Every finding on record at Letcher Manor

Based on observation, interview, record review and review of facility policy, the facility failed to ensure the resident could exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility for 3 of 19 sampled residents who required supervised smoking, Resident (R)22, R75, and R90.The findings include: Review of the facility's policy titled, Resident Rights, dated 08/13/2024, revealed, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. Review of the facility's policy titled, Facility Smoking/Non-Smoking Policy, last revised 11/08/2024, revealed This smoking policy promotes safety for residents, visitors, families, and stakeholders. It is the intent of the facility to provide for the safety of the residents who choose to smoke, as well as the safety of all facility residents, visitors and stakeholders. 1. Review of R90's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 02/02/2026. R90's diagnoses included cerebral ischemia. Review of R90's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/06/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 15 out of 15. This score indicated intact cognition. During an interview on 04/14/2026 at 8:48 AM, R90 stated she was a smoker and smoke breaks never started on time. R90 stated staff often argued in front of her and other residents about who would take them out for a smoke break. R90 further stated she felt she was discriminated against because she was a smoker and was treated like a child when staff would constantly tell her and other smokers how much time they had left to smoke. Further, she stated staff acted as though they did not want to be around the residents who smoked. R90 stated, the way they act about taking us to smoke, I want to ask them, do I have leprosy? Observation on 04/14/2026 during the 9:00 AM resident smoke break, revealed residents were provided with smoke aprons at 9:18 AM. Further, the first cigarette for the first resident to smoke once outside was not lit until 9:30 AM, 30 minutes after the smoke break was supposed to start. 2. Review of R22's Face Sheet located in the EMR, revealed the facility admitted the resident on 03/02/2026. R22's diagnoses included organ limited amyloidosis. Review of R22's admission MDS assessment, with an ARD of 03/09/2026, revealed the facility assessed the resident as having a BIMS sore of 15 out of 15. iThis score indicated intact cognition. During interview on 04/16/2026 at 11:45 AM, R22 stated she did not feel like staff cared about her as much as they did other residents because she was a smoker. R22 stated staff acted inconvenienced because they had to take the residents to smoke. She stated staff argued about who would take the smokers on smoke break. Additionally, she stated the smoke breaks never started on time and it was obvious staff did not care because it was not their break, it was the residents' break. 3. Review of R75's Face Sheet located in the EMR, revealed the facility admitted the resident on 05/13/2021. R22's diagnoses included peripheral vascular disease. Review of R75's Quarterly MDS assessment, with an ARD of 02/02/2026, revealed the facility assessed the resident as having a BIMS score of 15 out of 15. This score indicated intact cognition. During interview on 04/16/2026 at 11:50 AM, R75 stated smoke breaks were always late, and residents had to wait at the door for staff to take them outside to smoke. R75 further stated he often heard staff arguing about who was going to supervise the smoke breaks. In additional interview, R75 stated it always upset him to hear staff arguing about smoke breaks, and smoke breaks were even more late due to the arguing. Further, he stated smoke breaks generally ran about 15 minutes late. During interview on 04/15/2026 at 9:28 AM, State Registered Nurse Aide (SRNA) 3 stated the aides took turns taking residents out for smoke breaks or they just picked somebody to take them. She stated, due to staff being busy, smoke breaks ran late. SRNA 3 further stated she knew the residents did not like it when she was late starting the smoke break, but she ensured she allowed them the scheduled 15 minutes to smoke. During interview on 04/16/ 2026 at 10:36 AM, the Director of Nursing (DON) stated management was in charge of completing the smoke break schedules daily, and the smoke breaks were listed on the Daily Assignment Sheets. Further, the DON stated the specific SRNA to supervise smoke breaks was not listed and the less busy SRNA at the time was to supervise the smoke break. The DON stated it was her expectation smoke breaks started as close to the scheduled time as possible and no later than 10-15 minutes later than scheduled. In additional interview, the DON stated the decision as to which SRNA was to supervise smoke breaks should be discussed away from residents. She stated staff should not be arguing in front of residents about who was supervising smoke breaks. Additionally, the DON stated it was the residents' right to smoke. During interview on 04/16/2026 at 10:50 AM, the Administrator stated it was the residents' right to smoke and smoke breaks should start on time or no later than 10-15 minutes after the scheduled time. The Administrator further stated SRNAs should not be arguing in front of residents about who was going to supervise the smoke breaks.

Based on observation, interview, record review, review of the facility's policy, and the facility's Employee Confidentiality and Non-Disclosure Agreement, the facility failed to ensure confidentiality of the Electronic Medical Record (EMR) for 1 of 38 sampled residents, Resident (R)93. Observation on 04/15/2026 at 11:28 AM, on the F Hall, revealed staff left R93's computer display screen open on top of the unattended Medication cart, allowing the resident's personal and medical information to be visible to others on the unit.The findings include: Review of the facility's Employee Confidentiality and Non-Disclosure Agreement, revised April 2003, revealed employees should not leave your computer terminal or workstation unattended without logging off or using your system's screen saver function before leaving your work area or securing hardcopy information so that it may not be disclosed to unauthorized persons. Review of the facility's policy, titled Resident Rights, revealed, The resident has a right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. Review of R93's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 07/19/2024. R93's diagnoses included Type 2 diabetes mellitus. Observation on 04/15/2026 at 11:28 AM, revealed the medication cart located on the F Hall was left unattended. The computer display screen was left open with Resident 93's demographic and medical information visible and accessible to visitors, residents, and staff not assigned to the resident. Three non-clinical staff members were observed to be walking past the open computer display screen. Continued observation revealed Licensed Practical Nurse (LPN)6 returned to the medication cart at 11:29 AM, one minute later. LPN6, was interviewed on 04/15/2026 at 11:30 AM, related to leaving the computer display screen open with R93's confidential information visible. LPN6 stated, Yeah, I know. I forgot. It goes against resident privacy and stuff. In an interview on 04/16/2026 at 10:36 AM, with the Director of Nursing (DON), she stated staff was to ensure the computer screen was locked or closed prior to leaving the medication or treatment cart unattended in order to prevent a HIPAA (Health Insurance Portability and Accountability Act of 1996) violation and protect the resident's privacy and confidentiality. During an interview on 04/16/2026 at 10:50 AM, the Administrator stated the computer screen should be locked at all times when staff was away from their medication cart to protect the resident's confidentiality.

Based on interview, record review, and review of facility policy, the facility failed to provide medications in a timely manner to treat a Urinary Tract Infection (UTI) for 1of 38 sampled residents, Resident (R)117. R117 developed a UTI and Fosfomycin 3 grams as a single-dose treatment (antibiotic) was ordered on 11/11/2026 at 11:28 AM. However, the medication was not administered until 11/15/2025 at 4:23 PM, 4 days later. The resident experienced pain and discomfort.The findings include: Review of the facility's policy titled, Medication ordering and receiving from Pharmacy, dated November 2021, revealed the Administrator, Director of Nursing, and dispensing pharmacy established a daily delivery and pick-up schedule for medication orders. Review of R117's Face Sheet revealed the facility admitted the resident on 10/27/2022. R117's diagnoses included arthropathic psoriasis, and morbid obesity. Review of R117's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This score indicated intact cognition. Review of R117's Comprehensive Care Plan, revealed a focus for elimination deficit related to impaired mobility, contracture of the left knee, morbid obesity, and myalgia last revised on 01/23/2026. The interventions included: straight catheter as needed for urinalysis, and monitor for signs and symptoms of urinary tract infection. Review of R117's Primary Acute Note, dated 11/07/2025 at 12:01 PM, written by Nurse Practitioner (NP)1, revealed R117 was seen due to a fever of 102 degrees Fahrenheit overnight. Review of the Primary Follow-Up Note, dated 11/11/2025 at 12:00 PM, written by NP1, revealed in reference to the urinalysis completed on 11/07/2025, Out of abundance of caution would give Fosfomycin [A broad-spectrum antibiotic used as a single-dose treatment for uncomplicated lower urinary tract infections. It works by inhibiting bacterial cell wall synthesis] 3 g [grams] x1 dose since it had Extended Spectrum Beta Lactamase (ESBL) coverage while waiting on culture given +Leukocytes and +Nitrites on UA. Review of the urinalysis results, dated 11/07/2025, revealed Leukocytes 3+, Bacteria 3+, [NAME] Blood Cells too numerous to count (tntc). A urinalysis reflex culture (two step diagnostic process where a laboratory automatically performs a urine culture only if the initial urinalysis shows abnormal results) completed on 11/07/2025 for a clean catch urine was negative. The facility signed as receiving the results on 11/12/2025. Review of R117's Medication Administration Record (MAR), revealed orders for Fosfomycin Tromethamine Oral Packet three grams, one time by mouth, for Urinary Tract Infection (UTI) with a start date of 11/12/2025. A new entry on the MAR, dated 11/13/2025 at 8:43 AM, revealed instructions to hold the medication due to not being available from pharmacy; however, there was no documented evidence of a physician's order to hold the medication. Further review of the MAR. revealed a 'new entry for the Fosfomycin with a start date of 11/15/2025. Per the MAR, the medication was documented as administered on 11/15/2025 at 4:23 PM. Review of the Hospital Emergency Department (ED) Discharge Note, dated 11/24/2026, revealed R117 was transferred to the ED with a diagnosis of complicated UTI. R117 received Rocephin 1000 milligrams (mg) intramuscular (IM) injection (antibiotic), and Toradol 15 mg/milliliter IM for pain. The resident was discharged on 11/25/2026 at 209 AM. During an interview on 04/15/2026 at 11:30 AM with R117, she stated in November of 2025 she developed a Urinary Tract Infection (UTI) and had gone without treatment for approximately three weeks. She further stated Nurse Practitioner 1 had placed an order for an antibiotic that was a one-time dose back in November of 2025 and she never received the antibiotic. In additional interview, R117 stated she eventually ended up going to the Emergency Department (ED) due to high fever and was diagnosed with a urinary tract infection (UTI).Attempted to contact Licensed Practical Nurse (LPN)11 on 04/16/2026 at 4:38 PM, who had documented medication not available on 11/13/2025. However, no return call was received after leaving a message.During an interview on 04/16/2026 at 9:44 AM with the Infection Preventionist (IP) he stated when an antibiotic was ordered, the facility followed the McGreer criteria which is a standardized surveillance definition used in long-term care facilities to detect infections. The primary purpose for the McGreer criteria is to distinguish infection from colonization in nursing homes. Furthermore, when a urinalysis was ordered and did not meet the criteria for an antibiotic, the physician was contacted and made aware if changes needed. He stated he was not aware of the incident with R117 but stated the urinalysis did not meet the McGreer criteria. During an interview on 04/16/2026 at 3:55 PM, with the Director of Nursing (DON), she stated she was not sure why the Fosfomycin was not given on 11/11/2025 as ordered by NP1. She stated this was a medication that was used often in the facility and had been readily available from the pharmacy. The DON further stated if the Pharmacy did not have the ordered medication or if there was a delay in getting the ordered medication, the facility should have contacted the ordering provider and obtained an order for a comparable medication. Additionally, the DON stated the facility did not keep Fosfomycin antibiotic in the Emergency Medication Supply. Further, the DON stated it was her expectation medications were received timely from the pharmacy and administered to the resident. Furthermore, the DON stated there should have been documentation in the progress note explaining any delay with receiving medications and who was contacted. She further stated any delay in antibiotics could possibly lead to sepsis and pain.During an interview on 04/16/2026 at 2:25 PM with the Administrator, she stated her expectation was the policies be followed by all staff.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure medications which had been opened were properly labeled with the open and expiration dates for 1 of 8 medication carts.The findings include: Review of the facility's policy titled, Medication Storage in the Facility, dated November 2021, revealed the policy set forth included expiration dating (beyond-use date). Additional review of the policy revealed when the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated, if applicable for medications requiring a shortened expiration date. The nurse shall place a date opened sticker on the medication and enter the date opened and new date of expiration, if applicable. Observation on 04/15/2026 at 2:44 PM, of the A-station medication cart 2 for the F-Hall, with Licensed Practical Nurse (LPN)2 and the Director of Nursing (DON) present, revealed an open vial of Lantus insulin without an open or expiration date; and an open vial of Lispro insulin without an open or expiration date. During an interview with LPN2, on 04/15/2026 at 2:45 PM, she acknowledged medication should be labeled with the date opened. She stated failure to properly label insulin with an open date could place residents at risk for receiving out of date and ineffective medication due to potential loss of potency. During an Interview with the Director of Nursing, (DON), on 04/15/2026 at 2:48 PM, she confirmed the insulin had been opened but not dated. She stated it was her expectation for all opened medications to be marked with an open date and expiration date.

