Every finding on record at Hopkins Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to provide a notice of discharge to the resident or resident representative along with a copy of the notice to the Office of the State Long Term Care Ombudsman following discharge for 1 of 4 sampled closed record reviews, (Resident (R) 13). R13 was discharged to home on 10/12/2022. However, the facility failed to provide a written notification of transfer/discharge to R13 or the Office of the State Long-Term Care Ombudsman. The findings include: Policies were requested; however, the facility did not provide policies which were in effect on 10/12/2022 for the State Survey Agency (SSA) to review. Review of R13's closed electronic medical record (EMR) Admission Record revealed the facility admitted the resident on 09/30/2022, with diagnoses to include sepsis, type 2 diabetes mellitus and synovitis and tenosynovitis (inflammation) of the hand. Review of the Minimum Data Set (MDS) Assessment for R13 with an Assessment Reference Date (ARD) of 10/12/2022, located in the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognitive function. Additional review of R13's EMR revealed a Discharge Plan dated 10/12/2022. Further review revealed no additional documentation of discharge or discharge paperwork having been provided to the resident. Review of an electronic mail (e-mail) dated 05/14/2025, from the District Ombudsman, revealed she did not have anything from 2022 on (R13's) discharge. In interview on 05/14/2025 at 2:30 PM, the Regional [NAME] President of Operations, the facility's former Administrator, stated the transfer/discharge policy in effect for 09/30/2022 through 10/02/2022 was unavailable because of facility ownership changes. In interview on 05/15/2025 at 11:19 AM, the Director of Nursing (DON) stated discharge planning began at admission, with goals and plans shared with the team, and social services (SS) being involved. She stated that notification was documented in the resident's chart either in a progress notes or as a change in condition. The DON further stated paperwork was sent with the resident, sent to family, and she thought scanned into the resident's EMR. In an interview on 05/15/2025 at 11:48 AM, the facility Administrator stated the facility was responsible to notify the resident's family and ombudsman of transfers and discharges. He said under most circumstances written notification must be given. the Administrator further stated records should be retained and accessible; however, he was unaware of the specific length of time records should be kept.

Based on interview, record review, review of facility investigations and policies, the facility failed to ensure residents were protected from verbal and physical abuse for 2 of 14 sampled residents (Resident (R) 4 and R5). 1. On 07/17/2024, R4 reported to the Administrator that Kentucky Medication Aide (KMA) 3 had spoke to her like a dog, pointed her finger in the resident's face, and started cussing at her without cuss words. 2. On 10/19/2023, R7 hit R5 in the head with an open hand. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Per policy review, that included, but was not limited to, freedom from corporal punishment, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility policy titled, Resident Rights, revised February 2021, revealed employees should treat all residents with kindness, respect, and dignity. 1. Review of R4's electronic medical record (EMR) revealed the facility admitted the resident on 06/20/2022, with diagnoses which included anxiety disorder, hypertension, and unspecified psychosis. Review of the Minimum Data Set (MDS) Assessment for R4, with an Assessment Reference Date (ARD) of 02/18/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the facility's Self-Reported Incident Form Initial Report, dated 07/17/2024, revealed an incident of verbal abuse occurred on 07/17/2024 at approximately 12:45 PM, which R4 reported to the facility's Administrator immediately. Per review of the report, upon notification by R4, an investigation was initiated. Continued review revealed KMA 3 was immediately suspended and vacated the facility until further notice pending the outcome of the investigation. Review revealed a change in condition, head-to-toe skin assessment, and rapid mood screening (RMS) were initiated for R4. Further review revealed due to the complex nature of the allegation, all witnesses prepared written statements and interviews were conducted. In addition, R4's physician, family/Power of Attorney (POA), Department for Community Based Services (DCBS), Adult Protective Services (APS), and the Ombudsman were all notified. Review of the facility's Final Report/5 Day Follow-Up, revealed all materials related to the investigation had been reviewed and it was found the allegation against KMA 3 involving (alleged verbal abuse of) R4 was verified. Per review, the evidence suggested KMA 3 had conducted herself in an unprofessional manner and used a tone and language that could be construed as an act of verbal abuse. Review of the Report, revealed at the time the allegation was made KMA 3 was placed under one-to-one (1:1) observation by the Director of Nursing (DON) while the medication cart was counted. Continued review revealed KMA 3 was then escorted out of the facility and placed on suspension until further notice. Review revealed a verbal education regarding abuse, verbal abuse, and abuse prohibition and reporting was implemented by the Administrator, DON, and Assistant Director of Nursing (ADON) during the investigative period for all 76 active employees. Further review revealed Social Services (SS) or the Administrator conducted routine check-ins with R4 for four weeks following the incident to monitor for any potential distress and to ensure her concerns were resolved. Finally, review further revealed since the allegation against KMA 3 had been verified, she was terminated from employment and did not return to the facility. Review of the facility's, Quality Assurance and Performance Improvement (QAPI) log of activity for the 08/27/2024 meeting revealed abuse - 1 incident; resolved was listed as a topic which was reviewed/discussed. Review of KMA 3's personnel file revealed a hire date of 10/20/2023, as a State Registered Nursing Assistant (SRNA). Per review, KMA 3 transferred on 12/03/2023, into the position of Kentucky Medication Aide after successfully passing the Medication Aide exam on 11/20/2023. Continued review revealed a background check, adult caregiver, nurse aide registry, sex offender and license verification had been performed. Further review revealed no documented evidence of disciplinary actions. Additional review revealed the KMA had received abuse training and was terminated on 07/22/2024. In interview on 05/13/2025 at 2:30 PM R4 stated things are pretty good here now. She stated she had only had problems with that one staff member before and that person was not there anymore. R4 reported that person lost her job over some stuff that went on. She further stated she hated anyone losing a job, but when you do bad that's what happens. R4 said that person talked to her real mean. Telephonic attempts were made to interview KMA 3 on 05/14/2025 at 9:36 AM, 3:42 PM, and 7:45 PM; however, were unsuccessful. Voicemail messages were left each time; however, a return phone call was never received. In interview on 05/13/2025 at 2:20 PM, Licensed Practical Nurse (LPN) 1 stated she relayed another incident to SSD and DON that occurred that same day the incident with KMA 3 and R4 occurred. She stated R3's daughter informed her that her mom (the resident) was told she was acting like a baby by the med tech that morning. LPN 1 said R3 had relayed that information to her daughter when she came to visit the resident at lunch. She reported she she immediately went to tell the Social Services Director (SSD) and the DON. LPN 1 stated she was unaware of the incident involving KMA 3 and R4 when she reported what R3's daughter told her. She further stated however, at that time she learned that KMA 3 had already been removed from the floor and the med carts were being counted. In interview on 05/13/2025 at 2:10 PM, the Receptionist stated she did remember an incident involving KMA 3 and R4. She stated KMA 3 had been a med tech in the facility, and on the day of the incident, R4 called from her personal phone to the facility phone asking about some meds. The Receptionist said after receiving the call, she went to find KMA 3 to let her know because she was the person passing meds. She explained KMA 3 asked her to go to R4's room with her so that no one would put words in my mouth. The Receptionist reported she was surprised when KMA 3 was the one that was verbally aggressive towards the resident. She further stated KMA 3 was cussing and pointing her finger towards the resident. The Receptionist additionally said she got KMA 3 out of the room and went straight to find the Administrator. In interview on 05/13/2025 at 2:40 PM, the SSD stated she was still new when this all happened and remembered very little. She said she did remember KMA 3 as not being kind and it was a form of verbal abuse. The SSD explained her role was to check with residents to make sure they were okay after the incident. She further stated she also checked with staff to see if they had witnessed anything like this occurring. In interview with R11, R1, and R2 on 05/13/2025 at 10:00 AM, they stated they felt well taken care of, staff treated them with respect, and they felt safe in the facility. R3 (Who reported the second incident to her daughter) was unable to be interviewed 05/13/2025 through 05/15/2025 during multiple attempts each day. In interview on 05/15/2025 at 11:19 AM, the DON stated staff abuse education was provided on hire, annually and as needed. The DON said the education was normally provided by her and/or the ADON, and might be provided in person or through a video with a posttest. She explained if she were to witness abuse taking place, she would intervene immediately to keep the resident safe and then report it to the Administrator. The DON stated if an incident of abuse was not reported, it would be possible to have a negative outcome for the residents. She said when the abuse allegation involving R4 was made, KMA 3 was removed from the floor, med carts were counted and then she (KMA 3) was escorted out of the facility. The DON said she thought KMA 3 had been out of the building before the second incident was reported. She further stated resident and staff interviews, as well as staff education were completed as part of the facility's investigation. The DON also stated the facility substantiated the allegation of verbal abuse and KMA 3 was terminated. In interview on 05/15/2025 at 11:48 AM, the Administrator stated he was the facility's abuse coordinator, and said all allegations of abuse by staff were handled immediately. He stated the accused staff had been suspended, and they were not allowed back on the premises pending the results of the investigation. The Administrator said residents involved in alleged incidents of abuse were monitored for physical/psychosocial effects related to incidents. He explained he expected staff to immediately report suspected abuse after intervening to keep the residents safe. The Administrator stated, when recalling his memory of the incident between KMA 3 and R4, multiple people had been trying to find him to report the incident. He said the facility's reaction to the allegation was immediate as R4 asked to speak with him as soon as KMA 3 left her room. The Administrator reported KMA 3 had been pulled from off the floor and suspended pending the investigation, and the med cart counted with supervision prior to the KMA being escorted out of the building. He stated as the first investigation was beginning, report of the second incident came in. The Administrator said he was unaware of any allegations regarding KMA 3 until that day, and she (KMA 3) had not seemed problematic, and had been very pleasant and welcoming. He further stated KMA 3 had been terminated for substantiated allegation of abuse against R4. In addition, the Administrator said the facility investigation concluded that KMA could have presented herself in a different manner towards R3; however, there had been no witnesses to verify it reached a level of abuse in that instance. Surveyor: [NAME], [NAME] 2(a). Review of the EMR Admission Record for R5 revealed the facility admitted the resident on 05/29/2022 and discharged the resident on 03/29/2024. Continued review revealed R5 was admitted with the following diagnoses: mild neurocognitive disorder due to known physiological condition without behavioral disturbance, cognitive communication deficit, and unspecified psychosis not due to a substance or known physiological condition. Review of the Significant Change MDS with an ARD of 03/15/2024, revealed the facility assessed R5 to have a BIMS score of a 14 out of 15, indicating the resident was cognitively intact. (b). Review of the EMR Admission Record for R7 revealed the facility admitted the resident on 09/15/2022 and discharged the resident on 11/04/2024, with diagnoses to include: dementia with agitation, schizophrenia, and Alzheimer's disease. Review of the Significant Change MDS with an ARD of 08/20/2024, revealed the facility assessed R7 to have a BIMS score of a zero out of 15, indicating the resident was severely cognitively impaired. Review of the facility's Initial Report dated 10/19/2023, revealed on 10/19/2023 at 11:55 AM, R7 made physical contact with R5's head with her open palm. Continued review revealed the incident was witnessed by SRNA 2. Review of the facility's investigation Final/5-Day Follow Up Report, dated 10/20/2023, revealed the facility concluded the incident was witnessed and therefore verified to have taken place. Review of the psychiatry initial consult dated 10/27/2023, for R7 revealed the resident had been evaluated to have struck another resident on 10/19/2023. Continued review revealed staff reported R7 had been more easily agitated recently. Review of the hospital emergency department note dated 10/19/2023, revealed R7 had been seen for allegedly slapping another resident, having frequent emotional outbursts, and episodes of aggression, which were not uncharacteristic for her. During an interview with SRNA 2 on 05/13/2025 at 4:32 PM, she stated she was unable to recall all of the details of the incident due to the amount of time that had elapsed. After reading her signed witness statement, SRNA 2 stated she did remember seeing R7 hit R5 in her head with an open hand. She further stated she recalled she immediately separated the two residents. SRNA 2 additionally said R7 was confused most of the time and had the mind of a child. During an interview with SRNA 5 on 05/15/2025 at 10:40 AM, she stated R7 always had some behaviors requiring increased supervision. During an interview with the DON on 05/15/2025 at 11:18 AM, she stated R7 usually did not have physical behaviors towards anyone; however, did have a diagnosis of schizophrenia and had delusions. She stated R7 would yell at nothing and was usually only aggressive towards her delusions. The DON said R7 was monitored by the nursing staff frequently, and stayed in her room or sat at the nursing station. She reported R7 was followed by psychiatric services and had been sent out of the facility for psychiatric evaluations a few times. The DON further stated she expected staff to keep residents safe and report any incident or allegation of abuse to her, their supervisor or the Administrator immediately. During an interview with the Administrator on 05/15/2025 at 11:50 AM, he stated R7 was known to be eccentric and have behaviors. He stated she had diagnoses of schizophrenia, delusions, and hallucinations, but was not usually physically aggressive. The Administrator further stated he expected staff to intervene immediately then report any abuse directly to their supervisor then they should call or text him immediately. 47798

