Every finding on record at Lexington Country Place

Based on interviews, record review, and review of the facility's policy, the facility failed to promptly notify the physician of a fall for 1 of 8 residents sampled for falls, Resident (R) 13. Record review and interviews revealed R13 sustained a fall on 03/08/2026 at approximately 8:00 PM. R13 was observed to have a significant change in condition related to her physical functioning, mobility, and pain level. Record review revealed, however, the resident's physician was not notified promptly of these changes until the resident's family requested staff to contact the physician. On 03/10/2026, approximately two days after the resident fell, Resident 13 was diagnosed to have a fracture of the distal femoral shaft (portion of the femur just above the knee) with malalignment and soft tissue swelling.Immediate Jeopardy (IJ) was identified on 04/30/2026 in the area of 483.10 Resident Rights and was determined to exist on 03/08/2026. The facility submitted an acceptable IJ Removal Plan on 05/01/2026. The immediacy was determined to be removed on 05/01/2026, prior to exit.Refer to F689The findings include:Review of the facility's policy titled, Change in Condition, dated 08/01/2024, revealed the policy required staff to recognize and report physical, cognitive, or emotional changes, including use of tools to ensure timely communication. Additionally, the policy directed staff to complete a thorough assessment, document findings, and notify the physician promptly.Review of the facility's policy titled, Falls and Injuries, dated 08/01/2024, revealed the policy required staff to notify the resident's physician following a fall to ensure timely evaluation, treatment, and direction for ongoing care. According to the policy, the physician was expected to respond timely, and staff was directed to escalate concerns to the Medical Director if an appropriate or timely response was not received.Review of R13's admission Record revealed the facility admitted the resident on 02/03/2024 with diagnoses to include Parkinson's disease with dyskinesia, repeated falls, and cognitive communication deficit.Review of R13's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, indicating moderate cognitive impairment. Review of a Health Status Note, dated 03/08/2026 at 10:12 PM, found in R13's electronic medical record (EMR) under the Progress Notes tab, indicated staff found the resident on the floor attempting to find personal items. The resident was assessed as alert and oriented x 3/4. Furthermore, the resident had pain in her right knee, rated at five out of 10 on a numerical pain scale with 10 being the worst pain. According to the note, the Director of Nursing (DON) and R13's family member (F) 13 were notified. Documentation revealed the nurse called the resident's primary care physician and documented the physician was called to her office and was unable to talk to anybody.Review of a Fall Report, dated 03/08/2026 at 8:45 PM, revealed the resident was found on the floor of her room at 8:00 PM after attempting to reach for personal items. The resident was assessed as alert with pain rated as a 5 out of 10. Documentation revealed no injuries were observed. The report revealed predisposing environmental and situational factors were identified as other without further explanation. Psychological factors were documented as confusion. Per the Fall Report, Licensed Practical Nurse (LPN) 2 documented he notified R13's physician on 03/08/2026 at 9:00 PM.Review of a eINTERACT Change in Condition Evaluation, dated 03/08/2026 at 10:20 PM, revealed the Provider Notification Feedback section regarding change in condition and notification to physician indicated yes for physician notification on 03/08/2026 at 8:00 PM. However, under recommendation of the physician, the documentation stated, Nobody answered the call and was unable to leave message.Review of nursing Progress Notes, dated 03/08/2026 to 03/09/2026, found in R13's EMR under the Progress Notes tab, and requests for further documentation from the facility, revealed no documentation indicating the facility made additional attempts to notify the physician or continued follow-up communications regarding the resident's fall or change in condition until LPN2 sent a text on 03/09/2026 at 3:04 PM.Review of a text message communication regarding R13's fall, dated 03/09/2026 at 3:04 PM, revealed LPN2 wrote to the physician, [R13] fell in her room last night. I already talked to the office number before. Her daughter wants x-ray rt. Knee for pain. Let me know please if she needs it.Review of physical therapy's (PT) Interdisciplinary Resident Screen, dated 03/09/2026, revealed the Speech Therapist assessed R13 to have multiple significant changes in physical functioning, mobility, and pain level. The screen revealed the resident had been bed bound since the previous night, refused morning and afternoon meals, and experienced increased pain rated eight out of 10 on a numerical pain scale with 10 being the worst pain. Documentation revealed R13's right knee was swollen. The assessment further documented that the resident could not bear weight on the right knee and hip. There was no documentation indicating the physician was notified.Review of a nursing Health Status Note, dated 03/10/2026 at 11:09 AM, revealed LPN15 noted, CNA alerted me patient [resident] is crying in pain. Patient [resident] noted to be in bed, tears streaming down face. She said her leg hurts so bad she can not [sic] stand it. There was not document, however, the resident's physician was notified.Review of a Radiology Report, of R13's right knee, captured at the facility, dated 03/10/2026 at 1:06 PM, revealed a fracture of the distal femoral shaft with malalignment and soft tissue swelling.Observation of R13 on 04/27/2026 at 10:15 AM revealed the resident in bed with the covers removed, wearing only briefs. A bed alarm was present but not alarming. The resident was positioned sideways in bed in a partially upright, partially reclined position, with both legs hanging off the side of the bed. The room environment was unkempt and cluttered. R13's bedside table was positioned away from the resident's and out of the resident's reach. R13 stated she was trying to reach items on the bedside table and needed to get out of bed. The State Survey Agency (SSA) Surveyor notified staff.During a telephone interview with R13's family member (F) 13 on 04/29/2026 at 11:16 AM, she stated R13 had advanced dementia with associated Parkinson's disease psychosis and experienced frequent falls. F13 stated the resident did not recognize safety risks and could not consistently understand or follow instructions, which is why she admitted R13 to the facility to provide 24/7 supervision and staff assistance to ensure her safety. F13 stated despite sustaining a major injury requiring surgical intervention and subsequent return to the facility, R13 continued to experience falls. She stated R13 fell again within a short period of time after returning to the facility following surgical repair of a fractured femur. Further, she stated on 03/09/2026, sometime during the morning, R13 called her and stated she believed she had broken her leg and was in severe pain. Additionally, F13 stated the resident continued to complain of significant pain, difficulty with moving her right lower extremity, and demonstrated verbal behaviors indicating something was wrong. She stated although the resident could not always clearly verbalize her needs, staff could recognize changes in conditions through the resident's behavior and complaints of pain. F13 stated she spoke with LPN2 and requested an X-ray. She stated she did not receive any follow-up communication from the facility until the following afternoon, after the x-ray was completed, and staff notified her R13 sustained a femur fracture, which required transfer to the local emergency department (ED). During an interview with LPN2 on 04/27/2025 at 11:45 AM, he stated that when R13 fell on [DATE], he completed an assessment of the resident following the incident. He stated at the time of the assessment there was no visible bruising, redness, swelling, shortening, or external injury noted. LPN2 stated the resident complained of some pain but did not exhibit significant distress and remained in bed. Furthermore, LPN2 stated the facility's policy required notification of the physician, DON, and family following a fall. He stated communication with R13's physician typically occurred through an on-call service rather than direct physician contact. LPN2 stated he attempted to notify R13's physician on 03/08/2026 by calling the physician's medical practice on-call service but was unable to reach anyone and was unable to leave a voicemail. He reported he did not have direct contact information for the physician at that time. He stated he notified the DON of the fall but could not recall whether he informed her he was unable to reach the physician. He reported that on the morning of 03/09/2026, at approximately 9:00 AM, he spoke with the DON, who provided him with a contact number for the physician. He stated he subsequently contacted the physician later that day, though documentation reflected contact occurred at approximately 3:18 PM. He stated once the physician was contacted, an order for an x-ray was obtained per family request. When asked by the State Survey Agency (SSA) Surveyor why he did not notify the physician immediately after obtaining his cell phone number, the LPN stated he was busy with medication administration. The LPN further stated he did not contact the physician until after R13's family member (F) 13 contacted staff and requested an x-ray. LPN2 stated the x-ray was not completed until the following day and reported that timing of diagnostic services