ad Hoc meeting determination of the root cause and further discussed the facility's plan of action going forward. 11. On [DATE], the Medical Records Coordinator and the QA Nurse audited 100% of the 128 residents' charts to verify each resident's code status was correctly identified, and to ensure Physician Orders, Comprehensive Care Plans, and SRNA Care Plans were consistent for either Full Code or DNR status. Each resident's chart holds an identifying sticker on the outside spine to communicate the code status: a white sticker indicates a Full Code status, and a red sticker indicates DNR status. The Medical Records Coordinator updated each resident's Care Plan to reflect individual code status to be either Full Code or DNR. The QA Nurse and the Medical Records Coordinator will continue the audits daily Monday through Friday, and the House Supervisor will perform the audits on the weekends, until the IJ is removed. Audit results will be submitted daily for review by the DON, who will forward the data to the monthly QA meetings for interdisciplinary review. 12. On [DATE], the Central Supply clerk audited the facility's six (6) crash carts, utilized for managing a Code Blue event, for the presence of adequate supplies, and to ensure no expired items were located on the carts. The crash carts will be checked daily, Monday through Friday by the Central Supply Clerk, and by the House Supervisor on weekends, until the IJ is removed. The audits will utilize the Crash Cart check List Form, and all results will be submitted to the Administrator and the DON for their review. Subsequently, audit results will be presented at the monthly QA meeting, where any changes to the frequency of audits, or recommendations for further interventions, will be made. 13. Beginning [DATE], the Payroll/Human Resources (HR) Coordinator initiated a review of employee files for all nursing staff, to ensure current Cardiopulmonary Resuscitation (CPR) certificates, active nursing licenses and SRNA certifications, and the completion of background checks. The audit was completed on [DATE]. 14. On [DATE], the Medical Records Coordinator and the RDCS audited fifty (50) residents who expired at the facility during RN #1's employment between [DATE] and [DATE], to determine if RN #1 had been involved in any other Code Blue events. They found of the fifty (50) deaths, twenty-one (21) occurred while RN #1 was on duty; however, all residents except Resident #1 were a DNR status at the time of death. 15. On [DATE], while still on suspension, RN #1 called the facility and voluntarily resigned her position of employment with the facility. 16. On [DATE], the Administrator and the DON informed the Medical Director of the specific IJ citations, and discussed the facility's plan for correction of the deficient practice. 17. On [DATE], the Administrator and the DON in-serviced the facility's two (2) SSD's, the MDS Nurses and the Medical Records Coordinator related to the facility's new policy and procedure regarding Advance Directives, which includes the following actions: Social Services will review each resident's Advance Directives upon admission to the facility, including their wishes regarding code status, obtain a physician's orders [REDACTED]. Directives during the regularly scheduled Care Plan meetings. 18. On [DATE] through [DATE], all staff from every department, including Nursing, Dietary, Maintenance, Social Services, Activities, and Housekeeping, was in-serviced by the DON, SSD, SDC, QA Officer, and the Nursing Supervisor related to Advance Directives and Residents' Rights. Each staff member was required to complete a post-test with 100% accuracy on the subject matter. Immediate re-education was provided for any incorrect answers. 19. Between [DATE] and [DATE], all nursing staff, including nurses, KMAs and SRNA's were educated by the DON, SSD, SDC, QA Officer and the Nursing Supervisor on the following: differentiation between DNR and Full Code status; how to identify a resident's code status; how to call for and initiate a Code Blue; who should respond to a Code Blue immediately; where to locate the crash cart; contacting the Physician and calling 911; continuation of the code until EMS arrival; notification of the DON and Administrator; and documentation of all details of the code in the medical record. In addition, the training included how to manage the resident who had a DNR status, including an assessment for vital signs at five (5) minute intervals, pronouncement of death, notification of the Physician, the family and/or POA, and the DON and Administrator, and documentation in the medical record. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 20. Between [DATE] and [DATE], all nurses, KMA and SRNA's were in-serviced regarding the requirement for inclusion of the resident's Advance Directives and code status on the Comprehensive Care Plan. The training was provided by the DON, SDC and Nursing Supervisor. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. Two (2) staff members were on leave and did not receive the education. They will not be added to the schedule until they are in-serviced and able to complete the post-test accurately to ensure their competency. 21. As of [DATE], fifty-six (56) of one hundred and twenty-eight (128) residents had an Advance Directive for Full Code status. 22. On [DATE], the DON updated the new hire orientation outline to include training and post-tests related to professional nursing standards, identifying code status, Comprehensive Care Plans, Advance Directives, Residents' Rights, Code Blue Information sheet, Code Blue Nurses' Note guide, and the facility's Code Blue Protocol. In addition, orientation packets were developed for agency staff to educate on the same topics. All agency staff will be expected to complete the post-tests with 100% accuracy prior to providing direct care. 23. Between [DATE] and [DATE], all nurses, KMAs and SRNA's were in-serviced by the DON, SDC and the Nursing Supervisor related to professional nursing standards. Training references included the Lippincott Manual of Nursing Practice as it pertained to the provision of CPR, documentation, ensuring a physician's orders [REDACTED]. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 24. On [DATE], the facility conducted a mock Code Blue drill to assess staff knowledge retention after training related to initiating a Code Blue event immediately, and evaluated response time, accuracy in determining the code status of the mock resident, and adherence to the facility's policy and procedure. A mock Code Blue drill will be conducted quarterly by the SDC, QA nurse or the DON, and will cover all shifts on weekdays and weekends. Results of the drills will be brought by the Administrator or the DON to the facility QA meetings for interdisciplinary review. Any staff members identified to not follow facility policy and procedures will be re-educated, and a competency test will be administered until the staff member is able to display a thorough and accurate understanding of the policy and procedure. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed SRNA #1, Nursing Supervisor #1 (LPN #1/Supervisor), RN #1 and RN #2 were interviewed related to the Code Blue event involving Resident #1. Continued review of the investigation revealed RN #1 and RN #2 were suspended on [DATE], pending the investigation results. Interview, on [DATE] at 6:00 PM, with the DON revealed RN #1 called the facility on [DATE], and stated she was quitting and would not be returning to work, and hung up. 2. The State Survey Agency received the initial report regarding the delayed Code Blue event involving Resident #1 on [DATE]. 3. Review of the facility's investigation documentation of the incident revealed the DON notified Resident #1's family of RN #1's delay in initiating a Code Blue. Phone contact was attempted with Resident #1's RP/family which was unsuccessful and a message was left. However, no return call was received. 4. Review of the facility's in-service sign-in form dated [DATE] and [DATE], revealed 100% of nursing staff did receive training on the facility's Code Blue Protocol, which included education on immediate initiation of CPR, based on physician's orders [REDACTED]. Interviews on [DATE]: at 1:55 PM with LPN #1; at 4:15 PM, with LPN #2; at 3:20 PM, with LPN #8; and at 4:50 PM with RN #4 revealed they were inserviced on the facility's Code Blue procedures, how to identify a resident's code status, when to initiate CPR, and the code process. Interviews on [DATE]: at 3:49 PM, with SRNA #13, at 4:35 PM with SRNA #6; and at 4:58 PM with SRNA #12 revealed they were inserviced on the facility's Code Blue process, how to identify a resident's code status, call a Code Blue, take crash cart to room and wait for further directions. 5. Review of the facility's document titled, "Medical Emergency Code Reference", not dated, revealed the DON had revised the facility's policy and procedure to include the requirement for adding each resident's code status to the care plan. Interviews on [DATE] at 5:20 PM, with Social Services (SS) #13, and at 5:30 PM, with SS #2, revealed they were in-serviced related to SS responsibility for implementing an interim Advance Directive care plan to include the code status for all new residents upon admission and/or readmission. Interview on [DATE] at 4:50 PM, with the RN #4/MDS Coordinator revealed the MDS nurses were in-serviced related to MDS' responsibility to audit the interim care plan within 72 hours of every resident's admission, and/or readmission, and to assure Advance Directives with code status were present. 6. Interview, on [DATE] at 6:30 PM, with the DON revealed she developed a new system for Quarterly Care Plan meetings to discuss with residents and their RP if a change in code status is desired by the resident. Review of the facility's policy titled, "Care Plans" with a revised date of [DATE], revealed the Care Plan Team would review with the resident any existing/current Advance Directives to determine if a change in code status was desired by the resident at the Quarterly Care Plan meetings. Interviews, on [DATE] at 4:00 PM, with SS #2 and at 4:30 PM with SS #13, revealed Advance Directives including the code status was discussed with each resident at every care plan meeting now. Interview, on [DATE] at 4:50 PM, with RN #4/MDS Coordinator, revealed the care plan team did discuss Advance Directives including the code status with the resident or RP at each care plan meeting now. 7. Interview, on [DATE] at 6:30 PM, with the DON revealed she had developed a Code Blue Information form which was to be attached to Incident Reports for all Code Blue events that were to be turned in to her. The DON revealed she had also developed a reference book for all Code Blue events which were placed with each crash cart. Per the DON, she will submit all investigations to the facility's monthly QA meeting. Observation on [DATE] from 3:00 PM through 3:20 PM of each crash cart in the facility revealed a reference book for Code Blue events which included the Code Blue documentation form. Review of the facility's Code Blue reference book revealed a form titled, "Code Blue Documentation", dated [DATE], which was revised [DATE]. 8. On [DATE] at 2:00 PM a call was placed to the Ombudsman with no answer, a message left to return a call. The Ombudsman returned the call and revealed the Administrator did notify her of the delay in initiating a Code Blue for Resident #1, and explained the corrective actions taken by the facility and invited her to participate. Interview with the Administrator on [DATE] at 6:15 PM, revealed he had called the Ombudsman on [DATE] as per the AOC. 9. Interview with the Administrator on [DATE] at 6:15 PM, confirmed the facility's Medical Director was contacted by phone for the QA meeting on [DATE], to notify him of the delay in providing CPR and to discuss a plan of action. Interview, on [DATE] at 3:00 PM, with the facility's Medical Director and Resident #1's attending Physician revealed the Administrator, the DON and the RDCS had called on [DATE], to discuss the events which occurred with Resident #1's code on [DATE]. He stated "we" did put plans into action, and he felt the facility had a very active QA program. The Medical Director revealed the facility had a meeting monthly and he "rarely" missed a meeting. 10. Review of the facility's Ad hoc QA meeting sign-in sheet revealed the attendees included the Medical Director, Administrator, DON, QA Nurse, RDCS, RDO, UMs and SDC. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed during the QA meeting assignments were made and MR was assigned duties related to the Advance Directives regarding completing a daily audit. Per interview, the audit was for identification/verification of all residents' code status, by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the residents' charts, and inside the front cover of the charts matched the Physician Order. Further interview revealed this was reviewed by the DON/Administrator daily. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed on [DATE], a QA meeting was held with the Medical Director, Administrator, DON, Nursing Supervisor, SS, Dietary, Activities Director, Director of Rehabilitation and QA in attendance. Per interview, the QA attendees reviewed and authorized revision of the facility's current code status policy to include each resident's code status on the care plan. The QA Nurse revealed members were assigned specific tasks on the check list which they developed to ensure ongoing compliance. Further interview revealed the QA attendees determined the root cause of CPR provision for Resident #1 was due to RN #1's failure to follow the facility's policies and procedures related to code status and discussed an action plan. Interviews, on [DATE] at 4:00 PM, with SS #2, and at 4:30 PM with SS #13, revealed SS was assigned duties related to the new policy and procedure for Advance Directives. Per interview, SS was to obtain consents from the resident or POA, notify the nursing supervisor of the unit the resident was admitted to, and obtain a physician's orders [REDACTED]. Further interview revealed SS will initiate the Advance Directive care plan for residents. Interview on [DATE] at 4:50 PM, with RN #4/MDS Coordinator revealed the MDS nurses were assigned duties related to the new policy and procedure for Advance Directives. Per interview, MDS' duties were to audit the interim care plan within 72 hours of every admission, and/or readmission, to assure Advance Directives with code status were present. 11. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed MR was assigned duties related to Advance Directives to complete a daily audit for identification/verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, comprehensive care plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed MR and herself completed the daily audit Monday through Friday for identification and verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Per interview, the audits would continue until the Immediate Jeopardy (IJ) was abated. Review of the audits performed by MR and the QA Nurse confirmed completion of the tasks as assigned per the AOC. Interview on [DATE] at 6:30 PM, with the DON revealed the code status audits were turned in daily for her review. 12. Review of the Central Supply Clerk's (CSC) audit forms (Crash Cart Check List form) revealed the six (6) crash carts was audited daily for expired items and the presence of adequate supplies, with no issues identified beginning [DATE]. Interview, on [DATE] at 8:55 AM, with the CSC revealed he checked the six (6) crash carts daily Monday through Friday, and the House Supervisor checked them on the weekends for expired items and to ensure they were locked. Per interview, while doing the audit if an item was used from a crash cart the item was replaced and a new breakaway lock would be applied to the cart. The CSC revealed audits continued to be performed. Interview on [DATE] at 6:30 PM, with the DON revealed the audit results were reviewed and would be taken

Based on interview, record review, review of the facility's policy and procedures it was determined the facility failed to have an effective system to ensure Advance Directives for one (1) of eight (8) sampled residents (Resident #1) were honored regarding his/her requested Full Code status. On [DATE], Resident #1 signed Advance Directives requesting to be a Full Code (Full Code indicates life-saving measures would be instituted in the event of cardiac or [MEDICAL CONDITION]) with life-saving measures to include Cardiopulmonary Resuscitation (CPR). However, on [DATE] at approximately 8:30 AM, when State Registered Nursing Assistant (SRNA) #1 entered Resident #1's room, found him/her unresponsive and notified Registered Nurse (RN) #1, the RN failed to honor the resident's Advance Directives regarding his/her Full Code status. RN #1 checked for Resident #1's pulse, could not obtain one and failed to initiate CPR as per the resident's Advance Directives. SRNA #1 went to another unit and told RN #2 the resident was unresponsive and requested the RN come to Resident #1's room. Upon arrival to Resident #1's room, RN #2 asked RN #1 what the resident's code status was, as she had not checked. RN #1 informed her Resident #1 was a Full Code; however, neither RN initiated CPR as per the resident's Advance Directives. At approximately 9:05 AM, LPN #2/MDS Nurse and RN #4/MDS Coordinator went to Resident #1's room where CPR had still not been initiated. CPR was initiated per interview at approximately 9:05 AM to 9:10 AM, (thirty-five (35) to forty (40) minutes after the resident was found unresponsive), 911 was called, and Resident #1 was transported to the hospital emergency room (ER) where the resident was pronounced deceased at 9:38 AM. The facility's failure to ensure residents' Advance Directives regarding their requested Full Code status was followed has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], 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, "Advance Directives", revised [DATE], revealed the Policy noted Advance Directives included preferences regarding treatment options which included Do Not Resuscitate (DNR). However, continued review revealed no documented evidence the Policy addressed residents requesting to be a Full Code status. Per the Policy, the Director of Nursing (DON) or designee would notify the Physician of residents' Advance Directives so appropriate orders could be documented in the resident's medical record and care plan. Record review revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated no cognitive impairment. Review of the monthly physician's orders [REDACTED].#1 had an order to be a Full Code. Continued record review revealed a "Consent to Withhold Life Prolonging Extraordinary Measures" form dated [DATE], which gave residents the option to check whether they wanted CPR or not. Continued review of the [DATE] Form, signed by Resident #1 revealed the resident had checked he/she wanted to receive CPR. Review of the "Condition Alert" document in Resident #1's medical record revealed he/she was a Full Code. Review of the Nurse's Notes revealed a Note documented by RN #1 on [DATE] timed 8:40 AM, which stated SRNA #1 had informed RN #1 of Resident #1 not looking "too good". The Note revealed RN #1 went with SRNA #1 to Resident #1's room, where she shook the resident without a response, and checked for a pulse with none obtained and the resident had no respirations. Continued review revealed no documented evidence RN #1 immediately initiated CPR as per Resident #1's Advance Directives. Per the Note, RN #1 requested assistance from a nurse on another unit, and when she arrived CPR was then initiated and 911 called. Further review revealed Emergency Medical Services (EMS) arrived at 9:10 AM, placed Resident #1 on a backboard, and initiated an Automated External Defibrillator (a portable device which checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm used treat sudden [MEDICAL CONDITION]) with no pulse obtained and CPR was continued. Review of the EMS Run Sheet dated [DATE], revealed EMS were notified at 9:06:54 AM and arrived at the facility at 9:12:51. Review revealed at 9:13:14 EMS personnel were with Resident #1. Continued review revealed the chief complaint was documented as "[MEDICAL CONDITION]/death", CPR was continued and Resident #1 was intubated. Further review revealed Resident #1 was transported to the hospital ER at 9:29:37 AM. Review of the hospital ER record revealed EMS transported Resident #1 to the ER, where the resident was triaged at 9:33 AM. Continued review revealed Resident #1 presented to the ER in "cardio-pulmonary arrest", remained in asystole (no heart rate) in spite of interventions and was pronounced expired at 9:38 AM. Review of the facility's investigation dated [DATE], revealed the facility investigated an allegation of neglect regarding Resident #1, where RN #1 had not honored the resident's Advance Directives to be a Full Code and had not initiated CPR as per the resident's request. Per the investigation, RN #1 had not performed CPR due to her emotional state over finding Resident #1 expired. Continued review revealed the facility determined the other staff involved had followed the facility's policy and procedure related to "code status". Further review revealed the other staff included, SRNA #1, LPN #1/Supervisor and RN #2. However, interview with staff revealed the facility's policy was not followed regarding checking the resident's code status and initiating CPR if indicated. Interview was attempted and was unsuccessful with RN #1 on [DATE] at 1:05 PM, 2:00 PM, 4:30 PM and 5:15 PM, and on [DATE] at 10:10 AM. Interview, on [DATE] at 10:45 AM, with SRNA #1 revealed on [DATE] at approximately 8:30 AM, she had found Resident #1 unresponsive, and immediately notified RN #1 of this information. SRNA #1 stated RN #1 assessed Resident #1, observed no breathing and then began to cry. Per interview, SRNA #1 had to go to another unit and get RN #2 to come to Resident #1's room. However, per SRNA #1, CPR was not initiated at that time, and was not started until LPN #1/Supervisor arrived and told them CPR had to be initiated. Per SRNA #1, this was approximately ten (10) minutes after she had found Resident #1 unresponsive. Interview with RN #2, on [DATE] at 12:25 AM and [DATE] at 11:30 AM, revealed SRNA #1 informed her at approximately 8:35 AM on [DATE], that she needed to go to Resident #1's room. RN #2 stated she asked RN #1, who was present in the room, what Resident #1's code status was and was informed he/she was a Full Code, but RN #1 stated she was not going to put the resident "through that". According to RN #2, when she found out Resident #1 was a Full Code, she should have started CPR. However, she did not because she felt she didn't have help because RN #1 refused to perform CPR on the resident. Per interview, CPR was not initiated until after she notified LPN #1/Supervisor who came and told them they had to do CPR. Interview with LPN #1/Supervisor, on [DATE] at 12:05 PM, revealed she arrived in Resident #1's room at approximately 9:00 AM after RN #2 paged her overhead. LPN #1/Supervisor revealed she was aware Resident #1 was a Full Code. However, according to LPN #1/Supervisor, RN #1 and RN #2 were not performing CPR. She told them they had to start CPR and 911 should be notified. LPN #1/Supervisor revealed CPR should have been initiated, immediately after RN #1 assessed Resident #1 to have no pulse and not to be breathing. Per interview, the "code" was not performed timely, but should have been. Interview with LPN #2/MDS Nurse on [DATE] at 2:40 PM and RN #4/MDS Coordinator at 3:00 PM, revealed LPN #1/Supervisor called, at approximately 9:00 AM to 9:05 AM, to verify if a resident was a Full Code and was found unresponsive, should CPR be initiated anyway. Per interview, LPN #2/MDS Coordinator told LPN #1/Supervisor "yes, CPR had to be initiated". Interview revealed both LPN #2/MDS Nurse and RN #4/MDS Coordinator went immediately to Resident #1's room and CPR had not been initiated. According to LPN #2/MDS Nurse, RN #1 was "emotional" and told her she did not want to do CPR on Resident #1. Per LPN #2/MDS Nurse, RN #1 and RN #2 told her Resident #1 was found non-responsive at approximately 8:45 AM; however, CPR was not initiated until about 9:10 AM. Interview, on [DATE] at approximately 2:00 PM and on [DATE] at 6:05 PM, with the Director of Nursing (DON) revealed Resident #1 was a Full Code, CPR should have been started immediately; however, this was not done. The DON stated RN #1 told her she "just didn't want to do that" (CPR) to Resident #1 and RN #1 showed "no remorse". Interview, on [DATE] at 3:45 PM, with the Administrator revealed if a resident was a Full Code, CPR should be immediately initiated. Per interview, RN #1 told him and the DON she "couldn't do that" (CPR) to Resident #1. According to the Administrator, RN #1 did not follow Resident #1's advance directive, and did not act appropriately and when he and the DON asked her why she couldn't initiate the "Code Blue", she stated she knew she was supposed to, but believed Resident #1 "would not have wanted that". He stated RN #1 told him and the DON she knew she should have initiated the "Code Blue" as per facility policy; however, she couldn't. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) interviewed State Registered Nursing Assistant (SRNA) #1, Nursing Supervisor (NS) #1 (LPN #1/Supervisor), RN #1 and RN #2 regarding delay of the Code Blue event involving Resident #1. RN #1 and RN #2 were suspended on [DATE] pending the facility's investigation. 2. On [DATE], an initial report of the delayed Code Blue event was sent to the State Agency by the Administrator and the DON. 3. On [DATE], the DON notified Resident #1's family of the delay in initiating a Code Blue by RN #1. 4. On [DATE], the Staff Development Coordinator (SDC) initiated in-services with licensed nurses regarding immediate implementation of the facility's Code Blue Protocol for residents who had Advance Directives which indicated a Full Code status. Immediate training included face-to-face in-services with licensed staff on duty, and instruction by telephone for other licensed staff. On [DATE], the training was extended to include SRNA's and Kentucky Medication Aides (KMAs), and 100% of the nursing staff received the education. Training points included the immediate initiation of CPR, based on the physician's orders [REDACTED]. Utilized for the training was the facility's Code Blue Protocol. 5. On [DATE], the DON revised the facility's policy and procedure related to code status to include a requirement for adding each resident's code status to the care plan. 6. On [DATE], the DON developed a new system of quarterly care plan meetings with the resident and/or their Responsible Party (RP), the Social Worker, the unit nurse and the MDS nurse, to determine if any change in code status is desired by the resident. 7. On [DATE], the DON developed a Code Blue Information form to be attached to the incident report for all Code Blue events. Both forms are turned in to the DON for further investigation. The DON will submit results of all investigations to the monthly QA meetings. In addition, the DON developed a reference book for Code Blue events, and placed a book on each crash cart. 8. On [DATE], the Administrator notified the Ombudsman of the delay in initiating a Code Blue for Resident #1. The Administrator explained the corrective actions taken by the facility, and invited the Ombudsman to participate in the investigation process. 9. On [DATE], a Quality Assurance (QA) meeting was held by telephone conference. Participants included the Administrator, the DON, and the Medical Director, who was also the Attending Physician for Resident #1. The purpose of the meeting was to notify the Medical Director of the delay in providing CPR for Resident #1, and to discuss corrective actions. 10. On [DATE], an Ad Hoc QA meeting was held to establish corrective actions and monitoring to ensure future compliance related to the following: Code Blue response; residents' rights; and the facility's Abuse Policy. Attendees included the Administrator, DON, Medical Director, QA Nurse, RDCS, Regional Director of Operations (RDO), Unit Managers (UMs), and the SDC. The committee reviewed and authorized revision of the facility's current policy related to code status to include code status in each resident's Comprehensive Care Plan. In addition, the committee developed a checklist of items to be completed to ensure no other resident had the possibility of being affected by the deficient practice. Furthermore, the committee assigned individual members of the interdisciplinary team to carry out specific tasks stated on the check list, as well as, actions to ensure ongoing compliance. The committee determined the root cause of the delay in provision of CPR for Resident #1 was due to RN #1's failure to follow the facility's policy and procedure related to code status. Also, on [DATE], the regular monthly QA meeting was held and attended by the Administrator, DON, Medical Director, Social Services Director (SSD), QA Officer, Nursing Supervisor, Activities Director (AD), Director of Rehabilitation, Consultant Dietician, and the Dietary Manager Assistant. Participants confirmed the Ad Hoc meeting determination of the root cause and further discussed the facility's plan of action going forward. 11. On [DATE], the Medical Records Coordinator and the QA Nurse audited 100% of the 128 residents' charts to verify each resident's code status was correctly identified, and to ensure Physician Orders, Comprehensive Care Plans, and SRNA Care Plans were consistent for either Full Code or DNR status. Each resident's chart holds an identifying sticker on the outside spine to communicate the code status: a white sticker indicates a Full Code status, and a red sticker indicates DNR status. The Medical Records Coordinator updated each resident's Care Plan to reflect individual code status to be either Full Code or DNR. The QA Nurse and the Medical Records Coordinator will continue the audits daily Monday through Friday, and the House Supervisor will perform the audits on the weekends, until the IJ is removed. Audit results will be submitted daily for review by the DON, who will forward the data to the monthly QA meetings for interdisciplinary review. 12. On [DATE], the Central Supply clerk audited the facility's six (6) crash carts, utilized for managing a Code Blue event, for the presence of adequate supplies, and to ensure no expired items were located on the carts. The crash carts will be checked daily, Monday through Friday by the Central Supply Clerk, and by the House Supervisor on weekends, until the IJ is removed. The audits will utilize the Crash Cart check List Form, and all results will be submitted to the Administrator and the DON for their review. Subsequently, audit results will be presented at the monthly QA meeting, where any changes to the frequency of audits, or recommendations for further interventions, will be made. 13. Beginning [DATE], the Payroll/Human Resources (HR) Coordinator initiated a review of employee files for all nursing staff, to ensure current Cardiopulmonary Resuscitation (CPR) certificates, active nursing licenses and SRNA certifications, and the completion of background checks. The audit was completed on [DATE]. 14. On [DATE], the Medical Records Coordinator and the RDCS audited fifty (50) residents who expired at the facility during RN #1's employment between [DATE] and [DATE], to determine if RN #1 had been involved in any other Code Blue events. They found of the fifty (50) deaths, twenty-one (21) occurred while RN #1 was on duty; however, all residents except Resident #1 were a DNR status at the time of death. 15. On [DATE], while still on suspension, RN #1 called the facility and voluntarily resigned her position of employment with the facility. 16. On [DATE], the Administrator and the DON informed the Medical Director of the specific IJ citations, and discussed the facility's plan for correction of the deficient practice. 17. On [DATE], the Administrator and the DON in-serviced the facility's two (2) SSD's, the MDS Nurses and the Medical Records Coordinator related to the facility's new policy and procedure regarding Advance Directives, which includes the following actions: Social Services will review each resident's Advance Directives upon admission to the facility, including their wishes regarding code status, obtain a physician's orders [REDACTED]. Directives during the regularly scheduled Care Plan meetings. 18. On [DATE] through [DATE], all staff from every department, including Nursing, Dietary, Maintenance, Social Services, Activities, and Housekeeping, was in-serviced by the DON, SSD, SDC, QA Officer, and the Nursing Supervisor related to Advance Directives and Residents' Rights. Each staff member was required to complete a post-test with 100% accuracy on the subject matter. Immediate re-education was provided for any incorrect answers. 19. Between [DATE] and [DATE], all nursing staff, including nurses, KMAs and SRNA's were educated by the DON, SSD, SDC, QA Officer and the Nursing Supervisor on the following: differentiation between DNR and Full Code status; how to identify a resident's code status; how to call for and initiate a Code Blue; who should respond to a Code Blue immediately; where to locate the crash cart; contacting the Physician and calling 911; continuation of the code until EMS arrival; notification of the DON and Administrator; and documentation of all details of the code in the medical record. In addition, the training included how to manage the resident who had a DNR status, including an assessment for vital signs at five (5) minute intervals, pronouncement of death, notification of the Physician, the family and/or POA, and the DON and Administrator, and documentation in the medical record. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 20. Between [DATE] and [DATE], all nurses, KMA and SRNA's were in-serviced regarding the requirement for inclusion of the resident's Advance Directives and code status on the Comprehensive Care Plan. The training was provided by the DON, SDC and Nursing Supervisor. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. Two (2) staff members were on leave and did not receive the education. They will not be added to the schedule until they are in-serviced and able to complete the post-test accurately to ensure their competency. 21. As of [DATE], fifty-six (56) of one hundred and twenty-eight (128) residents had an Advance Directive for Full Code status. 22. On [DATE], the DON updated the new hire orientation outline to include training and post-tests related to professional nursing standards, identifying code status, Comprehensive Care Plans, Advance Directives, Residents' Rights, Code Blue Information sheet, Code Blue Nurses' Note guide, and the facility's Code Blue Protocol. In addition, orientation packets were developed for agency staff to educate on the same topics. All agency staff will be expected to complete the post-tests with 100% accuracy prior to providing direct care. 23. Between [DATE] and [DATE], all nurses, KMAs and SRNA's were in-serviced by the DON, SDC and the Nursing Supervisor related to professional nursing standards. Training references included the Lippincott Manual of Nursing Practice as it pertained to the provision of CPR, documentation, ensuring a physician's orders [REDACTED]. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 24. On [DATE], the facility conducted a mock Code Blue drill to assess staff knowledge retention after training related to initiating a Code Blue event immediately, and evaluated response time, accuracy in determining the code status of the mock resident, and adherence to the facility's policy and procedure. A mock Code Blue drill will be conducted quarterly by the SDC, QA nurse or the DON, and will cover all shifts on weekdays and weekends. Results of the drills will be brought by the Administrator or the DON to the facility QA meetings for interdisciplinary review. Any staff members identified to not follow facility policy and procedures will be re-educated, and a competency test will be administered until the staff member is able to display a thorough and accurate understanding of the policy and procedure. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed SRNA #1, Nursing Supervisor #1 (LPN #1/Supervisor), RN #1 and RN #2 were interviewed related to the Code Blue event involving Resident #1. Continued review of the investigation revealed RN #1 and RN #2 were suspended on [DATE], pending the investigation results. Interview, on [DATE] at 6:00 PM, with the DON revealed RN #1 called the facility on [DATE], and stated she was quitting and would not be returning to work, and hung up. 2. The State Survey Agency received the initial report regarding the delayed Code Blue event involving Resident #1 on [DATE]. 3. Review of the facility's investigation documentation of the incident revealed the DON notified Resident #1's family of RN #1's delay in initiating a Code Blue. Phone contact was attempted with Resident #1's RP/family which was unsuccessful and a message was left. However, no return call was received. 4. Review of the facility's in-service sign-in form dated [DATE] and [DATE], revealed 100% of nursing staff did receive training on the facility's Code Blue Protocol, which included education on immediate initiation of CPR, based on physician's orders [REDACTED]. Interviews on [DATE]: at 1:55 PM with LPN #1; at 4:15 PM, with LPN #2; at 3:20 PM, with LPN #8; and at 4:50 PM with RN #4 revealed they were inserviced on the facility's Code Blue procedures, how to identify a resident's code status, when to initiate CPR, and the code process. Interviews on [DATE]: at 3:49 PM, with SRNA #13, at 4:35 PM with SRNA #6; and at 4:58 PM with SRNA #12 revealed they were inserviced on the facility's Code Blue process, how to identify a resident's code status, call a Code Blue, take crash cart to room and wait for further directions. 5. Review of the facility's document titled, "Medical Emergency Code Reference", not dated, revealed the DON had revised the facility's policy and procedure to include the requirement for adding each resident's code status to the care plan. Interviews on [DATE] at 5:20 PM, with Social Services (SS) #13, and at 5:30 PM, with SS #2, revealed they were in-serviced related to SS responsibility for implementing an interim Advance Directive care plan to include the code status for all new residents upon admission and/or readmission. Interview on [DATE] at 4:50 PM, with the RN #4/MDS Coordinator revealed the MDS nurses were in-serviced related to MDS' responsibility to audit the interim care plan within 72 hours of every resident's admission, and/or readmission, and to assure Advance Directives with code status were present. 6. Interview, on [DATE] at 6:30 PM, with the DON revealed she developed a new system for Quarterly Care Plan meetings to discuss with residents and their RP if a change in code status is desired by the resident. Review of the facility's policy titled, "Care Plans" with a revised date of [DATE], revealed the Care Plan Team would review with the resident any existing/current Advance Directives to determine if a change in code status was desired by the resident at the Quarterly Care Plan meetings. Interviews, on [DATE] at 4:00 PM, with SS #2 and at 4:30 PM with SS #13, revealed Advance Directives including the code status was discussed with each resident at every care plan meeting now. Interview, on [DATE] at 4:50 PM, with RN #4/MDS Coordinator, revealed the care plan team did discuss Advance Directives including the code status with the resident or RP at each care plan meeting now. 7. Interview, on [DATE] at 6:30 PM, with the DON revealed she had developed a Code Blue Information form which was to be attached to Incident Reports for all Code Blue events that were to be turned in to her. The DON revealed she had also developed a reference book for all Code Blue events which were placed with each crash cart. Per the DON, she will submit all investigations to the facility's monthly QA meeting. Observation on [DATE] from 3:00 PM through 3:20 PM of each crash cart in the facility revealed a reference book for Code Blue events which included the Code Blue documentation form. Review of the facility's Code Blue reference book revealed a form titled, "Code Blue Documentation", dated [DATE], which was revised [DATE]. 8. On [DATE] at 2:00 PM a call was placed to the Ombudsman with no answer, a message left to return a call. The Ombudsman returned the call and revealed the Administrator did notify her of the delay in initiating a Code Blue for Resident #1, and explained the corrective actions taken by the facility and invited her to participate. Interview with the Administrator on [DATE] at 6:15 PM, revealed he had called the Ombudsman on [DATE] as per the AOC. 9. Interview with the Administrator on [DATE] at 6:15 PM, confirmed the facility's Medical Director was contacted by phone for the QA meeting on [DATE], to notify him of the delay in providing CPR and to discuss a plan of action. Interview, on [DATE] at 3:00 PM, with the facility's Medical Director and Resident #1's attending Physician revealed the Administrator, the DON and the RDCS had called on [DATE], to discuss the events which occurred with Resident #1's code on [DATE]. He stated "we" did put plans into action, and he felt the facility had a very active QA program. The Medical Director revealed the facility had a meeting monthly and he "rarely" missed a meeting. 10. Review of the facility's Ad hoc QA meeting sign-in sheet revealed the attendees included the Medical Director, Administrator, DON, QA Nurse, RDCS, RDO, UMs and SDC. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed during the QA meeting assignments were made and MR was assigned duties related to the Advance Directives regarding completing a daily audit. Per interview, the audit was for identification/verification of all residents' code status, by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the residents' charts, and inside the front cover of the charts matched the Physician Order. Further interview revealed this was reviewed by the DON/Administrator daily. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed on [DATE], a QA meeting was held with the Medical Director, Administrator, DON, Nursing Supervisor, SS, Dietary, Activities Director, Director of Rehabilitation and QA in attendance. Per interview, the QA attendees reviewed and authorized revision of the facility's current code status policy to include each resident's code status on the care plan. The QA Nurse revealed members were assigned specific tasks on the check list which they developed to ensure ongoing compliance. Further interview revealed the QA attendees determined the root cause of CPR provision for Resident #1 was due to RN #1's failure to follow the facility's policies and procedures related to code status and discussed an action plan. Interviews, on [DATE] at 4:00 PM, with SS #2, and at 4:30 PM with SS #13, revealed SS was assigned duties related to the new policy and procedure for Advance Directives. Per interview, SS was to obtain consents from the resident or POA, notify the nursing supervisor of the unit the resident was admitted to, and obtain a physician's orders [REDACTED]. Further interview revealed SS will initiate the Advance Directive care plan for residents. Interview on [DATE] at 4:50 PM, with RN #4/MDS Coordinator revealed the MDS nurses were assigned duties related to the new policy and procedure for Advance Directives. Per interview, MDS' duties were to audit the interim care plan within 72 hours of every admission, and/or readmission, to assure Advance Directives with code status were present. 11. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed MR was assigned duties related to Advance Directives to complete a daily audit for identification/verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, comprehensive care plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed MR and herself completed the daily audit Monday through Friday for identification and verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Per interview, the audits would continue until the Immediate Jeopardy (IJ) was abated. Review of the audits performed by MR and the QA Nurse confirmed completion of the tasks as assigned per the AOC. Interview on [DATE] at 6:30 PM, with the DON revealed the code status audits were turned in daily for her review. 12. Review of the Central Supply Clerk's (CSC) audit forms (Crash Cart Check List form) revealed the six (6) crash carts was audited daily for expired items and the presence of adequate supp