Based on observation, interview, record review, policy review, and review of the facility's investigation, it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #1). The facility admitted Resident #1 on 10/08/2021 with diagnoses to include Unspecified Dementia without Behavior Disturbance, Major Depressive Disorder, and Anxiety Disorder. The initial Elopement Risk Assessment, dated 10/08/2021, revealed the resident had a history of actual or attempted elopement in the past, wandering tendencies, and was impulsive. In addition, the Progress Note written by Registered Nurse (RN) #2, on 12/03/2021 at 9:45 AM, revealed the resident mentioned: just going home because {he/she} doesn't need to be here. Further, the Elopement Risk Assessment, dated 12/20/2021, revealed the resident had a history of wandering that placed the resident at significant risk of getting to a potentially dangerous place such as stairs, or outside the facility, and he/she had voiced the desire to leave. However, there was no documented evidence of interventions in place related to supervision and monitoring the resident in an attempt to prevent elopement. On 12/29/2021, Resident #1 eloped without staff's knowledge, and on that date the facility received a call from a neighbor (unidentified caller) at 4:30 AM, informing the facility there was a possible resident walking down the road with a cane. Upon notification, the facility initiated a headcount and determined Resident #1 was missing. The Occupational Therapy Assistant (OTA) left the facility to search for the resident in her car, and returned the resident to the facility on [DATE] at approximately 4:45 AM, which was about one (1) hour and forty-five (45) minutes since the resident was last seen by staff. Additionally, the facility's investigation revealed the root cause analysis determined the resident exited the facility when staff left the building on a break. However, an interview with the resident's family member on 01/21/2022, revealed the resident informed her, another resident from the facility entered the facility code to the keypad on the door to assist the resident with exiting the facility. Furthermore, upon return to the facility, the resident stated he/she fell while out of the facility. Review of the Radiology report, dated 12/29/2021 revealed the resident sustained Acute Left Lateral Rib Fracture of the ninth (9th) and tenth (10th) ribs. The facility's failure to ensure each resident received adequate supervision and monitoring 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 01/21/2022 and determined to exist on 12/29/2021, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; and 42 CFR 483.25 Quality of Care, F689. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 01/21/2022. An acceptable Allegation of Compliance (AoC) was received on 01/28/2022, alleging removal of the Immediate Jeopardy on 01/27/2022. The State Survey Agency validated removal of the Immediate Jeopardy on 01/27/2022, prior to exit on 02/03/2022, with remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; and 42 CFR 483.25 Quality of Care, F689, both at a Scope and Severity of a D while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F657) The findings include: Review of facility policy titled, Elopement of Resident, revised 02/28/2021, revealed residents were to be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the clinical assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a resident leaves the premises without authorization. Assess, evaluate, and identify resident's elopement risk upon admission, re-admission, quarterly, or with a significant change in conditions as defined by the Resident Assessment Instrument (RAI) manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. For residents identified as at risk, an interdisciplinary elopement prevention resident-centered care plan would be developed with resident participation and resident representative when applicable. Obtain a current photograph of the resident, complete the Elopement Risk Identification form for all residents at risk of elopement, and place in a binder that was easily accessible to staff. Review of Resident #1's medical record revealed the facility admitted the resident on 10/08/2021 with the diagnoses which included Dementia without Behavioral Disturbance, Anxiety, and Major Depressive Disorder. Review of Resident #1's Elopement Assessment, dated 10/08/2021, completed by Licensed Practical Nurse (LPN) #3, revealed the resident had diagnoses of Anxiety, Dementia, and Depression and had a history of actual or attempted elopement in the past, as well as, wandering tendencies. Further, the Assessment also noted the resident to be impulsive and to have a history of wandering that placed the resident at significant risk of getting to a potentially dangerous place. Review of the Comprehensive Care Plan, dated 10/11/2021, revealed Resident #1 was at risk for elopement related to Cognitive Loss/ Dementia. The goal dated 10/11/2021, revealed the resident would not attempt to leave the facility without an escort through the next review with a target date of 01/20/2022. Interventions in place as of 10/11/2021 included: encourage resident's participation in activity preferences; allow time for expression of feelings; provide empathy, encouragement, and reassurance; personalize resident's room with familiar items to assist him/her in identifying room; divert resident by giving alternative objects or activities; familiarize resident with own belongings and surroundings; listen to resident and try to calm and as appropriate redirect resident if nears exits or doorways. However, there was no documented evidence of interventions to address the need for supervision and monitoring; nor was there documented evidence of supervision level required to keep the resident safe. (Refer to F657) Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 10/15/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having wandering tendencies daily. Additional review revealed the facility assessed the resident as requiring limited assist of one (1) staff for transfers and as requiring supervision, and assist of one (1) staff for ambulation. Review of the Kardex report (Certified Nursing Assistant {CNA}Care Plan), undated, printed on 01/19/2022, revealed there were no interventions to address Resident #1 as an elopement risk. The yellow Elopement Binders located at the Nurse's Station on each of the two (2) halls (front and back halls), included Resident #1's Elopement Risk Identification form, undated, with demographic information, and a photo of the resident. Review of the Progress Note, dated 10/15/2021 at 10:06 AM, written by Licensed Practical Nurse (LPN) #2, revealed Resident #1 was wandering daily or almost daily and experiencing impulsive behavior. The Progress Note, dated 10/15/2021 at 11:25 AM, written by LPN #2, revealed Resident #1 was wandering in the hallway, with no exit seeking noted at this time. Review of Resident #1's Social Services Admission Assessment, dated 11/01/2021, revealed the resident had a history of Anxiety and the resident was at risk for mood fluctuations related to the diagnosis of Anxiety. Further, no behaviors had been noted in the previous seven (7) days. Review of the Progress Note, dated 11/05/2021 at 5:02 PM, written by Registered Nurse (RN) #2, revealed Resident #1 wandered on the unit, and was confused, but pleasant. The Progress Note, dated 11/12/2021 at 4:06 PM, written by RN #2, revealed Resident #1 was confused and wandered on the unit. Per this note, the resident stated he/she was a ghost and already dead. Review of the Progress Note, dated 11/26/2021 at 4:24 PM, written by RN #2, revealed Resident #1 wandered on the unit at times and talked about being a ghost and stated he/she did not need to be here because he/she could take care of us. Further review revealed RN #2 documented the resident was often confused. Review of Resident #1's Progress Note, dated 12/03/2021 at 9:45 AM, written by RN #2, revealed the resident wandered on the unit, and was confused and alert and oriented times one (1). Further review revealed the resident had delusional thoughts, and stated, he/she was a ghost and thought he/she was completing tasks like cleaning a garage. Continued review of Resident #1's progress note revealed the resident stated he/she was just going home because {he/she} doesn't need to be here. Review of Resident #1's Elopement Assessment, dated 12/20/2021, completed by Licensed Practical Nurse (LPN) #2, revealed the resident had Dementia. Further, the resident had a history of wandering that placed the resident at significant risk of getting to a potentially dangerous place, such as stairs, or outside the facility. Continued review revealed the resident voiced the desire to leave, made statements related to wanting to go home, and was impulsive with wandering tendencies. Review of the facility's Long Term Care Facility Self Reported Incident Form/ Initial Report, dated 12/29/2021, which was faxed to the Office of Inspector General (OIG) on 12/29/2021 at 3:42 PM, revealed Resident #1 eloped on 12/29/2021. The facility was contacted at approximately 4:30 AM, by an unidentified neighbor within the community. Continued review of the Incident Form revealed the neighbor witnessed an elderly person walking down the road with a cane and wished to report his concerns to the facility, to ensure the person was not a resident of the facility. Additional review of the Long Term Care Facility Self Reported Incident Form/Initial Report dated 12/29/2021, revealed the facility immediately initiated a physical room to room headcount. While the headcount was ongoing, the Occupational Therapy Assistant (OTA) headed to the vicinity the caller identified. Per the headcount, Resident #1 was identified as unaccounted for. At approximately 4:45 AM, Resident #1 was located by the OTA and escorted back to the facility where he/she was placed on one on one (1:1) monitoring. The Report was completed by the Center Executive Director (CED). Review of the facility's Timeline/Investigation, revealed on 12/29/2021 at approximately 4:32 AM, a caller identified as a nearby neighbor called the facility and spoke with Licensed Practical Nurse (LPN) #1. The caller notified LPN #1 a person with a cane was walking down a nearby road. LPN #1 immediately alerted all staff to a potential missing resident and a headcount was initiated. Resident #1 was identified as missing and RN #1 and LPN #1 initiated the elopement process including a search of all rooms, all windows and exit doors, and facility grounds. At approximately 4:35 AM, while the facility search was ongoing, the Occupational Therapist Assistant (OTA) proceeded to the vicinity in which the caller identified and Resident #1 was located at approximately 4:45 AM. The OTA interviewed Resident #1, and he/she told her, I followed someone out the back door and complained I fell and made complaints of pain to his/her side and right wrist. Further review of the Timeline/Investigation, revealed upon arrival to the facility, Resident #1 was placed on one on one (1:1) monitoring and LPN #1 initiated a head-to-toe assessment including vital signs, and a skin and pain assessment was completed. RN #1 checked all doors, and windows. Continued review of the timeline revealed RN #1 determined that all the doors and windows were secure, and doors were functioning properly. Staff interviews regarding the incident were initiated. At 8:15 AM, the Center Nurse Executive (CNE) called the resident's daughter/POA and informed her of the resident's elopement. The CNE requested permission to allow the resident to be transferred to a sister facility that had a locked Dementia unit and the daughter agreed. At 8:30 AM, the CNE notified the Advanced Practice Registered Nurse (APRN) on call for the Physician of the elopement and the resident's condition. At 9:30 AM, the resident was noted to have complaints of pain to the right wrist upon movement and pain to the left side. The physician was notified by LPN #2 and an order was received for an x-ray of the right wrist and forearm, bilateral ribs and chest. At 11:40 AM x-ray results were received which noted no fractures to the right wrist or forearm; however, there were acute appearing fractures noted to the left lateral 9th and 10th (ninth and tenth) ribs with displacement. At 12:03 PM, the resident's POA/daughter was notified of the resident's rib fractures. On 12/29/2021 at 3:45 PM, Resident #1 was discharged from the facility to the sister facility. Further review of the facility's Investigation initiated 12/29/2021 by the Center Executive Director (CED) and the Center Nurse Executive (CNE), revealed the Root Cause Analysis was completed and the Quality Assurance Performance Improvement (QAPI) team was involved, as well as, the Medical Director. Per the facility investigation, the root cause analysis determined it was likely that Resident #1 exited the back door after a staff member exited for some purpose without the staff member realizing that the resident had done so. Review of Resident #1's Progress Note, dated 12/29/2021 at 9:30 AM, revealed the Center Nurse Executive (CNE) documented the resident was noted to have mild complaint of tenderness to the right wrist upon movement, as well as, some discomfort upon movement to the left side. The resident ' s physician was notified and an order was obtained for x-rays of both. Review of Resident #1's Progress Note, dated 12/29/2021 at 11:00 AM, documented by the Social Worker after the elopement, revealed the Social Services Department (SSD) completed a Brief Interview for Mental Status (BIMS) with a score of seven (7) indicating severe cognitive impairment. Further review revealed the resident was able to recall two out of three (2/3) words after five (5) minutes. Continued review revealed the resident had a diagnosis of Dementia with periods of confusion noted. Per the note, Resident #1 initially was unable to recall the event when asked if he/she had left the building at any time last night. Then the resident stated, Oh yeah, I took a lap around. When asked if he/she remembered which way he/she went out, the resident stated, just went out this way and pointed towards the back of the building. There were no signs of distress noted, and the resident laid down to take a nap. Review of Resident #1's Radiology report of the bilateral ribs and chest, dated 12/29/2021 at 12:28 PM, revealed the resident ' s left lateral (ninth) 9th and (tenth) 10th rib fractures with displacement. Mild soft tissue swelling. The conclusion of the report revealed the resident had an acute appearing left rib fracture, correlated with the clinical exam and history. Review of Resident #1's Radiology report of the Forearm, dated 12/29/2021 at 12:28 PM, revealed there was no acute fracture or dislocation. Further, the osseous structures appeared intact. The resident ' s joint spaces were narrowed and the soft tissues were unremarkable. The conclusion of the report was that there were no acute findings or degeneration changes. Finally, the report stated a repeat study would be considered if the symptoms continued, persisted, or progressed. Resident #1's Elopement Risk Assessment, dated 12/29/2021, completed by the Assistant Director of Nursing (ADON), revealed post elopement, the resident had a history of past elopement wandering to dangerous places (outside) and the resident expressed the desire to leave. It was also noted that the resident was impulsive. Further review of Resident #1's Comprehensive Care Plan, dated 10/11/2021, revealed an intervention was added on 12/29/2021, after the resident eloped, to monitor the resident's location with one-to-one (1:1) observation. Review of the facility Evacuation Map, identified Resident #1's room (room #26), on the corner of the back hallway on the back unit, across from the nurse's station. Observation on 01/20/2022 from 1:23 PM - 1:36 PM, revealed Resident #1's room was in the back hall and twenty-four (24) feet from the back exit which was used by staff to leave the building to smoke. The doors had keypad access in order to bypass the door alarm when staff exited the building. Further observation revealed the door was tested by Maintenance, by pushing on the door bar and the alarm sounded, then the door would open after ten (10) seconds. Continued observation revealed there were alarms at each exit door and all exit doors were checked for proper functioning of the alarm system when tested by Maintenance. Interview with Maintenance during the observations revealed the door alarms were checked weekly for proper functioning. Review of the Weather History for 12/29/2021, revealed the temperature was fifty-four (54) degrees Fahrenheit with overcast/cloudy skies from 3:00 AM to 5:15 AM, with no wind. On 01/20/2022 at 5:30 PM, the State Survey Agency Representative drove from the facility to where it intersected with the road in which the resident was identified as being found on 12/29/2021. The distance from the facility to the road in which the resident was located was approximately (one tenth to two tenths of a mile (0.1 - 0.2) from the facility. At the stop sign where the two (2) roads intersected, there was the choice to go right or left. It was noted turning right led to a railroad crossing and turning to the left the road went a long distance. Interview with the Occupational Therapist Assistant (OTA), on 01/20/2022 at 8:33 AM, revealed as she arrived to work on 12/29/2021 at 4:30 AM, she witnessed staff checking the building for a resident and was informed someone phoned the facility to say a possible resident was seen walking on a nearby road. She stated it was dark and cold outside when she got in her car to search for the resident. She further stated she turned left onto the road identified by the caller and did not go very far before she saw someone walking. Per interview, she identified the person as Resident #1. Further interview revealed the resident was wearing jeans, a jacket, and a toboggan and was carrying a cane. Further, Resident #1 agreed to get in the car with her to head back to the facility. Continued interview revealed she assisted the resident back to his/her room on the back hall and LPN #1 assessed the resident. The OTA was unable to give an estimated distance of where the resident was located on the nearby road as she was unfamiliar with the area and did not recognize any landmarks in the area. Interview with Licensed Practical Nurse (LPN) #1, on 01/20/2022 at 3:06 PM, revealed she was assigned to Resident #1 at the time of the elopement on 12/29/2021, and she normally worked the back hall so she was familiar with the resident. She stated the night of the elopement Resident #1 was just up walking around which was normal for the resident. She stated she last saw the resident in the dining area at 3:00 AM, and she did not hear an alarm go off after that time. Per interview, at 4:30 AM, she received a call from a male neighbor (unidentified caller) who reported a possible resident walking in the road, and a brief description was given. She stated she hung up the phone, alerted staff, and a headcount was initiated, and staff searched the building and grounds. She further stated it was discovered Resident #1 was not in his/her room and was missing from the facility. She stated she had not heard any alarms going off prior to receiving the call from the neighbor. Further interview with LPN #1 on 01/20/2022 at 3:06 PM, revealed she received a call from the OTA at 4:45 AM, stating she had found Resident #1 on the same road in which the neighbor reported seeing a possible resident. Per interview, she assessed the resident upon his/her return to the unit, and the resident told her Resident #1 sustained a fall while outside. LPN #1 stated she did not note any injuries with her assessment, but the resident complained his/her side was sore and she medicated the resident with Tylenol (medication for mild to moderate pain). Further interview revealed the facility did not do routine headcounts. Per interview, prior to the resident's elopement, there was no plan in place to supervise and monitor the resident closely even though the resident had wandering tendencies and did make statements about wanting to go home. Continued interview revealed after the elopement, the resident was placed on one on one (1:1) monitoring until he/she was discharged later in the day on 12/29/2021. Interview with Registered Nurse (RN) #1, on 01/20/2022 at 8:15 AM, revealed during her shift on 12/29/2021, Resident #1 was walking the halls which was normal for this resident. She stated she had last seen Resident #1 on 12/29/2021 around 3:00 AM and at that time the resident was wearing jeans, jacket, and toboggan and was carrying a cane. She stated this attire was normal for the resident. Further interview with Registered Nurse (RN #1), on 01/20/2022, revealed LPN #1 received a phone call from a neighbor about a possible resident being on the road and she (RN #1) assisted with the headcount and search of the building, noting Resident #1 was missing. Per interview, she did not hear an alarm sound that night prior to Resident #1 leaving the building. Continued interview revealed RN #1 did not feel the resident was actually exit seeking nor did she feel like the resident required increased supervision prior to the elopement. Interview with Certified Nursing Assistant (CNA) #2, on 01/20/2022 at 1:09 PM, revealed on 12/29/2021, earlier in the night shift, he and another CNA set up Resident #1 for his/her bath which was normally given on night shift per the resident's preference. CNA #2 stated the resident dressed self, and was wearing jeans, a couple of shirts, a jacket, and a toboggan after the bath and carried his/her cane. Per interview, after the bath Resident #1 was agitated and up walking the halls. Further interview revealed around 3:00 AM he noted Resident #1 was in the building prior to him (CNA #1) and CNA #2 going out the back door to smoke. Per interview, he did not hear an alarm going off prior to participating in the headcount after being informed someone had called the facility to report a possible missing resident. CNA #2 stated he assisted with one on one (1:1) observations of Resident #1 when he returned to the facility on [DATE]. CNA denied any prior knowledge of the resident exit seeking prior to the elopement. Interview with CNA #1, on 01/20/2022 at 9:37 AM, revealed she was not working Resident #1's hall on 12/29/2021 at the time of the elopement but was working on the front hall. She stated she did not notice any wandering residents during her shift, nor did she hear any alarms sound. However, she stated she did participate in the headcount at about 4:30 AM that morning. Interview with Certified Nursing Assistant (CNA) #3, on 01/20/2022 at 3:53 PM, revealed she was assigned to Resident #1 on the night of 12/29/2021, during the time of the elopement. Per interview, at that time rounds were completed to check on the residents every two (2) hours and as needed. She stated she had assisted the resident with a bath earlier in the shift. She further stated after the bath the resident dressed self in a shirt, pants, jacket, and house shoes and he/she always had his/her cane close by. CNA #3 stated the resident did not mention leaving to her and he did not feel like the resident was exit seeking. Per interview she did not hear any alarms sound that night. Interview with Registered Nurse (RN) #2, on 01/21/2022 at 11:42 AM, revealed even though she documented in Resident #1's Progress Note dated 12/03/2021, the resident stated he/she mentioned just going home because {he/she} didn't need to be here, she did not feel like the resident needed increased supervision because he/she was never agitated. Per interview, the resident would normally wander throughout the facility. RN #2 stated she was not on duty the night the resident eloped. Interview with Licensed Practical Nurse (LPN) #2, on 01/21/2022 at 11:32 AM, revealed Resident #1 walked the hallways and would walk to the door, but not push the door. Per interview, she was not on duty during the shift the resident eloped. Interview with Resident #1's Power of Attorney (POA)/daughter, on 01/21/2022 at 9:47 AM, revealed she was notified regarding the resident's elopement from the facility on 12/29/2021. Later on 12/29/2021, Resident #1 informed her that a friend (another resident) knew the door code and let him/her out of the building. The POA/daughter stated prior to being admitted to the facility, the resident had lived with her sister for a couple of months. Per interview, during that time the resident had attempted to leave her sister's home, so her sister ended up placing alarms on the doors in her home. Further interview with the POA on 01/21/2022 at 11:10 AM, revealed she had not told the facility how the resident exited the building on 12/29/2021 and she had not been interviewed by the facility related to the event. Interview with the Minimum Data Set (MDS)/ RN, on 01/21/2022 at 2:35 PM, revealed on admission, a current photograph of the resident was obtained, and an Elopement Risk Identification form for all residents at risk of elopement was placed in the Elopement Binder along with the photo and this was her responsibility. Per interview, Resident #1 was at risk for elopement, and therefore his/her photo and Elopement Risk Identification form were in the Elopement Binder. Interview with the Center Nurse Executive (CNE), on 01/20/2022 at 12:40 PM, and post survey on 02/11/2022 at 10:47 AM, revealed on 12/29/2021, LPN #1 received a call from an unidentified caller reporting a possible resident walking in the road. Per interview, Resident #1 had eloped and was found by the Occupational Therapy Assistant (OTA) at 4:45 AM. Further interview revealed although the resident had a history of wandering and making delusional comments, as well as, making comments about wanting to go home prior to the elopement, staff including RN #2 felt the resident was not exit seeking. Per interview, she felt there were appropriate interventions in place prior to the elopement as the resident was just wandering and had not tried to actually exit the building. Continued interview with the CNE, on 01/20/2022 at 12:40 PM, and post survey on 02/11/2022 at 10:47 AM, revealed after Resident #1 eloped, the facility ensured there was one on one (1:1) supervision and monitoring until the resident was discharged from the facility. Additional interview revealed the CNE was unaware of any past elopements for Resident #1 prior to admission or after admission until the elopement on 12/29/2021. She stated after the elopement, it was identified the facility needed to ensure questions were asked during the admission process regarding resident elopement behaviors. Per the interview, a new questionnaire was developed for staff to utilize for new admissions with questions pertaining to the resident's history of wandering outside of their home or attempting to exit their home due to confusion. Telephone interview with the Center Executive Director (CED), on 01/21/2022 at 4:28 PM, revealed after Resident #1's elopement there was a Quality Assurance (QA) Quality Improvement meeting to evaluate where the breakdown happened. Further, the CED and CNE completed an elopement investigation. The CED stated the facility did not have a camera/video system and the door alarms were functioning correctly and the windows were secure at the time of the elopement. Further, the door alarms were being checked weekly prior to the elopement. Per interview, the resident was interviewed, as well as, staff on duty, the night of the elopement. The CED further stated it was determined by the process of elimination, Resident #1 must-have followed a staff member out of the building as no alarms sounded. Further interview revealed the resident's supervision level was adequate prior to the elopement since the facility had no knowledge that the resident had ever attempted to elope before. The facility implemented the following actions to remove the Immediate Jeopardy on 01/27/2022. 1. Resident #1 is no longer a resident of the facility as of 12/29/2021. 2. On 12/29/2021, Elopement Assessments were completed on forty-four out of forty-four (44/44) residents by the Assistant Director of Nursing (ADON). On 12/29/2021, a review of the Elopement Book was completed for inclusion of all residents identified as elopement risk for nine (9) out of nine (9) residents by the ADON. No new residents were assessed to be at risk for elopement at that time. On 12/29/2021, a review of all Comprehensive Care Plans and Certified Nursing Assistant (CNA) Kardex's/Care Plans for forty-four (44) out of forty-four residents was completed by the ADON to address the need for interventions related to increased supervision. No other residents required care plan updates or increased supervision at that time. 3. Starting 12/29/2021 through 01/05/2022, the Center Nurse Executive (CNE) and Assistant Director of Nursing (ADON) provided re-education with all staff regarding the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. A post-test to validate learning was completed for seventy-one (71) out of seventy-one (71) employees with a passing score of one hundred percent (100%). Any staff not available for education and post-test are required to complete mandatory re-education and post-test upon return to work. Newly hired staff will be provided education and complete a post-test during the orientation process. (The facility did not utilize agency staff) 4. On 12/29/2021 at 10:45 AM, the Maintenance Director checked all windows and doors. All windows were noted to be secure and all doors were in proper working order and alarms were functioning. At that time the door code to all facility doors was changed by the Maintenance Director. 5. On 12/29/2021 at 4:10 PM, Elopement drills were initiated by the Center Executive Director (CED) and Maintenance Director. Elopement drills are to be completed on each shift x seven (7) days, then one (1) shift per day x seven (7) days, then three (3) times per week x fourteen (14) days, then two (2) times a week x thirty (30) days, then one (1) time a week x thirty (30) days, then two (2) times a month x sixty (60) days, then monthly for two (2) months by the CED, CNE, member of Nursing Management or Maintenance Director. 6. On 12/29/2021 at 4:10 PM, Elopement education audits were initiated by the Center Executive Director and Maintenance Director. Elopement education audits are to be completed on each shift x seven (7) days; then one (1) shift per day x seven (7) days; then three (3) times per week x fourteen (14) days; the [TRUNCATED]