was dependent on availability. He stated he did not believe the situation required a stat (immediate) order at the time, as the resident had a history of pain.Interview with SRNA12 on 03/27/2026 at 2:15 PM revealed she cared for R13 on 03/10/2026 and observed R13 making complaints of pain throughout the shift. SRNA12 stated R13 said her whole leg hurt and the pain moved between the knee and hip. SRNA12 stated she cried in pain. SRNA12 stated she observed swelling in the knee and bluish discoloration of the leg, which she stated was not the resident's normal skin color.During a telephone interview with R13's physician on 04/30/2026 at 2:55 PM, he stated the facility did not notify him of R13's fall on 03/08/2026. The physician stated he first became aware of the fall through text message received on 03/09/2026 at approximately 3:00 PM indicating the resident's family requested an x-ray. He stated the text message did not include concerns regarding R13's pain level, swelling, injury, or decreased range of motion. The physician further stated staff did not contact him through his cell phone on 03/10/2026 and instead left a message with his office. He stated staff did not inform him R13 experienced increased pain or cried with complaints of pain rated eight out of 10. The physician stated if staff had informed him of R13's knee swelling, pain, and decreased range of motion, he would have sent R13 to the emergency department for evaluation rather than ordering an x-ray. He further stated nursing staff did not communicate the severity of R13's pain or injury when requesting the x-ray. The physician stated his preferred method of notification was direct contact through his personal cell phone. He stated the DON had his personal cell phone number, and his number was posted at the nurses' stations for staff use. The physician further stated he and facility staff previously discussed avoiding use of the on-call service, especially on weekends, because the on-call provider might not have been familiar with the resident.During an interview with the Director of Nursing (DON) on 04/28/2026 at 11:55 AM, she stated there was no defined process when initial attempts to notify the physician were unsuccessful. She stated nursing staff had the option to contact the facility's medical director if the physician was unreachable. The DON stated LPN2 notified her on 03/08/2026 at approximately 8:30 PM regarding R13's fall. She stated LPN2 informed her on 03/09/2026 at approximately 9:00 AM he had not notified the physician. The DON stated she provided LPN2 with the physician's personal cell phone number. The DON stated staff should have continued attempts to notify the physician rather than delaying notification until the following day. She stated she was unclear why LPN2 did not immediately notify the physician and instead waited until approximately 3:00 PM on 03/09/2026 to communicate by text message. When asked by the State Survey Agency (SSA) Surveyor regarding her expectations for physician notification, the DON stated LPN2 should have continued attempts to notify the physician, including use of the physician's personal cell phone number, and should have ensured contact occurred the same night.During an additional interview with the DON on 05/01/2026 at 6:00 PM, she stated it would have been reasonable for the nurse on duty to contact her if the resident required more urgent care or the physician did not respond promptly. The DON stated she could have intervened by contacting the physician directly regarding concerns about the lack of a timely response. She further stated nursing staff was expected to advocate for the resident's needs.During an interview with the Administrator on 04/29/2026 at 7:54 AM, she stated she had a concern regarding R13's fall on 03/08/2026. She stated the nurse reported attempting to contact the physician's office on the evening of the fall; however, there were no additional attempts made that evening. The Administrator stated the nurse's documentation indicated he called and did not get anybody. She stated the physician was not contacted until approximately 3:00 PM on 03/09/2026. The Administrator stated LPN2 escalated concerns to the DON at 9:00 AM and was provided the physician's personal cell phone number. However, she stated documentation of a text message revealed LPN2 waited until 3:00 PM to contact the physician through a text message. Additionally, the Administrator stated staff was expected to notify physicians in a timely manner regarding changes in condition, including falls. She stated she expected nursing staff to continue attempts to contact the physician or the DON when initial notification attempts were unsuccessful. The facility submitted an acceptable IJ Removal Plan on 05/01/2026 at 3:38 PM verbatim:Resident (R)13 sustained a fall on 03/08/26 at 8:45 p.m. An attempt was made to reach the physician immediately but there was no answer nor the ability to leave a message. On 3/09/2026 at 1:00 p.m. nurse called Physician office and spoke to office staff asking Dr. [NAME] to return call re: resident fall. However, at 3:04 p.m. on this date (03/9/2026) nurse called physician's cell phone to report right knee pain and request was made for Xray. Physician responded on 3/09/2026 at 3:18 p.m. and X-ray requested. On 3/10/2026 Portable X-Ray obtained resulting in R Femur Fracture. Physician notified us of the results on 3/10/2026 and order was obtained to transfer the resident to hospital for further evaluation and treatment.-The QAPI tool for the monitoring of MD notification for fall changes in status and for fall Root Cause analysis and intervention implementation is being utilized underthe [sic] supervision of the Administrator/Executive Director with all falls weekly X 2 weeks, then monthly X 2 months and then quarterly thereafter.An Ad hoc QAPI meeting was conducted on 04/30/26 with the QAPI committee members, including the Medical Director, Attending Physicians, Administrator, Director of Nursing, MOS Coordinator, Staff Development coordinator, Human Resource Coordinator and the Social Service Director to review the findings cited in the IJ Templates and the facility Removal Plan.Resident(s) affected by the IJ:Resident (R) 13 was identified to be affected by the deficiency. The resident had a fall on 03/08/2026 at 8:45 p.m. No external injuries are noted at this time. Resident complained of right knee pain but displayed normal ROM. M.D. office called no message left on 3/08/2026 at 9:00 p.m. MD office called again on 3/09/2026 at 1:06 p.m. then nurse messaged MD directly at 3:04 p.m. New order for X-Ray obtained. X-Ray resulted in a femur fracture on 3/10/2026 and MD notified with new orders to send to the hospital with the diagnosis of a fracture of right femur fracture.--Root cause analysis was completed on 03/13/2026 in which we rearranged resident's room and added intervention to the care plan. On 4/30/2026 another root cause analysis was completed re: this fall with the indicated intervention of Wheelchair caddy bag on inside of wheelchair for easy access of personal items. [NAME] added to the plan of care and SRNA Kardex.-Activity Staff have been educated by the Executive Director/Administrator to assist resident (R) 13 to activities daily (5 to 6 per day) to add supervision. Licensed Nurses have been educated to have resident out of the room as much as she allows, for meals, day area, etc. and this has been added to care plan and SRNA task. Education was started on 4/30/2026 by Staff Development Coordinator and no Licensed Nurse will work prior to education being completed. Resident started on 15-minute checks x 1 week beginning 05/01/2026 and Fall management team will reevaluate.-Director of Nursing, Unit Manager and MOS Nurse completed a new fall risk assessment for all residents, and they will correct any findings at the time. Audit completed 05/01/2026 and results will be discussed and reviewed in QAPI for input.Resident(s) the facility identified at risk for IJ:All residents with falls in the last 30 days were at risk of being affected by F580 and F689.Training:-All licensed nurses have received in-service education on the updated Change of Condition Policy and Procedure to include the facility protocol for MD notification by the Staff Development Coordinator beginning on 04/30/2026 and no Licensed Nursing Staff member will work prior to education. The licensed staff will contact the Medical Director if the attending physician does not respond within 30 minutes for an emergency or 3 hours for non-emergencies. The licensed nurses that have not completed the in-service training on 4/30/2026 will be educated prior to the next shift worked or they will not be allowed to clock in until fall training has been completed. The training will be included in the facility orientation program for all new hire licensed nurses from 5/1/26 going forward and any agency staff will receive education prior to working shift by the Staff Development Coordinator, Director of Nursing or Unit Manager. As of 05/01/2026 13 of the 17 full-time Nurses have been educated. There is 7 prn Nurses that will also receive education prior to the next day worked. All education was provided 1:1 with staff, the LPN #2 received all education on 5/01/2026 prior to beginning his shift. All Licensed Nurses demonstrated comprehension by repeating education back to Staff Development Coordinator.-The Fall Management Team consisting of but not limited to the Administrator and or Director of Nursing, Rehabilitation Director or other therapist if unavailable, MDS Nurse, Staff Development Nurse and the Social Worker (Admissions Coordinator if unavailable) have received in-service education on Fall Management Audit Tool (see attached) and the importance of verifying all information on the displayed on the tool with follow education and reviewed in QAPI. Falls will be reviewed daily Monday-Friday and the next business day for the weekend. The Fall Audit Tool will also be completed at weekly fall meeting. Education provided by Administrator/ Executive Director and completed on 04/30/26 which includes but are not limited to: Director of Nursing, Staff Development, MDS Nurse, Therapist, and Social Worker.