Based on interview, record review, review of the facility's policy and procedures, and review of the Kentucky Board of Nursing's (KBN's), "Accountability & Responsibility of Nurses" document and Advisory Opinions (AOS), it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality for one (1) of eight (8) sampled residents (Resident #1) regarding ensuring nursing staff honored the resident's Advance Directives. On [DATE], Resident #1 signed a document stating he/she requested to be a Full Code (Full Code indicates life-saving measures would be instituted in the event of cardiac or [MEDICAL CONDITION]) to include Cardiopulmonary Resuscitation (CPR). However, on [DATE], Registered Nurse (RN) #1 and RN #2 failed to ensure Resident #1's Advance Directives were honored regarding the Full Code. On [DATE] at approximately 8:30 AM, State Registered Nursing Assistant (SRNA) #1 found Resident #1 unresponsive and immediately notified RN #1 who assessed the resident; however, did not immediately initiate the facility's Code Blue process or CPR for Resident #1. SRNA #1 also notified RN #2 of the resident being unresponsive, and RN #2 also failed to initiate the facility's Code Blue process and CPR. Instead RN #2 overhead paged Licensed Practical Nurse (LPN) #1/Supervisor who responded and came to Resident #1's room where she told RN #1 and RN #2 to initiate CPR. However, LPN #1/Supervisor failed to ensure CPR was initiated and called the Minimum Data Set (MDS) office to verify if a Full Code resident was found unresponsive should CPR still be initiated. At approximately 9:05 AM, LPN #2/MDS Nurse and RN #4/MDS Coordinator went to Resident #1's room where CPR had still not been initiated. CPR was initiated per interview at approximately 9:05 AM to 9:10 AM, thirty-five (35) to forty (40) minutes, after the resident was found unresponsive, 911 was called, and Resident #1 was transported to the hospital emergency room (ER) where the resident was pronounced deceased at 9:38 AM. The facility's failure to ensure nursing staff implemented its Code Blue process and honored residents' Advance Directives regarding their requested code status has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], 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 KBN's, "Accountability & Responsibility of Nurses" document revealed KRS 314.021 (2) held nurses individually responsible and accountable for rendering safe, effective nursing care to clients and for judgements exercised and actions taken in the course of providing care. Review of the KBN's Advisory Opinion Statement (AOS) #36 "Resuscitation", approved February 2008, revealed nurses were "required" to honor the Advance Directives of "patients" who had the Advance Directives documented in their medical record, unless a Physician or healthcare facility refused to comply, and the "patient" and surrogate were informed of the refusal. Review of the facility's policy titled, "Cardiopulmonary Resuscitation (CPR)", undated, revealed if staff found a resident unresponsive they should call for help, assess the resident, check the resident's code status, if the resident was a Full Code call "paramedics" (911), initiate CPR and continue it until the "paramedics" arrived. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE]. Continued record review revealed on [DATE], Resident #1 had signed a document requesting to have CPR provided in the event he/she was non-responsive. Review of the February 2015 physician's orders [REDACTED]. Review of the Nurse's Notes revealed a Note dated [DATE] timed 8:40 AM documented by RN #1. Review of the Note revealed SRNA #1 had called RN #1 to Resident #1's room because the resident didn't "look too good". Per the Note, RN #1 found Resident #1 unresponsive after shaking the resident and checking for pulses and respirations. However, continued review of the Note revealed no documented evidence she immediately called a "Code Blue" or immediately initiated CPR for Resident #1 who had a Full Code status. The Note revealed RN #1 documented she called for "assist" from a nurse on another unit, and when the other nurse arrived 911 was called and CPR was then initiated. Further review of the Note revealed RN #1 documented 911 was there at 9:10 AM. Review of the EMS Run Sheet dated [DATE], revealed EMS was notified by the facility at 9:06:54 AM, were enroute at 9:08:03 AM, at 9:13:14 were with the "patient" (Resident #1). Continued review of the Run Sheet revealed EMS departed the facility with Resident #1 at 9:22:16 AM and arrived at the hospital ER at 9:29:37 AM. Further review revealed EMS assessed no vital signs for Resident #1 and noted his/her skin color was pale, skin temperature was cool and the resident's pupils were fixed. Review of the hospital ER record dated [DATE] revealed EMS arrived with Resident #1 and the resident was triaged at 9:33 AM. Per the ER record, Resident #1 presented to the ER in "cardio-pulmonary arrest", was treated for [REDACTED]. The ER record noted Resident #1 was pronounced as deceased at 9:38 AM. Review of the facility's investigation documentation dated [DATE], revealed an investigation had been conducted regarding an allegation of neglect involving Resident #1. Per the documentation, SRNA #1 found Resident #1 non-responsive at approximately 8:45 AM that morning and notified RN #1, who "due to her emotional state over" Resident #1 expiring had not honored the resident's Advance Directives "by initiating a Full Code". Continued review revealed other nurses had to initiate CPR for Resident #1 until EMS arrived. The investigation documentation revealed Resident #1 had "selected" to be a Full Code which was "indicated by" the resident's signature and was in the medical record. Review of the Form revealed RN #1 and RN #2 had been suspended pending the investigation outcome. Review of RN #1's written statement dated [DATE] at 3:25 PM, documented by the Director of Nursing (DON), revealed RN #1 reported SRNA #1 came to her at "about 8:45 AM", and said she needed to come and see Resident #1. Per the written statement, RN #1 went to Resident #1's room, shook him/her and checked for a pulse, but the resident had none. According to the statement, she also assessed Resident #1's vital signs and "there were none". The written statement noted RN #1 sent SRNA #1 to get a nurse on another unit, RN #2, who arrived in approximately one (1) minute. However, review of the written statement revealed no documented evidence RN #1 called a "Code Blue" or initiated CPR for Resident #1. Continued review of the written statement revealed RN #1 knew the white label on the spine of a resident's medical record indicated the resident was a Full Code, but she didn't know "why she did not call the code". RN #1's written statement noted CPR was not initiated until after another nurse, LPN #1/Supervisor came to Resident #1's room and told her and RN #2 to "code" the resident. Further review of RN #1's written statement revealed she initially "could not do this to" Resident #1 (provide CPR); however, after being told to she did "code" the resident. In addition, it was noted RN #1 thought CPR "started within five (5) minutes". Interview with RN #1 was attempted on [DATE] at 1:05 PM, 2:00 PM, 4:30 PM and 5:15 PM, and on [DATE] at 10:10 AM; however was unsuccessful each time. Continued review of the facility's investigation documentation revealed RN #2's written statement dated [DATE] timed 3:20 PM, which was documented by the DON. Per RN #2's written statement, SRNA #1 came and got her on [DATE] and told her RN #1 needed her. Review revealed when RN #2 arrived in Resident #1's room, she found RN #1 sitting on the resident's bed crying. According to RN#2's written statement, she checked Resident #1 for a pulse and did not find a pulse, and checked the resident's pupils. RN #2's written statement revealed she asked RN #1 the Resident #1's code status, a Do Not Resuscitate (DNR) or a Full Code, and RN #1 told her he/she was a Full Code. Further review of RN #2's written statement revealed she was told by RN #1 she (RN #1) was not going to put Resident #1 "through it" (CPR). In addition, the written statement revealed no documented evidence RN #2 initiated the facility's "Code Blue" process or CPR for Resident #1. Review revealed RN #2 left Resident #1 room to get LPN #1/Supervisor's opinion, then CPR was initiated which was performed for "a good while". Interview, on [DATE] at 12:25 AM and [DATE] at 11:30 AM, with RN #2 revealed she should have started CPR when she first entered Resident #1's room the morning of [DATE]. However, after RN #1 refused to do CPR for Resident #1 because she was not going to put the resident "through that", she felt she did not have any help (to perform CPR). Per interview, when she first entered Resident #1's room she did not know the resident's code status, but was told by RN #1 the resident was a Full Code. Further interview revealed she did not know how long it took to start "the code" (CPR), as she did not have her watch and hadn't looked at the clock. Per interview, CPR was not initiated until after LPN #1/Supervisor entered Resident #1's room and told her and RN #1 to initiate CPR. Further review of the facility's investigation documentation revealed LPN #1/Supervisor's written statement dated [DATE], untimed. Per the written statement on [DATE] at approximately 9:00 AM, she was paged overhead to call RN #2. The written statement revealed when she called RN #2, she was told Resident #1 "was dead" and she needed to "get up" there. LPN #1/Supervisor went to Resident #1's, room, as she went she saw the resident's chart which had a white label on it indicating he/she was a Full Code. The documentation revealed upon arrival to Resident #1's room she saw RN #1 sitting on the resident's bed patting his/her shoulder. According to the written statement, she asked why CPR was not initiated, and RN #1 told her she couldn't do that to Resident #1 as the resident would not want it. Per the written statement, LPN #1/Supervisor informed RN #1 that Resident #1 was a Full Code and she had to initiate CPR. LPN #1/Supervisor's written statement revealed she left Resident #1's room to call LPN #2/MDS Nurse to clarify if a resident was a Full Code and found non-responsive should CPR still be performed. Interview, on [DATE] at 12:05 PM, with LPN #1/Supervisor revealed on [DATE] at approximately 9:00 AM, she got to Resident #1's room after she had been paged overhead by RN #2. Continued interview revealed after arriving to Resident #1's room, she informed RN #1 and RN #2 CPR had to be started and 911 called. Per interview, RN #2 went to get the crash cart and LPN #1 went to call 911. Per interview, the "code" for Resident #1 was not performed timely, and CPR should have been initiated immediately after RN #1 assessed Resident #1, and observed the resident had no pulse and was not breathing. Review of the facility's investigation documentation revealed LPN #2/MDS Nurse's written statement dated [DATE] timed 1:45 PM, which was documented by the DON. Per the written statement, she had received a call from LPN #1/Supervisor on [DATE], to "double check code policy". The statement revealed after the call she went to Resident #1's room and observed RN #1 and RN #2 standing by the resident's bed, and she had to tell the nurses to start CPR. LPN #2/MDS Nurse's statement noted she was told by the nurse's Resident #1 had been found unresponsive at approximately 8:45 AM. The documentation revealed RN #1 had tears in her eyes and told her she "didn't want to have to do CPR on" Resident #1, and she told RN #1 CPR had to be done as the resident was a Full Code. Interview, on [DATE] at 2:40 PM, with LPN #2/MDS Nurse at approximately 9:00 AM to 9:05 AM on [DATE], LPN #1/Supervisor had called her to verify if a Full Code resident was found non-responsive whether CPR was still to be initiated. LPN #2/MDS Nurse stated she told LPN #1/Supervisor, "yes, CPR had to be initiated". Per interview, she left the MDS office and went immediately to Resident #1's room after the phone call. She stated after entering the resident's room she saw RN #1 holding an Ambu Bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) on one side of the bed, and RN #2 standing on the opposite side of the bed with the crash cart. According to LPN #2/MDS Nurse, she had to tell RN #1 and RN #2 to hook oxygen up to the Ambu Bag and start CPR. Continued interview revealed however, RN #1 was "emotional" and told her she didn't want to do that (start CPR) to Resident #1. LPN #2/MDS Nurse revealed she explained to RN #1 they had to start CPR because Resident #1 was a Full Code. She stated RN #1 and RN #2 told her Resident #1 had been found non-responsive at approximately 8:45 AM. Review of the facility's investigation documentation revealed RN #4/MDS Coordinator's written statement dated [DATE] at 1:30 PM documented by the DON. Per the written statement on [DATE], LPN #1/Supervisor called the MDS office to "say that nurse was not coding" Resident #1, and she thought they should be coding the resident. Review revealed she and LPN #2/MDS Nurse went to Resident #1's room and saw RN #1 holding the Ambu Bag by the resident's bed, and RN #2 was standing on the other side of the bed. The statement revealed RN #4/MDS Coordinator told RN #1 and RN #2 they had to lay the head of Resident #1's bed flat, and start CPR, which was done. Interview, on [DATE] at 3:00 PM, with RN #4/MDS Coordinator revealed on [DATE] at about 9:00 AM, LPN #2/MDS Nurse received a call from LPN #1/Supervisor requesting verification if a resident was found "lifeless" and was a Full Code whether CPR should be initiated. RN #4/MDS Coordinator revealed she and LPN #2/MDS Nurse went to Resident #1's room after the call, and observed RN #1 holding the Ambu Bag by the resident's bed, and RN #2 on the other side of the bed. RN #4/MDS Coordinator stated however, they did not observe chest compressions being done. She stated she could not recall for sure if the RN's were using the Ambu Bag. Interview, on [DATE] at approximately 2:00 PM and on [DATE] at 6:05 PM, with the Director of Nursing (DON) revealed for a resident found not breathing, a nurse was to assess the resident and if no pulse or breathing was found, the nurse should check the resident's code status. Per interview, for residents who were a Full Code CPR should be started immediately. Per the DON, Resident #1's CPR was not immediately initiated, but should have been. She stated RN #1 showed "no remorse" when she talked to her during the investigation, and told her (DON) she "just didn't want to do that to" the resident. The DON stated the facility suspended RN #1 and RN #2 pending the results of the investigation, and RN #1 terminated her employment with the facility on [DATE]. She stated RN #1 would be reported to the KBN by the facility. Interview, on [DATE] at 3:45 PM, with the Administrator revealed the nurse should be notified immediately if a resident was found non-responsive by a SRNA. The Administrator revealed, for a resident who was a Full Code, CPR should be immediately initiated and continued until EMS arrived and took over. Per interview, RN #1 did not act appropriately on [DATE]. Further interview revealed RN #2 should have initiated the code but he felt RN #1 stood in RN #2's way. He stated RN #2 did notify the supervisor who informed RN #1 to start CPR. However, interview statements on [DATE] at 3:20 PM, with RN #2 and [DATE] at 12:05 PM, with LPN #1/Supervisor, revealed they had not initiated CPR for Resident #1 timely per the facility's policy which stated "if staff found a resident unresponsive they should call for help, assess the resident, check the resident's code status, if the resident was a Full Code call "paramedics" (911), initiate CPR, and continue it until the "paramedics" arrived". The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) interviewed State Registered Nursing Assistant (SRNA) #1, Nursing Supervisor (NS) #1 (LPN #1/Supervisor), RN #1 and RN #2 regarding delay of the Code Blue event involving Resident #1. RN #1 and RN #2 were suspended on [DATE] pending the facility's investigation. 2. On [DATE], an initial report of the delayed Code Blue event was sent to the State Agency by the Administrator and the DON. 3. On [DATE], the DON notified Resident #1's family of the delay in initiating a Code Blue by RN #1. 4. On [DATE], the Staff Development Coordinator (SDC) initiated in-services with licensed nurses regarding immediate implementation of the facility's Code Blue Protocol for residents who had Advance Directives which indicated a Full Code status. Immediate training included face-to-face in-services with licensed staff on duty, and instruction by telephone for other licensed staff. On [DATE], the training was extended to include SRNA's and Kentucky Medication Aides (KMAs), and 100% of the nursing staff received the education. Training points included the immediate initiation of CPR, based on the physician's orders [REDACTED]. Utilized for the training was the facility's Code Blue Protocol. 5. On [DATE], the DON revised the facility's policy and procedure related to code status to include a requirement for adding each resident's code status to the care plan. 6. On [DATE], the DON developed a new system of quarterly care plan meetings with the resident and/or their Responsible Party (RP), the Social Worker, the unit nurse and the MDS nurse, to determine if any change in code status is desired by the resident. 7. On [DATE], the DON developed a Code Blue Information form to be attached to the incident report for all Code Blue events. Both forms are turned in to the DON for further investigation. The DON will submit results of all investigations to the monthly QA meetings. In addition, the DON developed a reference book for Code Blue events, and placed a book on each crash cart. 8. On [DATE], the Administrator notified the Ombudsman of the delay in initiating a Code Blue for Resident #1. The Administrator explained the corrective actions taken by the facility, and invited the Ombudsman to participate in the investigation process. 9. On [DATE], a Quality Assurance (QA) meeting was held by telephone conference. Participants included the Administrator, the DON, and the Medical Director, who was also the Attending Physician for Resident #1. The purpose of the meeting was to notify the Medical Director of the delay in providing CPR for Resident #1, and to discuss corrective actions. 10. On [DATE], an Ad Hoc QA meeting was held to establish corrective actions and monitoring to ensure future compliance related to the following: Code Blue response; residents' rights; and the facility's Abuse Policy. Attendees included the Administrator, DON, Medical Director, QA Nurse, RDCS, Regional Director of Operations (RDO), Unit Managers (UMs), and the SDC. The committee reviewed and authorized revision of the facility's current policy related to code status to include code status in each resident's Comprehensive Care Plan. In addition, the committee developed a checklist of items to be completed to ensure no other resident had the possibility of being affected by the deficient practice. Furthermore, the committee assigned individual members of the interdisciplinary team to carry out specific tasks stated on the check list, as well as, actions to ensure ongoing compliance. The committee determined the root cause of the delay in provision of CPR for Resident #1 was due to RN #1's failure to follow the facility's policy and procedure related to code status. Also, on [DATE], the regular monthly QA meeting was held and attended by the Administrator, DON, Medical Director, Social Services Director (SSD), QA Officer, Nursing Supervisor, Activities Director (AD), Director of Rehabilitation, Consultant Dietician, and the Dietary Manager Assistant. Participants confirmed the Ad Hoc meeting determination of the root cause and further discussed the facility's plan of action going forward. 11. On [DATE], the Medical Records Coordinator and the QA Nurse audited 100% of the 128 residents' charts to verify each resident's code status was correctly identified, and to ensure Physician Orders, Comprehensive Care Plans, and SRNA Care Plans were consistent for either Full Code or DNR status. Each resident's chart holds an identifying sticker on the outside spine to communicate the code status: a white sticker indicates a Full Code status, and a red sticker indicates DNR status. The Medical Records Coordinator updated each resident's Care Plan to reflect individual code status to be either Full Code or DNR. The QA Nurse and the Medical Records Coordinator will continue the audits daily Monday through Friday, and the House Supervisor will perform the audits on the weekends, until the IJ is removed. Audit results will be submitted daily for review by the DON, who will forward the data to the monthly QA meetings for interdisciplinary review. 12. On [DATE], the Central Supply clerk audited the facility's six (6) crash carts, utilized for managing a Code Blue event, for the presence of adequate supplies, and to ensure no expired items were located on the carts. The crash carts will be checked daily, Monday through Friday by the Central Supply Clerk, and by the House Supervisor on weekends, until the IJ is removed. The audits will utilize the Crash Cart check List Form, and all results will be submitted to the Administrator and the DON for their review. Subsequently, audit results will be presented at the monthly QA meeting, where any changes to the frequency of audits, or recommendations for further interventions, will be made. 13. Beginning [DATE], the Payroll/Human Resources (HR) Coordinator initiated a review of employee files for all nursing staff, to ensure current Cardiopulmonary Resuscitation (CPR) certificates, active nursing licenses and SRNA certifications, and the completion of background checks. The audit was completed on [DATE]. 