Based on observation, and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 04/14/2026, revealed Laundry Aide 7 folded a fitted sheet and flat sheet by holding the linens against his torso and legs; the shower room on Hall G had visible red droplets of what appeared as blood on the floor and a black, mold-like substance on a shower chair and room [ROOM NUMBER] had a bedpan stored in a bucket without a covering or bag, and without resident identification or date labeling. The findings include: 1. Observation on 04/14/2026 at 9:20 AM, revealed Laundry Aide 7 folding a fitted sheet and flat sheet by holding the linens against his torso and legs, allowing portions of the linens to come into contact with his clothing and the floor during the folding process. Interview on 04/14/2026 at 9:20 AM, with Laundry Aide 7, revealed he did not utilize a table or designated clean surface when folding linens and instead held the items against his body while folding. Laundry Aide 7 further stated, allowing clean linens to come into contact with personal clothing and the floor could increase the risk of contamination. 2. Observation on 04/14/2026 at 2:42 PM, revealed the shower room on Hall G had visible red droplets of what appeared as blood on the floor. Further observation revealed a black, mold-like substance present on a shower chair located in the same area. During an interview on 04/14/2026 at 2:42 PM, with Licensed Practical Nurse (LPN) 3, she looked at the red droplets on the floor and stated blood should not have been left unattended on the floor and should have been cleaned promptly. LPN3 stated failure to clean bodily fluids presented an infection control risk and could expose other residents to contaminants. She further acknowledged the presence of a mold-like substance indicated ineffective cleaning practices and was also an infection control concern. In additional interview, LPN 3 stated there was no specific staff member assigned responsibility to ensure showers were cleaned between each use. LPN3 stated cleaning responsibilities were shared among staff. During an interview on 04/16/2026 at 9:48 AM, with Housekeeping Aide20, she stated housekeeping staff cleaned the shower rooms daily, including shower stalls, sinks, toilets, and floors. Housekeeping Aide20 further stated cleaning the shower rooms between each resident use was the responsibility of nursing staff, including nurse aides. Further, she stated maintaining a clean environment was important to prevent the spread of infection and promote resident health. During an interview on 04/16/2026 at 9:50 AM, Housekeeping Aide19, stated maintaining a clean environment was important to support resident health and prevent the spread of infection. During an Interview on 04/16/2026 at 11:12 AM, with the Housekeeping Supervisor (HS), he stated housekeeping staff was responsible for daily cleaning and sanitizing of common areas, including shower rooms and shower chairs. The HS further stated cleaning the shower rooms between each resident use was the responsibility of nursing staff, which was important to prevent cross-contamination. Additionally, the HS stated housekeeping relied on communication from staff to identify when additional cleaning was needed. He acknowledged there was no formal system to ensure shower rooms were consistently checked after each use. Further, he stated housekeeping staff received infection control training as part of routine facility education. 3. Observation on 04/14/2026 at 10:20 AM, in room [ROOM NUMBER], revealed a bedpan stored in a bucket without covering or bag, and without resident identification or date labeling. During an interview on 04/14/2026 at 10:20 AM, with State Registered Nurse Aide (SRNA)1, she stated staff received infection control training at least annually. SRNA1 further stated bedpans should be stored in a bag and labeled appropriately. During additional interview, SRNA1 stated failure to properly store and contain items such as bedpans could increase the risk of contamination and transmission of germs to residents. Further, she acknowledged Resident (R)110 was assigned to room [ROOM NUMBER] and was able to ambulate to the bathroom. During an interview on 04/16/2026 at 9:44 AM, with the Infection Preventionist (IP), he stated there was no specific infection control concern the facility was focusing on at this time. He stated he made at least three rounds per day on each wing of the facility to provide oversight into infection control practices. The IP further stated he immediately provided on the spot education if an infection control issue was noted. During additional interview with the IP, on 04/16/2026 at 9:44 AM, he stated it was his expectation for blood and body fluids to be cleaned immediately by floor staff or housekeeping with the appropriate cleaning agents. He stated both nursing and housekeeping staff had access to cleaning agents and wipes for immediate use. In addition, he stated bath chairs in the shower rooms should be cleaned immediately between residents by SRNAs or housekeeping. During further interview with the IP, on 04/16/2026 at 9:44 AM, he stated bedpans should be stored in the bathroom in a bag and labeled with the resident's name. He further stated he expected all infection control practices to be followed as per their training. During an interview, on 04/16/2026 at 10:52 AM, with the Administrator, she stated it was her expectation for the facility to maintain a clean and sanitary environment. The Administrator stated the building had been divided into assigned areas to assist with identifying maintenance and housekeeping concerns, and those concerns were documented and reviewed during routine meetings Monday through Friday with all department heads. During continued interview on 04/16/2026 at 10:52 AM, with the Administrator, she stated both housekeeping and nursing staff shared the responsibility for cleaning shower rooms, including cleaning between each resident use. The Administrator stated bodily fluids, such as blood, should not be left on surfaces and items identified as dirty or containing mold-like substances should be cleaned promptly. The Administrator further stated the Housekeeping Supervisor and Director of Nursing were expected to provide oversight and follow-up to ensure areas such as shower rooms were maintained in a clean and safe condition. She further stated bed pans should be labeled and bagged.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to electronically transmit the discharge assessment within 14 days as required for 1 of 31 sampled residents, (Resident (R)82). R82 was discharged on [DATE]; however, the resident's Discharge Minimum Data Set (MDS) Assessment was not transmitted as of 02/27/2025. The findings include: Review of the CMS RAI Manual, dated 10/2024, revealed the MDS completion date must be no later than 14 days for a Discharge Assessment, whether return anticipated or not anticipated. Further review of the RAI Manual revealed the MDS Assessment should be submitted within 14 days of the completion date. Review of R82's Face Sheet revealed the facility admitted the resident on 08/28/2024, with diagnoses which included muscle wasting and atrophy, chronic kidney disease, anxiety, and anemia. Review of R82's electronic medical record (EMR) revealed the last documented MDS Assessment had an ARD of 10/07/2024, noting discharge return anticipated. Per review, the MDS assessment dated [DATE], revealed it had been signed by the MDS Coordinator on 10/10/2024 as verification that the assessment had been completed. However, review further revealed the MDS Assessment was listed as Exported but not Accepted, which indicated the MDS had not been transmitted and accepted as required by the RAI guidelines. In interview with MDS Nurse 1 and MDS Nurse 2, on 02/27/2025 at 10:17 AM, they stated it was important to follow the guidelines in the (CMS) RAI Manual for transmitting a MDS Assessment for tracking purposes. The two MDS Nurses further stated R82's Discharge MDS Assessment should have been transmitted within 14 days of R82's discharge date of [DATE], as required. They additionally stated R82's MDS Assessment would be transmitted on 02/27/2025. They further stated that it had not been transmitted due to an oversight. In interview with the Administrator on 02/27/2025 at 3:25 PM, she stated she expected her MDS staff to complete and transmit a discharged resident's Assessment timely, according to the RAI Manual.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan to meet the needs of 1 of 31 sampled residents, (Resident (R) 88). R88 was noted to have numerous refusals of wound care; however, the facility failed to develop the resident's comprehensive care plan to address her refusals The findings include: Review of the facility policy, Care Plan- Comprehensive H5MAPL0110, dated 09/2022, revealed the facility was to develop an individualized comprehensive care plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs. Continued review revealed each resident's comprehensive care plan was to incorporate identified problem areas, incorporate risk factors associated with identified problems, and reflect the resident's expressed wishes regarding care and treatment goals. Further review revealed assessments of residents were to be ongoing and care plans were to be revised as information about the resident and the resident's condition changed. Review of R88's electronic medical record (EMR) revealed the facility admitted the resident on 09/03/2024, with diagnoses that included osteoarthritis, difficulty in walking, and muscle wasting and atrophy. Review of R88's Comprehensive Care Plan revealed the facility identified a problem for alteration in skin integrity with a deep tissue injury (DTI) to the coccyx on 11/15/2024. Continued review revealed the facility assessed the pressure ulcer to R88's coccyx as a stage three. Further review revealed the interventions included: providing treatment as ordered; and to monitor the area to the coccyx for signs and symptoms of infection, decline, or improvement. Additionally, the review revealed the interventions included to notify the physician of any change every shift for wound care. Review R88's physician's orders revealed an order, dated 11/21/2024, to clean the pressure ulcer to the resident's coccyx with normal saline, pat dry, apply collagen particles to the wound bed, and cover with a bordered gauze dressing every day shift. Observation, on 02/26/2027 at 2:30 PM, revealed R88 had a bariatric bed. Further review of R88's physician's orders revealed no documented evidence of an order for a specialty air mattress. In addition, further review of R88's alteration in skin integrity care plan revealed no documented evidence that a specialty air mattress had been ordered or a care plan developed to address an intervention for a specialty mattress to assist with healing of the pressure ulcer. Review of R88's February 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed the resident refused wound care to her coccyx on 02/01/2025, 02/09/2025, 02/19/2025, 02/22/2025, 02/25/2025, and 02/26/2025. Review of R88's Progress Notes revealed the resident refused wound care to her coccyx on 02/22/2025, 02/25/2025, 02/26/2025 and 02/27/2025. Review of Advanced Practice Registered Nurse (APRN) 1's note, dated 02/18/2025, revealed R88 was noncompliant with wound care. Observation, on 02/26/2025 at 2:30 PM and 02/27/2025 at 10:30 AM, revealed R88 refused wound care to her coccyx. Further review of R88's Comprehensive Care Plan revealed no documented evidence the facility had care planned the resident's refusals or noncompliance with wound care to her coccyx. During interview with R88, on 02/26/2025 at 10:05 AM, she stated she did not feel well and did not wish to have the wound care done on that date. She further stated she had not allowed the wound care to be performed on 02/25/2025. During interview with MDS Coordinator 1, on 02/27/2025 at 10:17 AM, she stated behavior comprehensive care plans related to the residents refusal of wound care were completed by an MDS Nurse or the Social Services Director (SSD). She stated it was important to write a care plan to determine what interventions had been attempted and the effectiveness of those interventions regarding the resident allowing wound care. She further stated the comprehensive care plan was a guide for staff to know how to take care of residents. During interview with MDS Coordinator 2, also on 02/27/2025 at 10:17 AM, she stated wound care refusals should be care planned to show the different interventions attempted to encourage the resident to allow wound care in order to keep the wound from getting worse.

Based on observation, interview, record review and review of facility policy, the facility failed to provide adequate supervision and assistance devices to ensure the safety of its residents for 1 of 31 sampled residents (Resident (R)39). The facility allowed R39 to roam freely into other residents' hallways and rooms without providing adequate supervision of the resident to ensure the safety and well-being of all residents. The findings include: Review of the facility's investigation initiated on 09/22/2024, revealed on 09/22/2024, R8 followed R39 down the hall, with both residents being in wheelchairs. Per review, R8 was yelling, Hey, hey at R39 and making motions with his hands. Continued review revealed R8 grabbed R39's arm and wheelchair, and Registered Nurse (RN) 1 immediately separated the residents. Further review of the investigation revealed both residents were placed on one to one (1:1) supervision while the investigation was being completed. 1. Review of R8's Face Sheet revealed the facility admitted the resident on 10/21/2015, with diagnoses of aphasia following cerebral infarction, anxiety, and hemiplegia. Review of R8's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/23/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. 2. Review of R39's Face Sheet revealed the facility admitted the resident on 03/02/2017, with diagnoses of vascular dementia, bipolar disorder, and Moyamoya disease (a rare condition affecting the blood vessels of the brain). Review of R39's Annual MDS Assessment with an ARD of 07/08/2024, revealed the facility assessed the resident to have a BIMS score of nine of 15, indicating moderate cognitive impairment. Review of R39's Care Plan revealed a focus for elopement risk related to wandering, initiated 10/01/2018, with a goal that R39 would remain safe in the facility. Per review, the interventions included when R39 exhibited increased wandering, staff were to implement diversional activities. Observation on 02/24/2025 at 5:12 PM, revealed R39 wheeling himself into the doorway of another resident's room (room [ROOM NUMBER]). R8 (who was sitting in the hallway just outside his room [ROOM NUMBER]), told R39 to get out of room [ROOM NUMBER], and informed R39 he had no business in that room. Continued observation revealed R39 going down a hallway, out the door of that hallway, around and up another hall, and neither hallway was the hallway where R39's room was located. Further observation revealed R39 made multiple trips past R8's room. (During the observation, staff were not observed to be providing diversional activities as per the resident's care plan). During interview on 02/25/2025 at 10:15 AM, R8 stated R39 had taken smokeless tobacco from his room, and another resident had seen R39 do it; however, he could not recall who that resident was. (R8 had speech difficulties related to a prior stroke). Observation during the interview revealed R8 became visibly angry when discussing R39 taking his tobacco. During interview on 02/25/2025 at 10:27 AM, Registered Nurse (RN) 1 stated she witnessed the incident between R8 and R39 on 09/22/2025. She stated R8 had been wheeling down the hall and R39 was wheeling behind him yelling at R8. The RN reported she saw R8 grab R39's arm and wheelchair nearly tipping the wheelchair over, and staff intervened. RN 1 further stated three cans of smokeless tobacco had been tucked under R39's leg in the wheelchair. She additionally stated R39 had been moved to a room on a different hall, and R8 had been placed on 1:1 supervision. During interview on 02/26/2025 at 12:30 PM, Licensed Practical Nurse (LPN) 1 stated she was the nurse for the hall R39 resided on. She stated R39 wandered through the facility all the time via his wheelchair. The LPN stated if R39 was seen in an area where he should not be located, such as other residents' rooms, he was redirected by staff. She said no specific orders were noted for R8 for increased supervision; however, all residents should be checked on hourly. LPN 1 further stated there was no specific order or documentation to increase supervision for R39, however she stated the information to increase monitoring for R39 due to his wondering had been passed along in report at shift change. During interview on 02/26/2025 at 1:15 PM, the Social Services Director (SSD) stated she was aware of the incident between R8 and R39, and that R8 alleged R39 had stolen his cigarettes. She said she completed conflict resolution with R39 and R8. The SSD stated anytime R39 was observed in areas where he should not be, or attempting to go into other residents' rooms R39 was to be redirected. During interview on 02/26/2025 at 3:30 PM, State Registered Nursing Assistant (SRNA) 9 stated she often redirected R39 if she saw him in areas he should not be in. She further stated there was no specific order for increased supervision of R39 but it was passed along in report at shift change to redirect R39 if he was wandering in other residents' rooms. During interview on 02/27/2025 at 9:25 AM, the Administrator stated she remembered the incident that occurred involving R8 and R39. She reported she understood it was cigarettes that R39 was upset about during the incident, and he was informed his cigarettes were locked up at the facility. The Administrator further stated R39 had an ankle alarm on and had been placed on 1:1 supervision while the facility investigated the incident. In addition, she stated R39 had been moved to another hall.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare and serve food in a sanitary manner and in accordance with professional standards for food service safety. Observation of a test tray on 02/25/2025, with the Dietary Manager (DM) and Dietary Aide (DA) 1 revealed hot food temperatures (temps) were below 130 degrees Fahrenheit (F), and cold food items were above 41 degrees F. The failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's, Timely Meal Service policy, undated, revealed food was to be delivered promptly to assure safe, palatable, and high-quality food served at the proper temperature. Continued review revealed food was to be served at preferable temperatures (hot food hot and cold foods cold) as discerned by the residents and customary practice. Review of the facility's, Food Temperatures policy, undated, revealed all hot items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F. Per policy review, hot food items must not fall below 135 degrees F after cooking. Further review of the policy revealed all cold food items must be stored and served at a temperature of 41 degrees F or below. 1. Observation during a routine test tray temperature (temp) check on 02/25/2025 at 1:05 PM, revealed the food items were not within the required temperature standards, with hot foods below the required 135 degrees F, and cold food/drink above the required 41 degrees F or below. Per observation, the turkey was temped at 102.5 degrees F, mashed potatoes 129.7 degrees F, carrots 110.9 degrees F, and milk 43.7 degrees F. During interview on 02/25/2025 at 1:09 PM, the DM stated the meal service times were normal, and she was not sure what caused the food temperatures to be out of range. 2. Observation on 02/24/2025 at 4:00 PM; 02/25/2025 at 11:40 AM; and 02/26/2025 at 9:20 AM, revealed two stacks of plates sitting on the hot bar outside of the plate warmer. Continued observation revealed dietary staff removed stacks of plates from the plate warmer and placed them on the hot bar for use in the meal tray line. During interview on 02/26/2025 at 9:25 AM, the DM stated the plate warmer was not big enough to hold all the plates the facility used during meal service. The DM reported the cooks who were serving food pulled several plates from the warmer and stacked them on the side of the hot bar, allowing them to cool. In continued interview the DM said she felt the plates not being warm was the issue for the reduced temperatures of food items being served. The DM stated that if residents were served food items outside of the safe temperature range, it could lead to food poisoning, making the residents sick. The DM further stated it was important to serve residents foods at the right temperatures to give them a homelike experience. During interview on 02/27/2025 at 3:25 PM, the Administrator stated serving food outside of the safe handling zone could cause salmonella, gastrointestinal (GI) symptoms, food poisoning, or other illnesses. The Administrator said it was her expectation for warm foods to be served warm and cold foods to be cold. The Administrator further stated she wanted the food served to residents to be warm and something the residents enjoyed eating.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 31 sampled residents, (Resident (R)37, R95, R100, and R113). The findings include: Review of the facility's policy, Infection Prevention Program Overview, undated, revealed the goals of the infection prevention program were to decrease the risk of infection to residents. Per review, the goals also included maintaining compliance with state and federal regulations relating to infection prevention. Further review revealed the prevention of spread of infections was accomplished by use of hand hygiene, standard precautions and other barriers, and appropriate treatment and follow-up. Review of the facility's policy, Oxygen Use, revealed the oxygen tubing was to be kept off the floor. 1. Review of R37's Admission Record revealed the facility admitted the resident on 03/21/2022, with diagnoses which included diabetes, muscle weakness, and overactive bladder. Observation on 02/24/2025 at 4:00 PM, and on 02/27/2025 at 1:54 PM, revealed opened packages of adult protective briefs and individual briefs lying on the bathroom floor of R37's room. 2. Review of R95's Admission Record revealed the facility admitted the resident on 10/11/2024, with diagnoses which included diabetes, muscle wasting, and chronic kidney disease. Observation on 02/24/2025 at 4:20 PM, revealed R95's oxygen nasal cannula lying on the floor uncovered. Further observation revealed R95's nebulizer tubing lying on the resident's bedside table uncovered. 