-The need to complete Root Cause Analysis for all resident falls to determine the indicated intervention to address the fall causative/contributing factor(s).-The need to address the determined intervention on the resident care plan and Kardex. A list of interventions attached to the fall packet for brainstorming to make interventions person centered.-The need to implement the determined intervention timely and to monitor for effectiveness.Systems implemented to ensure all staff are trained prior to providing direct care to residents& determined competent on the materials trained:-Audit of all resident falls for the last 30 days from 4/30/26 for residents that are still in house was completed by Director of Nursing, Staff Development Coordinator, and Administrator/Executive Director to identify that all MD notification of changes had been completed. The physicians were notified of all resident fall changes in condition for the last 30 days.-An audit of all resident falls for the last 30 days from 4/30/26 for residents that are still in house was completed by Director of Nursing, Staff Development Coordinator, and Administrator/Executive Director to determine that Root Cause Analysis with determination and implementation of indicated interventions had been completed. Interventions indicated by Root Cause analysis were determined to be on the care plans and in place for all residents with falls in the last 30 days.- The QAPI tool for the monitoring of MD notification for fall changes in status and for fall Root Cause analysis and intervention implementation is being utilized under the supervision of the Administrator/Executive Director with all falls weekly X 2 weeks, then monthly X 2 months and then quarterly thereafterMonitoring:-Results of Fall Risk Assessment will be discussed in Quarterly QAPI meeting including but not limited to the Medical Director, Pharmacist Consultant, Administrator, Director of Nursing, MOS Nurse, Staff Development Coordinator and Compliance/QAPI Coordinator findings will be added to PIP as indicated.-Completed QAPI tools will be reviewed in the ongoing QAPI meetings to determine ongoing compliance.Alleged removal date:5/1/26

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents received adequate supervision and failed to keep residents free from falls for 1 of 8 sampled residents reviewed for falls, Resident (R) 13.Record review revealed R13 sustained a total of 10 falls from 12/29/2025 to 04/25/2026, including some with a documented injury. For one fall, on 03/08/2026, R13 suffered a non-displaced fracture of the right femur, extending to the resident's right knee. R13 was subsequently transferred to the emergency department and later returned to the facility on [DATE] and sustained a fall after transfer. Subsequent falls continued following hospitalization and surgical intervention. The falls occurred in the resident's room while attempting toileting, self-ambulating, or attempting to retrieve personal items. Additionally, interview and record review revealed the resident exhibited acute distress following the fall on 03/08/2026, including crying and reporting severe pain. Immediate Jeopardy (IJ) was identified on 04/30/2026 in the area of 42 CFR 483.25 Quality of Care and was determined to exist on 03/08/2026. Substandard Quality of Care (SQC) was also determined to exist. The facility submitted an acceptable IJ Removal Plan on 05/01/2026. The immediacy was determined to be removed on 05/01/2026, prior to exit.The findings include:Review of the facility's policy titled, Falls and Injuries, dated 08/01/2024, revealed the policy required staff to notify the resident's physician following a fall to ensure timely evaluation, treatment, and direction for ongoing care. The policy stated the Interdisciplinary Team (IDT) was responsible for identifying and implementing individualized fall prevention interventions based on assessment to reduce the risk of falls. Continued review of the policy revealed staff were responsible for communicating interventions during shift report and rounds and ensure the residents' environment was free from potential hazards.Additional review of the Falls and Injuries policy, dated 08/01/2024, revealed the physician was expected to respond timely, and staff were directed to escalate concerns to the medical director if an appropriate or timely response was not received.Review of R13's admission Record revealed the facility admitted the resident on 02/03/2024 with diagnoses to include Parkinson's disease with dyskinesia, repeated falls, and cognitive communication deficit.Review of R13's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS], score of nine out of 15, indicating moderate cognitive impairment. Continued review revealed R13 was assessed as dependent (helper did all of the effort) with toileting, lower body dressing, and putting on/taking off footwear; and substantial/maximal assistance (helper did more than half the effort) with bathing and upper body dressing.Review of R13's Care Plan Report, dated 08/28/2025 and revised on 01/08/2026 and 04/16/2026, found in the resident's electronic medical record (EMR) under the Care Plan tab, revealed a focus for potential injury from falls related to decreased mobility, Parkinson's disease, weakness, psychotropic medication use, and opioid medication use. Goals included minimizing falls and preventing injury through the review period. Interventions included: staff were to encourage the resident to eat dinner in the common area (initiated on 08/28/2025); to encourage the resident to remain in the day area for supervision until bedtime (initiated 01/08/2026); to encourage resident to stay up in day area for supervision until bedtime, anticipate and meet the resident's needs, encourage the resident to request assistance, maintain personal safety alarms to bed and wheelchair, offer toileting before bedtime, and monitor during rounds.1. (a) Review of the Health Status Note, dated 12/29/2025 at 4:00 PM, in R13's EMR under the Progress Notes tab, revealed a State Registered Nurse Aide (SRNA) found R13 on the floor in her room after attempting to change her clothes independently. She was assessed as having no injury. (b) Review of the Alert Note, dated 02/13/2026 at 8:02 AM, found in R13's EMR under the Progress Notes tab, revealed R13 slipped out of her wheelchair and complained of right arm soreness. No redness was noted.(c) Review of the Health Status Note, dated 02/22/2026 at 2:08 PM, in R13's EMR under the Progress Notes tab, revealed staff found R13 sitting on the floor next to the bedroom doorway after attempting to get ice. Staff documented the fall with injury; documenting only redness was observed to the right hip. (d) Review of the Health Status Note, dated 02/28/2026 at 6:20 AM, found in R13's EMR under the Progress Notes tab, revealed an alarm sounded and an SRNA responded as R13 ambulated toward the bathroom with a staggering gait and fell before staff could secure her. R13 struck the side of her head on the bed grab bar. No marks, bleeding, or complaints of headache were noted. The nurse noted the resident had old, scattered bruising to the body.(e) Review of the Health Status Note, dated 03/08/2026 at 8:45 PM, found in R13's EMR under the Progress Notes tab, revealed R13 sustained a fall and staff later helped the resident from the floor to the bed with a two-person assist.Review of R13's Fall Report, dated 03/08/2026 at 8:45 PM, revealed staff found the resident on the floor of her room at 8:00 PM after she attempted to reach for personal items. Nursing staff assessed R13 as alert with pain rated as a five out of 10 on a numerical scale, with 10 being the worst pain. Further review of the Fall Report revealed the nurse documented no injuries were observed for this fall.Review of a Health Status Note, dated 03/08/2026 at 10:12 PM, found in R13's electronic medical record (EMR) under the Progress Notes tab, indicated staff found the resident on the floor attempting to find personal items. Nursing staff assessed the resident as alert and oriented x 3/4. Furthermore, the resident had pain in her right knee, rated at five out of 10 on a numerical pain scale with 10 being the worst pain. Review of the eINTERACT SBAR Summary for Providers, dated 03/08/2026 at 10:20 PM, found in R13's EMR under the Progress Notes tab, indicated a change in condition (CIC) after a fall. The assessment documented vital signs, including a blood pressure of 150/85, pulse 89, and respirations 20. Review of R13's Neurological Record, dated 03/08/2026 through 03/10/2026, revealed on 03/08/2026 at 8:45 PM the section for motor response of the upper and lower extremities contained a line drawn through the boxes with no motor response documented on 03/08/2026 and 03/09/2026. Further review revealed the nurse did not assess or document motor function or external stimuli of the right lower extremity. Review of a text message communication regarding R13's fall, dated 03/09/2026 at 3:04 PM, revealed Licensed Practical Nurse (LPN) 2 wrote to the physician, [R13] fell in her room last night. I already talked to the office number before. Her daughter wants x-ray rt. Knee for pain. Let me know please if she needs it.Review of a Health Status Note, dated 03/09/2026 at 3:18 PM and documented by the Director of Nursing (DON) as a late entry note on 04/28/2026 at 5:23 PM, found in Resident 13's EMR under the Progress Notes tab, revealed