14. On [DATE], the Medical Records Coordinator and the RDCS audited fifty (50) residents who expired at the facility during RN #1's employment between [DATE] and [DATE], to determine if RN #1 had been involved in any other Code Blue events. They found of the fifty (50) deaths, twenty-one (21) occurred while RN #1 was on duty; however, all residents except Resident #1 were a DNR status at the time of death. 15. On [DATE], while still on suspension, RN #1 called the facility and voluntarily resigned her position of employment with the facility. 16. On [DATE], the Administrator and the DON informed the Medical Director of the specific IJ citations, and discussed the facility's plan for correction of the deficient practice. 17. On [DATE], the Administrator and the DON in-serviced the facility's two (2) SSD's, the MDS Nurses and the Medical Records Coordinator related to the facility's new policy and procedure regarding Advance Directives, which includes the following actions: Social Services will review each resident's Advance Directives upon admission to the facility, including their wishes regarding code status, obtain a physician's orders [REDACTED]. Directives during the regularly scheduled Care Plan meetings. 18. On [DATE] through [DATE], all staff from every department, including Nursing, Dietary, Maintenance, Social Services, Activities, and Housekeeping, was in-serviced by the DON, SSD, SDC, QA Officer, and the Nursing Supervisor related to Advance Directives and Residents' Rights. Each staff member was required to complete a post-test with 100% accuracy on the subject matter. Immediate re-education was provided for any incorrect answers. 19. Between [DATE] and [DATE], all nursing staff, including nurses, KMAs and SRNA's were educated by the DON, SSD, SDC, QA Officer and the Nursing Supervisor on the following: differentiation between DNR and Full Code status; how to identify a resident's code status; how to call for and initiate a Code Blue; who should respond to a Code Blue immediately; where to locate the crash cart; contacting the Physician and calling 911; continuation of the code until EMS arrival; notification of the DON and Administrator; and documentation of all details of the code in the medical record. In addition, the training included how to manage the resident who had a DNR status, including an assessment for vital signs at five (5) minute intervals, pronouncement of death, notification of the Physician, the family and/or POA, and the DON and Administrator, and documentation in the medical record. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 20. Between [DATE] and [DATE], all nurses, KMA and SRNA's were in-serviced regarding the requirement for inclusion of the resident's Advance Directives and code status on the Comprehensive Care Plan. The training was provided by the DON, SDC and Nursing Supervisor. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. Two (2) staff members were on leave and did not receive the education. They will not be added to the schedule until they are in-serviced and able to complete the post-test accurately to ensure their competency. 21. As of [DATE], fifty-six (56) of one hundred and twenty-eight (128) residents had an Advance Directive for Full Code status. 22. On [DATE], the DON updated the new hire orientation outline to include training and post-tests related to professional nursing standards, identifying code status, Comprehensive Care Plans, Advance Directives, Residents' Rights, Code Blue Information sheet, Code Blue Nurses' Note guide, and the facility's Code Blue Protocol. In addition, orientation packets were developed for agency staff to educate on the same topics. All agency staff will be expected to complete the post-tests with 100% accuracy prior to providing direct care. 23. Between [DATE] and [DATE], all nurses, KMAs and SRNA's were in-serviced by the DON, SDC and the Nursing Supervisor related to professional nursing standards. Training references included the Lippincott Manual of Nursing Practice as it pertained to the provision of CPR, documentation, ensuring a physician's orders [REDACTED]. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 24. On [DATE], the facility conducted a mock Code Blue drill to assess staff knowledge retention after training related to initiating a Code Blue event immediately, and evaluated response time, accuracy in determining the code status of the mock resident, and adherence to the facility's policy and procedure. A mock Code Blue drill will be conducted quarterly by the SDC, QA nurse or the DON, and will cover all shifts on weekdays and weekends. Results of the drills will be brought by the Administrator or the DON to the facility QA meetings for interdisciplinary review. Any staff members identified to not follow facility policy and procedures will be re-educated, and a competency test will be administered until the staff member is able to display a thorough and accurate understanding of the policy and procedure. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed SRNA #1, Nursing Supervisor #1 (LPN #1/Supervisor), RN #1 and RN #2 were interviewed related to the Code Blue event involving Resident #1. Continued review of the investigation revealed RN #1 and RN #2 were suspended on [DATE], pending the investigation results. Interview, on [DATE] at 6:00 PM, with the DON revealed RN #1 called the facility on [DATE], and stated she was quitting and would not be returning to work, and hung up. 2. The State Survey Agency received the initial report regarding the delayed Code Blue event involving Resident #1 on [DATE]. 3. Review of the facility's investigation documentation of the incident revealed the DON notified Resident #1's family of RN #1's delay in initiating a Code Blue. Phone contact was attempted with Resident #1's RP/family which was unsuccessful and a message was left. However, no return call was received. 4. Review of the facility's in-service sign-in form dated [DATE] and [DATE], revealed 100% of nursing staff did receive training on the facility's Code Blue Protocol, which included education on immediate initiation of CPR, based on physician's orders [REDACTED]. Interviews on [DATE]: at 1:55 PM with LPN #1; at 4:15 PM, with LPN #2; at 3:20 PM, with LPN #8; and at 4:50 PM with RN #4 revealed they were inserviced on the facility's Code Blue procedures, how to identify a resident's code status, when to initiate CPR, and the code process. Interviews on [DATE]: at 3:49 PM, with SRNA #13, at 4:35 PM with SRNA #6; and at 4:58 PM with SRNA #12 revealed they were inserviced on the facility's Code Blue process, how to identify a resident's code status, call a Code Blue, take crash cart to room and wait for further directions. 5. Review of the facility's document titled, "Medical Emergency Code Reference", not dated, revealed the DON had revised the facility's policy and procedure to include the requirement for adding each resident's code status to the care plan. Interviews on [DATE] at 5:20 PM, with Social Services (SS) #13, and at 5:30 PM, with SS #2, revealed they were in-serviced related to SS responsibility for implementing an interim Advance Directive care plan to include the code status for all new residents upon admission and/or readmission. Interview on [DATE] at 4:50 PM, with the RN #4/MDS Coordinator revealed the MDS nurses were in-serviced related to MDS' responsibility to audit the interim care plan within 72 hours of every resident's admission, and/or readmission, and to assure Advance Directives with code status were present. 6. Interview, on [DATE] at 6:30 PM, with the DON revealed she developed a new system for Quarterly Care Plan meetings to discuss with residents and their RP if a change in code status is desired by the resident. Review of the facility's policy titled, "Care Plans" with a revised date of [DATE], r

Based on interview, record review, review of the facility's policy and procedures, facility's investigation report, and the Emergency Medical Services (EMS) report, it was determined the facility failed to have an effective system to ensure one (1) of eight (8) sampled residents (Resident #1) received Cardiopulmonary Resuscitation (CPR) according to established professional standards to promote the highest practicable physical well-being of residents regarding their advance directives and code status. Resident #1 had Advance Directives, dated [DATE], requesting life-saving measures be instituted in the event of cardiac or [MEDICAL CONDITION], to include CPR. On [DATE] at approximately 8:30 AM, Resident #1 was found unresponsive by State Registered Nursing Assistant (SRNA) #1 who immediately notified Registered Nurse (RN) #1 of this information. However, after assessing Resident #1 for a pulse and not finding any, RN #1 failed to immediately initiate CPR for this resident. SRNA #1 then informed RN #2 of Resident #1 being unresponsive, who went to the resident's room without checking his/her code status. RN #2 asked RN #1 what the resident's code status was, and RN #1 told her it was a Full Code. Even though RN #2 was informed of this information and told RN #1 they needed to initiate CPR, the nurses failed to honor Resident #1's request for CPR provision. RN #2 overhead paged Licensed Practical Nurse (LPN) #1/Supervisor who entered Resident #1's room at approximately 9:00 AM, an observed neither RN was performing CPR. LPN #1/Supervisor told the RNs Resident #1 was a Full Code and CPR had to be initiated. However, LPN #1/Supervisor failed to ensure RN #1 and RN #2 initiated CPR, and left the resident's room to call LPN #2/MDS Nurse to verify providing CPR for Resident #1. At approximately 9:05 AM, LPN #2/MDS Nurse and RN #4/MDS Coordinator went to Resident #1's room where CPR had still not been initiated. CPR was initiated per interview at approximately 9:05 AM to 9:10 AM, thirty-five (35) to forty (40) minutes after the resident was found unresponsive, 911 was called, and Resident #1 was transported to the hospital emergency room (ER) where the resident was pronounced deceased at 9:38 AM. The facility's failure to provide the necessary care and services related to the resident's requested Full Code status and the provision of CPR, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], 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 "Medical Emergency Code Reference", undated, revealed a "Code Blue" might be called anytime a resident was determined to have a life threatening medical condition. Per the "Medical Emergency Code Reference", the "Code Blue" could be initiated by a Registered Nurse (RN) or Licensed Practical Nurse (LPN), who were to "overhead page" three (3) times the room number or location of the "Code Blue", all available nursing staff were to respond, staff were to the "check code status" of the resident, initiate Cardiopulmonary Resuscitation (CPR) if appropriate, contact the Physician and/or "send out 911" and "document all details of the code in the medical record". Review of the facility's policy titled, "Cardiopulmonary Resuscitation (CPR)", undated, revealed the purpose was to ventilate and establish circulation on a resident with absence of respirations and pulse. Per the Policy, as specific procedures for CPR were revised frequently, the procedure was to be verified with the American Heart Association and/or the American Red Cross in the area. Continued review revealed staff was to do the following: if a resident was unresponsive call for help; check the resident's code status and if he/she was a Full Code staff was to call "paramedics" (911); delegate someone to "take notes" on when the resident was found unresponsive, the time CPR was initiated, who provided chest compressions and ventilations; continue CPR until help arrived; and, document the "entire event" in the resident's medical record. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], revealed the facility assessed Resident #1 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15). Review of the Advance Directives, dated [DATE] and signed by Resident #1, revealed the resident requested to have a Full Code status which included CPR in the event of non-responsiveness. Review of the February 2015 monthly physician's orders [REDACTED]. However, review of a Nurse's Note [DATE] at 8:40 AM, RN #1 was called to Resident #1's room by State Registered Nursing Assistant (SRNA) #1 who told her the resident "don't look too good". Per the Note, RN #1 observed Resident #1 lying on the bed, she shook the resident with "no response", and checked for a pulse with none found and he/she had "no respirations". Even though RN #1's documentation noted this, there was no documented evidence she immediately initiated CPR, had a "Code Blue" paged overhead three (3) times, or contacted the Physician or 911, as per the facility's "Medical Emergency Code Reference". RN #1 documented she called for "assist" from a nurse on another wing, who arrived and CPR was then initiated and 911 called. Continued review revealed RN #1 noted at 9:10 AM, "911 here" who placed Automated External Defibrillator (AED) pads on the resident with no pulse obtained and the Emergency Medical Services (EMS) staff placed Resident #1 on a "backboard' and continued CPR. Review of a Nurse's Note dated [DATE] at 9:00 AM, documented by LPN #1/Supervisor revealed she was "overhead paged" to "call" the nurse's station on the unit Resident #1 resided, which she did and was told Resident #1 was "dead". LPN #1 documented she went to Resident #1's room and CPR was initiated. Continued review revealed at 9:05 AM, LPN #1 documented 911 was called and CPR continued until EMS arrived, and at 9:15 AM she noted EMS arrived and took over CPR. Review of the EMS Run Sheet dated [DATE], revealed the call from the facility was received at 9:06:54 AM, EMS personnel were enroute at 9:08:03 AM, "at the scene" at 9:12:51 AM, with the "patient" (Resident #1) at 9:13:14, departed the facility with the "patient" at 9:22:16 AM and arrived at the hospital ER at 9:29:37 AM. Per the EMS Run Sheet, Resident #1's chief complaint was "[MEDICAL CONDITION]/death", no vital signs were assessed, the resident's pupils were fixed, skin color was pale, and skin temperature was cool. Review of the hospital ER record revealed Resident #1 arrived via ambulance and was triaged at 9:33 AM. Per the record, Resident #1 was reportedly last seen responsive at 8:30 AM by staff of the facility, and the resident presented in "cardio-pulmonary arrest" to the ER. Continued review revealed CPR was in progress on arrival to the ER, and after "multiple rounds" of [MEDICATION NAME] (a medication used to to reverse [MEDICAL CONDITION]) the resident remained in asystole (no heart rate) and was pronounced deceased at 9:38 AM. Further review of a Nurse's Note dated [DATE] timed 8:45 AM, for Resident #1, with no nurse's signature, revealed nursing found Resident #1 unresponsive, with no pulse assessed by nursing. Continued review of the Note revealed CPR was initiated by RN #1 and RN #2 with CPR continuing until "911 arrived" at 9:15 AM. Further review of a Note timed 9:30 AM, revealed "called report" to the hospital. In addition, review of a Note timed 10:20 AM, revealed Resident #1 had "passed" per the hospital. However, further record review revealed no documented evidence all details of the code for Resident #1 were recorded to include staff having overhead paged the "Code Blue" three (3) times, contacted the Physician, the time CPR was initiated, who provided chest compressions, and ventilations, as per the facility's policy. Review of the facility's "Long Term Care Facility--Self-Reported Incident Form" and investigation attachment dated [DATE], revealed it was the facility's "Initial Report" and "5 Day Follow up/Final Report" of an incident which occurred on [DATE]. Review of the Form revealed the facility had investigated an allegation of neglect involving Resident #1, which was "in progress" related to "RN's response" to finding the resident with "no signs of life and if her actions were timely". According to the investigation information SRNA #1 found Resident #1 non-responsive at approximately 8:45 AM on [DATE], and notified RN #1. Per the investigation information the facility determined RN #1 "due to her emotional state over" Resident #1 expiring had not respected the resident's Advance Directives "by initiating a Full Code" and had other nurses in the facility initiate CPR until Emergency Medical Services (EMS) arrived. Continued review of the Form and attachment revealed Resident #1 had "selected" wanting to be a Full Code which was "indicated by" his/her signature and in the medical record. Review of the Form revealed RN #1 and RN #2 were suspended pending the investigation outcome. Review of the investigation documentation revealed witness statements were obtained from SRNA #1, LPN #1, LPN #2, RN #1, RN #2, and RN #4 which were signed and dated. Review of the facility's investigation revealed SRNA #1's written statement, dated [DATE] at 3:00 PM, which noted when she entered Resident #1's room after breakfast "she looked at him and felt that he was dead". Per SRNA #1's written statement, she immediately went to the nursing station and "got" RN #1 to come to the resident's room. Further review revealed "CPR was initiated within five (5) minutes". Interview with SRNA #1 on [DATE] at 10:45 AM, revealed she found Resident #1 in bed unresponsive at approximately 8:30 AM on [DATE]. SRNA #1 revealed she left Resident #1's room and immediately notified RN #1, and they both returned to the resident's room. Per interview, RN #1 assessed Resident #1 and "saw" that the resident was not breathing and started crying. SRNA #1 revealed she went to another unit and got RN #2 who came to Resident #1's room. SRNA #1 stated she asked the two RNs if they wanted her to get the "crash cart", but RN #2 said "we have it under control". However, per interview, CPR was not started until LPN #1/Supervisor entered the room and said CPR had to be initiated which was approximately ten (10) minutes after she had found Resident #1 non-responsive. Review of the facility's investigation report revealed RN #1's written statement, dated [DATE] at 3:25 PM and documented by the Director of Nursing (DON), revealed SRNA #1 had come to her at "about 8:45 AM", and said she needed to come and see Resident #1. RN #1 revealed she went to Resident #1's room, shook him/her and checked for a carotid, apical and radial pulse, but the resident did not have any. Per RN #1's written statement, she assessed Resident #1's vital signs and "there were none", so she sent SRNA #1 to get a nurse from another unit, and RN #2 arrived in approximately one (1) minute. Continued interview revealed she knew that a white label on the spine of a resident's medical record indicated the resident was a Full Code. However, she did not know "why she did not call the code". Further review of RN #1's written statement revealed CPR was not initiated until LPN #1/Supervisor came to the room and told her and RN #2 to "code" Resident #1. In addition, review revealed RN #1 stated she initially "could not do this to" Resident #1, but did "code" the resident as told to by LPN #1/Supervisor, and RN #1 believed CPR was "started within five (5) minutes". Interview with RN #1 was attempted on [DATE] at 1:05 PM, 2:00 PM, 4:30 PM and 5:15 PM, and on [DATE] at 10:10 AM with no success. Review of the facility's investigation report revealed RN #2's written statement, dated [DATE] at 3:20 PM documented by the DON, revealed SRNA #1 came to her unit and said RN #1 needed her. RN#2's written statement revealed when she arrived at Resident #1's room, she found RN #1 sitting on the bedside crying. Per the written statement, RN #2 checked Resident #1's pupils and checked for pulses and there were none. Continued review revealed RN #2 told the DON she asked RN#1 if Resident #1 was a DNR or a Full Code, and RN #1 replied a Full Code. RN #2's written statement revealed RN #1 told her she was not going to put Resident #1 "through it" (CPR). Further review revealed RN #2 reported she then notified LPN #1/Supervisor to get her opinion and CPR was initiated and performed for "a good while". Interview with RN #2 on [DATE] at 12:25 AM and [DATE] at 11:30 AM, revealed SRNA #1 came to get her to come to Resident #1's room at approximately 8:35 AM on [DATE]. RN #2 revealed she did not know Resident #1's code status upon entering the room; however, was informed by RN #1 he/she was a Full Code, but she (RN #1) was not going to put the resident "through that". Per interview, RN #2 should have started CPR when she first entered the room, but felt she did not have any help, because RN #1 refused to do CPR on Resident #1. RN #2 stated she did not know how long it took to start "the code" (CPR), because she did not look at the clock and did not have her watch on that day. Continued interview revealed CPR was not initiated until LPN #1/Supervisor entered the room and instructed her and RN #1 to initiate CPR. RN #2 revealed LPN #2/MDS Nurse documented the code information after CPR was initiated. Review of the facility's investigation report revealed LPN #1/Supervisor's written statement, dated [DATE] with no time noted, revealed at approximately 9:00 AM that morning (about thirty (30) minutes after SRNA #1 had found Resident #1 unresponsive) she was overhead paged by RN #2 to call the A unit where Resident #1 resided. LPN #1/Supervisor's written statement revealed when she called the unit she was informed by RN#2 that Resident #1 "was dead" and she needed to "get up here". Continued review revealed LPN #1/Supervisor went to the unit where she observed Resident #1's chart with a white label indicating the resident was a Full Code; however, when she entered the resident's room she saw RN #1 sitting on the resident's bed patting his/her shoulder. LPN #1/Supervisor's written statement revealed she asked why CPR had not been initiated and RN#1 told her she could not do that to the resident as he/she would not want it. Per the written statement, LPN #1 told RN #1 the resident was a Full Code, she had to start CPR, and then she went to call LPN #2/MDS Nurse for clarification of initiating CPR for residents with a Full Code status. Further review revealed RN#2 ran and got the crash cart, CPR was initiated and 911 called. Interview with LPN #1/Supervisor on [DATE] at 12:05 PM, revealed it was approximately 9:00 AM when she arrived at Resident #1's room after being overhead paged by RN #2. Per