3. Review of R100's Admission Record revealed the facility admitted the resident on 07/19/2024, with diagnoses which included diabetes, malignant neoplasm of the colon, and chronic obstructive pulmonary disease. Observation on 02/27/2025 at 1:54 PM, revealed opened packages of briefs and individual briefs lying on the bathroom floor of R100's room. 4. Review of R113's Admission Record revealed the facility admitted the resident on 11/25/2024, with diagnoses which included malnutrition, lack of coordination, and muscle wasting. Observation on 02/24/2025 at 4:25 PM, revealed R113's nebulizer tubing lying on R113's beside table uncovered. During interview on 02/27/2025 at 1:15 PM, the Infection Preventionist (IP) stated oxygen and nebulizer tubing should be stored in bags when not in use to prevent bacteria from growing and traveling into the resident's lungs. He said the tubing should not be dropped on the floor and then used for the resident as the tubing would have germs on it. The IP stated residents' incontinent supplies should be kept in the residents' closets or dressers and not left lying on the residents' bathroom floors or stored under the bathroom sink because that was a damp, dark place and you don't know what's growing. He additionally stated residents' individual briefs were to be thrown away because it was unknown what they (briefs) had touched, and therefore, could be a source of infection. The IP further stated residents' rooms should be checked every shift to ensure their briefs were stored appropriately in closets and dressers. During interview on 02/27/2025 at 3:25 PM, the Administrator stated incontinent supplies were to be kept in the resident's closet or bedside table and should never be left lying on the bathroom floor or under the bathroom sink. She stated the incontinent supplies in the bathroom floor would be an infection control issue and could cause the resident to have an infection. The Administrator further stated she expected staff to check the residents' rooms every two (2) hours and not allow incontinent supplies to be left lying on the floor.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were free from misappropriation of property. Controlled substances/medications were misappropriated without authorization from eight (Resident (R) 4, R10, R11, R13, R45, R78, R86 and R90) of 89 sampled residents. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed each resident had the right to receive treatment and supports for daily living safely. Per the policy, the facility shall exercise reasonable care for the protection of the resident's property from loss or theft. Review of the facility's policy titled, Resident Protection Plan, dated 09/15/2022, revealed each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy revealed Misappropriation of property was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings without the resident's consent. Review of the facility's policy titled, Master Control Log for Scheduled Drugs Sheet, last revision 06/2011, revealed a master control log would be utilized for all controlled drugs in the facility. The procedures indicated during narcotic count, the nurse would verify the count sheets matched the Master Control Log before accepting the narcotic keys. In addition, daily, the Director of Nursing (DON) would make a copy of the master Control Log to be maintained in a notebook in their office. However, the policy did not provide the procedure for controlled substance shift count, discrepancies and/or proper security procedures of narcotic keys. Review of a facility investigation revealed an investigation was initiated on 03/17/2024 at 9:50 PM. Staff interviews revealed that on 03/17/2024, there was reasonable suspicion that Licensed Practical Nurse (LPN) 1 was under the influence and, as a result, was removed from taking care of residents. LPN1 agreed to a drug screen and was suspended. As part of the investigation, interviewable residents on the hall assigned to LPN 1 were asked by the DON if they had received their medication. Although some residents could not remember for sure, others said no, they had not. During the facility investigation, narcotic count and cart counts were checked twice by the DON and Registered Nurse (RN)1. The investigation found that the narcotic count was accurate when LPN1 accepted the medication cart at the beginning of first shift on 03/17/2024. However, the Controlled Drug Count and cart review conducted on 03/17/2024 at approximately 6:30 PM (in response to the allegations against LPN1), revealed 12 narcotics/controlled substance medications were now unaccounted for and missing without a signature to indicate that they had been signed out for administration. The controlled drug reconciliation sheet revealed the following missing medications: a. R4 was missing one hydrocodone/APAP (Norco-a narcotic opioid used to treat pain) 5/325 milligram (mg) tablet, and one Lorazepam (Ativan - a benzodiazepine used to treat anxiety) 0.5 mg tablet. b. R10 was missing one hydrocodone/APAP 5/325 mg tablet, and one clonazepam (a benzodiazepine used to treat anxiety) 1 mg tablet. c. R11 was missing one gabapentin (Neurontin-a narcotic used to treat nerve pain) 600 mg tablet. d. R13 was missing one gabapentin 600 mg tablet. e. R45 was missing one clonazepam 0.5 mg tablet. f. R78 was missing one hydrocodone/APAP 5/323 mg tablet, and one alprazolam (a benzodiazepine used to treat anxiety and panic disorder) 0.5 mg tablet. g. R86 was missing one dronabinol (Marinol-a cannabinoid used to control nausea and vomiting) 10 mg. h. R90 was missing two gabapentin 100 mg tablets. Interviews with residents whose medications were missing included: a. Review of R10's Quarterly Minimum Data Set (MDS) assessment, dated 02/06/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14/15, indicating resident was cognitively intact. During an interview with R10 on 04/01/2024 at 12:20 PM, the resident recalled not receiving pain medication all day but did not experience any issues of uncontrolled pain. b. Review of R13's Quarterly MDS assessment, dated 03/14/2024, revealed the facility assessed the resident to have a BIMS score of 13/15, indicating the resident was cognitively intact. During an interview with R13 on 04/01/2024 at 1:25 PM, the resident stated, No, I did not get my Neurontin that morning. The resident said they had not experienced any issues with medication administration, such as not receiving narcotic medications, prior to the incident. c. Review of R78's Quarterly MDS assessment, dated 02/13/2024, revealed the facility assessed the resident to have a BIMS score of 10/15, indicating the resident was moderately impaired in cognition. During an interview with R78 on 04/01/2024 at 1:50 PM, the resident stated, No, I don't think I got my pain medication that day. R88 stated they were shocked regarding the misappropriation of their medication. d. Review of R86's Annual MDS assessment, dated 01/15/2024, revealed the facility assessed the resident to have a BIMS score of 15/15, indicating the resident was cognitively intact. During an interview with R86 on 04/01/2024 at 2:10 PM, the resident stated, I had taken a nap earlier in the day, but I'm pretty sure that I did not get my Marinol. e. Review of R90's Quarterly MDS assessment, dated 02/27/2024, revealed the facility assessed the resident to have a BIMS score of 15/15, indicating the resident was cognitively intact. During an interview with R90 on 04/01/2024 at 2:36 PM, the resident stated, No, I did not get my pain medication [Neurontin] that morning. The State Survey Agent (SSA) attempted a telephonic interview with LPN1, on 03/29/2024 at 2:55 PM and again on 03/30/2024 at 9:45 AM. LPN1 did not answer or return the surveyor's call. During an interview on 04/05/2024 at 2:28 PM, State Registered Nurse Aide (SRNA) 6 stated that at approximately 3:30 PM on 03/17/2024, they noticed something was not right. LPN1 was observed falling asleep at the nurse's station and slumped over the medication cart. During an interview on 04/05/2024 at 2:36 PM, with SRNA13, she stated on 03/17/2024 at approximately 4:30 - 5:00 PM, she observed LPN1 dozing off at the nurses' station and stated that when staff asked LPN1 if she was okay, she would eventually respond, back hurting. SRNA13 added that during evening medication pass, she observed LPN1 standing at the med room door, jiggling the doorknob, and then fidgeting in her pocket with keys for at least thirty (30) minutes. However, she added, LPN1 never entered nor tried to use the keys to open the med room door during this time. During an interview on 04/05/2024 at 2:16 PM with Kentucky Medication Aide (KMA) 2, she stated that at approximately 4:30 PM, around last med pass, something was wrong with LPN1, who could not comprehend, and just stood there in a daze and could hardly hold herself up. KMA2 stated she was concerned for the residents because a staff with an impaired judgement could cause a detrimental resident outcome. KMA2 stated none of the staff felt comfortable performing a narcotic count, because of the unknown outcome related to LPN1 ' s appearance and actions. KMA2 was not aware of the facility policy/procedure related to narcotic count and/or taking over of narcotic keys with a staff involved in this type of situation. During an interview on 04/04/2024 at 1:38 PM, LPN2 stated she worked as the Unit Coordinator on 03/17/2024 at approximately 10:20 AM and observed LPN1 on their first break, with normal appearance and clear speech. However, at approximately 4:30 PM, staff approached LPN2, saying that LPN1 was acting inappropriately, was under the influence, and was unable to perform work duties. LPN1 was observed passing out and asleep on her med cart. LPN2 contacted the Administrator and informed her of staff concerns and was instructed to remove LPN1 from resident care. LPN2 stated LPN1 was not coherent enough to count narcotics, let alone provide safe and adequate care to residents. During an interview on 03/22/2024 at 2:00 PM, RN4 stated that when she saw LPN1 at 3:00 PM, she contacted the Administrator immediately related to LPN1's appearance and actions. During an interview on 03/29/2024 at 11:00 AM. the DON stated that on 03/17/2024 at approximately 4:50 PM, she was notified by telephone per the Administrator regarding staff concerns related to LPN1 ' s behavior and was informed of the urgency to get to the facility, ensure resident safety and the immediacy to initiate an investigation. The DON stated on her arrival to the facility, she observed LPN1 sitting outside at the smoke [NAME], slumped over on her knees with eyes closed and slow to respond. The DON stated LPN1 had just been released from her primary physician to return to work duties related to a back injury, and LPN1 admitted to the DON that she had taken a self-prescribed narcotic earlier in the week. However, per the DON, LPN1 was never asked about the misappropriation of resident narcotic medications. The DON stated LPN1 informed her that she had completed the evening medication pass but had not signed off the medications. However, resident interviews and review of the facility's investigation revealed the residents stated they did not receive their medications. The DON stated, that after conducting the investigation, the facility found that LPN1 failed to ensure residents were free from misappropriation of property and the diversion of their medications. Per the DON, LPN1 was terminated after failing to promote a safe comfortable environment for all residents and for violation of facility policies. Interview with the Administrator on 04/03/2024 at 9:46 AM revealed her expectation was that each nurse must perform a narcotic count with the off-going nurse before their shift and prior to possession of the narcotic cart keys. During an additional interview on 04/05/2024 at 2:25 PM with the Administrator, she stated LPN1 was removed from resident care immediately upon staff notification of the LPN's apparent impairment and inability to perform work duties. The Administrator stated the Interdisciplinary Team (IDT) decided prior to receipt of LPN 1's drug screen results, that the facility would not continue her employment, based on residents not receiving their medication. The Administrator stated her expectation of all nursing staff, specifically with the administration of medications would be to follow the facility's policies and procedures related to Resident Rights policy, and Freedom from Misappropriation policy. Review of the facility's Employee File for LPN1 revealed a hire date of 01/12/2021. The Screening Report/State Criminal background checks, dated 01/13/2021 and 07/15/2023, revealed a cleared status for employment. LPN1 had a Kentucky Board of Nursing (KBN) validation, dated 03/20/2024, which showed a valid/current licensure, with no restrictions on the license. Further review of the employee file revealed a Negative urine drug screen result, dated 03/20/2024. An employee Termination Form dated 03/22/2024, noted the LPN was terminated related to standards of conduct violation. Additionally, LPN1's employee file revealed a letter of receipt from the KBN, addressed to the facility, with a subpoena record request, dated 03/20/2024, which noted acknowledgement of receipt of information submitted regarding the allegation of Missing Narcotics and nursing practice by LPN1.

Based on observation, interview, record review, manufacturer ' s recommendations, and review of the facility's policy, it was determined the facility failed to ensure it was free of a medication error rate of five percent or greater. During the medication pass observation of 69 opportunities for administration of medication, there were nine opportunities in which medications were not administered according to manufacturer ' s recommendations and/or the facility ' s medication policy, resulting in an error rate of 13.04%. The failure affected two (Resident (R) 25 and R113) of 19 sampled residents. R25 ' s insulin injection was not prepared correctly and R113 failed to receive the full value of eight crushed medications. The findings include: 1. Review of the manufacturer's recommendations for Tresiba insulin, dated 07/2022, revealed the insulin should not be removed from its flex pen by using a syringe. This could cause an incorrect dose resulting in low or high glucose (blood sugar). Review of R25's medical record revealed the resident had diagnoses including diabetes and chronic kidney disease. Review of R25's Comprehensive Care Plan (CCP), initiated on 02/15/2024, revealed the resident was at risk for hyperglycemia (elevated blood sugar) and hypoglycemia (low blood sugar.) Interventions included for staff to administer diabetic medications as ordered by the medical doctor. Review of R25's Physician's Orders, dated 03/26/2023, revealed an order for Tresiba (insulin), inject 22 units subcutaneously two times a day for diabetes Mellitus. Review of R25's Medication Administration Record (MAR) dated 03/01/2024 to 03/31/2024 and 04/01/2024 revealed R25 received 22 units of Tresiba twice a day as ordered. Observation during medication pass on 04/02/2024 at 9:25 AM revealed Licensed Practical Nurse (LPN) 3 removed the cap from the Tresiba flex pen and wiped the tip with an alcohol pad. She then pulled up the insulin from the prefilled Tresiba flex pen using a regular insulin syringe (rather than an adaptor designed for use with the flex pen.) LPN3 next knocked on R25's door and went in to administer the medication to R25. Although LPN3 was prepared to administer the medication, R25 refused the insulin and told LPN3 that they took the long-acting insulin at a different time. LPN3 then called the physician and left a message that R25 refused the morning insulin. During an interview with LPN3 on 04/02/2024 at 9:30 AM, she stated she cleaned the prefilled syringe site with an alcohol wipe to prevent the spread of infection. LPN3 stated she knew there were special adapters for use with the prefilled flex pens, but she did not have any of those on her medication cart and was not aware of where to go to get the special adapters. LPN3 stated she was not aware she could not use a syringe to pull up insulin from an insulin pen and was unaware of possible adverse reactions, including hypoglycemia, related to using a syringe to draw up the insulin from a flex pen. During interview with the Director of Nursing (DON) on 04/04/2024 at 9:25 AM, she stated staff were educated in orientation to use the needle that goes with the flex pen to administer insulin. She further stated that she was not aware of any staff drawing up insulin from the flex pens using a syringe. She stated she expected nursing staff to always administer medications properly per the physician orders, facility policies, and best practice. Continued interviewed revealed the proper technique for administering insulin from a flex pen was to use the needle adapters that go with the flex pen. During an interview with Pharmacist (RPh)1 on 04/04/2024 at 10:17 AM, he stated Tresiba should only be administered using the needle adapters for the flex pens. If a syringe were used, an incorrect dose could occur, causing the resident to experience an adverse reaction. During interview with the Administrator on 04/05/2024 at 4:22 PM, she stated she expected staff to follow established policies related to medication administration. 2. Review of the facility's policy, titled, MedWiz, dated 11/2021, revealed that when medications are crushed for oral administration and placed in food, the entire content of the food must be consumed to assure the entire dose of medication has been consumed. Review of R113's Physician's Orders, dated 02/19/2024, revealed orders included: a. Omeprazole 40 milligrams (mg), give one capsule by mouth two times a day for Gastro/esophageal reflux disease (GERD). b. Metoprolol 50 mg give one tablet by mouth two times a day for hypertension. c. Sertraline 50 mg give two tablets by mouth one time a day for mood stabilizer. d. Irbesartan 300 mg give one tablet by mouth one time a day for hypertension. e. Divalproex 125 mg give one tablet by mouth one time a day for mood stabilizer. f. Fexofenadine 180 mg give one tablet by mouth one time a day for allergies. g. Sennosides 25 mg give one tablet by mouth one time a day for bowel care. h. Multivitamin Tablet give one tablet by mouth one time a day for supplement. Further review of R113's orders, dated 09/15/2023, revealed that staff May crush medications (or open capsules) as indicated per pharmacy protocol. Observation on 04/03/2024 at 8:45 AM revealed LPN3 crushed the eight ordered medications in a small plastic bag. She then scooped up applesauce, put it in a 30 milliliter (ml) plastic cup, poured the crushed medications into the cup, and stirred the medications. LPN3 then went into R113's room and explained she had the resident's medications. She then placed the spoon with the crushed medications into R113's mouth. The resident closed their mouth and swallowed applesauce with the medications mixed in it. LPN3 then removed the spoon, which still contained approximately 25 % (percent) of the crushed medications and applesauce from the resident ' s mouth. LPN3 put the spoon back in the cup and then threw it in the trash container located next to the resident's bed. During interview with LPN3 at the time of the observation on 04/03/2024 at 8:45 AM, she said she thought R113 received all the medications and stated that failure to receive all the medication as ordered could result in a bad health outcome. When the surveyor asked LPN3 to check the medications in the trash can, LPN3 looked and stated there could be some medications left in the cup. LPN3 then continued with the medication pass without ensuring that the resident received all of the quantity of each of the eight medications ordered. During interview with the DON on 04/04/2024 at 9:25 AM, she stated staff were educated in orientation on administering crushed medications. She further stated staff should follow the facility policy and assure that all the medications that are crushed are taken by the resident. She also stated she was not aware of a staff member not giving all the crushed medications. During interview with the Administrator on 04/05/2024 at 4:22 PM, she stated she expected the DON to assure that the staff were following the facility's policies. 49360