Based on observation, interview, record review, policy review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1). Resident #1's Elopement Risk Assessment, dated 10/08/2021, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan, initiated 10/11/2021, revealed the resident was at risk for elopement related to Cognitive Loss/Dementia. Further, the Progress Note written by Registered Nurse (RN) #2, on 12/03/2021, revealed the resident mentioned: just going home because {he/she} doesn't need to be here. Also, the Elopement Risk Assessment, dated 12/20/2021, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence the elopement Comprehensive Care Plan was revised with resident-centered interventions related to supervision and monitoring in an attempt to prevent elopement. On 12/29/2021 at 4:30 AM, the facility received a call from an unidentified neighbor telling them there was a possible resident walking down the road with a cane. The facility immediately initiated a headcount and Resident #1 was not found in the building. The Occupational Therapy Assistant (OTA) searched for the resident in her car and returned the resident to the facility on [DATE] at approximately 4:45 AM, which was around one (1) hour and forty-five (45) minutes since the resident was last seen by staff. Moreover, upon return to the facility, the resident complained of sustaining a fall and having pain. The Radiology report, dated 12/29/2021, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure the Comprehensive Care Plan was revised has caused or is likely to cause serious injury, harm impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/21/2022 and determined to exist on 12/29/2021, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; and 42 CFR 483.25 Quality of Care, F689. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 01/21/2022. An acceptable Allegation of Compliance (AoC) was received on 01/28/2022, alleging removal of the Immediate Jeopardy on 01/27/2022. The State Survey Agency validated removal of the Immediate Jeopardy on 01/27/2022, prior to exit on 02/03/2022, with remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; and 42 CFR 483.25 Quality of Care, F689, both at a Scope and Severity of a D while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F689) The findings include: Review of facility policy titled, Elopement of Resident, revised 02/28/2021, revealed residents were to be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a resident leaves the premises without authorization. Assess, evaluate, and identify resident's elopement risk upon admission, re-admission, quarterly, or with a significant change in conditions as defined by the Resident Assessment Instrument (RAI) manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. For residents identified as at risk, an interdisciplinary elopement prevention resident-centered care plan would be developed with resident participation and resident representative when applicable. Interview with the Administrator, on 02/02/2022 at 4:30 PM, revealed the facility did not have a policy related to care plans. She stated the facility utilized the Resident Assessment Instrument (RAI) Manual, chapter four (4) as a guide to develop/revise the plan of care. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, Chapter four (4) dated October 2019, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well-developed and executed assessment and care plan: re-evaluate the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #1's clinical record revealed the facility admitted the resident on 10/08/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Elopement Risk Assessment, dated 10/08/2021, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #1 has a history of Dementia, Anxiety, and Depression. Continued review revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the assessment also noted the resident to be impulsive and to have a history of wandering that placed the resident at significant risk of getting to a potentially dangerous place. There was no scoring system on this Assessment. Resident #1's Comprehensive Care Plan, initiated 10/11/2021, revealed the resident was at risk for elopement related to Cognitive Loss/Dementia. The goal dated 10/11/2021, revealed the resident would not attempt to leave the facility without an escort through the next review (target date of 01/20/2022). The interventions as of 10/11/2021, included: encourage resident participation in activity preferences; allow time for expression of feelings; provide empathy, encouragement and reassurance; personalize resident's room with familiar items to assist him/her in identifying room; divert resident by giving alternative objects or activities; familiarize resident with own belongings and surroundings, and listen to resident and try to calm and as appropriate redirect resident if nears exits or doorways. Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 10/15/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8), out of fifteen (15) which indicated moderate cognitive impairment. Additional review revealed the facility assessed the resident as requiring limited assist of one (1) staff for transfers and as requiring supervision and assist of one (1) staff for ambulation. Additionally, the MDS Assessment revealed the resident had wandering tendencies daily. Review of Resident #1's Kardex report/Certified Nursing Assistant (CNA) Care Plan, dated as printed on 01/19/2022, with admitted [DATE], revealed there were no interventions on the care plan to address the resident's elopement risk. The yellow Elopement Binders located at the Nurse's Station on each of the two (2) halls (front and back halls), included Resident #1's Elopement Risk Identification form, undated, with demographic information, and also a photo of the resident. Review of the Progress Note, dated 10/15/2021 at 10:06 AM, revealed Licensed Practical Nurse (LPN) #2 documented regarding Resident #1: Wandering occurred daily or almost daily. The resident experienced impulsive behavior. Review of the Progress Note, dated 10/15/2021 at 11:25 AM, revealed LPN #2 documented regarding Resident #1: Resident wandered in the hallway, with no exit seeking noted at this time. Review of the Progress Note, dated 11/05/2021 at 5:02 PM, revealed Registered Nurse (RN) #2 documented regarding Resident #1: Resident wandered on the unit, confused but pleasant. Review of the Progress Note, dated 11/12/2021 at 4:06 PM, revealed RN #2 documented regarding Resident #1: Resident was confused and wandered on the unit. The resident stated he/she was a ghost and already dead. Review of the Progress Note, dated 11/26/2021 at 4:24 PM, revealed RN #2 documented regarding Resident #1: Resident wandered on the unit at times and talked about being a ghost. Registered Nurse (RN) #2 further documented the resident was often confused. Review of the Progress Note, dated 12/03/2021 at 9:45 AM, revealed RN #2 documented the resident (Resident #1) wandered on the unit, and was confused, alert, and oriented times one (1). She further stated the resident was often delusional in his/her thoughts, adding the resident stated he/she was a ghost and believed he/she was completing tasks like cleaning a garage. She further writes the resident stated he/she was just going home because {he/she} doesn't need to be here, but had not sought out an exit or packed his/her things. Review of the Elopement Risk Assessment, dated 12/20/2021 completed by Licensed Practical Nurse (LPN) #2, revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident voiced the desire to leave, made statements related to wanting to go home, and was impulsive with wandering tendencies. Although Resident #1's Elopement Risk Assessment, dated 10/08/2021 and 12/20/2021, revealed the resident was at significant risk of getting to a potentially dangerous place including stairs, or outside the facility, and the Progress Note, dated 11/05/2021 revealed the resident mentioned just going home because {he/she} doesn't need to be here, there was no documented evidence the Comprehensive Care Plan was revised with interventions related to supervision and monitoring. Review of the facility's Long Term Care Facility Self Reported Incident Form/Initial Report, dated 12/29/2021, faxed to the Office of Inspector General (OIG) on 12/29/2021 at 3:42 PM, revealed Resident #1 eloped on 12/29/2021. The facility was contacted at approximately 4:30 AM by an unidentified neighbor, within the community, who stated he witnessed an elderly person walking down the road with a cane and wanted to ensure he/she was not a resident. A physical room-to-room headcount was immediately initiated. During the ongoing headcount, the OTA headed to the vicinity the caller identified. After the headcount, Resident #1 was identified as unaccounted for. At approximately 4:45 AM, Resident #1 was located by the Occupational Therapy Assistant (OTA) and escorted back to the facility, and placed on one on one (1:1) monitoring. The Center Executive Director (CED) completed the Report. Resident #1's Progress Note, dated 12/29/2021 at 9:30 AM, written by the Center Nurse Executive (CNE), revealed the resident was noted to have mild complaint of tenderness to the right wrist upon movement, as well as, some discomfort upon movement to the left side. Further, the Physician was notified and an order was obtained for x-rays. Resident #1's Radiology report of the bilateral ribs and chest, dated 12/29/2021 at 12:28 PM, revealed: Left lateral 9-10 (ninth and tenth) rib fracture with displacement and mild soft tissue swelling. Further review of Resident #1's Comprehensive Care Plan, initiated 10/11/2021, revealed a revision with an intervention added on 12/29/2021, after the resident eloped, to monitor the resident's location with one-to-one (1:1) observation. Interview with the Occupational Therapist Assistant (OTA), on 01/20/2022 at 8:33 AM, revealed she arrived to work on 12/29/2021 at 4:30 AM. She stated when she arrived staff was checking the building as someone had called to say a possible resident was seen walking on a nearby road. Per interview, she got in her car and headed to the road the caller identified, and took a left turn. She stated before she got very far she saw someone walking which she identified as Resident #1. She further stated the resident agreed to get in the car with her and she returned the resident to the facility. Per interview, the resident was wearing jeans, a jacket, a toboggan, and carrying a cane and appeared as he/she would normally dress in the facility. Interview with Licensed Practical Nurse (LPN) #1, on 01/20/2022 at 3:06 PM, revealed she was assigned to Resident #1 on 12/29/2021, at the time of the elopement. She stated she last saw the resident in the dining area at 3:00 AM and he/she was up walking around as usual. Per interview, at 4:30 AM, she received a call from a male who identified himself as a nearby neighbor, stating he had seen a possible resident walking in the road and gave a brief description. She stated she then initiated a total headcount in the facility and it was discovered Resident #1 was not found in his/her room or anywhere in the facility. She further stated she had not heard any alarms going off prior to receiving the call from the neighbor. Further interview revealed she received a call from the Occupational Therapy Assistant at 4:45 AM, informing her Resident #1 had been found. Continued interview revealed she was unaware of any care plan interventions related to supervising and monitoring Resident #1 prior to the elopement. Interview with Registered Nurse (RN) #1, on 01/20/2022 at 8:15 AM, revealed she was working as the charge nurse on the night of 12/29/2021, and on that night she last saw Resident #1 around 3:00 AM. Per interview, at that time the resident was wearing jeans, a jacket, a toboggan, which was normal for the resident and he/she was also carrying a cane. Per interview, she did not hear an alarm sound that night prior to Resident #1 leaving the building. Further, RN #1 revealed the resident did not require increased supervision or a Care Plan revision related to the need for supervision and monitoring prior to the elopement, as the resident was not exit seeking. Interview with Certified Nursing Assistant (CNA) #2, on 01/20/2022 at 1:09 PM, revealed Resident #1 was agitated the night of 12/29/2021 and was up walking a lot prior to eloping. CNA #2 stated he and another staff member had gone out the back door to smoke around 3:00 AM and Resident #1 was in the building at that time. Per interview, the CNAs used the Kardex/CNA Care Plan to guide the care of the residents; however, there were no special precautions as far as supervision for this resident prior to the elopement. Interview with CNA #3, on 01/20/2022 at 3:53 PM, revealed she was assigned to Resident #1 on the night of 12/29/2021 and had assisted the resident with a bath which was the resident's usual time for bathing. Per interview, after the bath, the resident dressed and was wearing shirt, pants, jacket, house shoes with soles, and was walking with a cane. CNA #3 stated this was the way the resident always dressed. Further, the resident did not talk to CNA #3 about leaving the facility prior to his/her elopement and she did not hear any alarms go off that night. Further interview revealed the CNAs used the CNA Care Plan as a reference for providing care, but she did not remember any special interventions related to supervising and monitoring the resident prior to the elopement. Interview with the Minimum Data Set (MDS)/Registered Nurse (RN), on 01/21/2022 at 2:35 PM, revealed she was unaware of a care plan policy but utilized the Resident Assessment Instrument (RAI) Manual as a reference for developing and revising care plans. Continued interview revealed she, as the MDS Nurse, was responsible to develop/revise care plans on admission, quarterly, annually, and with significant change and the staff nurses updated care plans if there were changes in a resident's status or condition between MDS Assessments. Further interview revealed there was a Care Plan in place for Resident #1 related to being at risk for elopement; however, she further stated it was not revised to include specific interventions related to supervision and monitoring after the resident made remarks about going home, but should have. Interview with the Center Nurse Executive (CNE), on 01/20/2022 at 12:40 PM, and post survey on 02/11/2022 at 10:47 AM, revealed on 12/29/2021, LPN #1 received a call from an unidentified caller reporting a possible resident walking in the road. Per interview, Resident #1 had eloped and was found by the Occupational Therapy Assistant (OTA) at 4:45 AM. Further interview revealed although the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, she felt the resident's care plan had appropriate interventions in place prior to the elopement as the resident was just wandering and had not tried to actually exit the building. Telephone interview with the Center Executive Director (CED), on 01/21/2022 at 4:28 PM, revealed the resident's care plan related to his/her supervision level was adequate prior to the elopement since the facility had no knowledge that the resident had ever attempted to elope before. The facility implemented the following actions to remove the Immediate Jeopardy on 01/27/2022. 1. Resident #1 is no longer a resident of the facility as of 12/29/2021. 2. On 12/29/2021, Elopement Assessments were completed on forty-four out of forty-four (44/44) residents by the Assistant Director of Nursing (ADON). On 12/29/2021, a review of the Elopement Book was completed for inclusion of all residents identified as elopement risk for nine (9) out of nine (9) residents by the ADON. No new residents were assessed to be at risk for elopement at that time. On 12/29/2021, a review of all Comprehensive Care Plans and Certified Nursing Assistant (CNA) Kardex's/Care Plans for forty-four (44) out of forty-four residents was completed by the ADON to address the need for interventions related to increased supervision. No other residents required care plan updates or increased supervision at that time. 3. Starting 12/29/2021 through 01/05/2022, the Center Nurse Executive (CNE) and Assistant Director of Nursing (ADON) provided re-education with all staff regarding the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. A post-test to validate learning was completed for seventy-one (71) out of seventy-one (71) employees with a passing score of one hundred percent (100%). Any staff not available for education and post-test are required to complete mandatory re-education and post-test upon return to work. Newly hired staff will be provided education and complete a post-test during the orientation process. (The facility did not utilize agency staff) 4. On 12/29/2021 at 10:45 AM, the Maintenance Director checked all windows and doors. All windows were noted to be secure and all doors were in proper working order and alarms were functioning. At that time the door code to all facility doors was changed by the Maintenance Director. 5. On 12/29/2021 at 4:10 PM, Elopement drills were initiated by the Center Executive Director (CED) and Maintenance Director. Elopement drills are to be completed on each shift x seven (7) days, then one (1) shift per day x seven (7) days, then three (3) times per week x fourteen (14) days, then two (2) times a week x thirty (30) days, then one (1) time a week x thirty (30) days, then two (2) times a month x sixty (60) days, then monthly for two (2) months by the CED, CNE, member of Nursing Management or Maintenance Director. 6. On 12/29/2021 at 4:10 PM, Elopement education audits were initiated by the Center Executive Director and Maintenance Director. Elopement education audits are to be completed on each shift x seven (7) days; then one (1) shift per day x seven (7) days; then three (3) times per week x fourteen (14) days; then two (2) times a week x thirty (30) days; then one (1) time a week x thirty (30) days; then two (2) times a month x sixty (60) days; then monthly for two (2) months, by the CED, CNE, member of Nursing Management or Maintenance Director. 7. On 12/30/2021 at 4:30 PM, an Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting was held with the Center Executive Director (CED), Center Nurse Executive (CNE), and Medical Director, to discuss the elopement event at the facility regarding Resident #1, completion of a root cause analysis and staff re-education. 8. On 12/30/2021, a new Admission Questionnaire was formulated to be completed prior to each new admission by the Admission Director (AD), Center Executive Director, Center Nurse Executive (CNE) and Assistant Director of Nursing (ADON) regarding resident exit-seeking and elopement behaviors. On 12/30/2021, The Center Executive Director educated the CNE, ADON and AD regarding the use of the questionnaire during the admission process. 9. On 01/01/2022, implementation of the electronic Behavior Monitoring and Intervention tool in the Point Click Care system began for daily evaluation and documentation of behaviors and interventions. 10. On 01/03/2022, the Maintenance Director adjusted all door locking mechanisms to lock at ten (10) seconds upon exit. 11. On 01/21/2022, the Regional Property Manager suggested door delay alarms be purchased and placed on each door to decrease alarm times to ten (10) seconds for increased precaution. 12. On 01/24/2022, The Center Executive Director purchased door delay alarms for installation upon receipt on all exit doors for increased precaution. 13. On 01/24/2022, Exit door audits were initiated to review door function and alarm by the Maintenance Director with documentation to be completed in the Equipment Lifecycle System (TELS) weekly. 14. On 01/24/2022, the Center Executive Director re-educated the Maintenance Director to initiate a door code change as a need is identified and weekly x three (3) months, then bi-weekly x three (3) months, then monthly ongoing. 15. On 01/24/2022, a review of all residents' Progress Notes (44/44) from the prior three (3) months was completed by the Center Executive Director, Center Nurse Executive and Assistant Director of Nursing for exit-seeking behaviors. No additional residents were noted with exit-seeking behaviors and no increased supervision was required. Residents' Progress Notes will be reviewed for exit-seeking behaviors, interventions and need for increased supervision by the Center Nurse Executive, Assistant Director of Nursing or a member of Nursing Management for seven (7) days per week for two (2) weeks, then five (5) days a week x two (2) weeks, then three (3) days a week x four (4) weeks and then weekly x four (4) weeks. 16. On 01/24/2021, a review of the Behavior Monitoring and Intervention Report from 01/01/2022 through 01/24/2022, was completed for identification of exit-seek behaviors and interventions by the Center Nurse Executive, Assistant Director of Nursing or a member of Nursing Management. No additional residents were noted with exit-seeking behaviors or increased need for supervision. The Behavior Monitoring and Intervention Report will be reviewed for exit-seeking behaviors, interventions and increased need for supervision by the Center Nurse Executive, Assistant Director of Nursing or a member of Nursing Management starting 01/24/2022, seven (7) days per week for two (2) weeks, then five (5) days a week x two (2) weeks, then three (3) days a week x four (4) weeks and then weekly x four (4) weeks. 17. On 01/25/2021, the Center Executive Director, Center Nurse Executive and Assistant Director of Nursing, initiated re-education with all staff regarding the elopement policy, elopement risk identification form, behavior monitoring and interventions including increased supervision, identification of exit-seeking behaviors, identification of behavior changes indicative of exit-seeking behaviors, care planning for behavior changes, security of facility exits when entering and exiting the facility and security of the exit door key code. A post-test to validate learning was completed with seventy-two (72) out of seventy-three (73) staff with a passing score of 100%. Any staff unavailable at the time of education will receive education by the Center Executive Director, Center Nurse Executive or Assistant Director of Nursing upon their return to work. Newly hired staff will be provided education and complete a post-test during the orientation process. 18. On 01/26/2022, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the action plan including audits and re-education. QAPI members in attendance were as follows: Center Executive Director (CED), Center Nurse Executive (CNE), Assistant Director of Nursing (ADON), Health Information Manager, Business Office Manager, Clinical Reimbursement Specialist, Admissions Director, Maintenance Director, a CNA, RN, and LPN. Trends from the Elopement Drills, door function and alarm checks, Behavior Monitoring and Intervention audits, Nursing Progress audit and Care Plan and CNA Kardex updates will be identified and brought to the QAPI Committee weekly for four (4 ) weeks then monthly times six (6) months. The QAPI Committee consists of the CED, CNE, ADON, Human Resources, Food Services Director, Health Information Manager, Facility Medical Director, Housekeeping Manager, Business Office Manager, Clinical Reimbursement Specialist, Admissions Director, Director of Rehabilitation, and Maintenance Director. Additional follow up and/or in servicing will be completed until the issue is resolved and ongoing as determined by the QAPI committee. **The State Survey Agency validated the removal of immediate Jeopardy on 01/27/2022 as follows: 1. Review of the medical record revealed the facility discharged Resident #1 on 12/29/2021 at 3:45 PM to a sister facility. 2. Review of the Assessment History for Elopement Evaluation, revealed an Elopement Assessment was completed on 12/29/2021 for forty-four of forty-four (44/44) residents by the Assistant Director of Nursing (ADON). Review of the Elopement Book revealed nine (9) residents were assessed to be at risk for elopement. Review of the facility audits revealed Comprehensive Care Plans and CNA Kardex's were reviewed for forty-four (44) out of forty-four residents by the ADON. 3. Review of the signed In-service Records with the topic, Elopement and Behavior Management, dated 12/29/2021, revealed, seventy-one (71) out of seventy-one (71) employees were provided education with regarding the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. Post-test following education were reviewed with no concerns identified. Review of newly hired staff employee records, revealed two (2) staff were recently employed, and these staff members received education and completed a post-test regarding the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. Interview with Certified Medication Technician (CMT) #1, on 02/02/2022 at 4:47 PM, revealed she was hired on 01/13/2022 as a CMT for second shift. She stated during orientation she was educated on the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. Further, she completed a post-test. Interview with the Director of Rehab, on 02/02/2022 at 2:10 PM; Environmental Services Manager (EMS) on 02/02/2022 at 2:14 PM; Certified Nursing Assistant (CNA) #4 on 02/02/2022 at 2:18 PM; CNA #5 on 02/02/2022 at 2:50 PM; LPN #2 on 02/02/2022 at 2:26 PM; LPN #3 on 02/02/2022 at 2:37 PM; and the Dietary Manager on 02/02/2022 at 2:46 PM, revealed they received education related to the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. Further, they received a Post-test regarding the education. Interview with the Center Nurse Executive (CNE), on 02/03/2022 at 11:18 AM, revealed she and the ADON provided education to all staff on the elopement policy and procedures, identification and notification of exit-seeking behaviors, resident safety and increased supervision for residents at risk for elopement, door safety and alarm, accessing resident specific behaviors specifically exit-seeking behaviors and interventions on the Certified Nursing Assistant (CNA) Care Kardex and Person Centered Care Plan. She further stated they did a question and answer inservice and discussed scenarios. She further stated there was education related to the code yellow Elopement Binders, covering with your hand with inputting door codes and not sharing door codes. Per interview, post-tests were completed related to the education with no concerns noted. 4. Interview with the CED, on 02/03/2022 at 11:11 AM, revealed the Maintenance Supervisor had checked all door and windows on 12/29/2021 following the incident and all windows were noted to be secure and all doors were in proper working order and alarms were functioning. She stated the door codes were also changed at that time. The Maintenance Supervisor was unavailable for interview. 5. Review of the Emergency Preparedness Drills: Elopement Drill (Missing Resident), revealed elopement drills were conducted by the Maintenance Director, the CED and CNE beginning 12/29/2021 through 01/05/2022 on each shift; conducted daily 01/07/2022 through 01/11/2022; then conducted on 01/14/2022, 01/17/2022, 01/18/2022 and 01/31/2022. Signature Sheets and Post-tests were completed for all staff who participated during each drill. Interview with the Environmental Services Manager (ESM) on 02/02/2022 at 2:14 PM; Certified Nursing Assistant (CNA) #4, on 02/02/2022 at 2:18 PM; LPN #2 on 02/02/2022 at 2:26 PM; Dietary Manager on 02/02/2022 at 2:46 PM; LPN #3 on 02/02/2022 at 2:47 PM; CNA #5 on 02/02/2022 at 2:50 PM; revealed they participated in Elopement drills which were conducted by the CED, CNE, ADON, and Maintenan [TRUNCATED]