R13 fell in her room. According to the note, Resident's family requested an x-ray for knee pain, and an order was obtained for an x-ray of the right knee.Review of Physical Therapy's (PT) Interdisciplinary Resident Screen, dated 03/09/2026, revealed multiple significant changes in R13's physical functioning, mobility, and pain level. The screen revealed the resident had been bed bound since the previous night, refused morning and afternoon meals, and experienced increased pain rated eight out of 10 on a numerical pain scale with 10 being the worst pain. Documentation revealed R13's right knee was swollen. The assessment further documented that the resident could not bear weight on the right knee and hip.Review of an IDT Note, dated 03/09/2026 at 10:14 AM revealed the interdisciplinary team (IDT) met to review R13's 03/08/2026 fall. Further review revealed the team updated the resident's care plan to keep the resident's Reacher close and to follow up on a requested PT screening.Review of a Health Status Note, dated 03/10/2026 at 11:09 AM, found in R13's EMR under the Progress Notes tab, indicated an SRNA found R13 in bed, with tears streaming down her face. According to the note, She [R13] said her leg hurts so bad she can not [sic] stand it.Review of a Radiology Report, of the right knee and hip, dated 03/10/2026 at 1:06 PM, revealed a fracture of the right distal femoral shaft with malalignment and non-displaceable fracture of the right greater trochanter. Review of eINTERACT Transfer Form V5, dated 03/10/2026 at 6:20 PM, revealed R13 was transferred by ambulance to the local emergency department at 4:56 PM.Review of the ED to Hosp-admission Note, dated 03/10/2026, revealed R13 was admitted to the local hospital with a closed fracture of the right femur and an injury of her head. According to the report, R13 presented to the local hospital after a mechanical fall that occurred prior to arrival. The fall resulted in her hitting the back of her head and landing on her right leg. A computed tomography (CT) scan of the head showed no intracranial abnormality. Physical exam revealed the right lower extremity with positive shortening, positive external rotation, and attempted movements of the hip were painful and restricted. The resident had moderate tenderness overlying her distal femur and was given intravenous morphine (an opioid analgesic) for pain. Radiography of the right femur revealed a nondisplaced spiral type fracture involving the distal metadiaphysis of the right femur. The fracture extends to the anterior margin of the femoral component of the patient's right knee arthroplasty. Per the note, R13 underwent surgery for placement of an intramedullary rod stabilizing the distal femoral fracture. Observation of R13 on 04/27/2026 at 10:15 AM revealed the resident in bed with the covers removed, wearing only briefs. A bed alarm was present but not alarming. The resident was positioned sideways in bed in a partially upright, partially reclined position, with both legs hanging off the side of the bed. The room environment was unkempt and cluttered. R13's bedside table was positioned away from the resident's and out of the resident's reach. R13 stated she was trying to reach items on the bedside table and needed to get out of bed. The State Survey Agency (SSA) Surveyor notified staff.During a telephone interview with R13's family member (F) 13 on 04/29/2026 at 11:16 AM, she stated R13 had advanced dementia with associated Parkinson's disease psychosis and experienced frequent falls. F13 stated the resident did not recognize safety risks and could not consistently understand or follow instructions, which is why she admitted R13 to the facility to provide 24/7 supervision and staff assistance to ensure her safety. F13 stated despite sustaining a major injury requiring surgical intervention and subsequent return to the facility, R13 continued to experience falls. She stated R13 fell again within a short period of time after returning to the facility following surgical repair of a fractured femur. Further, she stated on 03/09/2026, sometime during the morning, R13 called her and stated she believed she had broken her leg and was in severe pain. Additionally, F13 stated the resident continued to complain of significant pain, difficulty with moving her right lower extremity, and demonstrated verbal behaviors indicating something was wrong. She stated although the resident could not always clearly verbalize her needs, staff could recognize changes in conditions through the resident's behavior and complaints of pain. F13 stated she spoke with LPN2 and requested an X-ray. She stated she did not receive any follow-up communication from the facility until the following afternoon, after the x-ray was completed, and staff notified her R13 sustained a femur fracture, which required transfer to the local emergency department (ED). During an interview with LPN2 on 04/29/2026 at 11:45 AM, he stated on 03/08/2026, he completed an assessment of the resident following the incident. He stated that at the time of the assessment, no visible bruising, redness, swelling, or external injury was noted. He stated the resident complained of some pain but did not exhibit significant distress and remained in bed. He stated he attempted to notify the physician on 03/08/2026 by calling the on-call service through a medical associate line but was unable to reach anyone and left no voicemail. He reported he did not have the physician's direct contact information at that time. He stated he notified the DON of the fall but could not recall whether he informed her he was unable to reach the physician.During continued interview with LPN2 on 04/29/2026 at 11:45 AM, LPN2 stated on the morning of 03/09/2026, at approximately 9:00 AM, he spoke with the DON, who provided him with a contact number for the physician. He stated he subsequently contacted the physician later that day, though documentation reflected contact occurred at approximately 3:18 PM. He stated, later in the day, F13 called him to say she wanted an X-ray ordered for R13. LPN2 stated he did not know why F13 wanted the X-ray, but he contacted the physician. He stated he did not know why he did not document the telephone conversation with F13, but stated, She just wanted an X-ray. LPN2 stated the X-ray at the facility was not completed until the following day, and the timing of diagnostic services was dependent on availability. He stated he did not believe the situation required a STAT (immediate) order at the time, as the resident had a history of pain, was receiving pain medication, including tramadol (narcotic analgesic) and acetaminophen (analgesic) for chronic pain, and was not expressing significant complaints beyond baseline.During a telephone interview with R13's Primary Care Physician (PCP) on 04/30/2026 at 2:55 PM, he stated R13 was admitted to the facility with a diagnosis of frequent falls. The PCP stated the facility did not notify him of R13's fall on 03/08/2026. The physician stated he first became aware of the fall through a text message received on 03/09/2026 at approximately 3:00 PM indicating resident's family requested an x-ray. He stated the text message did not include concerns regarding R13's pain level, swelling, injury, or decreased range of motion. He stated supervision with activities and anticipating the resident's needs were required to prevent falling and injury. He stated he expected staff to provide adequate supervision and interventions to prevent falls and accidents.During an interview with the Director of Nursing (DON) on 04/28/2026 at 3:45 PM, she stated the facility did not have a defined process for notifying physicians when initial attempts were unsuccessful. The DON stated staff should have continued attempts to notify the physician, including use of the physician's personal cell phone number if the on-call service did not answer, and should have made contact the same night rather than allowing a delay in care. The DON stated she was notified the night of R13's fall; however, she did not know until the following morning LPN2 had not notified the resident's physician. She further stated she did not know why LPN2 delayed contacting the physician until approximately six hours after receiving the physician's personal cell phone number on 03/09/2026. Furthermore, the DON stated LPN2 communicated with the physician by text message on 03/09/2026 regarding R13's pain and received an order for an x-ray; however, the facility did not obtain the x-ray until the following day and did not receive results until late that afternoon, delaying identification and treatment of R13's fracture. Additionally, when asked by the State Survey Agency (SSA) Surveyor why facility staff delayed R13's care for two days following her fall, the DON stated nursing notes and assessments did not identify an injury and documented the resident's pain as at zeroes, threes, and [NAME], which she stated was the resident's baseline. The DON further stated LPN2's nursing assessment did not indicate a need for a STAT (immediate) x-ray following the fall. She stated due to availability; it was not unusual if a non-STAT X-ray was delayed a day. (f) Review of a Health Status Note, dated 03/14/2026 at 4:36 PM, found in R13's EMR under the Progress Notes tab, revealed staff responded within a few minutes to R13's personal alarm sounding. Staff found R13 on the floor on the right side of the bed and documented she slid out of the bed. According to the note, R13 denied pain, no injuries were noted, and surgical dressing to the right knee and hip remained intact. Staff assisted R13 back to bed using a mechanical lift with the aid of three staff. The facility readmitted R13 following discharge from the local hospital after surgery and failed to ensure the resident was supervised to prevent falls.