interview, when she arrived in the resident's room, she told RN #1 and RN #2 that CPR had to be initiated and 911 notified. LPN #1/Supervisor revealed the "code" was not performed timely, and CPR should have been initiated immediately after RN #1 assessed Resident #1 and saw he/she was not breathing and had no pulse. Review of the facility's investigation report of LPN #2/MDS Nurse's written statement, dated [DATE] at 1:45 PM documented by the DON, revealed LPN #1/Supervisor had called the MDS office on [DATE], to "double check code policy" and she told LPN #1/Supervisor she was right. Per the written statement, she went to Resident #1's room where she observed RN #1 at the left side of the head of the resident's bed with RN #2 on the right side; however, LPN #2/MDS Nurse had to tell the two (2) RNs to start CPR. Review revealed RN #1 and RN #2 told her Resident #1 had been found unresponsive at about 8:45 AM. Continued review revealed LPN #2/MDS Nurse observed RN #1 to have tears in her eyes, and the RN told her she "didn't want to have to do CPR on" Resident #1. LPN #2/MDS Nurse's written statement revealed she told RN #1 they had to do CPR because the resident was a Full Code. Further review revealed CPR was then initiated and RN #2 stated "someone needs to be charting this", so LPN #2/MDS Nurse went to the nurse's station and someone gave her a Nurse's Note. In addition, the written statement revealed when the "Paramedics" arrived they asked how long Resident #1 had been like this, and one (1) of the RNs told the "Paramedics" the resident was found at 8:45 AM. Per the written statement, the "Paramedics" inquired if the resident had been "like this twenty (20) minutes" as it was now 9:05 AM. Interview with LPN #2/MDS Nurse on [DATE] at 2:40 PM revealed LPN #1 called the MDS office at approximately 9:00 AM to 9:05 AM an asked if a resident was a Full Code and found unresponsive with no pulse if CPR was initiated anyway. LPN #2/MDS Nurse revealed she told LPN #1, "yes CPR had to be initiated", and she went immediately Resident #1's room. Per interview, when she entered Resident #1's room RN #1 was holding the Ambu Bag (a hand-held device commonly used to provide positive pressure ventilation to patients not breathing or not breathing adequately), and RN #2 was on the opposite side of the bed with the crash cart. Continued interview revealed LPN #2/MDS Nurse told the two (2) RNs to hook up the oxygen to the Ambu Bag and start CPR. LPN #2/MDS Nurse stated RN #1 was "emotional" and told her "she did not want to do that to" Resident #1. Further interview revealed LPN #2/MDS Nurse explained to RN #1, Resident #1 was a Full Code and CPR had to be initiated. Per LPN #2/MDS Nurse the two (2) RNs told her Resident #1 had been found unresponsive at about 8:45 AM. LPN #2/MDS Nurse stated CPR started at approximately 9:10 AM (approximately twenty-five minutes after the resident was found unresponsive), LPN #1/Supervisor went and called 911, and EMS arrived at approximately 9:15 AM. Review of the facility's investigation report of RN #4/MDS Coordinator's written statement, dated [DATE] at 1:30 PM documented by the DON, revealed LPN #1/Supervisor called the MDS office on [DATE] to "say that nurse was not coding" Resident #1, and she thought they should be. Per the written statement, LPN #2/MDS Nurse who spoke to LPN #1/Supervisor told the Supervisor she was correct. Continued review revealed LPN #2/MDS Nurse and RN #4/MDS Coordinator went to Resident #1's room where they observed RN #1 holding the Ambu Bag and RN #2 was on the other side of the resident's bed. RN #4/MDS Coordinator's written statement revealed she told the two (2) RNs they had to put Resident #1's head of bed flat, which was done, and then LPN #2/MDS Nurse told RN #1 and RN #2 they had to start CPR, and it was then initiated. Further review of the written statement revealed RN #4/MDS Coordinator was unable to recall the specific time; however, knew "it was after 9:00 AM". Interview with RN #4/MDS Coordinator on [DATE] at 3:00 PM, revealed at approximately 9:00 AM on [DATE], LPN #1/Supervisor called the MDS office to verify with LPN #2/MDS Nurse, if CPR had to be initiated if a resident was "lifeless", but was a Full Code. RN #4 revealed LPN #2/MDS Nurse told LPN #1/Supervisor that "yes, it (CPR) had to be done". Per interview, RN #4/MDS Coordinator LPN #2/MDS Nurse went to Resident #1's room and saw RN #1 holding the Ambu Bag and RN #2 on the opposite side of the bed with the crash cart. RN #4 revealed she did not observe any chest compression being done at that time, and could not recall for sure if the Ambu Bag was being utilized. Further interview revealed EMS had been notified, so she left the room to wait for their arrival, and when EMS arrived she did not look at the clock for the exact arrival time. Interview with the Director of Nursing (DON), on [DATE] at approximately 2:00 PM and on [DATE] at 6:05 PM, revealed if a resident was found not breathing, the nurse should assess the resident and if no pulse or breathing, check for the resident's code status, then start CPR immediately for residents who were a Full Code. Per the DON, the facility utilized a "dot" system to indicate a resident's code status outside the room doors. She stated for residents who were a Full Code a dot was not placed by the door, and if a resident was a DNR status a red dot was placed by their door. The DON stated for residents who were a Full Code a white strip of tape was placed on the spine of the resident's medical record, and a strip of red was used on the records of those who were a DNR status. According to the DON, a Code Blue should be announced overhead three (3) times with the resident's room number, 911 should be called, and CPR should continue until EMS arrived and took over. The DON revealed for Resident #1 CPR was not started immediately; however, should have been. Interview with the Staff Development Coordinator (SDC), on [DATE] at 5:30 PM, revealed she had conducted one (1) mock code blue drill early in 2014. The SDC stated she had planned to continue to conduct the drills every three (3) months; however, she did not follow through with her plan and no further drills were conducted prior to the incident on [DATE]. Continued interview with the DON, on [DATE] at approximately 2:00 PM and on [DATE] at 6:05 PM, revealed when she interviewed RN #1 after the incident, RN #1 showed "no remorse" and said she "just didn't want to do that to" him/her. Per interview, RN #1 and RN #2 were suspended pending the facility's investigation, and on [DATE] RN #1 telephoned the facility and terminated her employment. Further interview with the DON revealed the facility reported RN #1 to the Kentucky Board of Nursing. Interview with the Administrator on [DATE] at 3:45 PM revealed, if a SRNA found the resident unresponsive a nurse should be notified immediately. Per interview, the resident's code status should be verified and the resident assessed. Continued interview revealed if the resident was a Full Code, CPR should be initiated immediately and continued until EMS arrived and took over. The Administrator revealed RN #1 did not act appropriately as it related to the facility's policies and procedures. He stated RN #1 told him she knew what the facility's policies and procedures were and knew she should have followed them; however, she did not believe it was what Resident #1 would have wanted. Per the Administrator, RN #1 should have followed the facility's policy. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) interviewed State Registered Nursing Assistant (SRNA) #1, Nursing Supervisor (NS) #1 (LPN #1/Supervisor), RN #1 and RN #2 regarding delay of the Code Blue event involving Resident #1. RN #1 and RN #2 were suspended on [DATE] pending the facility's investigation. 2. On [DATE], an initial report of the delayed Code Blue event was sent to the State Agency by the Administrator and the DON. 3. On [DATE], the DON notified Resident #1's family of the delay in initiating a Code Blue by RN #1. 4. On [DATE], the Staff Development Coordinator (SDC) initiated in-services with licensed nurses regarding immediate implementation of the facility's Code Blue Protocol for residents who had Advance Directives which indicated a Full Code status. Immediate training included face-to-face in-services with licensed staff on duty, and instruction by telephone for other licensed staff. On [DATE], the training was extended to include SRNA's and Kentucky Medication Aides (KMAs), and 100% of the nursing staff received the education. Training points included the immediate initiation of CPR, based on the physician's orders [REDACTED]. Utilized for the training was the facility's Code Blue Protocol. 5. On [DATE], the DON revised the facility's policy and procedure related to code status to include a requirement for adding each resident's code status to the care plan. 6. On [DATE], the DON developed a new system of quarterly care plan meetings with the resident and/or their Responsible Party (RP), the Social Worker, the unit nurse and the MDS nurse, to determine if any change in code status is desired by the resident. 7. On [DATE], the DON developed a Code Blue Information form to be attached to the incident report for all Code Blue events. Both forms are turned in to the DON for further investigation. The DON will submit results of all investigations to the monthly QA meetings. In addition, the DON developed a reference book for Code Blue events, and placed a book on each crash cart. 8. On [DATE], the Administrator notified the Ombudsman of the delay in initiating a Code Blue for Resident #1. The Administrator explained the corrective actions taken by the facility, and invited the Ombudsman to participate in the investigation process. 9. On [DATE], a Quality Assurance (QA) meeting was held by telephone conference. Participants included the Administrator, the DON, and the Medical Director, who was also the Attending Physician for Resident #1. The purpose of the meeting was to notify the Medical Director of the delay in providing CPR for Resident #1, and to discuss corrective actions. 10. On [DATE], an Ad Hoc QA meeting was held to establish corrective actions and monitoring to ensure future compliance related to the following: Code Blue response; residents' rights; and the facility's Abuse Policy. Attendees included the Administrator, DON, Medical Director, QA Nurse, RDCS, Regional Director of Operations (RDO), Unit Managers (UMs), and the SDC. The committee reviewed and authorized revision of the facility's current policy related to code status to include code status in each resident's Comprehensive Care Plan. In addition, the committee developed a checklist of items to be completed to ensure no other resident had the possibility of being affected by the deficient practice. Furthermore, the committee assigned individual members of the interdisciplinary team to carry out specific tasks stated on the check list, as well as, actions to ensure ongoing compliance. The committee determined the root cause of the delay in provision of CPR for Resident #1 was due to RN #1's failure to follow the facility's policy and procedure related to code status. Also, on [DATE], the regular monthly QA meeting was held and attended by the Administrator, DON, Medical Director, Social Services Director (SSD), QA Officer, Nursing Supervisor, Activities Director (AD), Director of Rehabilitation, Consultant Dietician, and the Dietary Manager Assistant. Participants confirmed the Ad Hoc meeting determination of the root cause and further discussed the facility's plan of action going forward. 11. On [DATE], the Medical Records Coordinator and the QA Nurse audited 100% of the 128 residents' charts to verify each resident's code status was correctly identified, and to ensure Physician Orders, Comprehensive Care Plans, and SRNA Care Plans were consistent for either Full Code or DNR status. Each resident's chart holds an identifying sticker on the outside spine to communicate the code status: a white sticker indicates a Full Code status, and a red sticker indicates DNR status. The Medical Records Coordinator updated each resident's Care Plan to reflect individual code status to be either Full Code or DNR. The QA Nurse and the Medical Records Coordinator will continue the audits daily Monday through Friday, and the House Supervisor will perform the audits on the weekends, until the IJ is removed. Audit results will be submitted daily for review by the DON, who will forward the data to the monthly QA meetings for interdisciplinary review. 12. On [DATE], the Central Supply clerk audited the facility's six (6) crash carts, utilized for managing a Code Blue event, for the presence of adequate supplies, and to ensure no expired items were located on the carts. The crash carts will be checked daily, Monday through Friday by the Central Supply Clerk, and by the House Supervisor on weekends, until the IJ is removed. The audits will utilize the Crash Cart check List Form, and all results will be submitted to the Administrator and the DON for their review. Subsequently, audit results will be presented at the monthly QA meeting, where any changes to the frequency of audits, or recommendations for further interventions, will be made. 13. Beginning [DATE], the Payroll/Human Resources (HR) Coordinator initiated a review of employee files for all nursing staff, to ensure current Cardiopulmonary Resuscitation (CPR) certificates, active nursing licenses and SRNA certifications, and the completion of background checks. The audit was completed on [DATE]. 14. On [DATE], the Medical Records Coordinator and the RDCS audited fifty (50) residents who expired at the facility during RN #1's employment between [DATE] and [DATE], to determine if RN #1 had been involved in any other Code Blue events. They found of the fifty (50) deaths, twenty-one (21) occurred while RN #1 was on duty; however, all residents except Resident #1 were a DNR status at the time of death. 15. On [DATE], while still on suspension, RN #1 called the facility and voluntarily resigned her position of employment with the facility. 16. On [DATE], the Administrator and the DON informed the Medical Director of the specific IJ citations, and discussed the facility's plan for correction of the deficient practice. 17. On [DATE], the Administrator and the DON in-serviced the facility's two (2) SSD's, the MDS Nurses and the Medical Records Coordinator related to the facility's new policy and procedure regarding Advance Directives, which includes the following actions: Social Services will review each resident's Advance Directives upon admission to the facility, including their wishes regarding code status, obtain a physician's orders [REDACTED]. Directives during the regularly scheduled Care Plan meetings. 18. On [DATE] through [DATE], all staff from every department, including Nursing, Dietary, Maintenance, Social Services, Activities, and Housekeeping, was in-serviced by the DON, SSD, SDC, QA Officer, and the Nursing Supervisor related to Advance Directives and Residents' Rights. Each staff member was required to complete a post-test with 100% accuracy on the subject matter. Immediate re-education was provided for any incorrect answers. 19. Between [DATE] and [DATE], all nursing staff, including nurses, KMAs and SRNA's were educated by the DON, SSD, SDC, QA Officer and the Nursing Supervisor on the following: differentiation between DNR and Full Code status; how to identify a resident's code status; how to call for and initiate a Code Blue; who should respond to a Code Blue immediately; where to locate the crash cart; contacting the Physician and calling 911; continuation of the code until EMS arrival; notification of t

Based on interview, record review, and review of the facility's policy and procedures it was determined the facility failed to have an effective system to ensure accurate clinical records were maintained for one (1) of eight (8) sampled residents (Resident #1). Resident #1 had Advance Directives which noted he/she requested to be a Full Code (Full Code indicates life-saving measures would be instituted in the event of cardiac or [MEDICAL CONDITION]) to include performance of Cardiopulmonary Resuscitation (CPR). On [DATE] at approximately 8:30 AM, Resident #1 was found to be unresponsive by State Registered Nursing Assistant (SRNA) #1 who immediately notified Registered Nurse (RN) #1 of this information. However, after checking for Resident #1's pulse and being unable to obtain one, RN #1 failed to immediately initiate CPR for this resident. RN #1, RN #2, Licensed Practical Nurse (LPN) #2/Minimum Data Set (MDS) and RN #4/MDS Coordinator initiated CPR for Resident #1 at approximately 9:05 AM to 9:10 AM; however, the nurses failed to ensure all details of the code were documented in the resident's medical record. Resident #1 was transported by ambulance to the hospital emergency room (ER) where the resident was pronounced as expired at 9:38 AM. The facility's failure to ensure the provision of CPR for a Full Code resident, with all details of the code accurately documented in the resident's records, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], 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, "Cardiopulmonary Resuscitation (CPR)", undated, revealed to delegate a person to "take notes" during a code on a resident found unresponsive which was to include the time CPR was initiated, who provided chest compressions and ventilations, and document the "entire event" in the resident's medical record. Review of the facility's, "Medical Emergency Code Reference" document, undated, revealed the purpose was to provide emergency care to a resident in need of urgent service. Per the "Medical Emergency Code Reference", the "Code Blue" could be initiated by a Registered Nurse (RN) or Licensed Practical Nurse (LPN), who were to "overhead page" three (3) times the room number or location of the "Code Blue", all available nursing staff were to respond, staff were to the "check code status" of the resident, initiate Cardiopulmonary Resuscitation (CPR) if appropriate, contact the Physician and/or "send out 911" and "document all details of the code in the medical record". Review of the medical record for Resident #1 revealed the facility admitted the resident on [DATE], and he/she was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Advance Directives, dated [DATE], and signed by Resident #1, revealed the resident requested to have a Full Code status which included CPR in the event of being unresponsive with no respirations or heart beat. Continued record review revealed a Nurse's Note dated [DATE] timed 8:40 AM, documented by RN #1, which noted SRNA #1 told her Resident #1 didn't "look too good", and when she arrived in the resident's room she shook him/her with no response. Per the Note, RN #1 noted Resident #1 had no respirations and she checked for a pulse with none found. RN #1 documented she called for "assist" from another nurse on a different unit, and when the other nurse arrived CPR was initiated. Review of RN #1's Nurse's Notes revealed at 9:10 AM, EMS arrived, placed Resident #1 on a backboard and put Automated External Defibrillator (AED) pads on the resident with no pulse obtained, and CPR was continued. However, continued review of RN #1's documentation revealed no documented evidence all details of the code were noted to include: overhead paging a "Code Blue", calling 911, contacting the Physician, noting what staff was present, and who was performing the respirations and doing the chest compressions, as per the facility's policy. Attempts to interview RN #1 were made on [DATE] at 1:05 PM, 2:00 PM, 4:30 PM and 5:15 PM, and on [DATE] at 10:10 AM; however, were unsuccessful. Continued review of the Nurse's Note revealed a Note dated [DATE] at 9:00 AM, documented by LPN #1/Supervisor which revealed she was "overhead paged" and called the nurse's station on the unit where Resident #1 resided. Per the Note, when she called she was informed Resident #1 was "dead". The Note revealed LPN #1/Supervisor went to the resident's room and CPR was initiated. Further review of the Nurse's Notes revealed at 9:05 AM, LPN #1/Supervisor noted 911 was called and CPR continued until EMS arrived. Review of the Nurse's Notes revealed at 9:15 AM, LPN #1/Supervisor documented EMS personnel arrived and took over CPR. However, further review of LPN #1/Supervisor's documentation revealed no documented evidence all details of the code were noted to include: overhead paging a "Code Blue", contacting the Physician, noting what staff was present, and who was performing the respirations and who was doing the chest compressions, as per the facility's policy. Interview with RN #2 on [DATE] at 12:25 AM and [DATE] at 11:30 AM, revealed she assisted in the code for Resident #1 after the resident was found unresponsive. However, record review revealed no documented evidence RN #2 had noted her participation in the code. Continued interview with RN #2 revealed LPN #2/MDS Nurse had documented the code in Resident #1's medical record. Further record review revealed on [DATE], a Nurse's Note timed 8:45 AM which revealed Resident #1 was unresponsive with no pulse by nursing, and CPR was initiated by RN #1 and RN #2 which continued until "911 arrived at 9:15" AM. However, interviews with staff revealed CPR was initiated for Resident #1, approximately 9:05 AM to 9:10 AM. Continued review of the 8:45 AM Nurse's Note on [DATE] revealed no documented evidence of a nurse's signature, or of all details of the code noted to include the time CPR was initiated, who provided chest compressions and ventilations, and Physician notification. Review of a Nurse's Note timed 9:30 AM revealed "called report" to the hospital; however, there was no documented evidence of the nurse's signature. Additionally, review of a Nurse's Note timed 10:20 AM, revealed Resident #1 had "passed" per the hospital, with no documented evidence of the nurse's signature. Interview with the Director of Nursing (DON) on [DATE] at 6:30 PM, revealed she would expect her licensed nurses to perform an assessment of a resident with a change in condition, such as being unresponsive, which would include checking the resident's vital signs, verifying their code status and initiating CPR right away if appropriate. She further stated nurses should ensure their documentation was complete and accurate, as per facility policy. Per interview, codes should be thoroughly and accurately documented; however, for Resident #1's code staff had not "adequately" documented the code. Interview with the facility's Administrator on [DATE] at 3:45 PM and [DATE] at 6:45 PM, revealed his expectations of licensed staff was to ensure documentation was complete, clear, and timely. Per interview, the information for codes should be documented as per the facility's policy. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) interviewed State Registered Nursing Assistant (SRNA) #1, Nursing Supervisor (NS) #1 (LPN #1/Supervisor), RN #1 and RN #2 regarding delay of the Code Blue event involving Resident #1. RN #1 and RN #2 were suspended on [DATE] pending the facility's investigation. 2. On [DATE], an initial report of the delayed Code Blue event was sent to the State Agency by the Administrator and the DON. 3. On [DATE], the DON notified Resident #1's family of the delay in initiating a Code Blue by RN #1. 4. On [DATE], the Staff Development Coordinator (SDC) initiated in-services with licensed nurses regarding immediate implementation of the facility's Code Blue Protocol for residents who had Advance Directives which indicated a Full Code status. Immediate training included face-to-face in-services with licensed staff on duty, and instruction by telephone for other licensed staff. On [DATE], the training was extended to include SRNA's and Kentucky Medication Aides (KMAs), and 100% of the nursing staff received the education. Training points included the immediate initiation of CPR, based on the physician's orders [REDACTED]. Utilized for the training was the facility's Code Blue Protocol. 5. On [DATE], the DON revised the facility's policy and procedure related to code status to include a requirement for adding each resident's code status to the care plan. 6. On [DATE], the DON developed a new system of quarterly care plan meetings with the resident and/or their Responsible Party (RP), the Social Worker, the unit nurse and the MDS nurse, to determine if any change in code status is desired by the resident. 7. On [DATE], the DON developed a Code Blue Information form to be attached to the incident report for all Code Blue events. Both forms are turned in to the DON for further investigation. The DON will submit results of all investigations to the monthly QA meetings. In addition, the DON developed a reference book for Code Blue events, and placed a book on each crash cart. 8. On [DATE], the Administrator notified the Ombudsman of the delay in initiating a Code Blue for Resident #1. The Administrator explained the corrective actions taken by the facility, and invited the Ombudsman to participate in the investigation process. 9. On [DATE], a Quality Assurance (QA) meeting was held by telephone conference. Participants included the Administrator, the DON, and the Medical Director, who was also the Attending Physician for Resident #1. The purpose of the meeting was to notify the Medical Director of the delay in providing CPR for Resident #1, and to discuss corrective actions. 10. On [DATE], an Ad Hoc QA meeting was held to establish corrective actions and monitoring to ensure future compliance related to the following: Code Blue response; residents' rights; and the facility's Abuse Policy. Attendees included the Administrator, DON, Medical Director, QA Nurse, RDCS, Regional Director of Operations (RDO), Unit Managers (UMs), and the SDC. The committee reviewed and authorized revision of the facility's current policy related to code status to include code status in each resident's Comprehensive Care Plan. In addition, the committee developed a checklist of items to be completed to ensure no other resident had the possibility of being affected by the deficient practice. Furthermore, the committee assigned individual members of the interdisciplinary team to carry out specific tasks stated on the check list, as well as, actions to ensure ongoing compliance. The committee determined the root cause of the delay in provision of CPR for Resident #1 was due to RN #1's failure to follow the facility's policy and procedure related to code status. Also, on [DATE], the regular monthly QA meeting was held and attended by the Administrator, DON, Medical Director, Social Services Director (SSD), QA Officer, Nursing Supervisor, Activities Director (AD), Director of Rehabilitation, Consultant Dietician, and the Dietary Manager Assistant. Participants confirmed the Ad Hoc meeting determination of the root cause and further discussed the facility's plan of action going forward. 11. On [DATE], the Medical Records Coordinator and the QA Nurse audited 100% of the 128 residents' charts to verify each resident's code status was correctly identified, and to ensure Physician Orders, Comprehensive Care Plans, and SRNA Care Plans were consistent for either Full Code or DNR status. Each resident's chart holds an identifying sticker on the outside spine to communicate the code status: a white sticker indicates a Full Code status, and a red sticker indicates DNR status. The Medical Records Coordinator updated each resident's Care Plan to reflect individual code status to be either Full Code or DNR. The QA Nurse and the Medical Records Coordinator will continue the audits daily Monday through Friday, and the House Supervisor will perform the audits on the weekends, until the IJ is removed. Audit results will be submitted daily for review by the DON, who will forward the data to the monthly QA meetings for interdisciplinary review. 12. On [DATE], the Central Supply clerk audited the facility's six (6) crash carts, utilized for managing a Code Blue event, for the presence of adequate supplies, and to ensure no expired items were located on the carts. The crash carts will be checked daily, Monday through Friday by the Central Supply Clerk, and by the House Supervisor on weekends, until the IJ is removed. The audits will utilize the Crash Cart check List Form, and all results will be submitted to the Administrator and the DON for their review. Subsequently, audit results will be presented at the monthly QA meeting, where any changes to the frequency of audits, or recommendations for further interventions, will be made. 13. Beginning [DATE], the Payroll/Human Resources (HR) Coordinator initiated a review of employee files for all nursing staff, to ensure current Cardiopulmonary Resuscitation (CPR) certificates, active nursing licenses and SRNA certifications, and the completion of background checks. The audit was completed on [DATE]. 14. On [DATE], the Medical Records Coordinator and the RDCS audited fifty (50) residents who expired at the facility during RN #1's employment between [DATE] and [DATE], to determine if RN #1 had been involved in any other Code Blue events. They found of the fifty (50) deaths, twenty-one (21) occurred while RN #1 was on duty; however, all residents except Resident #1 were a DNR status at the time of death. 15. On [DATE], while still on suspension, RN #1 called the facility and voluntarily resigned her position of employment with the facility. 16. On [DATE], the Administrator and the DON informed the Medical Director of the specific IJ citations, and discussed the facility's plan for correction of the deficient practice. 17. On [DATE], the Administrator and the DON in-serviced the facility's two (2) SSD's, the MDS Nurses and the Medical Records Coordinator related to the facility's new policy and procedure regarding Advance Directives, which includes the following actions: Social Services will review each resident's Advance Directives upon admission to the facility, including their wishes regarding code status, obtain a physician's orders [REDACTED]. Directives during the regularly scheduled Care Plan meetings. 18. On [DATE] through [DATE], all staff from every department, including Nursing, Dietary, Maintenance, Social Services, Activities, and Housekeeping, was in-serviced by the DON, SSD, SDC, QA Officer, and the Nursing Supervisor related to Advance Directives and Residents' Rights. Each staff member was required to complete a post-test with 100% accuracy on the subject matter. Immediate re-education was provided for any incorrect answers. 19. Between [DATE] and [DATE], all nursing staff, including nurses, KMAs and SRNA's were educated by the DON, SSD, SDC, QA Officer and the Nursing Supervisor on the following: differentiation between DNR and Full Code status; how to identify a resident's code status; how to call for and initiate a Code Blue; who should respond to a Code Blue immediately; where to locate the crash cart; contacting the Physician and calling 911; continuation of the code until EMS arrival; notification of the DON and Administrator; and documentation of all details of the code in the medical record. In addition, the training included how to manage the resident who had a DNR status, including an assessment for vital signs at five (5) minute intervals, pronouncement of death, notification of the Physician, the family and/or POA, and the DON and Administrator, and documentation in the medical record. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 20. Between [DATE] and [DATE], all nurses, KMA and SRNA's were in-serviced regarding the requirement for inclusion of the resident's Advance Directives and code status on the Comprehensive Care Plan. The training was provided by the DON, SDC and Nursing Supervisor. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. Two (2) staff members were on leave and did not receive the education. They will not be added to the schedule until they are in-serviced and able to complete the post-test accurately to ensure their competency. 21. As of [DATE], fifty-six (56) of one hundred and twenty-eight (128) residents had an Advance Directive for Full Code status. 22. On [DATE], the DON updated the new hire orientation outline to include training and post-tests related to professional nursing standards, identifying code status, Comprehensive Care Plans, Advance Directives, Residents' Rights, Code Blue Information sheet, Code Blue Nurses' Note guide, and the facility's Code Blue Protocol. In addition, orientation packets were developed for agency staff to educate on the same topics. All agency staff will be expected to complete the post-tests with 100% accuracy prior to providing direct care. 23. Between [DATE] and [DATE], all nurses, KMAs and SRNA's were in-serviced by the DON, SDC and the Nursing Supervisor related to professional nursing standards. Training references included the Lippincott Manual of Nursing Practice as it pertained to the provision of CPR, documentation, ensuring a physician's orders [REDACTED]. All participants were required to complete a post-test related to the training with 100% accuracy, with immediate re-education provided for any incorrect answers. 24. On [DATE], the facility conducted a mock Code Blue drill to assess staff knowledge retention after training related to initiating a Code Blue event immediately, and evaluated response time, accuracy in determining the code status of the mock resident, and adherence to the facility's policy and procedure. A mock Code Blue drill will be conducted quarterly by the SDC, QA nurse or the DON, and will cover all shifts on weekdays and weekends. Results of the drills will be brought by the Administrator or the DON to the facility QA meetings for interdisciplinary review. Any staff members identified to not follow facility policy and procedures will be re-educated, and a competency test will be administered until the staff member is able to display a thorough and accurate understanding of the policy and procedure. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed SRNA #1, Nursing Supervisor #1 (LPN #1/Supervisor), RN #1 and RN #2 were interviewed related to the Code Blue event involving Resident #1. Continued review of the investigation revealed RN #1 and RN #2 were suspended on [DATE], pending the investigation results. Interview, on [DATE] at 6:00 PM, with the DON revealed RN #1 called the facility on [DATE], and stated she was quitting and would not be returning to work, and hung up. 2. The State Survey Agency received the initial report regarding the delayed Code Blue event involving Resident #1 on [DATE]. 3. Review of the facility's investigation documentation of the incident revealed the DON notified Resident #1's family of RN #1's delay in initiating a Code Blue. Phone contact was attempted with Resident #1's RP/family which was unsuccessful and a message was left. However, no return call was received. 4. Review of the facility's in-service sign-in form dated [DATE] and [DATE], revealed 100% of nursing staff did receive training on the facility's Code Blue Protocol, which included education on immediate initiation of CPR, based on physician's orders [REDACTED]. Interviews on [DATE]: at 1:55 PM with LPN #1; at 4:15 PM, with LPN #2; at 3:20 PM, with LPN #8; and at 4:50 PM with RN #4 revealed they were inserviced on the facility's Code Blue procedures, how to identify a resident's code status, when to initiate CPR, and the code process. Interviews on [DATE]: at 3:49 PM, with SRNA #13, at 4:35 PM with SRNA #6; and at 4:58 PM with SRNA #12 revealed they were inserviced on the facility's Code Blue process, how to identify a resident's code status, call a Code Blue, take crash cart to room and wait for further directions. 5. Review of the facility's document titled, "Medical Emergency Code Reference", not dated, revealed the DON had revised the facility's policy and procedure to include the requirement for adding each resident's code status to the care plan. Interviews on [DATE] at 5:20 PM, with Social Services (SS) #13, and at 5:30 PM, with SS #2, revealed they were in-serviced related to SS responsibility for implementing an interim Advance Directive care plan to include the code status for all new residents upon admission and/or readmission. Interview on [DATE] at 4:50 PM, with the RN #4/MDS Coordinator revealed the MDS nurses were in-serviced related to MDS' responsibility to audit the interim care plan within 72 hours of every resident's admission, and/or readmission, and to assure Advance Directives with code status were present. 6. Interview, on [DATE] at 6:30 PM, with the DON revealed she developed a new system for Quarterly Care Plan meetings to discuss with residents and their RP if a change in code status is desired by the resident. Review of the facility's policy titled, "Care Plans" with a revised date of [DATE], revealed the Care Plan Team would review with the resident any existing/current Advance Directives to determine if a change in code status was desired by the resident at the Quarterly Care Plan meetings. Interviews, on [DATE] at 4:00 PM, with SS #2 and at 4:30 PM with SS #13, revealed Advance Directives including the code status was discussed with each resident at every care plan meeting now. Interview, on [DATE] at 4:50 PM, with RN #4/MDS Coordinator, revealed the care plan team did discuss Advance Directives including the code status with the resident or RP at each care plan meeting now. 7. Interview, on [DATE] at 6:30 PM, with the DON revealed she had developed a Code Blue Information form which was to be attached to Incident Reports for all Code Blue events that were to be turned in to her. The DON revealed she had also developed a reference book for all Code Blue events which were placed with each crash cart. Per the DON, she will submit all investigations to the facility's monthly QA meeting. Observation on [DATE] from 3:00 PM through 3:20 PM of each crash cart in the facility revealed a reference book for Code Blue events which included the Code Blue documentation form. Review of the facility's Code Blue reference book revealed a form titled, "Code Blue Documentation", dated [DATE], which was revised [DATE]. 8. On [DATE] at 2:00 PM a call was placed to the Ombudsman with no answer, a message left to return a call. The Ombudsman returned the call and revealed the Administrator did notify her of the delay in initiating a Code Blue for Resident #1, and explained the corrective actions taken by the facility and invited her to participate. Interview with the Administrator on [DATE] at 6:15 PM, revealed he had called the Ombudsman on [DATE] as per the AOC. 9. Interview with the Administrator on [DATE] at 6:15 PM, confirmed the facility's Medical Director was contacted by phone for the QA meeting on [DATE], to notify him of the delay in providing CPR and to discuss a plan of action. Interview, on [DATE] at 3:00 PM, with the facility's Medical Director and Resident #1's attending Physician revealed the Administrator, the DON and the RDCS had called on [DATE], to discuss the events which occurred with Resident #1's code on [DATE]. He stated "we" did put plans into action, and he felt the facility had a very active QA program. The Medical Director revealed the facility had a meeting monthly and he "rarely" missed a meeting. 10. Review of the facility's Ad hoc QA meeting sign-in sheet revealed the attendees included the Medical Director, Administrator, DON, QA Nurse, RDCS, RDO, UMs and SDC. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed during the QA meeting assignments were made and MR was assigned duties related to the Advance Directives regarding completing a daily audit. Per interview, the audit was for identification/verification of all residents' code status, by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the residents' charts, and inside the front cover of the charts matched the Physician Order. Further interview revealed this was reviewed by the DON/Administrator daily. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed on [DATE], a QA meeting was held with the Medical Director, Administrator, DON, Nursing Supervisor, SS, Dietary, Activities Director, Director of Rehabilitation and QA in attendance. Per interview, the QA attendees reviewed and authorized revision of the facility's current code status policy to include each resident's code status on the care plan. The QA Nurse revealed members were assigned specific tasks on the check list which they developed to ensure ongoing compliance. Further interview revealed the QA attendees determined the root cause of CPR provision for Resident #1 was due to RN #1's failure to follow the facility's policies and procedures related to code status and discussed an action plan. Interviews, on [DATE] at 4:00 PM, with SS #2, and at 4:30 PM with SS #13, revealed SS was assigned duties related to the new policy and procedure for Advance Directives. Per interview, SS was to obtain consents from the resident or POA, notify the nursing supervisor of the unit the resident was admitted to, and obtain a physician's orders [REDACTED]. Further interview revealed SS will initiate the Advance Directive care plan for residents. Interview on [DATE] at 4:50 PM, with RN #4/MDS Coordinator revealed the MDS nurses were assigned duties related to the new policy and procedure for Advance Directives. Per interview, MDS' duties were to audit the interim care plan within 72 hours of every admission, and/or readmission, to assure Advance Directives with code status were present. 11. Interview, on [DATE] at 3:50 PM, with Medical Records (MR) revealed MR was assigned duties related to Advance Directives to complete a daily audit for identification/verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, comprehensive care plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Interview, on [DATE] at 5:25 PM, with the QA Nurse revealed MR and herself completed the daily audit Monday through Friday for identification and verification of all residents' code status by ensuring the code status on the residents' door name plate, SRNA care plan, Comprehensive Care Plan, spine of the chart, and inside the front cover of the chart matched the physician's orders [REDACTED]. Per interview, the audits would continue until the Immediate Jeopardy (IJ) was abated. Review of the audits performed by MR and the QA Nurse confirmed completion of the tasks as assigned per the AOC. Interview on [DATE] at 6:30 PM, with the DON revealed the code status audits were turned in daily for her review. 12. Review of the Central Supply Clerk's (CSC) audit forms (Crash Cart Check List form) revealed the six (6) crash carts was audited daily for expired items and the presence of adequate supplies, with no issues identified beginning [DATE]. Interview, on [DATE] at 8:55 AM, with the CSC revealed he checked the six (6) crash carts daily Monday through Friday, and the House Supervisor checked them on the weekends for expired items and to ensure they were locked. Per interview, while doing the audit if an item was used from a crash cart the item was replaced and a new breakaway lock would be applied to the cart. The CSC revealed audits continued to be performed. Interview on [DATE] at 6:30 PM, with the DON revealed the audit results were reviewed and would be taken to the facility's monthly QA meeting. 13. Review of seven (7) employee files on [DATE], revealed the employee files were complete with current CPR cards, active nursing licenses and SRNA certifications, and background checks. Interview on [DATE] at 6:30 PM, with the DON revealed the employee file audits were completed as per the AOC on [DATE]. 14. Review of the audit completed on [DATE], revealed fifty (50) residents who had expired in the facility between [DATE] and [DATE], medical records were audited. Of the fifty (50) deaths, twenty-one (21) were identified to have occurred during the time frame. Interview with MR on [DATE] at 3:50 PM, revealed the audits were completed of residents who had expired from [DATE] to [DATE], the timeframe during which RN #1 was employed. Per interview, twenty-one (21) of the fifty (50) deaths occurred when RN #1 was on duty; however, only Resident #1 had been a Full Code, with the rest having a DNR status. 15. Interview, on [DATE] at 5:55 PM, with the DON revealed RN #1 had called the facility on [DATE], and said she quit and would not be returning to work. 16. Interview, on [DATE] at 3:00 PM, with the facility's Medical Director revealed the Administrator and DON had informed him of the IJ deficiencies and they discussed the facility's plan for correction for the identified deficiencies. 17. Review of the facility's inservice education revealed the two (2) SSD's, MDS Nurses and MR Coordinator were inserviced on [DATE], as per the AOC. Interview, on [DATE] at 3:50 PM, with MR Coordinator revealed she had received education related to the new policy and procedure for Advance Directives. Per interview, her assigned duties related to the Advance Directives were to complete a daily audit for identification/verification of all residents' code status by ensuring the code status on the residents' door name plate, SRN