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure its infection prevention and control program adequately addressed the prevention of communicable diseases to the extent possible. The facility failed to properly screen visitors and staff for signs and symptoms of the COVID-19 virus prior to allowing the visitors and staff to enter the building. The facility also failed to educate visitors on the proper use of personal protective equipment (PPE) which was to be worn for Resident #94 who was on transmission-based precautions (TBP) due to possible exposure to the COVID-19 virus. The facility further failed to ensure its staff wore the proper PPE required when providing care for two (2) residents in isolation, Resident #194 and Resident #26. The facility additionally failed to ensure it staff wore appropriate eye protection when in resident care areas as required in a high transmission county, failed to complete the required fit testing necessary for the use of N95 masks (filtering facepiece respirators). The deficient practice occurred during the COVID-19 pandemic, and had the potential to affect all the facility's residents. The findings include: Review of the facility's policy titled, Supplemental Guidance for Placement of Admissions and Readmissions, with a revision date of 11/19/2021, revealed all newly admitted and readmitted residents required observation regardless of whether they had been vaccinated, partially vaccinated or were unvaccinated. Per review, the exclusion to observing newly admitted or readmitted resident was if the resident had been fully vaccinated and had received a vaccine booster. Continued review revealed the facility was to have an Admission Observation Unit (AOU) which would be utilized for newly admitted or readmitted residents in order to segregate those residents for a ten (10) day observation period. Review revealed unvaccinated residents or residents who had been vaccinated with a prolonged close contact with someone who was COVID-19 positive within the prior fourteen (14) days residing in the AOU, were to be under person specific Airborne and Contact Precautions. Further review revealed the patient specific contact and airborne precautions included the use of gloves, gown, a N95 Respirator, and eye protection for everyone entering the resident's room. In addition, the resident's room was to have a patient specific precaution sign posted on the door. Review of the facility's policy titled, Use of Goggles, Face Shields and N95 Respirators on and Off Units, with a revision date of 09/24/2021, revealed when a COVID-19 outbreak occurred in the facility, the affected units were to be placed on Contact (plus) Airborne Precautions. Per review, staff were to wear goggles or a face shield, in addition to, an N95 respirator for which the staff member had to have been fit tested for. Further review revealed for the AOU and its rooms, staff were to follow the same practices as described above due to the increased risk of having a COVID-positive resident. Review of the Centers for Disease Control and Prevention (CDC) publication titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/2021, revealed healthcare (HCP) working in facilities located in counties with a substantial or high transmission rate were to wear PPE such as, eye protection (goggles or a face shield which covered the front and sides of the face) during all patient (resident) care encounters. 1. Review of Resident #194's record revealed the facility admitted the resident on 11/19/2021. Further review of the record revealed the Admission Minimum Data Set had not been submitted yet, so cognitive status was not documented. Review of Resident #194's Physician's Orders, revealed an order with a start date of 11/19/2021, for the facility staff to initiate contact and airborne precautions due to the resident's recent hospitalization and possible exposure to COVID-19 during the hospitalization . Review of Resident #194's Care Plan revealed no documented evidence of the type of isolation precautions the resident was supposed to be on. Observation on 11/30/2021 at 9:33 AM, revealed Resident #194's room door was closed with a PPE bin located outside of the room door. Per observation, there was a sign on the door stating Resident #194 was on Airborne precautions. Continued observation revealed visitors and/or staff must see the nurse before entering Resident #914's room. Observation additionally revealed entrance into the resident's room required staff and visitors to don and wear an N95 respirator, gown, face shield, and gloves prior to entering. Observation on 11/30/2021 at 12:00 PM, revealed Nursing Assistant (NA) #1 delivered Resident #194's noon meal tray to the resident's room. Continued observation revealed however, NA #1 did not don the appropriate and required PPE prior to entering the Resident #194's room. Per observation, the NA entered the resident's room wearing only the facial mask he/she had been wearing prior to entering. Observation revealed NA #1 placed the meal tray on Resident #194's overbed table and then assisted the resident with repositioning in bed to eat his/her meal. Further observation revealed Resident #194 had a family member in the room, who was sitting by the resident's bed with no PPE on at all. Interview, at the time of observation, revealed the family member stated that the facility had screened them at the front door; however, had not educated them on what PPE needed to be worn while in the building or what PPE needed to be worn while visiting Resident #194 in his/her room. Observation further revealed the family member pulled a face mask out of their pants' pocket and stated they knew they had to wear a face mask when they entered the facility, but that was all that staff had told them. Observation on 12/01/2021 at 8:46 AM, revealed no evidence of the PPE isolation bin which had been located outside Resident #194's room previously. In addition, observation revealed the door signage had also been removed. Interview on 12/01/2021 at 8:49 AM, with Licensed Practical Nurse (LPN) #2, revealed Resident #194 was not on any type of isolation. Per interview, the LPN did not know the Resident #194's vaccination status. LPN #2 further stated residents who had not been vaccinated were on isolation for ten (10) days after being admitted . Interview on 12/02/2021 at 1:59 PM, with the Director of Nursing (DON) revealed Resident #194 had refused the vaccine when it was offered to him/her by the facility. Per interview, unvaccinated residents were on quarantine for ten (10) days after admission. The DON stated Resident #194 had been admitted on [DATE], and should have been taken off the quarantine isolation on 11/30/2021. Continued interview revealed The DON if a resident was on any type of isolation while on quarantine and had a visitor, the visitor was only required to wear a mask. Per the DON however, staff must wear full PPE when in the room of a resident who was on isolation while in quarantine. Further interview revealed visitors were given a face mask while being screened at the front of the facility. The DON additionally revealed visitors used to be provided an information sheet on what PPE to wear for the resident they were visiting; however, the DON believed visitors were no longer being provided those handouts. 2(a). Review of Resident #26's record revealed the facility admitted the resident on 11/04/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #26 dated 10/14/2021, revealed the facility had assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #26's Physician's Orders revealed an order, with a start date of 12/21/2020, for [MEDICATION(S)] Nebulization Solution (a breathing treatment) every two (2) hours as needed for wheezing or shortness of breath. Observation on 11/30/2021 at 9:58 AM, revealed a PPE bin located in front of Resident #26's room door. Per observation, there was also a sign on the resident's door with which had a STOP sign that stated, Aerosol Generating Procedure in Progress. Please do not enter. If you must enter, remember .Wear an N95 respirator, gown, face shield, and gloves upon entering this room. Keep room door closed. Continued observation revealed LPN #1 was in Resident #26's room administering a nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further observation revealed LPN #1 walked out of Resident #26's room while stating there were no residents on isolation precautions at that time on that hall. Interview revealed LPN #1 stated the only PPE required for staff to wear was a regular facial mask. Observation further revealed LPN #1 walked to the nursing desk, where Registered Nurse (RN) #1 was sitting, and LPN #1 asked RN #1 why PPE bins were located outside of two (2) of the residents' rooms. RN #1 was observed and overheard telling LPN #1 the residents had been on isolation precautions; however, were no longer on the precautions, therefore the PPE bins were no longer needed and should have been moved. Observation on 11/30/2021 at 11:19 AM, revealed Resident #26 stated I can't breathe, to RN #1 who was in the resident's room wearing only a facial mask with no other PPE. Per observation, RN #1 stated Resident #26's pulse oximetry was 90% with the resident having six (6) liters of oxygen administered per minute via nasal cannula. Continued observation revealed RN #1 exited Resident #26's room to don a gown and gloves from the PPE bin located outside the resident's room door. The Surveyor attempted to interview Resident #26; however, the resident declined to be interviewed at that time. Further observation revealed RN #1 reentered Resident #26's room and informed the resident the RN would have LPN #1 provide pain medication for the resident to assist with his/her breathing difficulty. Interview on 12/01/2021 at 8:49 AM, with LPN #2 revealed she had been assigned to Resident #26's care that day. Per interview, the LPN stated Resident #26 was only on isolation when he/she was receiving a nebulizer treatment, due to that being an aerosol procedure. Interview on 12/02/2021 at 2:05 PM, the DON revealed Resident #26 was only on isolation precautions when he/she received an aerosol generating procedure (such as a nebulizer treatment). The DON stated, It's a policy that our corporation put into effect. It's an extra precaution. Further interview revealed during any aerosol generating procedure, staff must wear PPE to include a gown, N95 mask, goggles or face shield; however, only had to wear the PPE while the procedure was going on. 2(b). Review of the facility policy titled, IC405 Covid 19, dated 3/27/2020 and revised 06/07/2021, revealed, active screening was to be performed of all persons who entered the facility. Per review, all persons included employees, visitors, medically necessary personnel, contracted staff or vendors and volunteers. Review of the facility policy titled, Screening of Visitors and Employees, Return to Work Guidance for Employees, and Employee Workers Comp Procedures, dated 10/20/2021, revealed visitors with a temperature of 100 F [Fahrenheit] or higher or any listed signs or symptoms would not be permitted to enter the facility. Continued review revealed family visitors meeting any of the following would not be permitted entry into the facility: a fever or other symptoms as located on the screening form. Review of the facility policy titled, Screening Form Instructions for Screeners, dated 06/15/2021, revealed, visitors were to be screened for any symptoms and a temperature. Per review, the findings were to be recorded on the screening form for employees, and visiting healthcare personnel (HCP), and on the visitor's log. Upon entering the facility on 12/01/2021 at 7:40 AM, two (2) Surveyors had their temperatures obtained by the facility's Activities Director (AD); however no screening questions were asked of the Surveyors. Observation on 12/01/2021 at 7:54 AM and 8:00 AM, revealed a Surveyor entering the facility and the AD obtained that Surveyor's temperature; however, once again no screening questions were asked. 2(c). Review of the facility policy titled, SH408 Respiratory Protection and use of Respirators, dated 10/15/2009 and revised 11/01/2021, revealed the facility was to provide appropriate respiratory protection equipment, at no cost for its employees in accordance with the Occupational Safety and Health Administration (OSHA) standards. Per review, the OSHA standards included medically evaluating the employee for his/her ability to safely use a respirator, follow the fit testing guidelines and procedures in the Vita Learn Respirator Fit testing education to ensure employees were fit tested prior to using any N95 respirator, and employees were to follow the procedures for proper respirator use. Observation on 11/30/2021 at 10:03 AM, revealed LPN #1 had just completed providing a nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation during a medication (med) pass observation on 12/02/2021 at 3:12 PM, with LPN #1, revealed the LPN provided a nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, at the time of observation, revealed the LPN was unable to see through the face shield due to it fogging up. Further interview revealed LPN #1 again informed the Surveyor of not having been fit tested for the N95 mask the LPN was wearing over the face mask; however, had recently been told wearing an N95 mask was required when administering a nebulizer treatment. Interview on 12/01/2021 at 3:49 PM, with the Assistant Director of Nursing (ADON), who was also the facility's Infection Control Nurse revealed if a resident was receiving aerosol nebulizer treatments or were new admits to the facility, staff should adhere to the door signage for those residents. Continued interview revealed for those residents staff should wear a gown, gloves, N95 mask, and eye protection (a face shield or goggles), and ensure the resident's room door remained closed. Interview with the DON, on 12/01/2021 at 3:55 PM, revealed all staff received training on wearing N95 masks with a seal test prior to entering a resident's room during the pandemic. The DON demonstrated sealing her own mask across the nose bridge and adjusting the sides of the mask. Continued interview revealed the DON had taught the seal test procedure in order staff to do the seal test quickly prior to entering a resident room. The DON confirmed the facility had several different types of N95 masks and had not completed fit testing for staff. 3. Observation on 12/02/2021 at 7:14 AM, revealed LPN #1 was sitting at the nurse's desk in the facility's Back Hall area using the telephone. Per observation, a person outside the facility approached the exit door in the Back Hall area and motioned at the Surveyor to allow them entrance to the facility. The Surveyor informed LPN #1 that the Surveyors were not allowed to open exit doors and allow outside persons into the facility. Continued observation revealed the person outside again motioned at the Surveyor to let them in the door. The Surveyor informed Certified Nursing Assistant (CNA) #2, who had been walking down the hall, of the person outside the exit door which the Surveyor did not know and could not let in the door. Further observation revealed CNA #2 punched the entrance code for the exit door and allowed the person outside to enter the facility without being screened for the COVID-19 virus. Interview on 12/02/2021 at 7:40 AM, revealed LPN #1 stated the person standing outside the exit door had been a doctor. Per interview, the LPN had never seen a doctor use that exit door before to gain entrance into the facility. LPN #1 stated the doctor was let into the facility by another staff person while the LPN had been on the telephone. Further interview revealed that was why the doctor was not stopped for screening. Interview on 12/02/2021 at 7:42 AM, with CNA #2 revealed the CNA had not known who the person had been standing outside the exit door and, had thought the person was someone with the Surveyor. When the Surveyor reiterated telling CNA #2 he/she did not know the person outside the exit door, the CNA stated Oh. Interview on 12/02/2021 at 8:54 AM, with the DON, revealed the DON had been made aware of the doctor having been let into the facility without being screened. Per interview, the CNA had informed the DON the Surveyor had requested the CNA let the doctor in the building. The Surveyor then informed the DON of what had been told to the CNA regarding the Surveyor not knowing who the person was standing outside the exit door and that the Surveyor was not allowed to let the person into the facility. Further interview revealed nobody should use the exit door as an entrance to the facility. The DON further confirmed everyone must use the facility's business office door for entrance in order to be screened prior to entering the building.