(g) Review of a Health Status Note, dated 03/28/2026 at 4:33 PM, found in R13's EMR under the Progress Notes tab, revealed according to the note, R13 got up from the bed and turned off the bed alarm by herself. Staff found the resident on the floor while attempting to retrieve an item from the bedside table. Documentation revealed no injuries or pain were noted.(h) Review of a Health Status Note, dated 04/04/2026 at 8:35 PM, found in R13's EMR under the Progress Notes tab, revealed staff found R13 sitting on the floor near the dresser. According to the note, staff stated the resident attempted to self-toilet. R13 denied pain, and no injury was noted. Record review of the resident's CCP revealed staff failed to implement the resident's care plan to assist the resident with toileting.(i) Review of the Fall Report, dated 04/07/2026 at 8:00 PM, found in R13's EMR under the Progress Notes tab and provided by the facility, revealed staff found R13 sitting on the floor near the bed. No injury was noted, and R13 denied pain. Staff assisted R13 back to bed and activated the bed alarm.Review of an IDT Note, dated 04/07/2026 at 11:37 AM, revealed the IDT met to review R13's 03/08/2026 fall. Further review revealed the team updated the resident's care plan to offer more blankets to keep warm.(j) Review of a Health Status Note, dated 04/15/2026 at 7:45 PM, found in R13's EMR under the Progress Notes tab, revealed R13 fell while looking for books. Staff assisted R13 back to bed with the aid of a two-person assist. No injuries were noted.Review of an IDT Note, dated 04/16/2026 at 9:00 AM revealed the IDT met to review R13's 04/15/2026 fall. Further review revealed the team updated the resident's care plan to place an alarming mat at the bedside to alert staff when the resident got up.Review of a Health Status Note, dated 04/16/2026 at 12:50 PM, found in R13's EMR under the Progress Notes tab, revealed R13 got up from the wheelchair to turn off the bed alarm and lowered herself to the floor on the right side of the bed. Occupational Therapy (OT) observed the fall but did not intervene. No injuries were noted. Staff assisted R13 back to the wheelchair.(k) Observation of R13 on 04/28/2026 at 11:35 AM revealed she was sitting on the side of the bed. The bed alarm was not sounding. The bedside table had been pushed away and was not within reach of the resident. One large, insulated beverage container with lid and straw had been knocked over and water spilled onto the bedside table and onto the floor beside the bed. Additionally, another large, insulated beverage container was observed open and emptied approximately 1.5 feet away from the resident's bed. There was a large amount of water present on the floor, extending from R13's bed across the room and under her roommate's bed. R13 was attempting to get out of bed to clean up the spill. According to R13's roommate, R13 had tried to get her water off her bedside table, but when she pulled it, the cups fell off. The roommate stated the incident had happened about an hour ago. The SSA Surveyor notified the Unit Manager. Per the observation, the resident's care plan was not implemented.During an interview with State Registered Nurse Aide (SRNA) 1 on 04/28/2026 at 10:56 AM, she stated there was no specific timing or defined frequency for supervision of R13 other than staff checked on the resident A lot. SRNA1 stated R13's care plan was posted on the back of the bathroom door for nursing assistants to review, and new care plan updates were communicated during the shift report.During an interview with SRNA 12 on 04/29/2026 at 10:00 AM, she stated nursing aides monitor R13 during care and during rounds to ensure her safety. She stated R13 had a bed alarm and a wheelchair alarm. She stated there was no specific frequency defined for R13's supervision.During an interview with LPN2 on 05/01/2026 at 4:45 PM, he stated nurses communicated care plan updates and revisions during shift report. LPN 2 stated residents were rounded on frequently and nurses rounded on residents during medication pass. Continued interview with LPN2 revealed staff rounded on residences during check and change. He stated it was important to ensure residents' safety.During an interview with the MDS Nurse on 04/30/2026 at 1:30 PM, she stated care plan updates depended on IDT team communication, weekly review processes, and initiation through orders. She further stated, with inconsistent real-time updates from nursing staff, there was a potential for delays in incorporating new interventions, particularly on weekends. The MDS Nurse stated she was a member of the IDT team and attended clinical meetings. She stated she did not recall if the team discussed adding increased supervision to R13's care plan. The MDS nurse stated increased supervision was not defined beyond the existing care planned intervention to encourage the resident to remain in the day area for supervision. She stated the staff communicate changes in the care plan during shift report and rounding.During an interview with the Director of Nursing (DON) on 04/28/2026 at 3:45 PM, she stated IDT meetings were conducted daily after clinicals, with additional weekly meetings, which included falls review and at-risk residents. The DON stated the IDT notes were completed when residents were discussed, and any recommended interventions were expected to be initiated in the care plan by the Minimum Data Set (MDS) Nurse. She stated nurses could initiate interventions but typically did not because nursing staff were hesitant and instead communicated changes through her or the MDS Nurse, who would then notify the physician. Additionally, the DON stated staff monitored R13 frequently, describing checks as constant. However, when asked by the State Survey Agency (SSA) Surveyor to define what constant meant, including whether checks occurred every 15 minutes, every 30 minutes, or at another interval, the DON could not define the frequency of supervision or monitoring checks. She stated the resident's care plan did not define monitoring intervals.During an interview with the Medical Director on 04/30/2026 at 3:50 PM, he stated he was responsible for medical oversight of resident care, including review of clinical practices, care outcomes, and participation in Quality and Performance Improvement (QAPI) activities. He stated he collaborated with the interdisciplinary team, provided guidance to nursing and physicians, and was available for consultation regarding changes in a resident's condition. The Medical Director stated he had concerns regarding an increase in falls, and approximately 80 percent occurred during the daytime behind closed doors. He stated high-risk residents should be in increased visual situations, up and out of bed when possible, and toileted before and after meals, noting falls also occurred during transitions. He stated polypharmacy contributed to fall risks and remained a concern. The Medical Director stated he expected staff to provide adequate supervision, involve the residents in activities, keep the residents up and out of their rooms during the day, and toilet frequently to prevent falls.During an interview with the Administrator on 04/29/2026 at 7:54 AM, she stated the facility instituted a Falls Performance Improvement Plan (PIP) in 02/2026 due to the number of resident falls experienced within the facility. She stated R13 was admitted to the facility from home with a diagnosis of frequent falls. She stated the resident was appropriately care planned with interventions related to fall prevention. She further stated she expected staff to provide adequate supervision and interventions to prevent falls and ensure the residents' safety.During an additional interview with the Administrator on 05/01/2026 at 6:32 PM, she stated she had concerns regarding R13's falls and injuries. She stated documentation related to the falls was fragmented throughout multiple areas of the system, including risk management, post fall packets, and progress notes, which made information difficult to locate and contributed to inconsistencies of documentation and review. The Administrator stated she expected staff to complete a thorough post fall documentation including post fall evaluation, root cause analysis, and clear narrative documentation regarding the circumstances of the fall. The Administrator stated to ensure the facility identified the root cause of the fall, implemented appropriate interventions, and worked to prevent further falls and injuries, accurate and comprehensive documentation was important. The facility submitted an acceptable IJ Removal Plan on 05/01/2026 at 3:38 PM verbatim:Resident (R)13 sustained a fall on 03/08/26 at 8:45 p.m. An attempt was made to reach the physician immediately but there was no answer nor the ability to leave a message. On 3/09/2026 at 1:00 p.m. nurse called Physician office and spoke to office staff asking Dr. [NAME] to return call re: resident fall. However, at 3:04 p.m. on this date (03/9/2026) nurse called physician's cell phone to report right knee pain and request was made for Xray. Physician responded on 3/09/2026 at 3:18 p.m. and X-ray requested. On 3/10/2026 Portable X-Ray obtained resulting in R Femur Fracture. Physician notified us of the results on 3/10/2026 and order was obtained to transfer the resident to hospital for further evaluation and treatment.