Based on observation, interview, record review, review of the facility's policy, review of video surveillance, and review of the facility's credible Allegation of Compliance (AOC), it was determined the facility failed to ensure residents assessed as at risk for wandering and/or exit seeking behaviors received adequate supervision for two (2) of twenty-one (21) sampled residents, (Resident #5 and Resident #1). The facility failed to maintain a safe environment for sixteen (16) residents assessed as at risk for wandering/elopement. The facility failed to ensure the policies were effectively implemented to protect residents identified as "at risk" for wandering. The facility failed to ensure staff identified if a resident exited the building, in response to an alarm alert which signaled when a facility entrance/exit door had been opened. On 06/23/11, upon admission, the facility assessed Resident #5, as "at risk" for wandering. On 07/28/11, Resident #5 successfully exited the facility without staff knowledge, when a visitor held open the back door and allowed the resident to exit. The visitor entered a code on the door keypad and pushed a button to silence the door alarm. The facility failed to verify who had exited the building in response to the audible door alarm which resulted in the facility being unaware that Resident #5 had exited the building without supervision. On 08/16/11, the facility assessed Resident #1 as "at risk" for wandering. On 10/19/11, Resident #1 exited the facility without staff knowledge, through the Ambulance Exit Door after a visitor entered a code on the door keypad and opened the door. An alarm sounded to alert staff the door had been opened; however, an employee silenced the alarm without checking to ensure a resident had not exited the building. The facility' investigation failed to identify all causal factor which prevented the facility from developing effective intervention to prevent recurrence of elopement for both incidents. The facility's failure to provide adequate supervision, a secure environment, and an effective procedure to ensure resident safety when door alarms sounded placed Resident #1, Resident #5 and other residents at risk for wandering in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The facility provided an acceptable credible Allegation of Compliance (AOC) for the removal of Immediate Jeopardy on 10/22/11 alleging the removal on 10/21/11. The state agency verified Immediate Jeopardy was removed on 10/21/11 prior to exit on 10/22/11, with remaining non-compliance at 42 CFR 483.25 Quality of Care (F323) and 42 CFR 483.75 (F490) at S/S of an "E" while the facility's Quality Assurance continues to monitor for compliance of the facility door policy, "ENTRY/EXIT CODE ALARMS", which was revised 10/20/11. The findings include: Review of the facility policy, "Wanderer Protocol", undated, revealed an alarm panel at the nurses station alerts staff of persons entering/exiting the doors. Interview, on 10/14/11 at 12:15 PM, with the Social Service Director (SSD) and Assistant Director of Nursing (ADON) validated this was the current policy in effect. 1. Record review revealed the facility admitted Resident #5 on 06/23/11 with [DIAGNOSES REDACTED]. Review of Resident #5's "Wandering Risk Assessment", completed 06/23/11 identified the resident as "high risk" for wandering. Record review of the Social Service Notes, dated 06/23/11, revealed Resident #5 was added to the facility Wanderer List at that time. Review of Resident #5's Comprehensive Care Plan, dated 06/24/11, revealed the facility identified Resident #5 as having wandering behaviors which required staff redirection. Review of the Admission Minimum Data Set (MDS) Assessment, dated 06/30/11, revealed the facility assessed Resident #5 as being severely cognitively impaired with a score of six (6) out of fifteen (15) when the Brief Interview for Mental Status (BIMS) was conducted. Review of the Nurse's Notes, dated 07/18/11, revealed MDS Registered Nurse (RN) #11 documented that Resident #5 "followed a visitor out the front entrance. (He/she) was standing outside of door when this nurse (MDS RN #11) saw him". Interview with MDS RN #11, on 10/14/11 at 12:10 PM, revealed she was in the front lobby to check her mailbox when she noticed Resident #5 go out the front door, which was open for a delivery person who was exiting the building. She further stated the resident "wasn't coming back in by himself/herself right away" she entered the code to open the door and went outside to retrieve the resident. She stated she escorted Resident #5 back into the facility and reported the incident to the nurses on the unit where the resident resided. Review of Resident #5's care plan, dated 07/18/11, revealed the resident was "outside after following a visitor out door. RN brought me (Resident #5) back in". Record review of SSD Notes, dated 07/21/11, revealed Resident #5 "was at the back door today, looking at employee schedule. SSD was able to redirect resident to sunroom for activities. Administration and nurse on unit aware of situation". Further review of the SSD Notes documented Resident #5 was still "at risk" for wandering. Review of SSD Notes, dated 07/29/11, revealed Resident #5 was "looking around in back lobby by the exit doors" on 07/28/11 when "visitors were coming in the facility and assisted the resident outside the facility". Review of the facility's incident investigation, dated 07/29/11, revealed the facility reviewed the video recorded from security cameras which showed Resident #5 exited the facility when a visitor entered the keycode to enter the facility at the employee/back exit door, let him/her out, gave him/her a cigarette, lit the cigarette, entered the facility and silenced the alarm. Further review revealed Resident #5 stood by the exit, smoked the cigarette, then attempted to re-enter the building. The exit door was locked, therefore Resident #5 left the area and attempted to enter through another door. Resident #5 began knocking on the other door (designated as emergency exit only) when staff became aware the resident was outside. Staff went out the employee/back exit, and escorted the resident back into the facility. The facility was unable to provide evidence that staff supervised Resident #5 in order to prevent his/her exiting the building unsupervised. No staff was knowledgeable the resident had exited the building on 07/28/11 and there was no evidence staff redirected the resident away from the back doors on that date. In addition, there was no evidence facility staff visually checked who exited the building in response to an audible door alarm signaling the back door had been opened because a visitor had silenced the alarm. Interview with the Administrator and Director of Nursing (DON), on 10/18/11 at 11:15 AM, revealed the facility determined the causal factor of Resident #5 leaving the facility on 07/28/11 was that visitors did not recognize Resident #5 as a resident of the facility. She further stated interventions were resident centered such as a name tag designed similar to military "dog tags" which Resident #5 would be more likely to wear since the resident was noted to be a Veteran. The Administrator stated the facility did not make system changes because the system worked. However, interview, on 10/18/11 at 3:10 PM, with the Social Service Director (SSD) revealed the facility conducted an inservice on 07/29/11 to include staff members should be able to identify every wandering risk resident in the facility located in the Wandering Books located at the nurses stations and staff should check the door when the alarm went off. Interview further revealed on 07/30/11, distribution of the Wandering Book expanded to include non-nursing departments of dietary, laundry and rehabilitation. 2. Record review revealed the facility admitted Resident #1 on 08/15/11 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, dated 08/16/11, revealed the resident was identified as a "potential wanderer who looked like a visitor and was unsure how to get out of the facility but would find a way". The plan of care detailed staff was "to provide the resident a safe and comfortable environment" as the corresponding goal. The Care Plan noted Resident #1 was listed in the facility Wandering Book; however, the Care Plan did not document any interventions related to the resident's supervision needs or staff providing supervision. Review of Resident #1's "Wandering Risk Assessment", completed on 08/16/11, 09/1/11, and 09/12/11, revealed the facility assessed and identified the resident as "high risk" for wandering. Review of Social Progress Notes, dated 09/12/11, revealed the resident had moderate cognitive impairment. Review of the Nurse's Notes, dated 10/09/11 at 3:30 PM, stated Resident #1 "was found wandering down driveway on side of nursing home by SRNA (State Registered Nurse Aide) who was going home after his shift". Interview with the facility's Corporate President, on 10/13/11 at 10:00 AM, revealed security cameras had captured Resident #1's elopement from the facility on 10/09/11. Review of the video, on 10/13/11 at 10:15 AM, revealed Resident #1 exited the facility when a visitor entered an access code on the keypad at the "A station Ambulance Entrance" door. The timeline on the surveillance video revealed the resident was standing at the door, utilizing a walker (assistive device), for three (3) minutes prior to the visitor opening the door. The visitor opened the door and stepped to the side, holding the door open for Resident #1 to exit. Resident #1 walked out the door with the walker. The resident traveled about sixty (60) feet in thirty-two (32) seconds at which time an employee (SRNA #4) had exited the building. Interview with SRNA #4, on 10/13/11 at 4:10 PM, revealed at the completion of his shift on 10/09/11, he exited the building and noticed a man/woman on the driveway who had an unsteady gait, utilizing a walker making his/her way toward the main road. Continued interview revealed he thought maybe the person was a resident so he utilized his cellular phone and called the facility for assistance as he tried to catch up to the resident without startling him/her. Continued interview revealed SRNA #4 asked the resident if he/she lived around here and received an inappropriate response. The resident also stated he/she needed to find his/her daughter and refused to go inside. Facility staff responded to SRNA #4's call for assistance and escorted Resident #1 back inside the facility. Images reviewed from the surveillance cameras, on 10/19/11, further revealed the visitor was in the process of silencing the alarm at the keypad when the alarm was silenced at the nurse's station by an employee. Interview with the Administrator, on 10/19/11 at 1:00 PM, revealed an employee pushed the silence alarm and did not go to the door to see who exited the facility. She further stated the employee had been in-serviced on 07/29/11 after Resident #5 walked outside the facility as visitors entered the facility. Continued interview with the Administrator revealed the the facility staff on duty, on 10/09/11, failed to follow the facility's procedure because the staff silenced the alarm at the nurses station without checking the door when the alarm sounded. In addition, the Administrator stated the employee was in error. Interview further revealed the facility completed an investigation and identified the causal factor of the incident being the visitor failed to recognized Resident #1 was a resident. Review of the facility's investigation revealed the facility determined Resident #1 was on the wandering list, the doors were alarming properly, and the correct signage was in place; however, the investigation did not identify lack of supervision for a wandering resident as a causal factor. Review of the "corrective action" in the facility's investigation revealed no evidence the facility had addressed supervision for Resident #1 or the supervision for all residents the facility had identified as being at risk for wandering. Review of the facility "Wander List", at the time of the incident, revealed the facility identified sixteen (16) residents as "at risk" for wandering. An acceptable AOC was received on 10/22/11 alleging the Immediate Jeopardy was removed on 10/21/11. Review of the AOC revealed the facility implemented the following to remove the Immediate Jeopardy: 1. Facility designated the doors located in the back of the facility would be utilized by staff and employees for entry/exit twenty-four (24) hours a day, seven (7) days a week. In addition, the front door would also provide accessibility Monday through Friday, 8:00 AM until 5:00 PM. 2. On 10/14/11 signage on the doors was changed to state " 'STOP' ATTENTION ALL VISITORS & FAMILIES. IF YOU SEE ANY RESIDENTS STANDING NEAR THIS EXIT DOOR, DO NOT LET THEM OUT! CALL FOR A STAFF MEMBER TO HELP ENSURE THE RESIDENT DOES NOT LEAVE THE FACILITY. THANK YOU FOR YOUR COOPERATION". On 10/20/11 additional signage which stated "NO ENTRANCE by visitors or staff.." was posted to the A-station Ambulance Door, C/D Ambulance Door and Dietary Door (doors that exit in the dietary delivery area), and the C-station Door. 3. All facility doors remain alarmed but the silencing button located on the keypad/box beside the entrance/exit doors has been removed. Anyone entering or exiting the building will trigger an audible door alarm, which can only be silenced from the nursing station reset box. Verification a resident did not exit the building is required before the alarm is disarmed, therefore the alarm will sound until a staff member visually confirms no residents have exited the doors. 4. Staff inservices were conducted 10/20/11. Information included the silencing button located on the keypad/box near the doors has been removed. The door alarm will sound when a entrance/exit door to the facility is opened. The alarm will continue to sound until a staff member visually confirms no residents have exited the door. All staff members were in-serviced and directed to respond to the door alarm. A telephone in-service was conducted with employees not scheduled to work 10/20/11. Contract personnel was also in-serviced. Employees on leave or those employees the facility was unable to contact will be in-serviced prior to their return to work. Newly hired employees will be in-serviced during orientation. 5. Quality Assurance (QA) Monitoring by the Administrator, Director of Nursing and QA Nurse will be conducted every shift for one week starting 10/21/11 to ensure facility staff are compliant. If the monitoring is without incident the quality assurance checks will be weekly for four weeks then monthly thereafter for six months. The audit tool is specific to the sequence/response to (a) utilization of door code, (b) alarm sounded, (c) staff visually checked door, and (d) staff silenced door for the following locations - back door, front door, A-station ambulance door, and C/D station Ambulance door. 6. The facility Medical Director was involved daily with the development of policy and procedure changes in the facility. The following measures were validated as completed prior to exit on 10/22/11: 1. Observation on 10/21/11 revealed the doors at the back of the facility were locked. A buzzer/door bell located outside the facility could be pressed to notify staff someone requested entry or an access code required keypad could be utilized. Observations, on 10/21/11 and 10/22/11, revealed visitors and staff utilizing the back doors for entrance and exit. When the doors opened an alarm sounded. Continued observation revealed staff silenced the alarm at D-nurses station after visual confirmation a resident did not exit the building when the back door opened. Observations on, 10/21/11 at 9:15 AM, revealed staff sitting at the reception desk in the lobby area to monitor and disarm the alarm when the front entrance/exit door was utilized. Interviews with staff revealed the front door could only be utilized Monday through Friday from 8:00 AM until 5:00 PM. 2. Observations 10/14/11 verified the signage, " 'STOP' ATTENTION ALL VISITORS..." was in place on the facility entrance/exit doors. Interview with the Company President, on 10/14/11 at 5:00 PM, revealed the access code had been changed to provide the opportunity to inform visitors the back doors were now designated to use for entrance/exit into the facility. Interviews with the ADON on 10/15/11 at 7:00 PM, Registered Nurse (RN) #13 on 10/15/11 at 12:05 AM, and Licensed Practical Nurse (LPN) #14 on 10/16/11 at 6:05 AM revealed only the back doors were utilized for facility entry/exit. Observation on 10/22/11 confirmed signage " 'STOP'...no staff or visitors to enter...use back entrance" was posted on A-station Ambulance Door and C/D ambulance Door. Observations on 10/22/11 revealed signage dated 10/14/11 which stated "EMERGENCY PERSONNEL ONLY, NO exceptions-unless emergency. This is a temporary change for entering and exiting the building in order to maintain a secure environment for the residents who live here". Interview with the Administrator, on 10/22/11 at 7:10 PM, revealed signage will be amended regarding "temporary change". Further interview revealed she had notified the appropriate first responders, including the non-emergency ambulance services, of the facility's policy changes related to Entry/Exit doors. The ambulance doors remained available for use by emergency personnel; however, a new code was required to gain access. 3. On 10/21/11 observations revealed staff monitored the back doors and observed no residents exited the building prior to hitting the alarm reset button. Observations on 10/22/11 validated the removal of the "silencing button" and confirmed staff was verifying no resident exited the building prior to silencing the alarm. Observation, on 10/22/11 at 5:08 PM, revealed a visitor attempted to utilize the A-station Ambulance Door which triggered an audible alarm. Staff responded immediately, confirmed a resident had not exited the building before the alarm was silenced and informed the visitor of the changes in procedures regarding facility Entry/Exit. 4. The training was validated through review of sign-in sheets and staff interviews. Telephone inservices were noted on sign in-sheets by facility staff. Staff knowledge of the inservice information including the Wander Protocol and Exit Door Policy was validated during interviews conducted with six (6) employees from ancillary departments including 10/20/11 at 10:30 AM with the Activities Director; on 10/21/11 at 10:15 AM with Housekeeper #21; on 10/22/11 at 3:30 PM with Dietary Relief Cook #22; on 10/22/11 at 3:31 PM with Dietary Aide #23; on 10/22/11 at 3:40 PM with Laundry Worker #24; on 10/22/11 at 3:38 PM with the Dietary Manager; and Housekeeper #25 on 10/22/11 at 4:00 PM. In addition interviews were conducted to validate staff knowledge with the following nursing staff members: on 10/21/11, SRNA #5 at 10:55 AM, SRNA #6 at 11:15 AM, LPN #20 at 11:50 AM, SRNA #14 at 12:15 PM, and LPN #5 at 7:00 PM; on 10/22/11, SRNA #17 at 4:08 PM, SRNA #15 at 4:15 PM, RN #1 at 4:30 PM, and LPN #11 at 4:45 PM. In addition, telephone interviews were conducted on 10/22/11 with SRNA #18 at 6:00 PM, Kentucky Medication Aide (KMA) #1 at 6:30 PM, and LPN #16 at 7:30 PM to verify awareness of the content of the information from the in-service on 10/20/11. Interviews, on 10/22/11, with SRNA #16 at 7:00 PM and SRNA #19 at 7:05 PM, confirmed the facility contacted them by phone to conduct the in-service since they were not scheduled to work on 10/20/11. Interview with the Administrator, on 10/22/11 at 6:45 PM, revealed QA and Staff Development (SD) divided the employee roster to validate all employees were inserviced and identify any remaining employees that were unable to be contacted including any employees on scheduled leave of absence. She stated QA and SD would coordinate with Department Managers to ensure employees were in-serviced before they returned to work. Continued interview revealed Contracted Service employees were included in the in-services conducted 10/20/11 and all "new hires" would receive the information during orientation. 5. Interview with the Administrator, on 10/22/11 at 7:25 PM, revealed QA audits were started during day shift of 10/21/11. In addition to utilizing the audit tool, Administrative Staff made observations throughout the day to confirm staff visually monitored the facility entrance/exit doors. She further stated she assisted with the evening shift audit on 10/21/11. Observation, on 10/22/11 at 7:00 PM, revealed the Nursing House Supervisor at A-station Ambulance Door utilized the developed audit tool to conduct a Quality Assurance check. Interview with the administrator, on 10/22/11, revealed the door alarm policy and compliance will also be shared in the "Morning Meetings" with management staff and the Safety Meeting held monthly. 6. Interview with the Administrator, on 10/22/11 at 7:25 PM, revealed the Medical Director had been actively involved regarding the policy and procedure changes related to residents at risk for wandering and accessibility of exit doors. Further interview revealed communication included input from the Medical Director regarding alternative interventions that were explored such as wanderguard type alert system. Record review of the Monthly QA Meeting "Sign-In Sheet", dated 10/18/11, revealed the signature of the Medical Director. Immediate Jeopardy was verified removed on 10/21/11 prior to exit on 10/22/11 with remaining non-compliance at 42 CFR 483.25 Quality of Care, scope and severity of an "E" while the facility's Quality Assurance monitors the effectiveness of observation audits and compliance with the policy changes.