Based on observation, interview, and record review (should this say, facility policy review and not record review?), it was determined the facility failed to ensure resident rooms were equipped and/or located near a toilet and bathing facilities for twenty-six (26) of twenty-seven (27) rooms reviewed for variances. The findings include: Observation, on 11/30/2021 during the initial tour of the facility, resident rooms #1 through #12 were observed to accommodate fourteen (14) residents. Per observation, the rooms referenced did not have a private toilet room for the fourteen (14) residents' use. Continued observation revealed four (4) bathrooms with lavatories which the facility utilized to accommodate the residents residing in rooms #1 through #12. Observation of resident rooms #13 through #15, revealed the rooms accommodated eight (8) residents, with no private toilet rooms observed. Further observation revealed the facility utilized two (2) central bathrooms with two (2) lavatories to accommodate the eight (8) residents residing in rooms #13 through #15. Observation revealed resident rooms #17 through #26, were semi-private rooms that shared a toilet with an adjoining room; however, did not have a lavatory in each of the resident rooms. Per continued observation, residents were assisted to the bathrooms by staff; however, the layout of the bathrooms revealed residents who utilized wheelchairs for mobility were not accommodated. Further observation revealed the facility provided bedside commodes for residents' use which were being utilized by the residents. Interview on 11/30/2021 at 4:20 PM, with the Administrator, and provision of documentation revealed the facility had a waiver for the resident room sizes and for the lavatories not being located in or near each resident's room. Review of the letter dated 05/01/2006, provided by the Administrator, revealed the facility's waivers had been granted on 09/14/1977. Further interview revealed the Administrator stated the facility had not applied for a new waiver for the lavatories and was unaware of how often the waivers were required to be approved. Interview on 12/02/2021 at 7:50 AM, with the Maintenance Director revealed the facility did not have bathrooms located in the resident rooms on the facility's Front Hall, which were resident rooms #1 through #12. Continued interview revealed however, the facility provided bedside commodes and bathrooms located in the hallway for residents' use. Observation at the time of interview, revealed in order to reach a bathroom to use, a resident had to ambulate or wheel himself/herself in a wheelchair, down the hallway and turn a corner to access the bathroom. Continued observation revealed the Maintenance Director measured the distance between resident room #2 to the closest bathroom, with the results being approximately fifty-four (54) feet to the nearest bathroom. Further observation revealed the Maintenance Director measured the distance from resident room #12 to the closest bathroom as approximately twenty-three (23) feet.

Based on interview and record review, it was determined the facility failed to notify the resident and/or the resident's representative(s) of a hospital transfer in writing for two (2) of three (3) sampled residents, Resident #40, Resident #36, reviewed for hospitalization , out of the total sample of sixteen (16) residents. The findings include: The Survey Team requested a policy regarding the deficient practice; however, facility staff reported the facility had no such policy. 1. Review of Resident #40's record revealed a facility transfer form dated 10/26/2021 at 9:45 PM, which noted the resident had been sent to a local hospital due to a gastrointestinal (GI) bleed. Per review, there was no documented evidence related to facility staff having notified the resident and/or resident representative of the resident's transfer to the hospital. 2. Record review of a Resident #36's progress notes, revealed Resident #36 was sent to a local hospital on 10/28/2021 due to an altered mental status. Further review of the record revealed there was no documentation related to notifying the resident and/or resident representative of the resident's transfer to the hospital. Interview on 12/01/2021 at 10:53 AM, with the Director of Nursing (DON), revealed they only notified the family member via telephone when a resident was sent out to the hospital. Per interview, the facility did not provide a letter to the resident or resident's representative for hospital transfers; however, they did notify the Ombudsman of this information, via electronic mail (email) on a monthly basis. Interview on 12/02/2021 at 6:15 PM, with the Administrator, revealed they only notify the family verbally when a resident was transferred to the hospital.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure all residents were provided proper nail care necessary for residents dependent on nail care for one (1) of sixteen (16) sampled residents, Resident 40). Observation revealed Resident #40's fingernails were not trimmed and there was a dark brown substance underneath all his/her fingernails. The findings include: Review of the facility's policy titled, ADL: Fingernail Care, with an effective date of 12/01/2006, revealed, for the Activity of Daily Living (ADL) facility staff were to trim and clean a resident's fingernails as needed or requested. Per review, the purpose of providing appropriate nail care for residents was To promote hygiene of hands and nails. Record review revealed the facility admitted Resident #40 on 11/01/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's five (5) Day Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility had assessed Resident #40 with a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated moderate cognitive impairment. Continued review of the MDS Assessment revealed the facility had assessed Resident #40 as totally dependent regarding personal hygiene and requiring assist of one (1)person to complete his/her hygiene needs. Review of Resident #40's Comprehensive Care Plan, with a revision date of 09/21/2021, revealed the facility had care planned the resident to require assistance with all his/her ADL care. Per review, the interventions included for one (1) staff person to provide Resident #40 with the extensive assistance he/she required for grooming and/or personal hygiene. Observation on 11/30/2021 at 9:35 AM, revealed Resident #40 was lying on the bed in his/her room. Per observation, Resident #40's fingernails were approximately one quarter (1/4) inch to one half (1/2) inch long extending past the resident's fingertips. Continued observation revealed all of Resident #40's fingernails contained a dark brown substance underneath all of the nails. The Surveyor attempted to interview Resident #40 regarding his/her fingernails, at the time of observation, however, the resident did not respond when questioned. An additional observation on 12/01/2021 at 8:59 AM, revealed Resident #40 lying on the bed in his/her room with his/her hands under the covers. The Surveyor asked Resident #40 if he/she would show his/her hands to the Surveyor. Resident #40 removed his/her hands from under the covers, and observation revealed the resident's fingernails remained grown out and with the dark brown substance under all the nails. Interview at the time of observation revealed, Resident #40 stated staff never trim or clean my nails, while rubbing his/her fingertips over the elongated nails. Interview, on 12/01/2021 at 9:06 AM, with Certified Nursing Assistant (CNA) #1 revealed he/she was responsible for providing Resident #40's nail care needs. Per interview, nail care was typically completed on the resident's bath/shower day. CNA #1 stated Resident #40's bath day had been changed, so the CNA was unsure of when the last time was the resident had received a bath. Continued interview revealed all residents' nails were to be kept clean and trimmed to ensure they won't cut themselves. CNA #1 revealed the CNA had not provided any care to Resident #40 yet that day; however, had been assigned to the resident's care. Per the Surveyor's request, CNA #1 entered Resident #40's room at that time to look at the resident's nails. Further interview revealed the CNA stated, Oh, yeah, those are dirty and way too long. I will get them trimmed today. Observation at that time revealed CNA #1 asked Resident #40 if it was okay for the CNA to trim his/her nails, and the resident stated, Yes, please. Interview on 12/01/2021 at 9:14 AM, with Licensed Practical Nurse (LPN) #2 revealed the CNA's completed the nail care on residents, unless the resident was a Diabetic or on anticoagulant medication, in which case the nurses provided the nail care. Per interview, the CNA's were to complete nail care for residents as needed, particularly on the residents' bath days. LPN #2 further stated CNA's were to make sure residents' fingernails were not long and dirty, with debris underneath the nails. Interview on 12/01/2021 at 9:50 AM, with the Director of Nursing (DON) revealed the facility's expectations was for nail care to be completed by a CNA on each resident's bath day and as needed, unless the resident was Diabetic or on anticoagulants. Per interview, if a resident was Diabetic or on anticoagulants, then nail care was the nurse's responsibility. Further interview revealed it was ultimately the nurse's responsibility to ensure each resident's nails were kept clean and trimmed.

Based on observation, interview, and review of facility documentation, it was determined the facility failed to ensure two (2) of it's twenty-seven (27) rooms measured at least eighty (80) square feet per resident in multiple resident rooms, or one hundred (100) square feet in single resident rooms, resident rooms #13 and #15). The findings include: Review of the facility's wavier document dated 08/01/2018, from the Centers for Medicare and Medicaid (CMS) revealed the facility had been granted a waiver for resident rooms #13 and #15 for variations of the resident's room size. Further review of the waiver document revealed an expiration date of 02/21/2021 for the resident room waiver. Continued review of the facility's documentation revealed no documented evidence the facility submitted a waiver request for rooms 13 and 15, prior to the expiration date, nor of a waiver having been granted for those rooms after the expiration on 02/21/2021. Observation on 12/02/2021 at 11:10 AM, of Room #13 revealed the room measured approximately 28' (feet) W (wide) by 12' L (long), and Room #15 measured approximately 28' W by 12' L. Per observation, each room contained four (4) residents' beds and two (2) wardrobe closets which measured approximately 10' by 2'. Further observation revealed both resident rooms were less than the required eighty (80) square feet per resident. Interview on 12/02/2021 at 1:17 PM, with the Administrator, revealed the facility had been provided no guidance on how long the resident room waivers lasted. Continued interview revealed the residents residing in rooms #13 and #15 were living in less than the required square footage. In addition, the Administrator revealed resident rooms #13 and #15 contained four (4) residents' beds in each room.

Based on interview, and review of the Code of Federal Regulations (CFR), it was determined the facility failed to ensure two (2) of twenty-seven (27) rooms measured at least eighty (80) square feet (ft) per resident in multiple resident bedrooms or one-hundred (100) square ft in single resident rooms (Rooms #13 and #15). The findings include: Review of CFR 483.90(e)(1)(ii), implemented 11/28/17, revealed measurement of square footage measure at eighty (80) square feet per resident in multiple resident rooms and at least one-hundred (100) square feet in a single resident's room. room [ROOM NUMBER] measured 27' 9'' W by 11' 11 L and room [ROOM NUMBER] measured 27' 10 W by 11' 11 L, each room housed four (4) residents and contained two wardrobes that measured 10 foot by 2 foot, on 02/21/18. Both rooms housed four (4) residents which left less than eighty (80) square feet per resident. Observation on 10/14/19 revealed both rooms still contained the wardrobes and housed four (4) residents. Interview (Post Survey) with the Administrator, on 12/12/19 at 10:04 AM, revealed the facility had a waiver for the rooms and there were still four (4) beds in each room.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure recipes were being followed for meals being developed in the kitchen for the facility residents during supper meal preparation. The findings include: Review of the facility policy titled, Food: Quality and Palatability, last revised (MONTH) (YEAR), revealed menu items are prepared according to the menu and standardized recipes. It further states the cooks prepare food in accordance with recipes. Observation during follow up visit to the kitchen on 07/18/18 at 8:25 AM, revealed Cook #1 was making cucumber salad for the residents' lunch meal without using a recipe and adding ingredients without a recipe. Interview with Cook #1 on 07/18/18 at 8:25 AM, revealed she normally makes the cucumber salad without a recipe and goes by what she knew for the cucumber salad. She stated she is supposed to use the recipes. Interview on 07/18/18 at 8:36 AM with the Dietary Manager, revealed she expected recipes to be followed for everything that is made in the kitchen for the residents. Interview on 07/19/18 at 3:19 PM with the facility Administrator, revealed she expects the kitchen staff to follow the facility policies and procedures related to using recipes.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 07/17/18, revealed food being stored in the freezer was open to air and unsealed and the kitchen's manual can opener was visibly dirty. Review of the Census and Condition, dated 07/17/18, revealed forty-seven (47) of forty-eight (48) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Food Storage: Cold Foods, last revised (MONTH) (YEAR), revealed all foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Observation of Freezer #3 on 07/17/18 at 10:28 AM, revealed a box of dinner rolls open and unsealed. 2. Review of facility policy titled, Equipment, last revised (MONTH) (YEAR), revealed all food service equipment will be clean, sanitary and in proper working order. Further review of the policy, revealed all equipment will be routinely cleaned and all food contact equipment will be cleaned and sanitized after every use. Observation of the kitchen on 07/17/18 at 10:33 AM, revealed the can opener had a build up of brownish/black colored crust like material on the cutting edge and area surrounding the cutting edge. Interview with the Dietary Manager on 07/18/18 at 8:36 AM, revealed she expected the can opener to be cleaned after each use and to be run through the dishwasher every shift. She stated she expected all food items stored in the freezer to be sealed completely and not left open to air. Interview with facility Administrator on 07/19/18 at 3:19 PM, revealed she stated she expects the staff to also follow the facility policy and procedures in regards to cleaning the kitchen equipment and sealing of foods in the freezers.

Based on interview, and review of the Skilled Nursing Facility Beneficiary Protections Notifications it was determined the facility failed to ensure they issued the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents/beneficiaries when Medicare covered services were ending for two (2) of three (3) Medicare discharged unsampled residents (Resident #32 and #100). Review of Resident #32's and #100's Medicare Discharges, revealed the facility did not issue a SNFABN CMS Form . The findings include: Interview with facility Administrator on 07/19/18 at 03:18 PM, revealed the facility did not have a specific policy for issuing the SNFABN. 1. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #32 from Medicare Part 'A' services with the last covered day being 03/21/18; however, the resident still had benefit days that were not exhausted. Further review of this Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNFABN form CMS- . 2. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #100 from Medicare Part 'A' services with the last covered day being 04/8/18; however, the resident still had benefit days that were not exhausted. Further review of this Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNFABN form CMS- . Interview with the Administrator on 07/19/18 at 3:18 PM, revealed the facility had not issued the forms as per federal requirement due to they had a different understanding on the criteria related to some other information they had. She stated the facility is expected to follow the federal guidelines related to issuing the SNFABN notices.

Based on observation, interview, and review of the Code of Federal Regulations (CFR), it was determined the facility failed to ensure two (2) of twenty-seven (27) rooms measured at least eighty (80) square feet per resident in multiple resident bedrooms or one-hundred square feet in single resident rooms (Rooms #13 and #15). The findings include: Review of (CFR) 483.90(e)(1)(ii), implemented 11/28/17, revealed measurement of square footage measure at eighty (80) square feet per resident in multiple resident rooms and at least one-hundreds (100) square feet in single resident rooms. Observation of room measurements performed by the Maintenance Director, on 02/21/18, revealed the following: 1. room [ROOM NUMBER], occupied four (4) residents, measured 27' 9'' W by 11' 11 L with two wardrobes measuring 10 foot by 2 foot each which left less than 80 square foot per resident. 2. room [ROOM NUMBER], occupied by (4) residents, measured 27' 10 W by 11' 11 L, with two non-movable wardrobes measuring 10' by 2 which left less than 80 sq ft per resident . Interview on 02/21/18 at 1:05 PM, with the resident in room [ROOM NUMBER]B, revealed the room is to small for (4) residents. The resident stated although a privacy curtain is available, there is still not enough space to visit or keep many personal items. Interview with the Maintenance Director, on 02/21/18 at 11:40 AM, revealed he was made aware the rooms were below Federal requirements by the Regional Property Manager; however, the rooms were measured prior to his employment. Further interview revealed the facility will apply for a waiver. Interview with the Administrator, on 02/21/18 at 1:15 PM, revealed the facility does not have a waiver for the rooms that do not meet Federal requirements. She stated the facility will apply for a waiver to accommodate the deficient space.