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to develop a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] after a Right [MEDICAL CONDITION] due to a [DIAGNOSES REDACTED]. Review of Resident #1's care plan revealed no evidence that the facility developed a care plan to include interventions for monitoring the resident's medical condition. The findings include: Review of the facility policy titled Care Plans-Comprehensive, dated [DATE], revealed an individualized comprehensive care plan that included measurable objectives and timetable to meet the resident's medical and nursing needs would be developed for each resident. The policy also indicated each resident's care plan was designed to incorporate identified problem areas and incorporate risk factors associated with the identified problems. The care plan was also designed to aid in the prevention of, or reduction, in declines in the resident's functional status. Resident #1's medical record revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she required assistance of two (2) staff members with bed mobility and transfers. Resident #1 was interviewable with a brief interview for mental status (BIMS) score of eleven (11). Resident #1 expired at Facility #2 on [DATE]; therefore, the resident was not interviewed or observed during the investigation. Review of the resident's Comprehensive Care Plan, not dated, revealed staff identified that Resident #1 had deficits in self-care performance related to impaired mobility and bilateral BKA ([MEDICAL CONDITION]). Care plan interventions included skin inspections to observe for redness, open areas, scratches, cuts, and bruises and staff were to report changes to the nurse. The care plan provided no evidence that staff developed a care plan that addressed the resident's [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #1 on [DATE], an Angiogram (a test to evaluate the arteries that carry blood to the legs) was attempted of his/her left lower extremity (LLE). However, Resident #1's procedure could not be completed because the superficial femoral (groin area) and popliteal (knee area) arteries to his/her left lower extremity were occluded (blocked off). The resident returned to the facility on [DATE]; however, there was no care plan developed that included newly implemented interventions to ensure his/her LLE was monitored after the blood flow concern was identified. Interview with the DON on [DATE] at 10:00 AM revealed the facility did not obtain the Angiogram report until [DATE], nine days later. However, the DON stated that even though Resident #1's outpatient procedure indicated the blood flow to his/her left lower extremity was occluded (blocked) on [DATE], staff were not expected to update his/her care plan because there were no new physician orders received, and that wasn't up to us, that would be at the physician's discretion. She also stated Resident #1 was on daily skilled charting, and she felt that was sufficient monitoring/assessment for Resident #1's medical condition. Review of Resident #1's nursing assessments dated [DATE], [DATE], and [DATE] revealed staff documented that the resident had no [MEDICAL CONDITION] and his/her skin color was normal. However, Advanced Practice Registered Nurse (APRN) #1's documentation for Resident #1 on [DATE] revealed staff reported to the APRN that the resident's left foot/ankle was badly swollen. The APRN's documentation indicated she observed Resident #1 to have 1+ [MEDICAL CONDITION] to his/her left foot/ankle area and discoloration was also observed. Review of Resident #1's care plan provided no evidence that a care plan was developed to address the changes identified in the resident's condition on [DATE]. Further review of the APRN's documentation revealed on [DATE] she was informed that Resident #1's left foot/ankle was still swollen and becoming more discolored. APRN #1's documentation indicated she consulted with Resident #1's physician and ordered a portable Doppler of the resident's let lower extremity. Resident #1's physician orders revealed staff entered an order for [REDACTED]. However, Resident #1's care plan provided no evidence that a care plan was developed to address the ongoing changes in the resident's condition on [DATE], after the diagnostic test was ordered. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM revealed on [DATE], when she identified that Resident #1's foot was red, she informed APRN #1 of the resident's condition, and an order for [REDACTED]. diagnostic order. Review of the nursing documentation by LPN #1 revealed at 8:30 AM on [DATE], Resident #1's left foot had a large blister that covered the entire top of foot. LPN #1's documentation also indicated Resident #1 had no capillary refill and his/her foot was cold to touch. The record also indicated the resident was transferred to a local hospital for further evaluation and treatment on [DATE]. Review of the hospital record for Resident #1 from Facility #1 revealed he/she arrived on [DATE] at approximately 9:41 AM and his/her left foot was blue in color, cold to touch from the ankle down, his/her foot had no capillary refill, and his/her nailbeds to the left foot were dusky in color. Resident #1's hospital record indicated the resident was later transferred to Facility #2 on [DATE] for further evaluation and treatment. Review of Resident #1's hospital record from Facility #2 indicated he/she arrived at Facility #2 on [DATE] at approximately 8:22 PM, and was diagnosed with [REDACTED]. Surgical Services was consulted on [DATE] and the resident had a Left [MEDICAL CONDITION] on [DATE]. Interview with MDS Coordinator #1 on [DATE] revealed she was responsible for developing Resident #1's comprehensive care plan. She was aware that Resident #1 had a [DIAGNOSES REDACTED]. diagnosis. The MDS Coordinator also stated nursing staff was monitoring Resident #1 through the facility's weekly skilled charting, and therefore, the resident's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Continued interview with the Director of Nursing (DON) on [DATE] at 10:00 AM revealed she had reviewed Resident #1's care plan and had no concerns with the care plan that was developed for the resident.

Based on interview, record review, review of the facility policy, and review of Johns Hopkins information regarding [MEDICAL CONDITIONS], it was determined the facility failed to provide quality care and treatment for one (1) of three (3) sampled residents (Resident #1). On [DATE], a physician determined the resident's left femoral artery (groin area) was blocked, affecting blood flow to the left leg. On [DATE] and [DATE], an Advanced Practice Registered Nurse (APRN) documented the resident's left foot swollen/discolored, and on [DATE], the resident was transferred to the hospital when the resident had 2+ [MEDICAL CONDITION] with worsening purplish/black discoloration and cool, large blister formation. However, review of the resident's daily Skilled Charting Assessments for [DATE] through [DATE] revealed staff documented the resident's left leg/foot was normal. Resident #1's left lower leg was amputated at the hospital and the resident was transferred back to the facility on [DATE]. Review of the resident's admission nursing assessment revealed the resident had normal pulses in the left foot and no swelling, even though the resident's lower leg/foot had been amputated. The findings include: Review of the facility policy titled Charting and Documentation, dated [DATE], revealed all services provided to the resident, or any changes in the resident's medical condition, should be documented in the resident's medical record. A review of Johns Hopkins Medicine [MEDICAL CONDITIONS] information revealed [MEDICAL CONDITION] is a slow and progressive circulation disorder. [MEDICAL CONDITION] may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels. However, the legs and feet are most commonly affected. Further review revealed the most common cause of [MEDICAL CONDITION] is [MEDICAL CONDITION], the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs. It also decreases the oxygen and nutrients available to the tissue. Blood clots may form on the artery walls, further decreasing the inner size of the blood vessel and block off major arteries. Symptoms of [MEDICAL CONDITION] may include: Changes in the skin, including decreased skin temperature, or thin, brittle, shiny skin on the legs and feet; Weak pulses in the legs and the feet; Numbness, weakness, or heaviness in muscles; Pain (described as burning or aching) at rest, commonly in the toes and at night while lying flat; Paleness when the legs are elevated; or Reddish-blue discoloration of the extremities. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she was interviewable with a brief interview for mental status (BIMS) score of eleven (11) and required extensive assistance of two (2) staff members with bed mobility, transfers, and toileting. Resident #1 expired at Facility #2 on [DATE]. Review of Resident #1's Skilled Charting assessment dated [DATE] at 9:23 AM revealed the resident had no [MEDICAL CONDITION], no abnormal peripheral pulses, and his/her capillary refill was not sluggish. Review of Resident #1's medical record revealed he/she was transported out of the facility on [DATE] at 10:30 AM for an outpatient surgical procedure, an Angiogram (a test to evaluate the arteries that carry blood to the legs) of his/her left lower extremity (LLE). However, review of the surgical procedure results revealed the procedure could not be completed because the resident's superficial femoral (groin area) and popliteal (knee area) arteries to his/her left lower extremity were occluded (blocked off). Resident #1 returned to the facility on the same day the procedure was attempted, [DATE]. Interview with Physician #1 on [DATE] at 12:15 PM revealed he attempted to conduct the diagnostic Angiogram of Resident #1's LLE on [DATE], but was unable to complete the test because the resident's left leg was stopped up. He stated when he saw the resident on [DATE], his/her leg started to look bad and was red. Physician #1 also stated the residents LLE had been stopped up for a while; therefore, his/her pedal pulses would have most likely been weak/faint in the LLE. Interview with the DON on [DATE] at 10:00 AM revealed the facility did not obtain the results of Resident #1's procedure until [DATE] (nine days later). The DON stated that even when the results of the resident's attempted outpatient procedure were obtained, no new interventions were implemented to monitor the resident's lower extremity. According to the DON, the resident was on daily skilled charting, and she felt that was sufficient monitoring/assessment for Resident #1's medical condition. Review of Resident #1's Skilled Charting assessment dated [DATE] at 9:57 AM revealed the resident had no [MEDICAL CONDITION] and his/her skin color was normal. An interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM, the nurse who completed Resident #1's assessment on [DATE], revealed she had cared for Resident #1 and the resident had no [MEDICAL CONDITION] or discoloration to his/her left leg. However, review of Advanced Practice Registered Nurse (APRN) #1's documentation for Resident #1 on [DATE], at 4:35 PM revealed staff reported to the APRN that the resident's left foot/ankle was badly swollen. The APRN's documentation indicated she observed Resident #1 to have 1+ [MEDICAL CONDITION] to his/her left foot/ankle area and discoloration was also observed. Review of Resident #1's Weekly Nursing Assessment revealed on [DATE], at 4:44 PM, LPN #1 documented that Resident #1 had no [MEDICAL CONDITION] and his/her skin color to the LLE was normal. According to an interview with LPN #1 on [DATE] at 3:30 PM, the nurse who completed the assessment on [DATE], she did not observe any swelling or abnormal skin color. However, review of the APRN's documentation revealed on [DATE] at 4:44 PM (the same time that LPN #1 documented no concerns with the resident's left leg/foot) staff notified her that Resident #1's left foot/ankle was still swollen and becoming more discolored. The APRN's documentation indicated she consulted with the resident's physician and ordered staff to obtain portable Doppler of the LLE. Interview with LPN #2 on [DATE] at 10:40 AM revealed she was the nurse who notified the APRN on [DATE] that Resident #1's foot was red, and an order for [REDACTED].#1's left foot/leg. Review of Resident #1's Skilled Charting assessment dated [DATE] at 6:59 AM revealed LPN #1 again documented that the resident had no [MEDICAL CONDITION] and his/her skin color was normal. Continued interview with LPN #1 on [DATE] at 3:30 PM, revealed she did not observe any swelling or abnormal skin color to the resident's left leg. Further review of Resident #1's Skilled Charting Assessment revealed on [DATE] at 6:56 AM, LPN #1 again documented that the resident had no [MEDICAL CONDITION] and had normal peripheral pulses and capillary refill. However, review of the nursing documentation dated [DATE] revealed at 8:30 AM, approximately one and a half hours later, LPN #1 documented that Resident #1's left foot had a large blister that covered the entire top of foot. Further review of the documentation indicated Resident #1 had no capillary refill and his/her foot was cold to touch. The record also indicated he/she was transferred to a local hospital for further evaluation and treatment on [DATE]. Further, review of the APRN's documentation on [DATE] at 10:57 AM revealed staff informed her that Resident #1's left foot/ankle was more discolored, black, and cold. The APRN's documentation also indicated that she observed 2+ [MEDICAL CONDITION] with worsening purplish/black discoloration and cool, large blister formation. Continued interview with LPN #1 on [DATE] at 3:30 PM, revealed on [DATE], Resident #1's left foot/ankle was swollen, cool to touch, and purple/red in color. The LPN stated a large fluid-filled blister, which covered the top aspect of his/her foot, was also observed. According to LPN #1, even though assessments of Resident #1 were documented on [DATE] and [DATE] by the LPN, she had not cared for Resident #1 for approximately one (1) week, and there was a big change in his/her foot/ankle from her last assessment of the resident. She stated the DON and the resident's physician were notified of the change in Resident #1's condition and he/she was transferred and later admitted to the hospital on [DATE]. The LPN was unable to explain why the Skilled Charting Assessment she documented showed no concerns. Review of the hospital record for Resident #1 from Facility #1 revealed he/she arrived on [DATE] at approximately 9:41 AM and his/her left foot was cold to touch from the ankle down, was blue in color, his/her foot had no capillary refill, and his/her nailbeds to the left foot were dusky in color. Further review revealed the resident was later transferred to Facility #2 on [DATE] for further evaluation. Review of Resident #1's hospital record from Facility #2 indicated the resident arrived at the facility on [DATE] at approximately 8:22 PM and was diagnosed with [REDACTED]. Continued review revealed Surgical Services was consulted and the resident had a Left [MEDICAL CONDITION] on [DATE]. Continued interview with Physician #1 on [DATE] at 12:15 PM revealed when he reevaluated the resident at the hospital on [DATE] or [DATE] (unable to recall exact date), his/her left foot/ankle was bluish and black. However, he stated he evaluated the resident in [DATE] and offered an admission and evaluation of his/her LLE because it was starting to get stopped up then. The physician stated Resident #1 refused an admission at that time due to COVID, and wanted to wait. He stated an outpatient appointment was set for [DATE] to further evaluate his/her LLE. Physician #1 stated that after evaluating the resident on [DATE] it was inevitable that he/she would have required an amputation, and no actions taken would have made a difference in the outcome for the resident. Continued review of Resident #1's medical record revealed the facility readmitted the resident on [DATE] after the resident had a below knee amputation of the left leg. However, even though the resident's lower leg/foot had been amputated, review of the resident's Nursing Admission Assessment revealed staff documented the resident had palpable pedal pulses in the left foot of normal quality and had no [MEDICAL CONDITION]. A post-survey interview with the Administrator on [DATE] confirmed there were errors on the [DATE] assessment. She stated the information for the Nursing Admission Assessment automatically pulls over from a previous assessment and the nurse forgot to change the information regarding the resident's left leg. According to the Administrator, she believed Resident #1's other nursing assessments were accurate. Interview with the DON on [DATE] at 3:40 PM revealed nurses conducted head-to-toe assessments of Resident #1 daily, and she felt the assessment were adequate to monitor the resident's condition. She stated she had no process to ensure that daily nursing assessments were accurate according to the resident's current clinical condition. However, the DON stated the nurse's assessment stands.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered comprehensive care plan for three (3) of twenty-nine (29) sampled residents (Resident #68 and Resident #94 related to respiratory care (oxygen therapy), and Resident #110 related to range of motion). Review of the comprehensive person-centered care plan for Resident #68 and Resident #94 revealed the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident for Resident #68 and the actual liter flow for Resident #94. In addition, the facility failed to specifically address the limitations in range of motion (ROM) to Resident #110's hands and plan interventions to prevent further declines in ROM. The findings include: Review of the facility's care plan policy, not dated, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The policy stated care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes. Each resident's comprehensive care plan was designed to incorporate identified problem areas; risk factors associated with identified problems; build on the resident's strengths, reflect treatment goals, timetables, and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. An observation of Resident #68 on 11/06/19 at 4:15 PM revealed the resident was observed lying in bed on his/her back and was receiving oxygen at two (2) liters via nasal cannula. A review of Resident #68's medical record revealed the resident was admitted by the facility on 06/17/16 with [DIAGNOSES REDACTED]. Review of the most current quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had been assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15). The MDS revealed the facility had assessed the resident to be interviewable. The MDS also indicated the resident received oxygen. The medical record also revealed a physician's orders [REDACTED]. A review of Resident #68's comprehensive care plan dated 09/24/19 revealed interventions for oxygen that included obtaining oxygen saturation levels every week on room air, encouraging oxygen at all times, and observing for signs and symptoms of respiratory deficits. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident. An interview with Registered Nurse (RN) #1 on 10/30/19 at 2:25 PM, revealed she made rounds on her residents at least every two (2) hours and checked oxygen during her rounds to ensure the residents were receiving oxygen as directed by the care plan. The RN stated the care plan was where the information was kept regarding the care needs of the residents and she was required to check it at least every shift she worked. 2. An observation of Resident #94 on 11/06/19 at 11:17 AM, revealed the resident was observed lying in bed on his/her back and was receiving oxygen at two (2) liters via [MEDICAL CONDITION] mask. A review of Resident #94's medical record revealed the resident was readmitted by the facility on 04/12/19, with [DIAGNOSES REDACTED]. Review of the most current significant change MDS assessment dated [DATE] revealed Resident #94 had been assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15). The MDS revealed the facility had assessed the resident to be interviewable. The MDS also indicated the resident received oxygen, suctioning, and had a [MEDICAL CONDITION]. A review of Resident #94's monthly physician's orders [REDACTED]. A review of the comprehensive care plan for Resident #94 dated 02/12/19 revealed interventions for oxygen that included encouraging oxygen at all times via [MEDICAL CONDITION], obtaining oxygen saturation levels every week on room air if on oxygen. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen to be administered to the resident. An interview conducted with MDS Coordinator #1 on 11/07/19 at 5:15 PM, revealed she was responsible for developing the person-centered comprehensive plans of care for Resident #68 and Resident #94. The MDS Coordinator revealed she had not been aware she was required to develop interventions related to the liter flow of oxygen to be delivered and the route. Interview conducted with the Director of Nursing (DON) on 11/07/19 at 5:32 PM, revealed she attended care plan meetings where residents' comprehensive care plans were reviewed and had not identified any concerns with residents' comprehensive care plans. The DON stated she had not been aware person-centered care plans were required to have the liter flow of oxygen to be administered as well as the route to be used. 3. Review of the Resident Assessment Instrument, Section G0400, revealed instructions on assessing range of motion in residents. For each hand, instruct the resident to make a fist and then open the hand .If assessing upper extremity ROM by observing the resident, making a fist mimics useful actions for grasping and letting go of utensils. Review of Resident #110's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's record revealed the resident was receiving therapy on 04/24/19 through 05/07/19 for passive range of motion (PROM) to bilateral hands and bilateral upper extremities. Review of a therapy note dated 05/02/19 revealed Resident #110 had difficulty using a call light and a paddle-type call light was ordered to improve the resident's ability to make his/her needs known. Review of Resident #110's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Further review of the resident's MDS revealed they needed extensive assistance with all Activities of Daily Living (ADLs). Review of the resident's MDS, Section G0400 (Functional Limitation in Range of Motion), revealed the resident was coded as having 0 impairment in upper extremity and lower extremity range of motion. Review of Resident #110's Care Plan, no revision date, revealed the resident was receiving restorative nursing of passive range of motion due to weakness. Interventions in place for this focus were: 1) Restorative nursing program for Range of Motion (ROM); 2) Active/Passive ROM to affected extremity 10 reps, one set; 3) Trapeze on bed when indicated to assist resident with independent bed mobility; and 4) Allow resident sufficient time to move independently. Further review of the resident's care plan revealed the resident required extensive assistance with bed mobility, dressing, grooming, and bathing and total assistance with locomotion, transfers, and eating. Review of Resident #110's State Registered Nursing Assistant Kardex revealed the resident was receiving restorative nursing for range of motion to the affected extremity, but failed to mention which extremity. Further review of the Kardex revealed under the heading of Mobility two interventions: 1) Encourage and assist turning and repositioning every (Q) 4 hours and PRN (as needed). Use positioning device as needed or indicated; and 2) Encourage to elevate legs related to [MEDICAL CONDITION]. Observation and interview with Resident #110 on 11/05/19 at 4:17 PM revealed the resident was alert and oriented and able to answer questions appropriately. When asked if the resident had braces he/she wore on his/her hands the resident answered sometimes. No braces were in place during this observation. Further observations on 11/06/19 at 9:55 AM, 11/06/19 at 4:02 PM, and 11/07/19 at 7:03 PM revealed the resident was not wearing braces. Observation on 11/06/19 at 4:02 PM revealed the resident was unable to make a fist with either hand. Interview with Resident #110's family on 11/06/19 at 5:02 PM revealed the resident was fed by the staff at the facility. Interview with State Registered Nursing Assistant (SRNA) #1 on 11/06/19 at 9:29 AM revealed the resident was fed via staff and the staff assisted with all activities of daily living (ADLs). The SRNA stated that the resident was unable to dress himself/herself due to not being able to lift his/her arms. Interview with the Therapy Director on 11/07/19 at 2:16 PM revealed the resident had been picked up on caseload for therapy in (MONTH) through (MONTH) 2019. He stated they tried splints on the resident at that time. He further stated that the resident had limitations in his/her range of motion to both hands. Interview with the MDS Coordinator on 11/07/19 at 6:53 PM revealed the resident is able to close (his/her) hands when they want to; they pick up a Vienna (sausage) and eat it. Further interview with the MDS nurse revealed they would develop a care plan related to concerns identified. Interview with the Director of Nursing on 11/07/19 at 7:12 PM revealed they review care plans when the resident is admitted to the facility and then periodically thereafter. She further revealed she had identified no concerns with care plans.