Based on observation, interview, record review, review of the facility's policy, review of video surveillance, and review of the credible Allegation of Compliance (AOC), 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 for residents who had been assessed by the facility as being at risk for wandering and/or exit seeking behaviors regarding adequate supervision to prevent elopement of two (2) of twenty-one (21) sampled residents, (Resident #5 and Resident #1). The facility administration failed to identify that their system to thoroughly investigate incidents, determine causal factors, and implement appropriate action plans in response to a resident exiting the facility without staff knowledge was not effective. The facility administration failed to assure developed and implemented policies and procedures were effective in ensuring safety and supervision regarding residents identified as "at risk" for wandering. The facility failed to ensure staff supervised residents identified as a wandering risk when persons exited the building and silenced the audible door alarm. On 06/23/11, upon admission and again on 07/18/11 and 07/21/11 the facility assessed Resident #5 as "at risk" for wandering. On 07/28/11, Resident #5, successfully exited the facility without staff knowledge when visitors entered the building, held open the door and allowed the resident to exit. The visitor entered an access code to the door keypad and pushed a button located on the keypad box to silence the alarm, triggered when the door was opened. The staff failed to verify who exited the building in response to the audible door alarm and was unaware Resident #5 had exited the building. The facility Administration failed to identify the root cause of the incident and failed to develop and implement appropriate action plans in response to the incident on 07/28/11. These failures resulted in a second elopement occurrence. On 08/16/11 the facility identified Resident #1 as "at risk" for wandering. On 10/09/11, Resident #1 successfully eloped from the facility without staff knowledge after a visitor let the resident out the door and staff silenced the audible door alarm without ensuring a resident requiring supervision had not exited the building. It was determined the facility's failures to identify the root cause of the elopements was due to the lack of supervision of residents with identified wandering risks while doors were unsecured/unsupervised and the failure to revise policies and procedures to ensure their effectiveness in preventing elopement placed identified residents assessed as having wandering risk in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The facility was informed of the Immediate Jeopardy and Substandard Quality of Care on 10/18/11 at F323 at a scope and severity (S/S) of a "K" and F490 at a S/S of a "K". (Refer to F323) The facility provided an acceptable credible Allegation of Compliance (AOC) for the removal of Immediate Jeopardy on 10/22/11 alleging the removal on 10/21/11. The state agency verified Immediate Jeopardy was removed 10/21/11 prior to exit on 10/22/11, with remaining non-compliance at 42 CFR 483.25 Quality of Care (F323) and 42 CFR 483.75 (F490) at scope and severity of "E" while the facility's Quality Assurance continues to monitor for compliance of the facility door policy, " ENTER/EXIT CODE ALARMS", which was revised 10/20/11. The findings include: Refer to F323. Review of the "Wanderer Protocol", undated, revealed an alarm panel at the nurses station alerts staff a facility entrance/exit door had been opened. Interview with the Assistant Director of Nursing (ADON), on 10/14/11 at 12:15 PM, clarified the procedure included staff was required to check the door whenever an alarm sounded. Interview with Social Services Director (SSD), on 10/18/11 at 3:10 PM, revealed facility staff was inserviced on 07/29/11 to clarify the procedure included checking the door when an alarm sounded and staff should be able to identify every wandering risk resident in the facility. Those residents were listed in the Wandering Books located at the nurses stations. On 07/30/11, the distribution of the Wandering Book expanded to include dietary, laundry and rehabilitation departments. Interview with the SSD and ADON, on 10/14/11 at 12:15 PM validated the policy as current. Interview with Staff Development Coordinator, on 10/13/11 at 12:10 PM, revealed in-services regarding the "Wandering Protocol" were conducted with employees after the incident 07/28/11 when unknown to the facility staff, Resident #5 exited the building when the back doors were opened by visitors. She further acknowledged the facility had no formal process to ensure all employees were inserviced or validation of the employees' comprehension of the content. Interview with the Social Services Director, on 10/14/11 at 4:30 PM, revealed the facility saw the incident when Resident #5 exited the facility 07/28/11 as the resident exited with a purpose the smoke. Interview with the Administrator, on 10/18/11 at 3:10 PM, revealed when Resident #5 exited the facility on 07/28/11, the Interdisciplinary Team reviewed the video and determined the incident was not an elopement because Resident #5 was not wandering but exited with a purpose. Interview further revealed the facility staff had not supervised the resident who they had assessed as a wandering risk nor had they identified that staff was not aware of the resident's whereabouts. She further stated the changes made were to Resident #5's care plan but Administration changed nothing related to the facility's systems because Administration did not identify a system problem. Continued interview with the Administrator revealed when Resident #1 eloped from the facility, the facility identified the causal factor of the incident as the visitor not knowing Resident #1 was a resident and stated "you can't control the visitor" and therefore Resident #1 was placed on one to one observation. Interview with the Quality Assurance (QA) Coordinator, on 10/14/11 at 2:45 PM, revealed when a resident exited the facility, the incident was investigated immediately by the charge nurse and/or Nursing House Supervisor and Director of Nursing (DON) and appropriate interventions put into place. Administration, QA, and the Safety Committee further investigate. She further revealed incidents were reviewed daily. Incidents were evaluated to determine the cause as well as make recommendations and suggestions regarding interventions. Incidents and accidents are also tracked as part of QA. However, while the facility utilized this process review of the facility's investigations for Resident #5's elopement on 07/28/11 and Resident #1's elopement on 10/09/11 revealed no evidence the facility had identified the causal factors as being lack of supervision to residents who had been assessed and identified as wander risks. In addition, there was no evidence the investigations determined the causal factor of staff/visitors silencing the audible door alarms without checking the doors to ensure a resident had not exited. An acceptable AOC was received on 10/22/11 alleging the Immediate Jeopardy was removed on 10/21/11. Review of the AOC revealed the facility implemented the following to remove the Immediate Jeopardy: 1. Facility designated the doors located in the back of the facility would be utilized by staff and employees for entry/exit twenty-four (24) hours a day, seven (7) days a week. In addition, the front door would also provide accessibility Monday through Friday, 8:00 AM until 5:00 PM. 2. On 10/14/11 signage was changed to state " 'STOP' ATTENTION ALL VISITORS & FAMILIES. IF YOU SEE ANY RESIDENTS STANDING NEAR THIS EXIT DOOR, DO NOT LET THEM OUT! CALL FOR A STAFF MEMBER TO HELP ENSURE THE RESIDENT DOES NOT LEAVE THE FACILITY. THANK YOU FOR YOUR COOPERATION". On 10/20/11 additional signage which stated "NO ENTRANCE by visitors or staff.."was posted to the A-station Ambulance Door, C/D Ambulance Door and Dietary Door (doors that exit in the dietary delivery area), and the C-station Door. 3. All facility doors remain alarmed but the silencing button located on the keypad/box beside the entrance/exit doors has been removed. Anyone entering or exiting the building will trigger an audible door alarm, which can only be silenced from the nursing station reset box. Verification a resident did not exit the building is required before the alarm is disarmed, therefore the alarm will sound until a staff member visually confirms no residents have exited the doors. 4. Staff inservices were conducted 10/20/11. Information included the silencing button located on the keypad/box near the doors has been removed. The door alarm will sound when a entrance/exit door to the facility is opened. The alarm will continue to sound until a staff member visually confirms no residents have exited the door. All staff members were in-serviced and directed to respond to the door alarm. A telephone in-service was conducted with employees not scheduled to work 10/20/11. Contract personnel was also in-serviced. Employees on leave or those employees the facility was unable to contact will be in-serviced prior to their return to work. Newly hired employees will be in-serviced during orientation. 5. Quality Assurance Monitoring by the Administrator, Director of Nursing and Quality Assurance Nurse will be conducted every shift for one week starting 10/21/11 to ensure facility staff are compliant. If the monitoring is without incident the quality assurance checks will be weekly for four weeks then monthly thereafter for six months. The audit tool is specific to the sequence/response to (a) utilization of door code, (b) alarm sounded, (c) staff visually checked door, and (d) staff silenced door for the following locations - back door, front door, A-station ambulance door, and C/D station Ambulance door. 6. The facility Medical Director was involved daily with the development of policy and procedure changes in the facility. The following measures were validated as completed prior to exit on 10/22/11: 1. Observation on 10/21/11 revealed the doors at the back of the facility were locked. A buzzer/door bell located outside the facility that could be pressed to notify staff someone requested entry or an access code required keypad could be utilized. Observations on 10/21/11 and 10/22/11 revealed visitors and staff utilizing the back doors for entrance and exit. When the doors opened an alarm sounded. Continued observation revealed staff silenced the alarm at D-nurses station after visual confirmation a resident did not exit the building when the back door opened. Observations on Friday 10/21/11 at 9:15 AM, revealed staff sitting at the reception desk in the lobby area to monitor and disarm the alarm when the front entrance/exit door was utilized. Interviews with the Administrator on 10/21/11 at 1:00 PM, revealed the front door could only be utilized Monday through Friday from 8:00 AM until 5:00 PM. 2. Observations 10/14/11 verified the signage, " 'STOP' ATTENTION ALL VISITORS..." was in place on the facility entrance/exit doors. Interview with the Company President on 10/14/11 at 5:00 PM revealed the access code had been changed to provide the opportunity to inform visitors the back doors were now designated to use for entrance/exit into the facility. Interviews with the ADON on 10/15/11 at 7:00 PM, Registered Nurse (RN) #13 on 10/15/11 at 12:05 AM, and Licensed Practical Nurse (LPN) #14 on 10/16/11 at 6:05 AM revealed only the back doors were utilized for facility entry/exit. Observations on 10/22/11 revealed signage dated 10/14/11 which stated "EMERGENCY PERSONNEL ONLY, NO exceptions-unless emergency. This is a temporary change for entering and exiting the building in order to maintain a secure environment for the residents who live here". Interview with the Administrator on 10/22/11 at 7:10 PM revealed signage will be amended regarding "temporary change". Further interview revealed she had notified the appropriate first responders, including the non-emergency ambulance services, of the facility's policy changes related to Entry/Exit doors. The ambulance doors remain available for use by emergency personnel however, a new code was required to gain access. 3. On 10/21/11 observations revealed staff monitored the back doors and observed no residents exited the building prior to hitting the alarm reset button. Observations on 10/22/11 validated the removal of the "silencing button" and confirmed staff was verifying no resident exited the building prior to silencing the alarm. Observation on 10/22/11 at 5:08 PM revealed a visitor attempted to utilize the A-station Ambulance Door which triggered an audible alarm. Staff responded immediately, confirmed a resident had not exited the building before the alarm was silenced and informed the visitor of the changes in procedures regarding facility Entry/Exit. 4. The training was validated through review of sign in sheets and staff interviews. Telephone inservices were noted on sign-in sheets by the facility staff. Staff knowledge of the inservice information including the Wander Protocol and Exit Door Policy was validated during interviews conducted with six (6) employees from ancillary departments including 10/20/11 at 10:30 AM with the Activities Director; on 10/21/11 at 10:15 AM with Housekeeper #21; on 10/22/11 at 3:30 PM with Dietary Relief Cook #22; on 10/22/11 at 3:31 PM with Dietary Aide #23; on 10/22/11 at 3:38 PM with the Dietary Manager; on 10/22/11 at 3:40 PM with Laundry Worker #24; and Housekeeper #25 on 10/22/11 at 4:00 PM. In addition, interviews were conducted to validate staff knowledge with the following nursing staff members: on 10/21/11, SRNA #5 at 10:55 AM, SRNA #6 at 11:15 AM, LPN #20 at 11:50 AM, SRNA #14 at 12:14 PM, and LPN #5 at 7:00 PM; on 10/22/11 SRNA #17 at 4:08 PM, SRNA #15 at 4:15 PM, RN #1 at 4:50 PM, and LPN #11 at 4:45 PM. In addition, telephone interviews were conducted on 10/22/11 with SRNA #18 at 6:00 PM, Kentucky Medication Aide (KMA) #1 at 6:30 PM, and LPN #16 at 7:30 PM to verify awareness of the content of the information from the inservice on 10/20/11. Interviews, on 10/22/11, with SRNA #16 at 7:00 PM and SRNA #19 at 7:05 PM, confirmed the facility contacted them by phone to conduct the in-service since they were not scheduled to work on 10/20/11. Interview with the Administrator, on 10/22/11 at 6:45 PM, revealed QA and Staff Development (SD) divided the employee roster to validate all employees were inserviced and identify any remaining employees that were unable to be contacted including any employees on scheduled leave of absence. She stated QA and SD would coordinate with Department Managers to ensure employees were in-serviced before they returned to work. Continued interview revealed Contracted Service employees were included in the in-services conducted 10/20/11 and all "new hires" would receive the information during orientation. 5. Interview with the Administrator, on 10/22/11 at 7:25 PM, revealed QA audits were started during day shift of 10/21/11. In addition to utilizing the audit tool, Administrative Staff made observations throughout the day to confirm staff visually monitored the facility entrance/exit doors. She further stated she assisted with the evening shift audit on 10/21/11. Observation, on 10/22/11 at 7:00 PM, revealed the Nursing House Supervisor at A-station Ambulance Door utilized the developed audit tool to conduct a Quality Assurance check. Interview with the administrator, on 10/22/11, revealed the door alarm policy and compliance will also be shared in the "Morning Meetings" with management staff and the Safety Meeting held monthly. 6. Interview with the Administrator, on 10/22/11 at 7:25 PM, revealed the Medical Director had been actively involved regarding the policy and procedure changes related to residents at risk for wandering and accessibility of exit doors. Further interview revealed communication included input from the Medical Director regarding alternative interventions that were explored such as wanderguard type alert system. Record review of the Monthly QA Meeting "Sign-In Sheet", dated 10/18/11, revealed a signature noted to be the Medical Director. Immediate Jeopardy was verified to be removed on 10/21/11, prior to exit on 10/22/11 with remaining non-compliance at 42 CFR 483.25 Quality of Care, scope and severity of an "E" and 42 CFR 483.75 Administration, scope and severity of an "E" while the facility's Quality Assurance monitors the effectiveness of observation audits and compliance with the policy changes.