Based on interview, record review, and review of Diseases and Conditions Scabies from the Mayo Clinic, it was determined the nursing staff were performing out of their scope of practice by diagnosing residents to have scabies and providing treatment for [REDACTED].#2, #5 and #7) and seven (7) unsampled residents (Resident's #A, #B, #D, #E, #F, #G and #H). On 05/04/17, the Medical Director assessed seven (7) residents with the Assistant Director of Nursing (DON) and diagnosed them as having scabies and ordered treatment for [REDACTED]. to the blanket order for scabies treatment of [REDACTED]. This required the ADON to go outside his/her scope of practice and diagnose Residents #2, #5 and #7, and Unsampled Residents #A, #B, #D, #E, #F, #G and #H with scabies. The findings include: Interview with the Vice President of the Kentucky Board of Nursing, on 05/10/17 at 10:00 AM, revealed a Medical Doctor or Advanced Registered Nurse Practitioner or Physician's Assistant must assess and give a [DIAGNOSES REDACTED]. She stated diagnosing was out of the scope of practice for a Registered Nurse (RN) or Licensed Practical Nurse (LPN). She stated a nurse can assess the resident for signs and symptoms but the Physician or Extender must make the diagnosis. Review of the method of testing for Scabies found in the Diseases and Conditions Scabies from the Mayo Clinic, dated 07/07/15, revealed to diagnose scabies, a doctor [MEDICATION NAME] the skin, looking for signs of mites, including the characteristic burrows. When a doctor locates a mite burrow, he/she may take a scraping from that area of the skin to examine under a microscope. The microscopic examination can determine the presence of mites or their eggs. In addition, the Center for Disease Control and Prevention Guidelines, dated 11/29/13, revealed a [DIAGNOSES REDACTED]. Whenever possible, the [DIAGNOSES REDACTED]. This can be done by carefully removing the mite from the end of its burrow using the tip of a needle or by obtaining a skin scraping to examine under a microscope for mites, eggs, or mite fecal matter (scybala). However, a person can still be infested even if mites, eggs, or fecal matter cannot be found; fewer then 10-15 mites may be present on an infested person who is otherwise healthy. Review of Residents' #2, #5 and #7, and Unsampled Residents #A, #B, #D, #E, #F, #G and #H skin assessments and physician's orders [REDACTED]. The treatment was completed on 05/04/17 for each resident. Interview with the ADON, on 06/01/17 at 8:18 AM, revealed she made rounds with the Medical Director on 05/04/17, and as she made rounds with the Medical Director, the Medical Director assessed seven (7) residents and diagnosed them as having scabies. She stated the Medical Director ordered [MEDICATION NAME] five (5%) cream to be applied for those seven (7) residents. She stated the Medical Director left her a blanket order to treat any other residents who she may find that had the scabies type characteristic rash. She stated during her rounding with the Medical Director he had showed her what to look for when determining if a resident had scabies. She stated she determined, through performing skin assessments, there were an additional ten (10) residents (Resident's #2, #5, and #7, and Unsampled Residents #A, #B, #D, #E, #F, #G and #H) that had what looked to be scabies and she took the blanket order the Medical Director left her, made copies of the order and added the additional ten (10) residents' names to the orders for treatment using the [MEDICATION NAME] cream. She stated she made the decision to treat the additional ten (10) residents with the [MEDICATION NAME] cream based on her decision and assessment. She stated she did not consult the Medical Director or any another physician prior to making the determination that those other residents had scabies and needed treatment. She further stated it is not in her scope of practice to diagnose. Interview with the Medical Director, on 06/01/17 at 1:29 PM, revealed he did go to the facility on [DATE] and looked at several residents who had been itching and had a rash. He stated he diagnosed several of the residents as having scabies and ordered [MEDICATION NAME] cream for treatment. He stated he left a blanket order for the nursing staff to treat any additional residents that the nursing staff thought had scabies after the staff assessed them. He stated during rounds on the residents he showed the ADON what to look for to determine what scabies was. He stated he felt like it would be alright for the nursing staff to determine which other residents had signs and symptoms of scabies and to treat those residents with [MEDICATION NAME] cream by using the blanket order he left. Interview with the Director of Nursing (DON), on 06/01/17 at 9:04 AM, revealed she was aware the Medical Director left a blanket order for the ADON and that the ADON assessed ten (10) additional residents as having scabies and used the blanket order to treat the ten (10) additional residents with [MEDICATION NAME] cream. She stated she did not think it was inappropriate for the ADON to make a decision as to what additional residents appeared to have scabies and be treated for [REDACTED]. She stated the ADON was taught how to determine what scabies was when she did rounds with the Medical Director and the Medical Director taught the ADON what to look for. Interview with facility Administrator on 06/01/17 at 9:33 AM, revealed she would not expect a licensed staff member to make any type of medical [DIAGNOSES REDACTED].

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of eleven (11) sampled residents were treated and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality (Resident #4). Observation on 05/31/17 at 8:50 AM, revealed Housekeeper #4 opened Resident #4's door without knocking and the privacy curtain was not pulled all the way around the resident; leaving the resident undressed and visible to visitors in the hallway. The findings include: Review of the facility policy; OPS213 Treatment: Considerate and Respectful, dated 06/01/96 and last revised 09/01/13, revealed the facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity means that in their interactions with patients, staff carry out activities that assist the resident to maintain and enhance his/her self esteem and self worth. Purpose: To provide residents the right to a quality of life that supports independent expression, decision making, and respect. 1.6 Respect residents' private space and property 1.6.2 revealed to knock on doors and request permission to enter. 1,8 Privacy revealed to maintain resident privacy of body including keeping residents sufficiently covered. Record review revealed the facility admitted Resident #4 on 04/26/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/17, revealed the facility assessed Resident #4's cognition as moderately impaired with a Brief Interview for Mental Status score of nine (9) indicating the resident was interviewable. Observation on 05/31/17 at 8:50 AM, while this surveyor was in the resident's room observing a skin and wound assessment, revealed Housekeeper #4 opened the resident's door without knocking. The resident was undressed and the privacy curtain was not pulled all the way around the resident leaving the resident undressed and visible to visitors in the hallway. Interview with Resident #4 related to the housekeeper entering the room, on 06/02/17 at 11:30 AM, revealed he/she felt ashamed when someone left his/her door opened while he/she was undressed. She stated I don't want to be seen. Interview with the Certified Occupational Therapy Assistant, on 06/02/17 at 11:00 AM, revealed while assisting with Resident #4's Skin Assessment and Wound Care, she tried to ensure the door was closed and the privacy curtain was pulled completely around the resident while any treatment was was being provided per the facility policy. Interview with Licensed Practical Nurse (LPN) #1, on 06/12/17 at 8:30 AM, revealed she should have pulled the curtain completely around the resident to ensure privacy and dignity during the resident's skin assessment and wound assessment. She stated she should have immediately asked the housekeeper to close the door instead of leaving it open during the conversation between her and the housekeeper. Interview with Housekeeper #4, on 06/01/17 at 9:05 AM, revealed she was supposed to knock on the door prior to entering the room and she did not knock on the door yesterday. She stated she should have knocked on the door and stated I was not thinking. Interview with the Housekeeping Supervisor, on 06/01/17 at 9:15 AM, revealed the policy stated to never walk into a room without knocking first to make ones self known whether the door was open or closed. She stated staff had been educated on the policy and she expected all of her staff to follow the policy since this was the resident's home and personal private space. Interview with the Director of Nursing (DON), on 06/02/17 at 10:10 AM, revealed she expected staff to follow the policy for privacy for all residents and for staff to knock on doors prior to entering a resident's room.

Based on observation, interview, record review and facility policy review, the facility failed to ensure care was provided by qualified persons in accordance with each resident's written plan of care for two (2) of eleven (11) sampled residents (Residents #1, #4). Resident #4 was care planned for two (2) staff to provide extensive assistance for bed mobility; however, observations of Resident #4 on 05/30/17 from 11:45 AM to 12:50 PM, and from 1:45 PM to 2:50 PM, and at 3:20 PM, and 3:45 PM, revealed no staff entered the resident's room to turn or reposition the resident. The resident remained on his/her back throughout the observations. Resident #1 was care planned for one (1) staff to provided total care for bathing, dressing and grooming; however, observations revealed Resident #1 remained in the same sweatshirt with food on it from 05/30/17 through 05/31/17. In addition, the resident's dentures were not in his/her mouth. The findings include: Review of the facility policy titled, OPS416 Person-Centered Care Plan, dated 11/28/16, revealed the center must develop and implement a baseline person-centered care plan within forty-eight (48) hours for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. The purpose is to attain or maintain the patient's highest practicable physical, mental and psychosocial well-being. Record review revealed the facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/17, revealed the facility assessed Resident #4's cognition as moderately impaired with a Brief Interview for Mental Status score of nine (9) indicating the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance with two (2) persons for bed mobility. Review of the Resident #4's Comprehensive Care Plan last revised 05/23/17, and Certified Nurse Aide (CNA) Care Plans, not dated, revealed to provide extensive assist of two (2) people for bed mobility; however, observations of Resident #4 on 05/30/17 from 11:45 AM to 12:50 PM, from 1:45 PM to 2:50 PM, and at 3:20 PM, and 3:45 PM revealed the resident was on his/her back and no staff entered the resident's room to turn or reposition the resident in bed per the care plan. Interview with Certified Nurse Aide (CNA) #2, on 06/01/17 at 9:25 AM, while she was performing personal care for Resident #4, revealed Resident #4 mostly turns him/herself; however, Resident #4 spoke up and stated, I cannot turn myself. CNA #2 could not explain why the resident was on his/her back during the observations this surveyor made on 05/30/17 and stated the resident must be turning him/herself back on back. She revealed she was not aware of what the CNA care plans said about assistance and was aware the CNA care plan was there to assist her in caring for the residents. She stated it was standard practice to turn and reposition residents every two hours or sooner if needed; and it was also when she checked to make sure the resident was dry. Interview with Licensed Practical Nurse (LPN) #1 on 05/31/17 at 9:30 AM revealed she expected her CNA's to follow the care plans for the residents care. She stated she expected the CNA's to turn and reposition each resident every two (2) hours. Interview with Director of Nursing (DON), on 06/02/17 at 10:10 AM, revealed she expected the CNA's to follow Resident #4's Care Plan for bed mobility related to turning and repositioning the resident with two (2) assist. She stated if the Comprehensive Care Plan or the CNA Care Plan did not specify how often to turn the resident, she expected the staff to turn the resident every two (2) hours. 2. Record review revealed the facility admitted Resident #1 on 01/15/17 with [DIAGNOSES REDACTED]. Review of the Resident #1's Comprehensive and Nurse Aide Care Plan, created on 03/08/17, revealed the resident required staff assist of one (1) with bathing, grooming and dressing; however, observations on 05/30/17 at 11:35 AM, and 3:05 PM; on 05/31/17 at 8:35 AM, 10:45 PM, and 2:15 PM; and on 06/01/17 at 8:40 AM, revealed Resident #1 had on the same blouse (a wine colored sweatshirt, which was soiled with dried food). In addition, each observation also revealed Resident #1's dentures remained on the nightstand at the bedside and were never observed in the resident's mouth. Interview with Certified Nursing Assistant (CNA) #4, on 06/02/17 at 10:45 AM, revealed it is the CNA's responsibility to ensure Resident #1's grooming and personal care is provided as indicated on the Nurse Aide Care plan. CNA #4 stated Resident #1's clothing should be changed daily and dentures put in at grooming time. Interview with Director of Nursing (DON), on 06/02/17 at 3:40 PM, revealed she would expect the staff to ensure each resident individual care needs are met, and for staff to follow the Comprehensive and Nurse Aide care plan related to the resident care needs.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of eleven (11) sampled residents (Resident #1), who was unable to perform own care, received the necessary services to maintain grooming, bathing, dressing. Resident #1 was assessed and care planned to be dependent on one staff to provide grooming, dressing, and bathing; however, observations on 05/30/17 and 05/31/17 revealed Resident #1 had on the same sweatshirt that was soiled with food and no dentures. The findings include: Interview with the Director of Nursing (DON), on 06/02/17 at 11:05 AM, revealed the facility did not have a policy and/or procedure related to ADLS. Record review revealed the facility admitted Resident #1 on 01/15/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Inventory of Mental Status (BIMS) score of thirteen (13), indicating the Resident #1 was interviewable. Further review revealed the resident was dependent on staff for bathing, dressing and grooming. Review of the Resident #1's Comprehensive and Nurse Aide Care Plan, created on 03/08/17, revealed the resident required staff assist of one (1) with bathing, grooming and dressing. Observations on 05/30/17 at 11:35 AM and 3:05 PM; on 05/31/17 at 8:35 AM, 10:45 PM, and 2:15 PM; and on 06/01/17 at 8:40 AM, revealed Resident #1 had on the same sweatshirt which was soiled with dried food. In addition, each observation also revealed Resident #1's dentures remained on the nightstand at the bedside and were never observed in the resident's mouth. Interview with Certified Nursing Assistant (CNA) #4, on 06/02/17 at 10:45 AM, revealed Resident #1 was dependent on staff for all his/her care needs and is care planned for a shower twice a week and bed bath all other days. CNA #4 stated Resident #1's clothing should be changed daily and dentures put in at grooming time. CNA #4 further revealed it is the CNA's responsibility to ensure Resident #1 grooming and personal care is provided. Interview with the Director of Nursing (DON), on 06/02/17 at 11:05 AM, revealed she expected resident care needs to be met. The DON stated she would expect Resident #1 ADLS and grooming needs to be provided by the CNA.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of eleven (11) sampled residents received the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing (Resident #4). Observation on 05/30/17 revealed the facility failed to turn and reposition Resident #4 every two (2) hours per facility protocol. On 05/19/17. Resident #4 was identified to have a Stage II Pressure ulcer on the left buttock. The findings include: Review of facility policy titled, Nsg236 Skin Integrity Management, dated 07/01/01, revealed the implementation of an individual resident's skin integrity management occurs within the care delivery process. Staff continually observes and monitors residents for changes and implements revisions to the plan of care as needed. The purpose is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Practice Standards include to perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in Point Click Care (PCC). Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. Record review revealed the facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the type Minimum Data Set (MDS) assessment, dated 05/03/17, revealed the facility assessed Resident #4's cognition as moderately impaired with a Brief Interview for Mental Status score of nine (9) indicating the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance with two (2) staff members for bed mobility. Review of the Resident #4's Comprehensive Care Plan last revised 05/23/17, and Certified Nurse Aide (CNA) Care Plans, not dated, revealed to provide extensive assist of two (2) people for bed mobility. Review of Skin Inspection, dated 04/26/17, revealed Resident #4 had moisture associated skin damage to right buttock was identified with no measurements noted. Review of a physician's orders [REDACTED]. Apply skin prep to peri wound, cover with [MEDICATION NAME]. Change dressing every three (3) days and as needed for leakage/dislodgement. Review of Resident #4's Comprehensive Care Plan, initiated on 04/28/17, revealed Resident #4 had actual skin breakdown related to Stage II to right buttocks. Review of the Skin Inspection, dated 05/19/17, revealed Resident #4 was identified to have a Stage II pressure ulcer measuring 0.3 cm x 0.2 cm x 0 cm to right buttock and a left buttock Stage II pressure ulcer measuring 0.8 cm x 0.6 cm x 0.1 cm. Review of a physician's orders [REDACTED]. Observations of Resident #4 on 05/30/17 from 11:45 AM to 12:50 PM, from 1:45 PM to 2:50 PM, and at 3:20 PM, and 3:45 PM revealed the resident was on his/her back and no staff entered the resident's room to turn or reposition the resident in bed per the care plan. Observation of a skin assessment for Resident #4, on 05/31/17 at 8:50 AM revealed there were approximate one quarter sized dark red, bruised looking area to the left buttock and one (1) to right buttock. The nurse failed to measure the areas although she had the measuring tools lying on the bed. The areas appeared to be thin skinned with no opened areas, but appeared fragile. The skin around the quarter sized areas was also dark red which appeared like the resident had been lying on area for an extended period of time. Interview with Certified Nurse Aide (CNA) #2, on 06/01/17 at 9:25 AM, revealed Resident #4 mostly turns him/herself; however, she could not explain why the resident was on his/her back during the observations this surveyor made on 05/30/17. She stated the resident must be turning him/herself back on back. She also stated she was not aware of what the CNA care plans said about assistance. Interview with Licensed Practical Nurse (LPN) #1 on 05/31/17 at 9:20 AM after skin assessment was completed, revealed she expected Resident #4 to be turned and repositioned every two (2) hours or as needed. She stated the CNA's would know that by looking at the Comprehensive Care Plan and the CNA care plans. Interview with Director of Nursing (DON), on 06/02/17 at 10:10 AM, revealed she expected no residents admitted to the facility would develop a pressure ulcer ulcer if avoidable. She stated she expected staff to turn and reposition the residents per the Comprehensive Care Plan and Certified Nurse Care Plan to help prevent any new breakdown on residents' skin. She also revealed she expects any new or worsening wounds to be reflected in the resident's skin assessment.