-The QAPI tool for the monitoring of MD notification for fall changes in status and for fall Root Cause analysis and intervention implementation is being utilized underthe [sic] supervision of the Administrator/Executive Director with all falls weekly X 2 weeks, then monthly X 2 months and then quarterly thereafter.An Ad hoc QAPI meeting was conducted on 04/30/26 with the QAPI committee members, including the Medical Director, Attending Physicians, Administrator, Director of Nursing, MOS Coordinator, Staff Development coordinator, Human Resource Coordinator and the Social Service Director to review the findings cited in the IJ Templates and the facility Removal Plan.Resident(s) affected by the IJ:Resident (R) 13 was identified to be affected by the deficiency. The resident had a fall on 03/08/2026 at 8:45 p.m. No external injuries are noted at this time. Resident complained of right knee pain but displayed normal ROM. M.D. office called no message left on 3/08/2026 at 9:00 p.m. MD office called again on 3/09/2026 at 1:06 p.m. then nurse messaged MD directly at 3:04 p.m. New order for X-Ray obtained. X-Ray resulted in a femur fracture on 3/10/2026 and MD notified with new orders to send to the hospital with the diagnosis of a fracture of right femur fracture.--Root cause analysis was completed on 03/13/2026 in which we rearranged resident's room and added intervention to the care plan. On 4/30/2026 another root cause analysis was completed re: this fall with the indicated intervention of Wheelchair caddy bag on inside of wheelchair for easy access of personal items. [NAME] added to the plan of care and SRNA Kardex.-Activity Staff have been educated by the Executive Director/Administrator to assist resident (R) 13 to activities daily (5 to 6 per day) to add supervision. Licensed Nurses have been educated to have resident out of the room as much as she allows, for meals, day area, etc. and this has been added to care plan and SRNA task. Education was started on 4/30/2026 by Staff Development Coordinator and no Licensed Nurse will work prior to education being completed. Resident started on 15-minute checks x 1 week beginning 05/01/2026 and Fall management team will reevaluate.-Director of Nursing, Unit Manager and MOS Nurse completed a new fall risk assessment for all residents, and they will correct any findings at the time. Audit completed 05/01/2026 and results will be discussed and reviewed in QAPI for input.Resident(s) the facility identified at risk for IJ:All residents with falls in the last 30 days were at risk of being affected by F580 and F689.Training:-All licensed nurses have received in-service education on the updated Change of Condition Policy and Procedure to include the facility protocol for MD notification by the Staff Development Coordinator beginning on 04/30/2026 and no Licensed Nursing Staff member will work prior to education. The licensed staff will contact the Medical Director if the attending physician does not respond within 30 minutes for an emergency or 3 hours for non-emergencies. The licensed nurses that have not completed the in-service training on 4/30/2026 will be educated prior to the next shift worked or they will not be allowed to clock in until fall training has been completed. The training will be included in the facility orientation program for all new hire licensed nurses from 5/1/26 going forward and any agency staff will receive education prior to working shift by the Staff Development Coordinator, Director of Nursing or Unit Manager. As of 05/01/2026 13 of the 17 full-time Nurses have been educated. There is 7 prn Nurses that will also receive education prior to the next day worked. All education was provided 1:1 with staff, the LPN #2 received all education on 5/01/2026 prior to beginning his shift. All Licensed Nurses demonstrated comprehension by repeating education back to Staff Development Coordinator.-The Fall Management Team consisting of but not limited to the Administrator and or Director of Nursing, Rehabilitation Director or other therapist if unavailable, MDS Nurse, Staff Development Nurse and the Social Worker (Admissions Coordinator if unavailable) have received in-service education on Fall Management Audit Tool (see attached) and the importance of verifying all information on the displayed on the tool with follow education and reviewed in QAPI. Falls will be reviewed daily Monday-Friday and the next business day for the weekend. The Fall Audit Tool will also be completed at weekly fall meeting. Education provided by Administrator/ Executive Director and completed on 04/30/26 which includes but are not limited to: Director of Nursing, Staff Development, MDS Nurse, Therapist, and Social Worker.-The need to complete Root Cause Analysis for all resident falls to determine the indicated intervention to address the fall causative/contributing factor(s).-The need to address the determined intervention on the resident care plan and Kardex. A list of interventions attached to the fall packet for brainstorming to make interventions person centered.-The need to implement the determined intervention timely and to monitor for effectiveness.Systems implemented to ensure all staff are trained prior to providing direct care to residents& determined competent on the materials trained:-Audit of all resident falls for the last 30 days from 4/30/26 for residents that are still in house was completed by Director of Nursing, Staff Development Coordinator, and Administrator/Executive Director to identify that all MD notification of changes had been completed. The physicians were notified of all resident fall changes in condition for the last 30 days.-An audit of all resident falls for the last 30 days from 4/30/26 for residents that are still [TRUNCATED]

Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident received necessary care and services following a fall when staff failed to perform a thorough assessment, failed to accurately evaluate and document pain, and failed to obtain timely diagnostic services, resulting in a delay in identification of a femur fracture, for 1 of 8 sampled residents, Resident (R) 13. Refer to F580 and F689The findings include:Review of the facility's policy titled, Quality of Care, revised 08/01/2024, revealed the residents received treatment and care by qualified persons in accordance with professional standards of practice. The policy further stated each resident received care and services to maintain their highest practicable physical, mental, and psychosocial well-being.Review of the facility's policy titled, Change in Condition, dated 08/01/2024, revealed the facility outlined processes for early identification, assessment, reporting, and management of a change in resident condition. The policy required staff to recognize and report physical, cognitive, or emotional changes, including the use of tools to ensure timely communication. Additionally, the policy directed staff to complete a thorough assessment, document the findings, and notify the physician promptly. Review of the facility's policy titled, Falls and Injuries, dated 08/01/2024, revealed the policy required staff to notify the resident's physician following a fall to ensure timely evaluation, treatment, and direction for ongoing care. According to the policy, the physician was expected to respond timely, and staff was directed to escalate concerns to the medical director if an appropriate or timely response was not received.Review of R13's admission Record revealed the facility admitted the resident on 02/03/2024 with diagnoses to include Parkinson's disease with dyskinesia, repeated falls, and cognitive communication deficit.Review of R13's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating moderate cognitive impairment. Continued review revealed R13 was assessed as dependent (helper did all of the effort) with toileting, lower body dressing and putting on/taking off footwear, and substantial/maximal assistance (helper did more than half the effort) with bathing and upper body dressing.Review of R13's Care Plan Report, revised 04/16/2026, found in the resident's electronic medical record (EMR) under the Care Plan tab, revealed a focus for potential injury from falls related to decreased mobility, Parkinson's disease, weakness, psychotropic medication use, and opioid medication use. Goals included minimizing falls and preventing injury through the review period. Interventions included supervision and redirection, staff encouragement to request assistance, maintain personal safety alarms to bed and wheelchair, offer toileting before bedtime, and monitor during rounds.Review of a Health Status Note, dated 03/08/2026 at 8:45 PM, found in Resident 13's EMR under the Progress Notes tab, revealed R13 sustained a fall, and staff later helped the resident from the floor to the bed with a two-person assist.Review of a Fall Report, dated 03/08/2026 at 8:45 PM, revealed staff found the resident on the floor of her room at 8:00 PM after she attempted to reach for personal items. Licensed Practical Nurse (LPN) 2 assessed R13 as alert, with pain rated five out of 10 on a numerical scale (10 being the worst pain). However, documentation revealed the nurse did not observe any injuries. There was no indication LPN2 assessed for bruising, swelling, shortening, rotation, or deformity of the right leg.Review of a Health Status Note, dated 03/08/2026 at 10:12 PM, found in R13's EMR under the Progress Notes tab, indicated staff found the resident on the floor attempting to locate personal items. The resident was assessed as alert and oriented x 3/4. Furthermore, staff documented the resident had pain in her right knee, rated five out of 10 on a numerical pain scale (10 being the worst pain), but there was no assessment documenting the absence of bruising, swelling, shortening, rotation, or deformity of the right leg. According to the note, the Director of Nursing (DON) and R13's family member (F) 1 were notified at the time of the fall. However, the nurse did not contact the primary care physician. LPN2 documented the physician was called to her office and was unable to talk to anybody.Review of the eINTERACT SBAR [Situation Background, Assessment, Recommendation] Summary for Providers, dated 03/08/2026 