Based on observation, interview, and resident record review it was determined the facility failed to accurately complete an assessment for one (1) of twenty-nine (29) sampled residents (Resident #110) related to the resident's range of motion. Resident #110 was determined to have limited range of motion (ROM) to bilateral hands; however, the facility failed to identify/assess the limitations in range of motion to the resident's hands. The findings include: Review of the facility policy, Resident Assessment Instrument - Basic Process, dated 08/01/13, revealed The Interdisciplinary Assessment Team must use the MDS (Minimum Data Set) form currently mandated by Federal and State regulations to conduct the resident assessment. Review of the Resident Assessment Instrument, Section G0400, revealed instructions on assessing range of motion in residents. For each hand, instruct the resident to make a fist and then open the hand .If assessing upper extremity ROM by observing the resident, making a fist mimics useful actions for grasping and letting go of utensils. Review of Resident #110's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's record revealed the resident was receiving therapy on 04/24/19 through 05/07/19 for passive range of motion (PROM) to bilateral hands and bilateral upper extremities. Review of a therapy note dated 05/02/19 revealed Resident #110 had difficulty using the call light and a paddle-type call light was ordered to improve the resident's ability to make needs known. Review of Resident #110's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impact. Further review of the resident's MDS revealed the resident required extensive assistance with all Activities of Daily Living (ADLs). Review of the resident's MDS, Section G0400 (Functional Limitation in Range of Motion), revealed the resident was coded as having 0 impairment in upper extremity and lower extremity range of motion. Review of Resident #110's State Registered Nursing Assistant Kardex revealed the resident was receiving restorative nursing for range of motion to the affected extremity, but the plan failed to mention which extremity. Observation and interview with Resident #110 on 11/05/19 at 4:17 PM revealed the resident was alert and able to answer questions appropriately. When asked if the resident had braces to be worn on their hands the resident answered sometimes. No braces were in place during this observation. Further observations on 11/06/19 at 9:55 AM, 11/06/19 at 4:02 PM, and 11/07/19 at 7:03 PM revealed the resident not to be wearing braces. Observation on 11/06/19 at 4:02 PM revealed the resident was unable to make a fist with either hand. Interview on 11/06/19 at 5:02 PM with Resident #110's family revealed the resident was fed by the staff at the facility. The family member further revealed the family brought food in to the resident and fed him/her because the resident had a hard time feeding himself/herself. Interview with State Registered Nursing Assistant (SRNA) #1 on 11/06/19 at 9:29 AM revealed the resident is fed via staff and the staff assist with all activities of daily living (ADLs). The SRNA stated that the resident was unable to dress himself/herself due to not being able to lift his/her arms. Interview with the Therapy Director on 11/07/19 at 2:16 PM revealed the resident had been picked up on caseload for therapy in (MONTH) through (MONTH) 2019. He stated they tried splints on the resident at that time. He further stated that the resident had limitations in range of motion to both hands. Record review of Occupational Therapy Treatment Encounter Notes(s) revealed on 04/30/19 Patient and Caregiver Training: Patient educated regarding treatment techniques for improving bilateral hand range of motion/joint mobility to improve independence with self-feeding. Interview with the MDS Coordinator on 11/07/19 at 6:53 PM revealed the resident is able to close (his/her) hands when they want to, they pick up a Vienna (sausage) and eat it. Interview with the Director of Nursing on 11/07/19 at 7:12 PM revealed she did not monitor MDS's for accuracy.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure the discharge summary included a recapitulation of the resident's stay that included pertinent information regarding the resident's course of illness/treatment or therapy, and pertinent radiology and consultation results for one (1) of two (2) closed records reviewed (Resident #115). The findings include: Review of the facility policy titled Discharge Summary and Plan, dated 08/01/13, revealed the discharge summary would include a recapitulation of the resident's stay at the facility. Review of the closed record for Resident #115 revealed the resident was admitted to the facility on [DATE] for rehab services due to a [MEDICAL CONDITION] and right wrist that required surgery. Further review of the record for Resident #115 revealed the resident was discharged on [DATE] to a Personal Care Home (PCH). Review of a document titled Medical - Nursing Discharge Summary, dated 08/26/19, revealed the time and date that the resident was discharged as well as the resident's condition at discharge were included on the form. The Medical - Nursing Discharge Summary included a section titled Complete Summary from Admission to Discharge that stated that the resident had completed rehab services and the fracture was healed. Further review of the discharge summary revealed no evidence of a recapitulation of the resident's stay at the facility that included pertinent radiology reports/results, consultation results, or pertinent information regarding the resident's treatment/therapy during his/her stay at the facility. Interview with the Social Services Director (SSD) on 11/07/19 at 4:40 PM revealed the resident was discharged back to the PCH on 08/26/19 where the resident previously resided. The SSD stated that the discharge summary was completed by nursing staff and he does not complete the summary. Interview with the Unit Coordinator on 11/07/19 at 5:56 PM revealed that the area of the discharge summary that addresses the recapitulation of the resident's stay would be the area titled Complete Summary from Admission to Discharge. Interview with Registered Nurse (RN) #1 on 11/07/19 at 5:56 PM and 7:11 PM with the Unit Coordinator present during the interview revealed she completed the Medical - Nursing Discharge Summary for Resident #115 when the resident was discharged on [DATE]. RN #1 stated that she was not trained to give any details about the resident's stay at the facility when filling out the summary of a resident's stay or to do a recapitulation of the resident's stay.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of twenty-nine (29) sampled residents (Resident #68 and Resident #94) who were provided respiratory care (oxygen therapy) received care according to the person-centered comprehensive care plan. Review of the comprehensive person-centered care plan for Resident #68 and Resident #94 revealed the residents had an intervention for the facility to provide oxygen as ordered by the physician. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident. The findings include: Review of the facility's policy titled, Nursing Guidelines: Devices Used In The Delivery Of Oxygen, Humidity, And Aerosols, dated 1996, revealed staff would apply the oxygen per nasal cannula or [MEDICAL CONDITION] collar on the resident and would then monitor for signs of oxygen-induced hypoventilation such as shallow respirations, dyspnea, confusion, restlessness, and tremors. The policy did not address who was responsible for developing the care plan related to oxygen therapy. 1. Observation of Resident #68 on 11/06/19 at 4:15 PM revealed the resident was observed lying in bed on his/her back and was receiving oxygen at two (2) liters via nasal cannula. Review of Resident #68's medical record revealed the resident was admitted by the facility on 06/17/16, with [DIAGNOSES REDACTED]. Review of the most current quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 had been assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15). The MDS revealed the facility had assessed the resident to be interviewable. The MDS also indicated the resident received oxygen. Review of Resident #68's monthly physician's orders [REDACTED]. Review of the comprehensive care plan for Resident #68 dated 09/24/19, revealed interventions for oxygen that included obtaining oxygen saturation levels every week on room air, encouraging oxygen at all times, and observing for signs and symptoms of respiratory deficits. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident. 2. Observation of Resident #94 on 11/06/19 at 11:17 AM revealed the resident was observed lying in bed on his/her back and was receiving oxygen at two (2) liters via [MEDICAL CONDITION] mask. Review of Resident #94's medical record revealed the resident was readmitted by the facility on 04/12/19, with [DIAGNOSES REDACTED]. Review of the most current significant change MDS assessment dated [DATE], revealed Resident #94 had been assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15). The MDS revealed the facility had assessed the resident to be interviewable. The MDS also indicated the resident received oxygen, suctioning, and had a [MEDICAL CONDITION]. Review of Resident #94's monthly physician's orders [REDACTED]. Review of the comprehensive care plan for Resident #94 dated 02/12/19 revealed interventions for oxygen that included encouraging oxygen at all times via [MEDICAL CONDITION], and obtaining oxygen saturation levels every week on room air if on oxygen. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen to be administered to the resident. Interview with Registered Nurse (RN) #1 on 10/30/19 at 2:25 PM, revealed she made rounds on her residents at least every two (2) hours and checked oxygen during her rounds to ensure the residents were receiving oxygen as directed by the care plan. The RN stated the care plan was where the information was kept regarding the care needs of the residents. Interview conducted with MDS Coordinator #1 on 11/07/19 at 5:15 PM, revealed she had been responsible for developing the person-centered comprehensive plan of care for Resident #68 and Resident #94. The MDS Coordinator revealed she had not been aware she was required to develop interventions related to the liter flow of oxygen to be delivered and the route. Interview conducted with the Director of Nursing (DON) on 11/07/19 at 5:32 PM, revealed she made rounds daily to ensure residents were being provided the care they require. The DON stated she monitored to ensure residents were being provided oxygen as directed by the physician. The DON stated she had not been aware person-centered care plans were required to have the liter flow of oxygen to be administered as well as the route to be used. The DON stated she had not identified any concern with oxygen administration.