Based on interview, record review, and facility policy review it was determined the facility failed to immediately notify one (1) of eleven (11) sampled residents' representative of a scheduled appointment (Resident #3). The facility made a Dermatologist appointment for Resident #3; however, staff failed to notify the resident's responsible party of the appointment so the responsible party could accompany the resident to the appointment on 03/30/17. The findings include: Interview (Post Survey) with the Administrator, on 06/12/17 at 2:40 PM, revealed the facility did not have a specific policy related to notifying the family or responsible party with changes and the facility follows the Federal and State guidelines. Record review revealed the facility admitted Resident #3 on 12/11/15 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Review of Resident #3's record, revealed Resident #3 had a Dermatology appointment on 03/30/17; however, interview with Resident #3's responsible party, on 05/31/17 at 5:40 PM, revealed he was not notified of Resident #3's dermatology appointment that was on 03/30/17 until after the appointment. He stated he was upset that he was not notified due to he goes to all of Resident #3's appointments and wants to be a part of all appointments. He stated Resident #3 is confused and cannot speak for himself and it would not be appropriate for this resident to go to an appointment by himself. Interview with Licensed Practical Nurse (LPN) #1 on 05/31/17 at 11:30 AM, revealed the former Director of Nursing (DON) had made a follow up Dermatology appointment for Resident #3 related to a continual skin condition. She stated the former DON obtained the order and set the appointment up and she figured the former DON would therefore have notified the family of the appointment since the former DON in fact did set the appointment up. She stated after Resident #3 had went to the appointment and the family was upset about not knowing of it ahead of time, the former DON had stated she thought LPN #1 set the appointment up. She stated families and or responsible parties are supposed to be notified with any new orders for resident appointments. Interview with the Director of Nursing (DON), on 05/31/17 at 12:09 PM, revealed she was not the DON at the time of the Dermatology appointment for Resident #3 and the former DON was in place at that time. She stated she expected the licensed staff who arranged the appointment or who takes a new physician's orders [REDACTED]. Interview with Administrator, on 06/02/17 at 2:35 PM, revealed the former DON of the facility was the person who had gotten the order and set up the Dermatology appointment for Resident #3. She stated the former DON failed to notify Resident #3's responsible party of the order and appointment. She stated she would have expected the former DON to have ensured the resident's responsible party had been informed of the order and appointment.

Based on observation, interview, record review, review of the facility's policy and procedures, review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14 "Patient Care Orders", and Lippincott Manual of Nursing Practice, 10th Edition, copyright 2014, it was determined the facility failed to provide services in accordance with acceptable standards of practice, for two (2) of thirteen (13) sampled residents (Resident #8). The facility failed to administer medication according to the five (5) rights (right resident, right medication, right time, right dose, right route); failed to report a medication error in a timely manner; and, failed to investigate the incident to determine if any other medication errors were made and to inservice staff members to prevent a reoccurrence of these type of errors. In addition, the facility failed to ensure wound care was provided according to Nursing Practice guidelines for Resident #1 when a Licensed Nurse failed to wash her hands and change gloves after the glove became contaminated with feces and prior to providing wound care. On 02/15/14, Resident #8 was ordered [MEDICATION NAME] XL 500 milligrams (mg,) two (2) tabs by mouth once daily for seven (7) days. Registered Nurse (RN) #3 received the order and transcribed the order on the resident's Medication Administration Record (MAR). The medication was ordered to be given once a day; however, the RN transcribed administration times as 6:00 AM, 2:00 PM, and 10:00 PM, three times a day. On 02/15/14, Resident #8 received the first dose of 1000 mg of [MEDICATION NAME], at 10:00 PM. On 02/16/14, the resident received 1000 mg doses at 6:00 AM, 2:00 PM, and 10:00 PM, for a total of 3000 mg, instead of the 1000 mg per day, ordered by the physician. On 02/17/14, the resident received 1000 mg doses at 6:00 AM and 2:00 PM, for a total of 2000 mg that day instead of the ordered amount of 1000 mg a day. The Licensed Practical Nurse (LPN) and two (2) Certified Medication Aides (CMAs), who administered the medications, failed to identify the transcription error. On 02/17/14 at approximately 10:00 PM, Registered Nurse (RN) #1 identified the transcription error. Interview with the Advanced Practice Registered Nurse (APRN) revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure and/or gastro-intestinal disorders. The facility's failure to ensure medication was transcribed correctly and failure to ensure medication was administered according to the nursing standards of practice, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/12/14 and was determined to exist on 02/16/14. The facility was notified of Immediate Jeopardy on 04/12/14. The findings include: Review of a Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14, last revised 10/2010, revealed nurses are individually held responsible and accountable for rendering safe, effective nursing care to clients and for judgments exercised and actions taken in the course of providing care. Registered Nurses and Licensed Practical Nurses' nursing practice includes the administration of medication and treatment prescribed by a physician which are consistent with the recognized standards of practice. The components of medication administration includes but is not limited to preparing and giving medication in the prescribed dosage, route, and frequency and the supervision, teaching of, and delegation to other personnel in the performance of activities relating to nursing care. Review of the facility's policy and procedure titled, "Medication Administration," last revised 01/02/14, revealed the purpose was to provide a safe, effective medication administration process. Further review revealed the accepted standard of practice would be followed. Review of the facility's "Clinical Competency Validation", dated 03/20/11, revealed the standards included for staff administering medications to check orders on the MAR carefully, check specific administration directions, clarify the medication order when necessary, check the label on the medication, calculate the correct dose, administer the routes of medication properly, document appropriately on the MAR, and report and record any side effect, error, or unusual information regarding the medication. Record review revealed the facility admitted Resident #8 on 10/06/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/08/14, revealed the facility had assessed Resident #8's cognitive status as severely impaired with a Brief Interview Mental Status (BIMS) score of three (3). Review of a physician's orders [REDACTED]. Review of the February 2014 MAR revealed [MEDICATION NAME] 500 mg two (2) tabs daily for seven (7) days, for a daily dose of 1000 mg. However, administration times were transcribed as 6:00 AM, 2:00 PM, and 10:00 PM. Interview with RN #3, on 04/11/14 at 4:00 PM, and review of a Nurse's Note, dated 02/15/14, revealed RN #3 obtained the new telephone order on 02/15/14 at 3:15 PM and transcribed it onto the MAR. RN #3 stated she wrote the times down on the MAR as 6:00 AM, 2:00 PM, and 10:00 PM, as she had confused this with another order she was working on at the time. Further review of the February 2014 MAR revealed the resident received the first dose of [MEDICATION NAME] 1000 mg at 10:00 PM on 02/15/14. On 02/16/14, the resident received three (3) doses, 1000 mg at 6:00 AM, 2:00 PM and 10:00 PM for a total of 3000 mg instead of the 1000 mg a day. On 02/17/14, the resident received two (2) doses, 1000 mg at 6:00 AM and 1000 mg at 2:00 PM for a total of 2000 mg instead of the 1000 mg a day. The LPN and two (2) CMAs administering the medication at these times failed to identify the transcription error. Interview with CMA #1, on 04/12/14 at 11:15 AM, revealed she administered the medication on 02/17/14 at 2:00 PM and should have caught the error. She stated, "I usually look to see if the MAR matches the label on the medication and I missed it". Interview with LPN #2, on 04/12/14 at 11:30 AM, revealed she administered [MEDICATION NAME] XL 500 mg two (2) tablets on 02/15/14 at 10:00 PM, on 02/16/14 at 6:00 AM, and at 10:00 PM, and on 02/17/14 at 6:00 AM. She further stated it was the facility's policy and procedure to check the medication label against the order to ensure accuracy with right medication, dose and time. She stated she was not sure what happened because she always checked the medication label against the order to ensure it was accurate. Interview with the current Director of Nursing (DON), on 04/12/14 at 4:20 PM, revealed the LPN and two (2) Certified Medication Aides (CMAs) who administered the six (6) doses of the medication, should have verified the order on the Medication Administration Record (MAR) and the times of administration with the physician's orders [REDACTED]. She stated they should have noted the error before six (6) doses were given improperly. Interview with the APRN, on 04/11/14 at 12:55 PM, revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure and/or gastro-intestinal disorders. 2. Review of the Lippincott Manual of Nursing Practice, 10th Edition, copyright 2014, page 1083, revealed hand hygiene is the single most recommended measure to reduce the risks of transmitting infection. Hand hygiene should be performed in between patient contacts; after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. It may also be necessary to clean hands in between tasks on the same patient to prevent cross-contamination of different body sites. Review of the facility's "Aseptic Wound Dressings" policy and procedure, last revised 01/02/14, revealed if a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves. In addition, it stated that wound dressings were performed using aseptic technique to decrease the risk of wound contamination and cross-contamination during dressing changes. Record review revealed the facility readmitted Resident #1 on 03/12/14 with [DIAGNOSES REDACTED]. Observation of incontinent care and wound care provided by LPN #3 to Resident #1, on 04/09/14 at 9:25 AM, revealed LPN #3 donned clean gloves and used disposable moist towelettes located on the bedside table to clean stool off the resident's buttocks. The stool was noted to contaminate her glove. Further observation revealed the LPN did not change her gloves or perform hand hygiene but obtained a fresh moist towelette from the bedside table to clean the wound bed of the resident's pressure ulcer. She then removed a container of prescribed [MEDICATION NAME] (skin protectant paste) from the resident's bedside table, opened the container wearing the same visibly contaminated glove and applied the medication to the wound bed with the finger of the contaminated glove. The LPN failed to wash her hands and change glove between providing the incontinent care and the wound care. Interview with LPN #3, on 04/09/14 at 9:36 AM, revealed she always changed gloves between incontinent care and wound care and stated she thought she did. She stated it was good nursing practice to ensure gloves were changed and hands washed to prevent infection. Interview with the Director of Nursing and Administrator, on 04/09/14 at 10:45 AM, revealed the LPN should have changed gloves and washed her hands according to the facility's policy and procedure and should not have provided wound care with the soiled gloves. **The facility implemented the following actions to remove the Immediate Jeopardy: The resident was assessed by the APRN on 02/17/14 and 02/24/14 with no negative side effects from the antibiotic identified. An audit of the current MARs and Physician/APRN orders, was completed on 04/16/14 with no errors identified. A MAR to medication cart audit was completed by the Licensed Pharmacy Technician, on 04/14/14 and all MAR orders and medication times were correct. All current residents were reassessed on 04/12/14, by two (2) licensed staff, for signs and symptoms of medication reactions and none were identified. Seventeen (17) of twenty-one (21) Licensed Nurses and three (3) of four (4) Certified Medication Aides (CMA) were re-educated by the DON/ADON and or the Nurse Educator on 04/16/14, regarding the appropriate transcription of physician medication orders, checking residents for allergies, the five (5) rights of medication administration, immediate notification of the physician/ ARNP/DON and responsible party, upon identification of a medication error and staff completed clinical competencies and return demonstration on medication passes and transcription of physician orders. Four (4) Licensed Nurses and one CMA were to have this training prior to working the floor, as some of these staff were either on sick leave, vacation or worked as needed. The DON, ADON and Administrative RNs audited current MARs and Physician Orders, MARs to chart reviews, allergies and physician/responsible party notifications, every day, beginning 04/14/14, for fourteen (14) days, then five (5) days a week for sixty (60) days, then no less than three (3) times a week for an additional thirty (30) days. No discrepancies were identified and the audits were on-going. Additional audits will be determined by the monthly Quality Improvement (QI) Committee and corrective action and /or re-education will be provided at the point of discovery. Licensed Pharmacists or Licensed Pharmacy Technicians will complete MAR to chart checks monthly, with corrective action, if indicated and findings reported to the DON and ADON. Audit tools will be brought to the monthly QI meetings, by the ADM/DON and or ADON for review with additional plans put into place as warranted by the QI Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review on 04/24/14 revealed Resident #8 had no negative outcome from the event and a review of the clinical record, MARS and physician orders [REDACTED]. Review of the MARs and physician orders [REDACTED].#1, #9, #11, #12 and #19), on 04/24/14, revealed there were no medication transcription errors. Review of the MAR and physician orders [REDACTED]. Review of the inservice log, dated 04/13-16/14, on 04/24/14 revealed all but five (5) licensed staff and CMAs were inserviced and a post test and repeat demonstration was completed to verify competency of transcription of physician orders [REDACTED]. Any other staff working as needed or staff on vacation or sick leave, were to be re-educated prior to working the floor and this was verified by interview with one CMA and a review of the CMA's training record and stated she had been re-educated on 04/21/14, prior to work that day. Interviews with RN #1, LPN #4, LPN #5, CMA #1, CMA #3, and CMA #4 on 04/24/14 at 12:50 PM, 1:00 PM, 1:15 PM, 1:20 PM, 1:36 PM and 2:10 PM and review of the training logs, dated 04/13-16/14, revealed training was completed by the DON/ADON and Administrative RNs, which included transcription of physician orders [REDACTED]. Review of the Quality Improvement (QI) audits and interviews conducted with the ADON and DON, on 04/24/14 at 10:40 AM, revealed results of the audits were discussed in the QI meetings, as stated in the AoC, training was provided to licensed nursing staff as well as the CMAs and the auditing was ongoing.