at 10:20 PM, found in R13's EMR under the Progress Notes tab, indicated a change in condition (CIC) after a fall. LPN2 documented vital signs, including blood pressure of 150/85, pulse 89, and respirations 20, which were higher than R13's baseline. The SBAR did not note pain or physical assessment outcomes.Review of R13's Neurological Record, dated 03/08/2026 through 03/10/2026, revealed on 03/08/2026 at 8:45 PM, the section for motor response of the upper and lower extremities contained a line drawn through the boxes with no motor response documented on 03/08/2026 and 03/09/2026. Review further revealed LPN2 did not assess or document motor function or external stimuli of the right lower extremity. Documentation by LPN15 on 03/10/2026 at 7:00 AM revealed the resident could move all extremities appropriately.Review of an IDT Note, dated 03/09/2026 at 10:14 AM, found in R13's EMR under the Progress Notes tab, indicated the interdisciplinary team (IDT) reviewed R13's fall from over the weekend. Further review revealed the team updated the resident's care plan to keep the resident's reacher close and to follow up on a requested PT screening. Additional review revealed no indication the IDT team implemented or discussed added supervision interventions following the fall.Review of a text message communication regarding R13's fall, dated 03/09/2026 at 3:04 PM, revealed LPN2 wrote to the physician and stated, [R13] fell in her room last night. I already talked to the office number before. Her daughter wants x-ray rt. Knee for pain. Let me know please if she needs it. The physician responded yes through the same text at 3:18 PM.Review of a Health Status Note, dated 03/09/2026 at 3:18 PM and documented by the Director of Nursing (DON) as a late entry note on 04/28/2026 at 5:23 PM, found in Resident 13's EMR under the Progress Notes tab, revealed R13 fell in her room. According to the note, Resident's family requested an X-ray for knee pain, and an order was obtained for an X-ray of the right knee.Review of the Interdisciplinary Resident Screen, dated 03/09/2026 and completed by the Speech Therapist (ST), revealed multiple significant changes in R13's physical functioning, mobility, and pain level. The screen revealed the resident had been bed-bound since the previous night, refused morning and afternoon meals, and experienced increased pain rated eight out of 10 on a numerical pain scale (10 being the worst pain). Documentation revealed R13's right knee was swollen. The assessment further documented the resident could not bear weight on the right knee and hip.Review of a Health Status Note, dated 03/10/2026 at 11:09 AM, found in R13's EMR under the Progress Notes tab, indicated a State Registered Nurse Aide (SRNA) notified the nurse that R13 was crying in pain. LPN15 stated R13 had tears streaming down face and R13 stated her leg hurts so bad she can not [sic] stand it. According to the note, the nurse applied diclofenac cream (a topical non-steroidal anti-inflammatory). The note stated a call was placed to the physician about pain, they stated they will fax a new order. However, the note did not specify what information the physician's office staff provided, did not identify the new order to be faxed, and did not indicate the LPN requested a return call from the physician. Review of R13's EMR revealed on 03/10/2026 there were no new orders received from the physician related to the call at 11:09 AM.Review of a Radiology Report, of R13's right knee and hip, dated 03/10/2026 at 1:06 PM, revealed a fracture of the right distal femoral shaft with malalignment and a nondisplaced fracture of the right greater trochanter.Review of eINTERACT Transfer Form V5, dated 03/10/2025 at 6:20 PM, revealed R13 was transferred by ambulance to the local emergency department (ED) at 4:56 PM.Review of ED to Hosp-admission Note, dated 03/10/2026, revealed R13 was admitted to the local hospital with a closed fracture of the right femur and an injury to the head. According to the report, R13 presented to the local hospital after a mechanical fall that occurred prior to arrival. The fall resulted in her hitting the back of her head and landing on her right leg. A computed tomography (CT) scan of the head showed no intracranial abnormality. Physical exam revealed the right lower extremity with positive shortening and external rotation, and attempted hip movements were painful and restricted. The resident had moderate tenderness overlying her distal femur and was given intravenous morphine (an opioid analgesic) for pain. Radiography of the right femur revealed a nondisplaced spiral type fracture involving the distal metadiaphysis of the right femur. The fracture extends to the anterior margin of the femoral component of the patient's right knee arthroplasty. R13 underwent surgery for the placement of an intramedullary rod stabilizing a distal femoral fracture.During a telephone interview with Family (F) 13 on 04/29/2026 at 11:16 AM, she stated R13 had advanced dementia, associated Parkinson's disease psychosis, and experienced frequent falls. She stated R13 did not recognize safety risks and could not consistently understand or follow instructions, which was why she admitted her mother to the facility to provide 24/7 supervision and staff assistance to ensure her safety. F13 stated on 03/09/2026, sometime during the morning, R13 called her and stated she believed she had broken her leg and was in severe pain. Additionally, F13 stated the resident continued to complain of significant pain, difficulty with moving her right lower extremity, and demonstrated verbal behaviors indicating something was wrong. She stated although the resident could not always clearly verbalize her needs, staff could recognize changes in conditions through the resident's behavior and complaints of pain. F13 stated her mother had a high pain tolerance but would verbalize her pain and where it hurt. F13 stated she spoke with LPN2 and requested an X-ray. She stated she did not receive any follow-up communication from the facility until the following afternoon, after the x-ray was completed, and staff notified her R13 sustained a femur fracture, which required transfer to the local emergency department (ED). She further stated she did not understand why there was a delay in follow-up care.During an additional interview with F13 on 04/29/2026 at 3:35 PM, she stated she did not come to the facility to see R13 after the 03/08/2026 fall because she was told there was no injury. She stated she first saw R13 in the ED after transfer from the facility on 03/10/2026. F13 stated when she met R13 in the ED, R13 stated her pain was the worst pain ever. She stated R13's pain was unbearable when she was touched or moved. F13 stated she was confused about how staff failed to recognize the severity of R13's injury and pain following the fall and did not seek a higher level of care sooner.During an interview with LPN2 on 04/29/2026 at 11:45 AM, he stated on 03/08/2026, he completed an assessment of the resident following the incident. He stated that at the time of the assessment, no visible bruising, redness, swelling, or external injury was noted. He stated the resident complained of some pain but did not exhibit significant distress and remained in bed. He further stated R13's cognition fluctuated, with periods of confusion and communication deficits. LPN2 said R13's continued behaviors contributed to repeated falls despite awareness of fall risks. He stated he attempted to notify the physician on 03/08/2026 by calling the on-call service through a medical associate line but was unable to reach anyone and left no voicemail. He reported he did not have the physician's direct contact information at that time. He stated he notified the DON of the fall but could not recall whether he informed her he was unable to reach the physician.During continued interview with LPN2 on 04/29/2026 at 11:45 AM, LPN2 stated on the morning of 03/09/2026, at approximately 9:00 AM, he spoke with the DON, who provided him with a contact number for the physician. He stated he subsequently contacted the physician later that day, though documentation reflected contact occurred at approximately 3:18 PM. When asked by the SSA Surveyor why he failed to contact the physician immediately after receiving the cell phone number, he stated he did not see anything wrong and was busy with medication administration. He stated, later in the day, F13 called him to say she wanted an X-ray ordered for R13. LPN2 stated he did not know why F13 wanted the X-ray, but he contacted the physician. He stated he did not know why he did not document the telephone conversation with F13, but stated, She just wanted an X-ray. LPN2 stated the X-ray at the facility was not completed until the following day, and the timing of diagnostic services was dependent on availability. He stated he did not believe the situation required a STAT (immediate) order at the time, as the resident had a history of pain, was receiving pain medication, including tramadol (narcotic analgesic) and acetaminophen (analgesic) for chronic pain, and was not expressing significant complaints beyond baseline.During an interview with the Director of Nursing (DON) on 04/28/2026 at 3:45 PM, she stated the facility did not have a defined process for notifying physicians when initial attempts were unsuccessful. The DON stated staff should have continued attempts to notify the physician, including use of the physician's personal cell phone number if the on-call service did not answer, and should have made contact the same night rather than allowing a delay in care. The DON stated she was notified the night of R13's fall; however, she did not know until the following morning LPN2 had not notified the resident's physician. She further stated she did not know why LPN2 