Based on observations, interview, record review, review of a facility timeline and investigation, and review of the facility's policies, it was determined the facility failed to implement the care plan for one (1) of thirty-seven (37) sampled residents (Resident #44). The facility assessed Resident #44 to be at risk for elopement and developed a care plan for Wandering Ways. According to a Watch Schedule form dated 09/20/18, staff were required to monitor the resident every fifteen (15) minutes due to Wandering Ways. However, on 09/20/18, at 5:30 PM, the staff member conducting the monitoring failed to locate the resident, even though the facility's timeline revealed the resident was in his/her room from 5:30 PM to 5:32 PM. Review of the facility's timeline revealed at 5:32 PM, Resident #44 attempted to exit through the B Hall door. Then at 5:35 PM, the resident exited the facility through a door on the G Hall. A facility staff member found the resident in the parking lot when leaving the facility at 5:37 PM, and assisted the resident back inside. There was no injury noted. The facility's failure to ensure resident care plans were implemented to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/28/18, and determined to exist on 09/20/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 09/28/18. An acceptable Allegation of Compliance was received on 10/09/18, which alleged removal of the Immediate Jeopardy on 10/06/18. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/06/18, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's care plan policy, not dated, revealed an individualized comprehensive care plan, that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs, was developed for each resident. The policy stated care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes. Each resident's comprehensive care plan was designed to incorporate identified problem areas; risk factors associated with identified problems; build on the resident's strengths, reflect treatment goals, timetables, and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Review of the facility's Elopements/Missing Residents policy, dated 03/23/18, revealed staff were required to promptly report any resident who tried to leave the premises or was suspected of being missing to the Charge Nurse or Director of Nursing. Observation of Resident #44 on 09/25/18 during initial tour at 8:00 AM, and at 8:58 AM, revealed the resident was in his/her room. Further observation of Resident #44 on 09/26/18 at 4:25 PM revealed State Registered Nurse Aide (SRNA) #12 was in the bedroom with the resident. SRNA #12 stated she was providing one on one (1:1) supervision of the resident because the resident had visitors earlier that day. Review of Resident #44's medical record revealed the facility admitted the resident on 07/13/18 with [DIAGNOSES REDACTED]. Review of the Watch Schedule-Admission forms for Resident #44 revealed upon admission on 07/13/18, staff observed the resident's whereabouts every fifteen (15) minutes for twenty-four (24) hours. On 07/15/18 at 9:00 PM, the monitoring was decreased to every hour and the resident continued to be monitored every hour until 07/19/18. Review of the Watch Schedule revealed on 07/19/18 at 9:00 AM, the facility increased Resident #44's supervision back to every fifteen (15) minute checks. Interview with the Administrator on 09/27/18 at 10:57 AM, revealed Resident #44 was placed back on every fifteen (15) minute checks on 07/19/18 due to professional judgement. Review of Resident #44's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS further revealed the resident was independent with ambulating in the resident's room, but required supervision for ambulation in the corridor and locomotion on/off the unit. The facility assessed Resident #44 to have no behavioral symptoms, but assessed the resident to wander one to three days during the assessment period. Further review of the assessment revealed the facility did not assess whether the resident's wandering placed him/her at significant risk of getting to a potentially dangerous place (stairs, outside of the facility) or whether the wandering impacted the privacy or activities of others. Review of an Elopement Risk assessment dated [DATE], revealed the facility assessed Resident #44 to be at risk for elopement due to being physically able to leave on his/her own; cognitive impairment with poor decision-making skills; [DIAGNOSES REDACTED]. Review of Resident #44's Comprehensive Care Plan revealed the facility identified the resident had an Activities of Daily Living self-care deficit related to dementia and weakness, and required supervision with ambulation in the corridor and on/off the unit. The care plan also stated the resident was on Wandering Ways and had a code alert bracelet (bracelet that alerts staff when a resident tries to exit a door equipped with a wander guard system). Continued review of the Watch Schedule forms dated from 07/19/18 through 09/19/18 revealed staff documented that Resident #44 wandered throughout the facility including resident rooms, the facility lounge, hallways, and courtyard. Review of a Resident Accident/Incident Report dated 09/20/18, at 5:35 PM, and review of the Resident Abuse Investigation Report Form, revealed Resident #44 exited the facility on 09/20/18 at 5:35 PM, and an Occupational Therapist (OT) assisted the resident back inside at 5:37 PM. The Accident/Incident Report stated the resident had followed a visitor out an exit door (G Hall door) before the door relocked. According to the reports, the resident sustained [REDACTED]. Review of a timeline provided by the facility revealed Courtesy Aide #1 left Resident #44's room at 5:15 PM on 09/20/18. At 5:32 PM (two minutes after the resident's 15-minute check was due) the resident went out and back into his/her room, then out again, and tried to open the door on the B Hall. The timeline did not address whether the Courtesy Aide was seen looking for the resident in the resident's room at 5:30 PM when the fifteen (15) minute check was due. According to the timeline, the resident then walked down the F Hall, went through the double doors, and exited the facility through the G Hall door at 5:35 PM. At 5:37 PM, the OT entered the parking lot and saw Resident #44 in the parking lot. The OT assisted the resident back inside the facility at 5:39 PM, and assisted the resident to the B Hall nurses' station to report the incident to Licensed Practical Nurse (LPN) #2. According to the Watch Schedule form, on 09/20/18 staff were required to monitor the resident every fifteen (15) minutes due to Wandering Ways. Staff documented that Resident #44 was in his/her room with family at 5:15 PM on 09/20/18. However, staff documented that the 5:30 PM check was not completed until 5:40 PM. Interview with Courtesy Aide #1 on 09/28/18 at 12:08 PM revealed at 5:30 PM on 09/20/18 the resident was not in his/her room, and he started to look for the resident. He stated he was still looking for the resident at 5:40 PM, when he saw Resident #44 with a staff member at nurses' station B. The aide stated he then escorted the resident to his/her room and documented that the 5:30 PM fifteen (15) minute check was completed at 5:40 PM. Interview with SRNA #11 on 09/28/18 at 10:20 AM, and SRNA #12 (Staff Coordinator) on 09/28/18 at 11:03 AM, revealed they supervised the courtesy aides. SRNA #11 stated the courtesy aides had been instructed to report immediately if they could not locate a resident. However, SRNA #12 stated a time could not be placed on when a resident should be reported missing. She stated it depended on how long it took to search the facility. Interview with the Quality Assurance (QA) Nurse on 09/27/18 at 9:47 AM, revealed not being able to locate Resident #44 during the 5:30 PM check should have been reported so staff could have helped search for the resident. Interview with the Administrator on 09/28/18 at 11:30 AM, revealed the reasoning behind fifteen (15) minute checks for Resident #44 was due to a multitude of reasons. She stated one reason was that the resident was very agile and mobile. The Administrator stated, however, that the Watch Schedule was not a set program and the courtesy aide provided extra supervision that was not required to be an exact fifteen (15) minute check. The interview further revealed there was no policy or procedure regarding the Watch Schedule monitoring, and no policy or procedure to direct staff if a resident could not be located. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 10/06/18: 1.A. Resident #1 was placed on 1:1 supervision immediately after this occurrence and continues to be a resident at the facility. 1.B. On 09/24/18, a university hospital Neurologist evaluated Resident #1 via telemedicine and reviewed the resident's behaviors and medications. The Neurologist recommended reducing the resident'[MEDICATION NAME] 10 mg to 5 mg daily, discontinuing [MEDICATION NAME] 150 mg, and beginning [MEDICATION NAME] 50 mg daily. The resident's attending physician agreed with the recommendation and orders were written for the changes on 09/24/18. 1.C. Resident #1's care plan was updated on 09/20/18 to ensure that following family visits, the resident would receive 1:1 monitoring for a minimum of thirty (30) minutes or until family-seeking behaviors subside. 1.D. On 09/20/18, Resident #1's elopement assessment was conducted by the licensed nurse on duty (LPN). 1.E. Resident #1 had a code alert bracelet in place from the date of admission on 07/13/18, per family request, due to a history of wandering, which the facility was made aware of at the time of admission. The placement was also noted on the resident's Baseline care plan. 2.A. All residents at risk for elopement were immediately checked and all were accounted for by nursing staff on 09/20/18. Code alert bracelets for residents on the Wandering Way Program were checked for placement and proper operation by facility staff (Courtesy Aide) with no concerns noted on 09/20/18. 2.B. Care plans were reviewed by the Director of Nursing, QA Nurse, Unit Coordinators, and MDS staff for all residents at risk for elopement on 09/21/18 and 09/22/18; no concerns were noted. 2.C. Maintenance inspected all door locking and alarm mechanisms on 09/20/18 and all were operating properly. Rehabilitation door settings were reduced from twenty (20) to ten (10) seconds on 09/21/18. This setting allows the door to remain open for 10 seconds, and upon expiration, the door alarm shall sound. The door settings were within the Manufacturer's recommendation of 0-120 seconds. The facility elected to reduce the time setting on the door to ten (10) seconds as a precaution. Regardless of the time set on the door, for example, whether the door is actually open three (3) seconds or twenty (20) seconds, once the door is closed, it will reset the alarm/locking mechanisms in two (2) seconds per the manufacturer/vendor. This two (2) second interval was present at the date of the event, and remains present to date. This change was initiated while the facility conducted an investigation and ordered Code Alert Sensors for these side doors. 2.D. Maintenance increased all exit door operational checks from weekly to daily until further review on 09/20/18. 2.E. All residents identified as a risk for elopement are monitored per the facility's wandering ways protocol. Photographs of all at risk residents and a list will be maintained for easy identification of elopement risk residents. These residents will be checked every one (1) hour per the protocol. An hourly (1 hour) check will be considered timely if performed within 15 minutes of the scheduled time. These checks are documented. 2.F. Any resident who attempts to leave the building unauthorized will be monitored a minimum of every fifteen (15) minutes for twenty-four (24) hours following the attempt. A fifteen (15) minute check will be considered timely if performed within five (5) minutes of the scheduled time. Should the resident not be in the last location observed, an additional five (5) minutes shall be provided to check areas where the resident normally congregates. Should a resident not be located within the allotted timeframe, the staff member performing the check shall implement the missing person protocol. 3.A. On 09/20/18 and 09/21/18, all staff, licensed and unlicensed, were provided in-service by the Administrator, Director of Nursing, and QA staff on the elopement/missing resident policies and door/alarm processes with the exception of those on leave, who will be in-serviced prior to returning to work. Staff were instructed to limit use of the side exit doors that were routinely utilized by visitors, EMS (Emergency Medical Services), or others. 3.B. Signs were placed to encourage visitors, EMS, and others to use the front door. Should any side door be used, 1:1 staff supervision of the entry/exit will be in place to ensure the door closure mechanisms and alarms are engaged. The exterior keypad has been disabled to limit the use of these doors until Code alert sensors can be installed. All staff capability to use phone/keypad codes to remotely open side exit doors in the patient care area were removed by maintenance personnel on 09/28/18. All side doors in the patient care areas will only open by holding the emergency fifteen (15) second panic bar to ensure alarms sound. This requires 1:1 supervision at the door to check and ensure alarms were engaged. Nurses and Kentucky Medication Aides (KMAs) manually reset the alarms at the door utilizing a separate engagement code. 3.C. The electronic medical record (EMR) elopement risk assessment tool was revised by the EMR Specialist RN to capture previous history of wandering/elopement from the home setting, regardless of the resident's current physical/mental capability. Previously, the EMR assessment did not allow you to proceed if you answered that the resident was physically unable to elope. This was changed so the data is collected on all residents, regardless of physical condition. The content did not change, the order of the questions changed. Licensed nursing staff (RN and LPN) were educated related to this change on 10/05/18. 4.A. Quality Assurance (QA) processes were implemented to ensure compliance, specifically competency door checklists for nurses and KMAs. This process is being monitored by the Director of Nursing and QA Nurse. The Director of Nursing/QA Nurse will audit five (5) employees weekly to ensure competency with elopement policies and door operations. The audits include the employees' ability to verbalize the locking mechanism on all doors, their knowledge that the door will release after fifteen (15) seconds when pressing on the panic bar, and knowledge of supervising doors until alarms are reset. Staff are instructed to remove at risk residents from door areas to provide safety. 4.B. Daily, all orders and 24-hour reports are reviewed during the morning meetings. MDS Nurses will bring care plans to the meeting to ensure they are revised utilizing the information obtained during this meeting. Those in attendance at the morning meeting are the Administrator, Director of Nursing, MDS Staff, QA Nurse, Unit Coordinators, Social Services, Activities, and Dietary. 4.C. Weekly, the Director of Nursing or QA Nurse will audit four (4) care plans to ensure the care plans accurately reflects the residents' care needs. 4.D. A QA Meeting was held on 10/04/18 to discuss the elopement and the corrective actions the facility has implemented following the elopement. The QA committee consists of the Medical Director, Administrator, Director of Nursing, QA Nurse, Social Services, Activities, Dietary, MDS Staff, and Unit Coordinators. The QA Committee will meet weekly for four (4) weeks beginning 10/04/18 and then monthly. ****The State Agency determined Immediate Jeopardy was removed on 10/06/18 based on the following: 1.A. Review of Resident #1's medical record revealed the facility placed Resident #1 on 1:1 supervision immediately after the incident. Interview conducted with Courtesy Aide #1 on 10/11/18 at 9:30 AM, revealed he had provided 1:1 supervision after Resident #1 left the facility unattended. 1.B. Review of a physician progress notes [REDACTED]. The Progress Note revealed the Neurologist recommended medication changes. Review of the resident's Medication Administration Records (MARs) revealed the medication changes were started on 09/24/18. 1.C. Review of Resident #1's comprehensive plan of care revealed the facility updated the care plan on 09/20/18, with an intervention to provide 1:1 supervision for a minimum of thirty (30) minutes or until family-seeking behaviors had subsided, following any family visit. Interviews conducted with Courtesy Aide #1 on 10/11/18 at 9:30 AM, State Registered Nurse Aide (SRNA) #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, and Courtesy Aide #14 on 10/11/18 at 10:30 AM, revealed the staff had provided 1:1 supervision for at least thirty (30) minutes after Resident #1's family visits. 1.D. Review of an elopement assessment dated [DATE] revealed the facility assessed Resident #1 to be at risk for elopement. Interview conducted with Licensed Practical Nurse (LPN) #2 on 10/11/18 at 10:25 AM, revealed she had completed the elopement assessment on 09/20/18 for Resident #1, and the resident was at risk for wandering. 1.E. Review of Resident #1's care plan revealed Resident #1 had a code alert bracelet placed upon admission on 07/13/18. Interview with the Minimum Data Set (MDS) Coordinator on 10/11/18 at 1:30 PM, revealed she had completed Resident #1's initial care plan and the resident was assessed to have wandering tendencies. In addition, on 07/19/18, the resident was placed on the Wandering Ways Protocol with a code alert bracelet. Interviews conducted with Courtesy Aide #1 on 10/11/18 at 9:30 AM, SRNA #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, LPN #2 on 10/11/18 at 10:25 AM, Courtesy Aide #14 on 10/11/18 at 10:30 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, Registered Nurse (RN) #1 on 10/11/18 at 12:55 PM, and RN #5 on 10/11/18 at 1:00 PM, revealed Resident #1 had worn a code alert bracelet since the resident's admission to the facility on [DATE]. 2.A. Review of facility documentation revealed on 09/20/18, after Resident #1 eloped, nursing staff checked all residents at risk for elopement and staff checked all code alert bracelets for placement and operation. No concerns were identified. Interview with Courtesy Aide #1 on 10/11/18 at 9:30 AM, revealed he immediately checked all residents who had been identified as being at risk for elopement and had documented that the residents were all accounted for. The Courtesy Aide also revealed he checked to ensure residents' code alert bracelets were present and functioning properly. The Courtesy Aide stated he did not identify any concerns. 2.B. Interviews conducted with LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, the MDS Coordinator on 10/11/18 at 1:30 PM, the QA Nurse on 10/11/18 at 1:56 PM, and the Director of Nursing (DON) on 10/11/18 at 1:56 PM, revealed they had reviewed elopement assessments and care plans for all residents who had been assessed to be at risk for elopement to ensure accuracy and appropriate interventions were in place for the residents. 