Based on interview, record review, and review of the facility's " Medication Administration", "Clinical Competency Validation" and "Medication Errors" policies and procedures, and Event Report, it was determined the facility failed to have an effective system to ensure one (1) of thirteen (13) sampled residents (Resident #8), was free of excess dosing of medication and received only the medication in doses clinically indicated to treat the resident's condition. Record review revealed on 02/15/14, Registered Nurse (RN) #3 received an order for [REDACTED]. RN #3 transcribed the order on the Medication Administration Record (MAR). The medication was ordered to be given once a day and RN #3 transcribed the order as once a day. However, she transcribed the administration times as 6:00 AM, 2:00 PM, and 10:00 PM; three (3) times a day instead of the once daily time, as ordered. Further review revealed on 02/15/14, Resident #8 received the first dose of 1000 mg of the medication at 10:00 PM. On 02/16/14, the resident received the antibiotic three (3) times at 6:00 AM, 2:00 PM, and 10:00 PM, for a total dose that day of 3000 mg, instead of the 1000 mg per day, as ordered. On 02/17/14, the resident received the medication two (2) times at 6:00 AM and 2:00 PM, for a total of 2000 mg. During the time the medication was administered, from 02/15/14 through 02/17/14, one Licensed Practical Nurse (LPN) and two Certified Medication Aides (CMAs) failed to follow the Five Rights of Medication Administration, (right dose, time, resident, drug and route,) and failed to identify the transcription error. In addition, the twenty-four (24) hour checks for new physician orders [REDACTED]. On the evening of 02/17/14, at approximately 10:00 PM, RN #1 noted the medication error and did not administer the medication. However, RN #1 failed to notify the physician, the Director of Nursing (DON) or the resident's family, per facility policy, of the Medication Errors. She notified LPN #1, the oncoming nurse, in shift change report, on 02/17/14 at approximately 10:00 PM; however, LPN #1 also failed to notify the physician, the DON, or the resident's family. LPN #1 notified the oncoming shift supervisor, the next day, on 02/18/14, at approximately 8:00 AM and the Director of Nursing (DON) was made aware of the medication error. The DON then notified Resident #8's physician and family. In addition, the Clinical Committee failed to notice the error during the weekend review of physician orders [REDACTED]. Interview with the Advanced Practice Registered Nurse (APRN) on 04/11/14 at 12:55 PM, revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure and/or gastro-intestinal disorders. The facility's failure to have an effective system to ensure the resident was free from excessive doses of a medication caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/12/14 and was determined to exist on 02/16/14. The findings include: Review of the facility's "Medication Administration" policy and procedure, last revised 01/02/14, revealed its purpose was to provide a safe, effective medication administration process. Further review revealed the accepted standard of practice would be followed. In addition, a review of the "Clinical Competency Validation" dated 03/20/11, revealed the standards were for Licensed Staff and Certified Medication Assistants (CMAs) to check orders in the MAR carefully, check specific administration directions, clarify the medication order when necessary, check the label on the medication, calculate the correct dose, administer the routes of medication properly, document appropriately on the MAR, and report and record any side effect, error, or unusual information regarding the medication. Review of the facility's "Medication Errors" policy and procedure, last revised 01/02/14, revealed upon discovery of a medication error, the staff would evaluate the patient for adverse effects, report immediately to the DON, and notify the physician, patient, and responsible party. In addition, the person discovering the incident will complete a Resident/Patient Incident Report. Further review revealed the facility would investigate the incident and implement interventions to prevent further errors. Record review revealed the facility admitted Resident #8, on 06/10/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/08/14, revealed the facility assessed Resident #8's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Resident #8's physician's orders [REDACTED]. Review of the February 2014 MAR revealed an order for [REDACTED]. Further review of the MAR revealed staff administered [MEDICATION NAME] XL 1000 mg at 10:00 PM on 02/15/14 , at 6:00 AM, 2:00 PM, and 10:00 PM on 02/16/14 and at 6:00 AM and 2:00 PM on 02/17/14. This resulted in Resident #8 receiving two (2) times the amount of [MEDICATION NAME] (6000 mg) over three days, instead of the 1000 mg per day that was ordered. Interview with the Advanced Practice Registered Nurse (APRN) on 04/11/14 at 12:55 PM, revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure and/or gastro-intestinal disorders. Interview with RN #3, on 04/11/14 at 4:00 PM, revealed she obtained the new telephone order on 02/15/14 at 3:15 PM and transcribed it onto the MAR. RN #3 stated she wrote the times down on the MAR as 6:00 AM, 2:00 PM, and 10:00 PM, as she had confused this with another order she was working on at the time. Interview with LPN #2, on 04/12/14 at 11:30 AM, revealed she administered [MEDICATION NAME] XL 500 mg 2 tablet on 02/15/14 at 10:00 PM, on 02/16/14 at 6:00 AM, and at 10:00 PM, and on 02/17/14 at 6:00 AM. She further stated it was the facility's policy and procedure to check the medication label against the order to ensure accuracy with the right medication, dose and time. She stated she was not sure what happened as this was her customary practice. Interview with CMA #1, on 04/12/14 at 11:15 AM, revealed she administered the medication on 02/17/14 at 2:00 PM and should have caught the error. She stated, "I usually look to see that the MAR matches the label on the medication and I missed it". Interview with RN #1, on 04/12/14 at 10:20 AM, revealed she was the first staff member who noted the discrepancy on the MAR, on 02/17/14 at approximately 10:00 PM, and did not administer the 10:00 PM dose. The RN stated she did not call the DON, the physician, or the resident's family. Furthermore, she did not follow the facility's policy and procedure and complete an incident report for the medication errors. She stated she reported it to LPN #1, the oncoming nurse, at approximately 10:00 PM during shift change report. Interview with LPN #1, on 04/12/14 at 10:30 AM, revealed she was told by RN #1 in report about the error and stated RN #1 stated she had reported it to the DON. LPN #1 stated she "assumed it was being taken care of" and stated, "I didn't follow up on it, I was under the impression that she (RN #1) had taken care of it". Review of the documentation of the twenty-four (24) hour chart reviews, for the front and back hall nursing stations, revealed the 24 hour chart checks had not been completed on the front hall, where the incident occurred, since 02/10/14. Interview with the current DON, on 04/12/14 at 10:50 AM and 4:20 PM, revealed the staff administering the medication should have followed the facility's policy and procedure on Medication Administration, to include the five rights. The DON stated her expectation was the RN should have notified the DON, Physician, and the resident's family when the medication error was identified. The DON stated the RN should have followed the policy and procedure and should have completed an incident report for the medication error. In addition, the DON revealed the midnight shift nurses should have completed twenty-four hour chart checks to assess for new orders and verify the correctness of the transcription of the orders. She stated this was an ongoing process to ensure orders were not missed and were correct. The DON stated an investigation was not conducted to identify why the facility's procedures of 24 hour chart reviews and following the five (5) rights of medications administration were not followed by staff, and how the clinical team had failed to identify the transcription error. Interview with the Interim DON, on 04/11/14 at 4:00 PM, revealed the Clinical Team's process was to gather all newly written physician orders, every morning, Monday through Friday, for verification of correctness. For orders written on the weekend, the Clinical Team met on Monday morning to gather and verify the correctness of the orders written over the weekend and checked them against the MAR for accuracy. The DON stated on 02/17/14, she reviewed the order against the MAR, for [MEDICATION NAME] 1000 mg every day and stated "I overlooked it myself". She revealed she was not called or made aware of the incident until 02/18/14, at approximately 8:00 AM, the day after the error was found. Review of the facility's Event Report, dated 02/18/14, revealed the facility had identified a physician's orders [REDACTED]. Further review of the Event Report revealed there was no documented evidence the facility had completed an investigation to identify the failures related to this incident and implemented interventions to prevent further errors. Interview with the Administrator, on 04/11/14 at 11:00 AM, revealed the facility had not conducted an investigation, as it was determined the incident was a transcription error. **The facility implemented the following actions to remove the Immediate Jeopardy: The resident was assessed by the APRN on 02/17/14 and 02/24/14 with no negative side effects from the antibiotic identified. An audit of the current MARs and Physician/APRN orders, was completed on 04/16/14 with no errors identified. A MAR to medication cart audit was completed by the Licensed Pharmacy Technician, on 04/14/14 and all MAR orders and medication times were correct. All current residents were reassessed on 04/12/14, by two (2) licensed staff, for signs and symptoms of medication reactions and none were identified. Seventeen (17) of twenty-one (21) Licensed Nurses and three (3) of four (4) Certified Medication Aides (CMA) were re-educated by the DON/ADON and or the Nurse Educator on 04/16/14, regarding the appropriate transcription of physician medication orders, checking residents for allergies, the five (5) rights of medication administration, immediate notification of the physician/ ARNP/ DON and responsible party, upon identification of a medication error and staff completed clinical competencies and return demonstration on medication passes and transcription of physician orders. Four (4) Licensed Nurses and one CMA were to have this training prior to working the floor, as some of these staff were either on sick leave, vacation or worked as needed. The DON, ADON and Administrative RNs audited current MARs and Physician Orders, MARs to chart reviews, allergies and physician/responsible party notifications, every day, beginning 04/14/14, for fourteen (14) days, then five (5) days a week for sixty (60) days, then no less than three (3) times a week for an additional thirty (30) days. No discrepancies were identified and the audits were on-going. Additional audits will be determined by the monthly Quality Improvement (QI) Committee and corrective action and /or re-education will be provided at the point of discovery. Licensed Pharmacists or Licensed Pharmacy Technicians will complete MAR to chart checks monthly, with corrective action, if indicated and findings reported to the DON and ADON. Audit tools will be brought to the monthly QI meetings, by the ADM/ DON and or ADON for review with additional plans put into place as warranted by the QI Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review on 04/24/14 revealed Resident #8 had no negative outcome from the event and a review of the clinical record, MARS and physician orders [REDACTED]. Review of the MARs and physician orders [REDACTED].#1, #9, #11, #12 and #19), on 04/24/14, revealed there were no medication transcription errors. Review of the MAR and physician orders [REDACTED]. Review of the inservice log, dated 04/13-16/14, on 04/24/14 revealed all but five (5) licensed staff and CMAs were inserviced and a post test and repeat demonstration was completed to verify competency of transcription of physician orders [REDACTED]. Any other staff working as needed or staff on vacation or sick leave, were to be re-educated prior to working the floor and this was verified by interview with one CMA and a review of the CMA's training record and stated she had been re-educated on 04/21/14, prior to work that day. Interviews with RN #1, LPN #4, LPN #5, CMA #1, CMA #3, and CMA #4 on 04/24/14 at 12:50 PM, 1:00 PM, 1:15 PM, 1:20 PM, 1:36 PM and 2:10 PM and review of the training logs, dated 04/13-16/14, revealed training was completed by the DON/ADON and Administrative RNs, which included transcription of physician orders [REDACTED]. Review of the Quality Improvement (QI) audits and interviews conducted with the ADON and DON, on 04/24/14 at 10:40 AM, revealed results of the audits were discussed in the QI meetings, as stated in the AoC, training was provided to licensed nursing staff as well as the CMAs and the auditing was ongoing.

Based on interview, record review and review of the facility's "Medication Error" policy and procedure, it was determined the facility failed to notify the physician and the resident's family member in a timely manner, for one (1) of thirteen (13) sampled residents (Resident #8), related to an excessive dose medication error, resulting in the resident receiving two (2) times the medication dose ordered by the physician over a three (3) day period. On 02/15/14 at approximately 3:15 PM, the facility received a telephone order from the physician, for Resident #8 to be administered [MEDICATION NAME] (an antibiotic) 500 milligrams (mg), two (2) tablets once daily for seven (7) days. Registered Nurse (RN) #3 received the telephone order and transcribed the order on the Medication Administration Record (MAR). The medication was ordered to be given once a day, however, RN #3 transcribed the administration times for three (3) times a day, at 6:00 AM, 2:00 PM, and 10:00 PM. On 02/15/14 at 10:00 PM, Resident #8 received the first dose of medication. On 02/16/14, the resident received the antibiotic three (3) times at 6:00 AM, 2:00 PM, and 10:00 PM, for a total dose of 3000 mg, instead of the 1000 mg per day the physician had ordered. On 02/17/14, the resident received the medication two (2) times at 6:00 AM and 2:00 PM, for a total of 2000 mg, instead of the 1000 mg ordered by the physician. On 02/17/14 at approximately 10:00 PM, RN #1 noted the medication error resulting from the failure to correctly transcribe the times the medication was to have been administered; however, RN #1 failed to notify the physician, the Director of Nursing (DON) or the resident's family. The RN notified the oncoming nurse, Licensed Practical Nurse (LPN) #1, during shift change report, who also failed to notify the physician, the DON, and the resident's family. LPN #1 informed the oncoming shift, the next day on 02/18/14, of the error. On 02/18/14 at approximately 8:00 AM, ten (10) hours after the medication error was noted, the DON was made aware of the medication error and notified Resident #8's physician and family. This error resulted in the resident receiving two (2) times the ordered dose of the antibiotic over the three (3) day period. There was no documented evidence that RN #1 or LPN #1 assessed Resident #8 after they became aware of the medication error. Interview with the Advanced Practitioner Registered Nurse (APRN), revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure, and/or gastro-intestinal disorders. The facility's failure to ensure the physician and family member were made aware of the medication error has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/12/14 and was determined to exist on 02/16/14. The findings include: Review of the facility's "Medication Errors", policy and procedure, last revised 01/02/14, revealed upon discovery of a medication error, the staff would evaluate the patient for adverse effects, report immediately to the DON, and notify the physician, patient, and responsible party. Record review revealed the facility admitted Resident #8 on 06/10/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/08/14, revealed the facility assessed Resident #8's cognitive status as severely impaired with a Brief Interview Mental Status (BIMS) score of three (3), indicating the resident was not interviewable. Review of a physician's orders [REDACTED]. Further review revealed the resident received the first dose of the medication on 02/15/14 at 10:00 PM. On 02/16/14, the resident received three (3) doses of medication: 1000 mg at 6:00 AM, 2:00 PM, and 10:00 PM, three (3) times the amount ordered by the physician. On 02/17/14, Resident #8 received two (2) doses of medication, 1000 mg at 6:00 AM and 2:00 PM, two (2) times the amount ordered by the physician. Interview with RN #1, on 04/12/14 at 10:20 AM, revealed she was the first staff member who noted the discrepancy on the MAR, on 02/17/14 at approximately 10:00 PM. She stated she did not administer the 10:00 PM dose. The RN stated she did not call the resident's physician and family but stated she reported to LPN #1, the oncoming nurse, at shift change, that the medication had not been administered and the medication error had been discovered. Interview with LPN #1, on 04/12/14 at 10:30 AM, revealed she was told by RN #1 in report about the error and stated RN #1 said she had reported it to the DON. LPN #1 stated she "assumed it was being taken care of " and, "I didn't follow up on it, I was under the impression that she (RN #1) had taken care of it". Interview with the DON, on 04/11/14 at 4:00 PM, revealed she was not called regarding the incident and was not made aware of the incident until 02/18/14 at approximately 8:00 AM, after six (6) doses of the medication had been administered. Interview with the current DON on 04/12/14 at 4:20 PM, revealed her expectation, was the RN should have notified the DON, physician, and the resident's family when the medication error was identified. Interview with the Advanced Practitioner Registered Nurse (APRN), on 04/11/14 at 12:55 PM, revealed the doses of [MEDICATION NAME] could have resulted in kidney and/or liver failure, and/or gastro-intestinal disorders. She stated she was not made aware of the medication error until 02/18/14. **The facility implemented the following actions to remove the Immediate Jeopardy: The resident was assessed by the APRN on 02/17/14 and 02/24/14 with no negative side effects from the antibiotic identified. An audit of the current MARs and Physician/APRN orders, was completed on 04/16/14 with no errors identified. A MAR to medication cart audit was completed by the Licensed Pharmacy Technician, on 04/14/14 and all MAR orders and medication times were correct. All current residents were reassessed on 04/12/14, by two (2) licensed staff, for signs and symptoms of medication reactions and none were identified. Seventeen (17) of twenty-one (21) Licensed Nurses and three (3) of four (4) Certified Medication Aides (CMAs) were re-educated by the DON/ADON, and or the Nurse Educator on 04/16/14, regarding the appropriate transcription of physician medication orders, checking residents for allergies, the five (5) rights of medication administration, immediate notification of the physician/ARNP/DON and responsible party, upon identification of a medication error and staff completed clinical competencies and return demonstration on medication passes and transcription of physician orders. Four (4) Licensed Nurses and one CMA were to have this training prior to working the floor, as some of these staff were either on sick leave, vacation or worked as needed. The DON, ADON and Administrative RNs audited current MARs and Physician Orders, MARs to chart reviews, allergies and physician/responsible party notifications, every day, beginning 04/14/14, for fourteen (14) days, then five (5) days a week for sixty (60) days, then no less than three (3) times a week for an additional thirty (30) days. No discrepancies were identified and the audits were on-going. Additional audits will be determined by the monthly Quality Improvement (QI) Committee and corrective action and /or re-education will be provided at the point of discovery. Licensed Pharmacists or Licensed Pharmacy Technicians will complete MAR to chart checks monthly, with corrective action, if indicated and findings reported to the DON and ADON. Audit tools will be brought to the monthly QI meetings, by the ADM/DON and or ADON for review with additional plans put into place as warranted by the QI Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review on 04/24/14 revealed Resident #8 had no negative outcome from the event and a review of the clinical record, MARs and Physician order [REDACTED]. Review of the MARs and Physician order [REDACTED].#1, #9, #11, #12 and #19), on 04/24/14, revealed there were no medication transcription errors. Review of the MAR and Physician order [REDACTED]. Review of the inservice log, dated 04/13-16/14, on 04/24/14 revealed all but five (5) licensed staff and CMAs were inserviced and a post test and repeat demonstration was completed to verify competency of transcription of physician orders [REDACTED]. Any other staff working as needed or staff on vacation or sick leave, were to be re-educated prior to working the floor and this was verified by interview with one CMA and review of the CMA's training record. She had been re-educated on 04/21/14, prior to work that day. Interviews with RN #1, LPN #4, LPN #5, CMA #1, CMA #3, and CMA #4 on 04/24/14 at 12:50 PM, 1:00 PM, 1:15 PM, 1:20 PM, 1:36 PM and 2:10 PM and review of the training logs, dated 04/13-16/14, revealed training was completed by the DON/ADON and Administrative RNs, which included transcription of physician orders [REDACTED]. Review of the Quality Improvement (QI) audits and interviews conducted with the ADON and DON, on 04/24/14 at 10:40 AM, revealed results of the audits were discussed in the QI meetings, as stated in the AoC, training was provided to licensed nursing staff as well as the CMAs and the auditing was ongoing.

Based on observation, interview, record review, and review of the facility's "Pain Management" policy and procedure, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing according to the comprehensive assessment and plan of care for one (1) of thirteen (13) sampled residents (Resident #1) related to pain. During an observation on 04/09/14, Registered Nurse (RN) #1 was told by Resident #1 his/her toe was hurting. RN #1 replied to Resident #1, "It is hard for it not to hurt when it is infected". RN #1 left the room and did not perform a pain assessment or offer the resident any comfort measures for pain control. The findings include: Review of the facility's policy and procedure titled, "Pain Management", last revised 01/02/14, revealed staff was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain and to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. In addition, if the Nursing Assessment indicated pain, the nurse would obtain treatment orders as indicated and at a minimum of daily, patients would be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. Record review revealed Resident #1 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/19/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of "12", which indicated the resident was interviewable. The resident was assessed to have the presence of pain with the pain occurring frequently. Review of the Comprehensive Care Plan for Pain related to Arthritis, pressure points, skin breakdown and Peripheral [MEDICAL CONDITION], dated 03/21/14, revealed interventions to monitor pain on a scale of zero to ten (0-10); administer pain medication per physician's orders [REDACTED]. Review of Resident #1's Physician Orders, dated 03/13/14, revealed an order for [REDACTED]. Observation on 04/09/14 at 3:06 PM, revealed Resident #1 stated to RN #1, "My toe on my left foot hurts." RN #1 stated to Resident #1, "It's hard for it not to hurt when it is infected." Further observation revealed the RN did not assess the resident's level of pain and did not offer any comfort measures for the resident's pain. Interview with Resident #1, on 04/09/14 at 4:00 PM, revealed he/she had pain due to [MEDICAL CONDITION] (infection/inflammation of deep tissue) of the foot and when staff moved him/her it would cause him/her pain and it would take a while for the pain to go away. During interview with RN #1, on 04/09/14 at 3:25 PM, she stated she had not checked the resident's orders for pain but stated, "I will now". Interview with the Director of Nursing (DON) and the Administrator, on 04/09/14 at 10:45 AM, revealed their expectation would have been for the nurse to have assessed the resident's pain, checked the physician's orders [REDACTED]. as per the plan of care.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to provide a pain assessment and interventions for pain according to the care plan for for one (1) of thirteen (13) sampled residents (Resident #1) related to pain. On 04/09/14, Registered Nurse (RN) #1 was told by Resident #1 his/her toe was hurting. RN #1 replied to Resident #1, "It is hard for it not to hurt when it is infected". RN #1 left the room and did not perform a pain assessment or offer the resident any comfort measures for pain control per the resident's care plan. The findings include: Review of the facility's policy and procedure titled, "Pain Management", last revised 01/02/14, revealed staff was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain and to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. In addition, if the Nursing Assessment indicated pain, the nurse would obtain treatment orders as indicated and at a minimum of daily, patients would be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. Record review revealed Resident #1 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/19/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of "12", which indicated the resident was interviewable. The resident was assessed to have the presence of pain with the pain occurring frequently. Review of the Comprehensive Care Plan for Pain, dated 03/21/14, revealed interventions to monitor pain on a scale of zero to ten (0-10); administer pain medication per physician's orders [REDACTED]. Observation on 04/09/14 at 3:06 PM, revealed Resident #1 stated to RN #1, "My toe on my left foot hurts." RN #1 stated to Resident #1, "It's hard for it not to hurt when it is infected." Further observation revealed the RN did not assess the resident's level of pain and did not offer any comfort measures for the resident's pain. Review of Resident #1's Physician Orders, dated 03/13/14, revealed an order for [REDACTED]. Interview with Resident #1, on 04/09/14 at 4:00 PM, revealed his/her [MEDICAL CONDITION] (infection/inflammation of deep tissue) of the foot caused him/her pain and when the staff moved him/her it would cause him/her pain and it would take a while for the pain to go away. Interview with RN #1, on 04/09/14 at 3:25 PM, revealed she had not assessed the resident's pain and had checked to see if their were any orders for pain medication but she would now. Interview with the Director of Nursing (DON) and the Administrator, on 04/09/14 at 10:45 AM, revealed when the resident complained of pain they expected the nurse to have assessed the resident's pain, checked the physician's orders [REDACTED].