2.C. Review of a Door Test Log revealed the Maintenance Supervisor inspected all doors on 09/20/18 to ensure they were working properly. Observation of exit doors on 10/11/18 at 9:50 AM, revealed the doors had been set with a ten (10) second alarm and relocked in two (2) seconds after closing. Further observation revealed signs were in place on all exit doors to use the front door only. Interview with the Maintenance Director on 10/11/18 at 1:45 PM, revealed he immediately checked the exit door where Resident #1 exited on 09/20/18. The Maintenance Director stated he also checked all other exit doors and had found all were working appropriately and identified no concerns. He stated the door alarms/locking mechanisms were within the parameters of the manufacturer's recommendations. The Maintenance Director stated he had lowered the door alarm settings on the Rehabilitation Unit exit door to ten (10) seconds on 09/21/18. However, the door would also lock two (2) seconds after it was closed. According to the Maintenance Director, Code Alert Sensors had been ordered for the exit doors. 2.D. Review of a Door Test Log revealed the Maintenance Director had checked all exit doors to ensure they were working properly daily since 09/20/18. Interview with the Maintenance Director on 10/11/18 at 1:45 PM, revealed he checked exit doors weekly until the incident on 09/20/18, involving Resident #1 and had done the checks daily since. The Maintenance Director stated he had not identified any concerns with the exit doors. 2.E. Elopement Assessments for the twelve (12) residents the facility assessed to be at risk for elopement were reviewed and no concerns were identified. Review of the Wandering Ways Logs revealed all twelve (12) residents were being observed for wandering every hour. The residents were also observed to be wearing code alert bracelets. Further observation revealed a sneaker picture had been placed on their nameplates outside their rooms and on their care plans. In addition, pictures of all residents who had been assessed to be at risk for elopement were located on each unit. Interviews conducted with Courtesy Aide #1 on 10/11/18 at 9:30 AM, SRNA #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, LPN #2 on 10/11/18 at 10:25 AM, Courtesy Aide #14 on 10/11/18 at 10:30 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, and RN #5 on 10/11/18 at 1:00 PM, revealed all residents who had been assessed to be at risk for elopement were to be monitored at least hourly to ensure the resident was in a safe area. The staff stated they were aware that a sneaker sticker was in place on the nameplates for all residents who were at risk for elopement as well as a picture of the resident at each unit. 2.F. Continued interviews with Courtesy Aide #1 on 10/11/18 at 9:30 AM, SRNA #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, LPN #2 on 10/11/18 at 10:25 AM, Courtesy Aide #14 on 10/11/18 at 10:30 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, and RN #5 on 10/11/18 at 1:00 PM, revealed if a resident had attempted to elope from the facility, staff were required to monitor the resident every fifteen (15) minutes for twenty-four (24) hours after the attempt. The staff stated they had a fifteen (15) minute timeframe to obtain the hourly check and a five (5) minute timeframe to obtain a fifteen (15) minute check to be considered timely. The staff stated they were required to implement the missing resident protocol if the resident was unable to be located within the timeframe. 3.A. Review of in-service rosters dated 09/20/18 and 09/21/18 revealed all staff had been in-serviced by the Administrator, DON, and QA Nurse on the Elopement/Missing Resident policy and the door alarm processes. The rosters revealed staff were instructed to limit the use of the side exit doors which had been previously used by EMS and visitors. 3.B. Observation of exit doors on 10/11/18 at 9:50 AM, revealed signs had been placed on exit doors reminding everyone to use the front door to enter and exit the facility. Observation also revealed the exterior keypads had been disabled. The side doors in the resident care areas were observed to only open if the panic bar was held for fifteen (15) seconds, which also resulted in an alarm sounding. Further observation revealed the alarms had to be manually reset by entering a code. Interviews conducted with the Administrator on 10/10/18 at 3:39 PM, Courtesy Aide #1 on 10/11/18 at 9:30 AM, SRNA #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, LPN #2 on 10/11/18 at 10:25 AM, Courtesy Aide #14 on 10/11/18 at 10:30 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, the DM on 10/11/18 at 1:10 PM, the AD on 10/11/18 at 1:15 PM, SS on 10/11/18 at 1:20 PM, the MDS Coordinator on 10/11/18 at 1:30 PM, the Maintenance Director on 10/11/18 at 1:45 PM, the QA Nurse on 10/11/18 at 1:56 PM, and the DON on 10/11/18 at 1:56 PM, revealed they had attended in-services by the Administrator, DON, and QA Nurse on 09/20/18 and 09/21/18, related to the facility's Elopement/Missing Resident policy and the door/alarm processes. The staff revealed the side doors were locked and required a nurse to lock/unlock the door. The staff revealed they were required to instruct visitors and Emergency Medical Services to use the front door; however, if the side doors were used, they were required to supervise any entry or exit. The staff revealed only nurses or a KMA were allowed to manually reset the alarms at the side doors using a code on the inside of the door and the outside keypads had been disabled. 3.C. Review of the facility's new Elopement Risk assessment revealed the assessment had been changed to add a question to indicate the resident's previous history of wandering/elopement prior to admission to the facility. Review of an in-service roster dated 10/05/18, revealed all licensed nursing staff had attended an in-service related to the new elopement risk assessment. Interviews conducted with LPN #2 on 10/11/18 at 10:25 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, the MDS Coordinator on 10/11/18 at 1:30 PM, the QA Nurse on 10/11/18 at 1:56 PM, and the DON on 10/11/18 at 1:56 PM, revealed they had attended the in-service related to the new elopement risk assessment. The nurses revealed a question had been added related to the resident's previous history of elopement prior to admission to the facility. 4.A. Review of door competency checklists revealed the facility documented all nurses and KMAs were competent. The checklists were signed by the DON and QA Nurse. Interview conducted with the DON and QA Nurse on 10/11/18 at 1:56 PM, revealed they confirmed all staff members' competency and were now completing random audits of five (5) staff members weekly to ensure staff competency related to the door processes. The interview revealed they had not identified any concerns with the audits and were reporting the findings to the QA Committee. Interviews conducted with Courtesy Aide #1 on 10/11/18 at 9:30 AM, SRNA #10 on 10/11/18 at 9:35 AM, SRNA #8 on 10/11/18 at 9:49 AM, SRNA #13 on 10/11/18 at 10:00 AM, LPN #2 on 10/11/18 at 10:25 AM, Courtesy Aide #14 on 10/11/18 at 10:30 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, and the MDS Coordinator on 10/11/18 at 1:30 PM, revealed the DON and QA Nurse had tested their competency and knowledge of the facility's exit door procedures. The staff verbalized they understood that the doors could be unlocked by pushing the panic bar for fifteen (15) seconds. The staff stated only nurses and KMAs were able to unlock and relock the exit doors and to reset the alarms. The staff further stated they were aware that they were required to remove any resident at risk for elopement from the exit doors. 4.B. Review of minutes of the facility's morning meetings revealed facility staff documented that physician's orders [REDACTED]. Interviews conducted with the Administrator on 10/10/18 at 3:39 PM, LPN #2 on 10/11/18 at 10:25 AM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, the Dietary Manager on 10/11/18 at 1:10 PM, the Activity Director on 10/11/18 at 1:15 PM, SS on 10/11/18 at 1:20 PM, the MDS Coordinator on 10/11/18 at 1:30 PM, the QA Nurse on 10/11/18 at 1:56 PM, and the DON on 10/11/18 at 1:56 PM, revealed they attended a morning meeting where all new physician's orders [REDACTED]. The staff stated care plans were updated with any changes. 4.C. Review of audit sheets completed by the DON and QA Nurse revealed they had audited four (4) resident care plans each week to ensure the care plans accurately reflected the residents' needs. Interview with the DON and QA Nurse on 10/11/18 at 1:56 PM, revealed they were responsible for auditing at least four (4) care plans each week to ensure the care plans accurately reflected the care required by the resident. 4.D. Review of QA Meeting minutes dated 10/04/18, revealed the facility QA Committee that included the Medical Director had met to discuss the elopement and corrective actions taken by the facility. Interviews conducted with the Medical Director on 10/10/18 at 2:23 PM, the Administrator on 10/10/18 at 3:39 PM, LPN #1 on 10/11/18 at 10:50 AM, LPN #4 on 10/11/18 at 12:52 PM, RN #1 on 10/11/18 at 12:55 PM, RN #5 on 10/11/18 at 1:00 PM, the DM on 10/11/18 at 1:10 PM, the AD on 10/11/18 at 1:15 PM, SS on 10/11/18 at 1:20 PM, the MDS Coordinator on 10/11/18 at 1:30 PM, the QA Nurse on 10/11/18 at 1:56 PM, and the DON on 10/11/18 at 1:56 PM, revealed they had attended the QA Meeting on 10/04/18, and had discussed the elopement and corrective actions taken. The interviews also revealed they would meet weekly for at least the next four (4) weeks.

Based on observations, interview, record review, review of a facility timeline and investigation, and review of the facility's policies, it was determined the facility failed to provide supervision to prevent accidents for one (1) of thirty-seven (37) sampled residents (Resident #44). The facility assessed Resident #44 to be at risk for elopement from the facility and had initiated monitoring to determine the resident's whereabouts every fifteen (15) minutes. However, on [DATE], at 5:30 PM, the staff member conducting the monitoring failed to locate the resident. Review of the facility's timeline revealed at 5:32 PM, Resident #44 was attempting to leave the facility through a door on the B Hall of the facility. Then, at 5:35 PM, the resident exited the facility through a door on the G Hall. Staff had opened/unlocked the door to allow visitors to exit the facility and Resident #44 exited while the door was still disabled. A facility staff member found the resident in the parking when leaving the facility at 5:37 PM, and assisted the resident back inside, without injury. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Elopements/Missing Residents policy, dated [DATE], revealed staff were required to promptly report any resident who tried to leave the premises or was suspected of being missing to the Charge Nurse or Director of Nursing. Review of the Wandering Ways program, undated, revealed the intent of the program was to identify and make all staff aware of residents at risk for elopement. Review of the program further revealed residents at risk for elopement would have a small picture of a sneaker on a nameplate outside the room door. Staff were required to monitor these residents every hour and the residents were encouraged to wear a monitoring bracelet that would alert the staff when the resident was attempting to exit the front door. Observation of Resident #44 on [DATE], during initial tour at 8:00 AM, and at 8:58 AM, revealed the resident was in his/her room. An interview with the resident at 8:58 AM revealed the resident replied, don't know when asked about his/her family. The resident then proceeded to show the surveyor a code alert bracelet on the resident's left ankle. The resident stated he/she did not know why it was there and then stated, They just put it on. Observation of Resident #44 on [DATE] at 4:25 PM revealed the resident was lying on the bed and State Registered Nurse Aide (SRNA) #12 was in the room with the resident. SRNA #12 stated she was providing one on one (1:1) supervision of the resident because the resident had visitors earlier that day. Review of the medical record revealed the facility admitted Resident #44 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #44's Admission Nursing Assessment, dated [DATE], revealed staff documented that the resident exhibited wandering behavior. The assessment revealed staff was unable to orient the resident to any aspect of the facility, including activities, disaster plans, call light, bed controls, etc. The assessment further revealed the resident was independent with bed mobility, transferring, and ambulation/locomotion, and did not utilize any assistive devices. However, review of an Elopement Risk assessment dated [DATE], revealed the resident was not at risk for elopement. Review of Resident #44's baseline care plan dated [DATE], revealed the facility identified that the resident had cognitive loss and a behavioral symptom of wandering. The care plan further revealed the facility identified that the resident was at fall/safety/elopement risk and developed interventions that included a code alert bracelet (bracelet that alerts staff when a resident tries to exit a door equipped with a wander guard system) and hourly checks of the resident. Review of Watch Schedule-Admission forms for Resident #44 revealed upon admission on [DATE], staff observed the resident's whereabouts every fifteen (15) minutes for twenty-four (24) hours. On [DATE] at 5:00 PM, the facility decreased the monitoring to every thirty (30) minutes until [DATE] at 9:00 PM, when the monitoring was decreased to every hour and the resident continued to be monitored every hour because the resident was on the hourly checks/Wandering Ways Program. Further review of the Watch Schedule revealed on [DATE] at 9:00 AM, the facility increased Resident #44's supervision back to every fifteen (15) minute checks. Continued review of the Watch Schedule revealed staff documented that the resident wandered throughout the facility including resident rooms, the facility lounge, hallways, and courtyard. Interview with the Administrator on [DATE] at 10:57 AM, revealed Resident #44 was placed back on every fifteen (15) minute checks on [DATE] due to professional judgement. Review of Resident #44's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS further revealed the resident was independent with ambulating in the resident's room, but required supervision for ambulation in the corridor and locomotion on/off the unit. The facility assessed Resident #44 to have no behavioral symptoms, but was assessed to wander one to three days during the assessment period. Further review of the assessment revealed the facility did not assess whether the wandering placed the resident at significant risk of getting to a potentially dangerous place (stairs, outside of the facility) or whether the wandering impacted the privacy or activities of others. Review of an Elopement Risk assessment dated [DATE], revealed Resident #44 was assessed to be at risk for elopement due to being physically able to leave on his/her own; cognitive impairment with poor decision-making skills; [DIAGNOSES REDACTED]. Review of Resident #44's comprehensive care plan revealed the facility identified the resident had an Activities of Daily Living self-care deficit related to dementia and weakness, and required supervision with ambulation in the corridor and on/off the unit. The care plan also stated the resident was on Wandering Ways and had a code alert bracelet. Further review of the Watch Schedule form revealed on [DATE], staff continued every fifteen (15) watches of the resident due to Wandering Ways. Staff documented that Resident #44 was in his/her room with family at 5:15 PM on [DATE]. According to the Watch Schedule Form, staff did not observe the resident again until 5:40 PM, twenty-five (25) minutes later. Review of a Resident Accident/Incident Report dated [DATE], at 5:35 PM, revealed an Occupational Therapist assisted Resident #44 to the nurse. The report stated the resident had followed a visitor out an exit door (G Hall door) before the door relocked. According to the report, the resident sustained [REDACTED]. Review of the Resident Abuse Investigation Report Form revealed on [DATE] at 5:35 PM, Resident #44 exited the building at 5:35 PM and staff joined the resident at 5:37 PM, two minutes later. The Investigation Report stated the resident had visitors at 5:20 PM. The resident came out of his/her room, saw another visitor leaving at 5:35 PM, and walked out the door behind the visitors. The report stated the resident had no injury. Review of a timeline provided by the facility revealed Courtesy Aide #1 left Resident #44's room at 5:15 PM on [DATE]. At 5:32 PM, the resident came out of his/her room, went back in, then out again, and tried to open the door on the B Hall. According to the timeline, the resident then walked down the F Hall, went through double doors, and then exited the facility through the G Hall door at 5:35 PM. At 5:37 PM, the OT (Occupational Therapist) entered the parking lot and motioned for Resident #44. The OT assisted the resident back inside the facility at 5:39 PM and assisted the resident to the B Hall nurses' station to report the incident to LPN #2. Review of the weather history for the area revealed the temperature on [DATE] at approximately 5:35 PM was approximately 82 degrees. Observation of the resident's picture taken on [DATE] when the resident left the facility revealed the resident was wearing jeans, a shirt, and tennis shoes. Interview with Courtesy Aide #1 on [DATE] at 12:08 PM revealed he was monitoring Resident #44 every fifteen (15) minutes on [DATE]. Courtesy Aide #1 stated he observed the resident in his/her room at 5:15 PM, with family. According to the aide, when he attempted to observe Resident #44 at 5:30 PM, the resident was not in his/her room, and he started to look for the resident. He stated he was still looking for the resident at 5:40 PM, when he saw Resident #44 with a staff member at nurses' station B. The aide stated he then escorted the resident to his/her room and documented that the 5:30 PM fifteen (15) minute check was completed at 5:40 PM. Interview with LPN #2 on [DATE] at 2:23 PM, revealed on [DATE] when Resident #44 exited the building she had released/unlocked the G Hall door from nurses' station B. She stated she heard the door close, and did not see Resident #44 go out the door. She further stated she was talking with a family member when she released the door lock and turned to continue to talk with them after she heard the door close. LPN #2 stated she was not aware the resident had exited the facility until the OT returned the resident to the building. According to LPN #2, the G Hall exit door was commonly used for visitors and families visiting residents in the Rehabilitation Unit and it was common practice to unlock the door to allow entrance/exit to the facility. Interview with the Occupational Therapist (OT) on [DATE] at 9:35 AM, revealed she was walking to her car at the end of the day and observed Resident #44 in the parking lot. She stated she knew Resident #44 was a facility resident as she had seen him/her in the facility before. She further stated she talked to the resident to build a rapport and then assisted the resident back into the facility without incident. The OT stated she did not hear the door alarm, nor did an alarm sound when she assisted the resident back into the building. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:21 AM revealed she was assigned to care for Resident #44 on [DATE]. She stated she was not aware Resident #44 had exited the facility until the OT assisted the resident back into the facility. LPN #1 stated the resident had exited the building through the G Hall exit door. The LPN stated the resident was wearing a code alert bracelet; however, the LPN did not think the door the resident exited was equipped with a wander guard system. Interview with Maintenance staff on [DATE] at 9:54 AM, revealed the exit door on the G Hall only alarmed/unlocked when the release bar on the door was held. He stated the door was not set up to alarm when someone with a code alert bracelet exited the door. Interview with the Maintenance Director on [DATE] at 11:14 AM, revealed on [DATE], the G Hall exit door had a twenty (20) second delay before the door locked and the alarm reset. He stated that once the door alarm on the G Hall was reset from the nurses' station, it took twenty (20) seconds before the door would relock and the alarm would sound again. He stated if the door closed and the twenty (20) seconds had not expired, a resident could exit the door as it was still unlocked and no alarm would sound. Interview with the Administrator on [DATE] at 11:30 AM, revealed the Watch Schedule monitor check was not a set program. She stated the reasoning behind fifteen (15) minute checks for Resident #44 was due to a multitude of reasons, but stated one reason was that the resident was very agile and mobile. The Administrator stated the Courtesy Aide monitoring the resident provided extra supervision and the monitoring was not required to be an exact fifteen (15) minute check. She stated there was no policy or procedure in relation to the Watch Schedule monitoring. The Administrator stated the video footage was part of the facility's Quality Assurance Program and would not allow the State Survey Agency to view the video footage. ****The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1.A. Resident #1 was placed on 1:1 supervision immediately after this occurrence and continues to be a resident at the facility. 1.B. On [DATE], a university hospital Neurologist evaluated Resident #1 via telemedicine and reviewed the resident's behaviors and medications. The Neurologist recommended reducing the resident'[MEDICATION NAME] 10 mg to 5 mg daily, discontinuing [MEDICATION NAME] 150 mg, and beginning [MEDICATION NAME] 50 mg daily. The resident's attending physician agreed with the recommendation and orders were written for the changes on [DATE]. 1.C. Resident #1's care plan was updated on [DATE] to ensure that following family visits, the resident would receive 1:1 monitoring for a minimum of thirty (30) minutes or until family-seeking behaviors subside. 1.D. On [DATE], Resident #1's elopement assessment was conducted by the licensed nurse on duty (LPN). 1.E. Resident #1 had a code alert bracelet in place from the date of admission on [DATE], per family request, due to a history of wandering, which the facility was made aware of at the time of admission. The placement was also noted on the resident's Baseline care plan. 2.A. All residents at risk for elopement were immediately checked and all were accounted for by nursing staff on [DATE]. Code alert bracelets for residents on the Wandering Way Program were checked for placement and proper operation by facility staff (Courtesy Aide) with no concerns noted on [DATE]. 2.B. Care plans were reviewed by the Director of Nursing, QA Nurse, Unit Coordinators, and MDS staff for all residents at risk for elopement on [DATE] and [DATE]; no concerns were noted. 2.C. Maintenance inspected all door locking and alarm mechanisms on [DATE] and all were operating properly. Rehabilitation door settings were reduced from twenty (20) to ten (10) seconds on [DATE]. This setting allows the door to remain open for 10 seconds, and upon expiration, the door alarm shall sound. The door settings were within the Manufacturer's recommendation of ,[DATE] seconds. The facility elected to reduce the time setting on the door to ten (10) seconds as a precaution. Regardless of the time set on the door, for example, whether the door is actually open three (3) seconds or twenty (20) seconds, once the door is closed, it will reset the alarm/locking mechanisms in two (2) seconds per the manufacturer/vendor. This two (2) second interval was present at the date of the event, and remains present to date. This change was initiated while the facility conducted an investigation and ordered Code Alert Sensors for these side doors. 2.D. Maintenance increased all exit door operational checks from weekly to daily until further review on [DATE]. 2.E. All residents identified as a risk for elopement are monitored per the facility's wandering ways protocol. Photographs of all at risk residents and a list will be maintained for easy identification of elopement risk residents. These residents will be checked every one (1) hour per the protocol. An hourly (1 hour) check will be considered timely if performed within 15 minutes of the scheduled time. These checks are documented. 2.F. Any resident who attempts to leave the building unauthorized will be monitored a minimum of every fifteen (15) minutes for twenty-four (24) hours following the attempt. A fifteen (15) minute check will be considered timely if performed within five (5) minutes of the scheduled time. Should the resident not be in the last location observed, an additional five (5) minutes shall be provided to check areas where the resident normally congregates. Should a resident not be located within the allotted timeframe, the staff member performing the check shall implement the missing person protocol. 3.A. On [DATE] and [DATE], all staff, licensed and unlicensed, were provided in-service by the Administrator, Director of Nursing, and QA staff on the elopement/missing resident policies and door/alarm processes with the exception of those on leave, who will be in-serviced prior to returning to work. Staff were instructed to limit use of the side exit doors that were routinely utilized by visitors, EMS (Emergency Medical Services), or others. 3.B. Signs were placed to encourage visitors, EMS, and others to use the front door. Should any side door be used, 1:1 staff supervision of the entry/exit will be in place to ensure the door closure mechanisms and alarms are engaged. The exterior keypad has been disabled to limit the use of these doors until Code alert sensors can be installed. All staff capability to use phone/keypad codes to remotely open side exit doors in the patient care area were removed by maintenance personnel on [DATE]. All side doors in the patient care areas will only open by holding the emergency fifteen (15) second panic bar to ensure alarms sound. This requires 1:1 supervision at the door to check and ensure alarms were engaged. Nurses and Kentucky Medication Aides (KMAs) manually reset the alarms at the door utilizing a separate engagement code. 3.C. The electronic medical record (EMR) elopement risk assessment tool was revised by the EMR Specialist RN to capture previous history of wandering/elopement from the home setting, regardless of the resident's current physical/mental capability. Previously, the EMR assessment did not allow you to proceed if you answered that the resident was physically unable to elope. This was changed so the data is collected on all residents, regardless of physical condition. The content did not change, the order of the questions changed. Licensed nursing staff (RN and LPN) were educated related to this change on [DATE]. 4.A. Quality Assurance (QA) processes were implemented to ensure compliance, specifically competency door checklists for nurses and KMAs. This process is being monitored by the Director of Nursing and QA Nurse. The Director of Nursing/QA Nurse will audit five (5) employees weekly to ensure competency with elopement policies and door operations. The audits include the employees' ability to verbalize the locking mechanism on all doors, their knowledge that the door will release after fifteen (15) seconds when pressing on the panic bar, and knowledge of supervising doors until alarms are reset. Staff are instructed to remove at risk residents from door areas to provide safety. 4.B. Daily, all orders and 24-hour reports are reviewed during the morning meetings. MDS Nurses will bring care plans to the meeting to ensure they are revised utilizing the information obtained during this meeting. Those in attendance at the morning meeting are the Administrator, Director of Nursing, MDS Staff, QA Nurse, Unit Coordinators, Social Services, Activities, and Dietary. 4.C. Weekly, the Director of Nursing or QA Nurse will audit four (4) care plans to ensure the care plans accurately reflects the residents' care needs. 4.D. A QA Meeting was held on [DATE] to discuss the elopement and the corrective actions the facility has implemented following the elopement. The QA committee consists of the Medical Director, Administrator, Director of Nursing, QA Nurse, Social Services, Activities, Dietary, MDS Staff, and Unit Coordinators. The QA Committee will meet weekly for four (4) weeks beginning [DATE] and then monthly. ****The State Agency determined Immediate Jeopardy was removed on [DATE] based on the following: 1.A. Review of Resident #1's medical record revealed the facility placed Resident #1 on 1:1 supervision immediately after the incident. Interview conducted with Courtesy Aide #1 on [DATE] at 9:30 AM, revealed he had provided 1:1 supervision after Resident #1 left the facility unattended. 1.B. Review of a physician progress notes [REDACTED]. The Progress Note revealed the Neurologist recommended medication changes. Review of the resident's Medication Administration Records (MARs) revealed the medication changes were started on [DATE]. 1.C. Review of Resident #1's comprehensive plan of care revealed the facility updated the care plan on [DATE], with an intervention to provide 1:1 supervision for a minimum of thirty (30) minutes or until family-seeking behaviors had subsided, following any family visit. Interviews conducted with Courtesy Aide #1 on [DATE] at 9:30 AM, State Registered Nurse Aide (SRNA) #10 on [DATE] at 9:35 AM, SRNA #8 on [DATE] at 9:49 AM, SRNA #13 on [DATE] at 10:00 AM, and Courtesy Aide #14 on [DATE] at 10:30 AM, revealed the staff had provided 1:1 supervision for at least thirty (30) minutes after Resident #1's family visits. 1.D. Review of an elopement assessment dated [DATE] revealed the facility assessed Resident #1 to be at risk for elopement. Interview conducted with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:25 AM, revealed she had completed the elopement assessment on [DATE] for Resident #1, and the resident was at risk for wandering. 1.E. Review of Resident #1's care plan revealed Resident #1 had a code alert bracelet placed upon admission on [DATE]. Interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 1:30 PM, revealed she had completed Resident #1's initial care plan and the resident was assessed to have wandering tendencies. In addition, on [DATE], the resident was placed on the Wandering Ways Protocol with a code alert bracelet. Interviews conducted with Courtesy Aide #1 on [DATE] at 9:30 AM, SRNA #10 on [DATE] at 9:35 AM, SRNA #8 on [DATE] at 9:49 AM, SRNA #13 on [DATE] at 10:00 AM, LPN #2 on [DATE] at 10:25 AM, Courtesy Aide #14 on [DATE] at 10:30 AM, LPN #1 on [DATE] at 10:50 AM, LPN #4 on [DATE] at 12:52 PM, Registered Nurse (RN) #1 on [DATE] at 12:55 PM, and RN #5 on [DATE] at 1:00 PM, revealed Resident #1 had worn a code alert bracelet since the resident's admission to the facility on [DATE]. 2.A. Review of facility documentation revealed on [DATE], after Resident #1 eloped, nursing staff checked all residents at risk for elopement and staff checked all code alert bracelets for placement and operation. No concerns were identified. Interview with Courtesy Aide #1 on [DATE] at 9:30 AM, revealed he immediately checked all residents who had been identified as being at risk for elopement and had documented that the residents were all accounted for. The Courtesy Aide also revealed he checked to ensure residents' code alert bracelets were present and functioning properly. The Courtesy Aide stated he did not identify any concerns. 2.B. Interviews conducted with LPN #4 on [DATE] at 12:52 PM, RN #1 on [DATE] at 12:55 PM, RN #5 on [DATE] at 1:00 PM, the MDS Coordinator on [DATE] at 1:30 PM, the QA Nurse on [DATE] at 1:56 PM, and the Director of Nursing (DON) on [DATE] at 1:56 PM, revealed they had reviewed elopement assessments and care plans for all residents who had been assessed to be at risk for elopement to ensure accuracy and appropriate interventions were in place for the residents. 2.C. Review of a Door Test Log revealed the Maintenance Supervisor inspected all doors on [DATE] to ensure they were working properly. Observation of exit doors on [DATE] at 9:50 AM, revealed the doors had been set with a ten (10) second alarm and relocked in two (2) seconds after closing. Further observation revealed signs were in place on all exit doors to use the front door only. Interview with the Maintenance Director on [DATE] at 1:45 PM, revealed he immediately checked the exit door where Resident #1 exited on [DATE]. The Maintenance Director stated he also checked all other exit doors and had found all were working appropriately and identified no concerns. He stated the door alarms/locking mechanisms were within the parameters of the manufacturer's recommendations. The Maintenance Director stated he had lowered the door alarm settings on the Rehabilitation Unit exit door to ten (10) seconds on [DATE]. However, the door would also lock two (2) seconds after it was closed. According to the Maintenance Director, Code Alert Sensors had been ordered for the exit doors. 2.D. Review of a Door Test Log revealed the Maintenance Director had checked all exit doors to ensure they were working properly daily since [DATE]. Interview with the Maintenance Director on [DATE] at 1:45 PM, revealed he checked exit doors weekly until the incident on [DATE], involving Resident #1 and had done the checks daily since. The Maintenance Director stated he had not identified any concerns with the exit doors. 2.E. Elopement Assessments for the twelve (12) residents the facility assessed to be at risk for elopement were reviewed and no concerns were identified. Review of the Wandering Ways Logs revealed all twelve (12) residents were being observed for wandering every hour. The residents were also observed to be wearing code alert bracelets. Further observation revealed a sneaker picture had been placed on their nameplates outside their rooms and on their care plans. In addition, pictures of all residents who had been assessed to be at risk for elopement were located on each unit. Interviews conducted with Courtesy Aide #1 on [DATE] at 9:30 AM, SRNA #10 on [DATE] at 9:35 AM, SRNA #8 on [DATE] at 9:49 AM, SRNA #13 on [DATE] at 10:00 AM, LPN #2 on [DATE] at 10:25 AM, Courtesy Aide #14 on [DATE] at 10:30 AM, LPN #1 on [DATE] at 10:50 AM, LPN #4 on [DATE] at 12:52 PM, RN #1 on [DATE] at 12:55 PM, and RN #5 on [DATE] at 1:00 PM, revealed all residents who had been assessed to be at risk for elopement were to be monitored at least hourly to ensure the resident was in a safe area. The staff stated they were aware that a sneaker sticker was in place on the nameplates for all residents who were at risk for elopement as well as a picture of the resident at each unit. 2.F. Continued interviews with Courtesy Aide #1 on [DATE] at 9:30 AM, SRNA #10 on [DATE] at 9:35 AM, SRNA #8 on [DATE] at 9:49 AM, SRNA #13 on [DATE] at 10:00 AM, LPN #2 on [DATE] at 10:25 AM, Courtesy Aide #14 on [DATE] at 10:30 AM, LPN #1 on [DATE] at 10:50 AM, LPN #4 on [DATE] at 12:52 PM, RN #1 on [DATE] at 12:55 PM, and RN #5 on [DATE] at 1:00 PM, revealed if a resident had attempted to elope from the facility, staff were required to monitor the resident every fifteen (15) minutes for twenty-four (24) hours after the attempt. The staff stated they had a fifteen (15) minute timeframe to obtain the hourly check and a five (5) minute timeframe to obtain a fifteen (15) minute check to be considered timely. The staff stated they were required to implement the missing resident protocol if the resident was unable to be located within the timeframe. 3.A. Review of in-service rosters dated [DATE] and [DATE] revealed all staff had been in-serviced by the Administrator, DON, and QA Nurse on the Elopement/Missing Resident policy and the door alarm processes. The rosters revealed staff were instructed to limit the use of the side exit doors which had been previously used by EMS and visitors. 3.B. Observation of exit doors on [DATE] at 9:50 AM, revealed signs had been placed on exit doors reminding everyone to use the front door to enter and exit the facility. Observation also revealed the exterior keypads had been disabled. The side doors in the resident care areas were observed to only open if the panic bar was held for fifteen (15) seconds, which also resulted in an alarm sounding. Further observation revealed the alarms had to be manually reset by entering a code. Interviews conducted with the Administrator on [DATE] at 3:39 PM, Courtesy Aide #1 on [DATE] at 9:30 AM, SRNA #10 on [DATE] at 9:35 AM, SRNA #8 on [DATE] at 9:49 AM, SRNA #13 on [DATE] at 10:00 AM, LPN #2 on [DATE] at 10:25 AM, Courtesy Aide #14 on [DATE] at 10:30 AM, LPN #1 on [DATE] at 10:50 AM, LPN #4 on [DATE] at 12:52 PM, RN #1 on [DATE] at 12:55 PM, RN #5 on [DATE] at 1:00 PM, the DM on [DATE] at 1:10 PM, the AD on [DATE] at 1:15 PM, SS on [DATE] at 1:20 PM, the MDS Coordinator on [DATE] at 1:30 PM, the Maintenance Director on [DATE] at 1:45 PM, the QA Nurse on [DATE] at 1:56 PM, and the DON on [DATE] at 1:56 PM, revealed they had attended in-services by the Administrator, DON, and QA Nurse on [DATE] and [DATE], related to the facility's Elopement/Missing Resident policy and the door/alarm processes. The staff revealed the side doors were locked and required a nurse to lock/unlock the door. The staff revealed they were required to instruct visitors and Emergency Medical Services to use the front door; however, if the side doors were used, they were required to supervise any entry or exit. The staff revealed only nurses or a KMA were allowed to manually reset the alarms at the side doors using a code on the inside of the door and the outside keypads had been disabled. 3.C. Review of the facility's new Elopement Risk assessment revealed the assessment had been changed to add a question to indicate the resident's previous history of wandering/elopement prior to admission to the facility. Review of an in-service roster dated [DATE], revealed all licensed nursing staff had attended an in-service related to the new elopement risk assessment. Interviews conducted with LPN #2 on [DATE] at 10:25 AM, LPN #1 on [DATE] at 10:50 AM, LPN #4 on [DATE] at 12:52 PM, RN #1 on [DATE] at 12:55 PM, RN #5 on [DATE] at 1:00 PM, the MDS Coordinator on [DATE] at 1:30 PM, the QA Nurse on [DATE] at 1:56 PM, and the DON on [DATE] at 1:56 PM, revealed they had attended the in-service related to the new elopement risk assessment. The nurses revealed a question had been added related to the resident's previous history of elopement prior to admission to the facility. 4.A. Review of door competency checklists revealed the facility documented all nurses and KMAs were competent. The checklists were signed by the DON and QA Nurse. Interview conducted with the DON and QA Nurse on [DATE] at 1:56 PM, revealed they confirmed all staff members' competency and were now completing random audits of five (5) staff members weekly to ensure staff competency related to the door processes. The interview revealed they had not identified any concerns with the audits and were reporting the findings to the QA Committee. <br (TRUNCATED)