delayed contacting the physician until approximately six hours after receiving the physician's personal cell phone number on 03/09/2026. Furthermore, the DON stated LPN2 communicated with the physician by text message on 03/09/2026 regarding R13's pain and received an order for an x-ray; however, the facility did not obtain the x-ray until the following day and did not receive results until late that afternoon, delaying identification and treatment of R13's fracture. Additionally, when asked by the State Survey Agency (SSA) Surveyor why facility staff delayed R13's care for two days following her fall, the DON stated nursing notes and assessments did not identify an injury and documented the resident's pain as at zeroes, threes, and [NAME], which she stated was the resident's baseline. The DON further stated LPN2's nursing assessment did not indicate a need for a STAT (immediate) x-ray following the fall. She stated due to availability; it was not unusual if a non-STAT X-ray was delayed a day. During an interview with State Registered Nurse Aide (SRNA) 12 on 05/01/2026 at 3:30 PM, she stated she worked 7:00 AM to 7:00 PM on 03/08/2026 and was not present when the fall occurred between 7:00 PM and 8:00 PM. She stated she worked again on 03/10/2026 and cared for R13. SRNA12 stated she noticed a change from baseline, and R13 did not attempt to get out of bed, which was not typical for her. SRNA12 stated R13 complained of pain throughout the shift and reported her whole leg hurt, with the pain moving between the knee and hip. She stated R13 cried, had tears on her face, did not want to be touched, and at times refused care. She stated she observed swelling in the knee and a bluish discoloration of the leg. SRNA12 stated the leg did not appear to be the resident's normal skin color. Additionally, the SRNA stated she reported the pain, crying, swelling, and discoloration to the nurse, whom she identified as LPN15. SRNA12 stated she reported concerns more than once during the shift, including when the resident was crying. However, she stated LPN15 did not respond promptly to R13. She stated the nurse did not come in immediately to assess the resident and estimated about a 20 to 30 minute gap before she responded. SRNA12 further stated nurses did not respond immediately to SRNAs concerns. She stated they sometimes delayed care or dismissed care concerns altogether.During a telephone interview with LPN15 on 05/01/2026 at 5:01 PM, she stated she called the physician's office to report R13's pain. She stated the office informed her a fax would be sent, and she did not know what the fax would include but assumed it would contain a new order for pain management. She stated she assessed R13 for pain but could not recall if she assessed R13's right leg. LPN15 stated R13 was sent to the local ED after the x-ray revealed a fracture. She stated she never received a fax from R13's physician's office and did not call the office back until after she received the x-ray report, despite R13's continued complaint of pain. LPN15 stated X-ray results were sent electronically. She stated she checked throughout the afternoon for the results, but the report did not arrive until approximately 4:30 PM. She stated the radiologist read the X-ray at 1:08 PM, but the facility did not receive the electronic message until 4:30 PM.During an interview with Registered Nurse (RN) 1 on 04/30/2026 at 10:10 AM, she stated nonverbal indicators of pain included facial grimacing and behaviors during care. She stated residents unable to verbally communicate pain might indicate pain by nodding yes or no. RN1 stated staff used the Pain Assessment in Advanced Dementia (PAINAD) scale for residents with cognitive impairment who were unable to accurately communicate pain using a numerical pain scale. She stated the PAINAD scale differed from the numerical pain scale, which asked residents to rate pain from zero to 10, with 10 representing the most severe pain. RN1 stated residents with cognitive impairment could answer questions related to the numerical pain scale; however, in her assessment, she used the PAINAD scale because it provided a more accurate assessment of pain. Furthermore, she stated the PAINAD scale was especially important following a fall or injury in residents because it allowed staff to more readily identify pain behaviors and possible injury in residents with cognitive impairment who might not accurately verbalize injury. During an interview with the Speech Therapist (ST) on 05/01/2026 at 2:12 PM, she stated she had completed a post-fall screening for R13 on the afternoon of 03/09/2026 following the resident's fall on 03/08/2026. The ST stated she did not normally complete post-fall screenings; however, due to staffing constraints, she provided the screening and remained in direct contact with the Director of Physical Therapy (DPT) regarding the resident's condition. The ST stated R13 appeared to be in significant pain. She stated she observed swelling to the resident's right knee and, through questioning and prompting, identified pain rated an eight on a PAINAD scale involving both the knee and hip, raising concern for injury beyond the knee. The ST stated, due to the resident's moderate to severe cognitive impairment, use of a PAINAD assessment rather than a standard numerical pain scale was appropriate because the resident required cueing, prompting, and simplified communication to accurately express pain symptoms. The ST stated a knee x-ray had already been ordered; however, after consultation with the DPT, concerns were raised for possible fracture and the need for imaging of the entire leg and hip. She stated the DPT had notified nursing and requested a full-leg X-ray. Furthermore, the ST stated review of nursing documentation, dated 03/09/2026, did not reflect findings such as redness, swelling, pain, or motor response documentation. She stated nursing staff should have recognized the severity of the resident's pain and completed a more comprehensive post-fall assessment based on the resident's presentation and reported pain complaints.During a telephone interview with R13's Primary Care Physician on 04/30/2026 at 2:55 PM, he stated R13 was admitted to the facility with a diagnosis of frequent falls. He stated supervision, activities, and anticipating the resident's needs were required to prevent falls and injuries. He stated he expected staff to provide adequate supervision and interventions to prevent falls and accidents. Additionally, the physician stated the text message received from the nursing staff did not indicate the severity of R13's condition but only stated the family requested an X-ray. The physician stated it would have been appropriate for nursing staff to transfer the resident immediately to a higher level of care if they felt the resident required additional evaluation, and he was not immediately reachable. He further stated the facility had access to his personal cell phone number, which he had communicated to the facility as his preferred method of contact. He stated the on-call service would only get an unfamiliar provider for the resident, and that it would take longer. He stated he was in the office during the week, and messages left with the office staff might not get a timely response.During an interview with the Medical Director on 04/30/2026 at 3:50 PM, he stated he was responsible for medical oversight of resident care, including the review of clinical practices and care outcomes, and participation in Quality and Performance Improvement (QAPI) activities. He stated he collaborated with the interdisciplinary team, provided guidance to nursing and physicians, and was available for consultation regarding changes in resident condition. The Medical Director further stated he expected staff to provide quality care in accordance with the professional standards of practice to maintain the resident's highest practicable physical, mental, and psychosocial well-being.During an additional interview with the DON on 05/01/2026 at 6:00 PM, she stated R13 was known to have a high pain tolerance per the family's report, and staff did not indicate increased pain or worsening of condition. The DON stated R13's physician was contacted on 03/10/2026. However, documentation did not clearly reflect the clinical information communicated, the urgency conveyed, or the direction provided by the physician's office. She stated on 03/10/2026, staff delayed care waiting for a faxed physician's order despite the resident's documented change in condition. The DON stated there was uncertainty about whether an order was received, and the physician might have intended to fax the orders. She stated she expected nursing staff to advocate for residents and to elevate concerns when a physician did not respond appropriately or in a timely manner. The DON stated it was a significant concern for a resident to receive delayed care. She further stated it would have been appropriate for nursing staff to escalate concerns to supervisory staff if they believed the physician was not adequately addressing the resident's condition or if the physician's response was delayed.During an interview with the Administrator on 04/29/2026 at 7:54 AM, she stated staff should complete a full assessment immediately following a fall and continue to monitor the resident. She stated nursing staff was expected to document all findings and interventions in the resident's EMR. She stated R13 was admitted to the facility from home with a diagnosis of frequent falls, and the resident was care planned appropriately with interventions related to fall prevention. She further stated she expected staff to provide adequate supervision and interventions to prevent falls and ensure resident safety.During an additional interview with the Administrator on 05/01/2026 at 6:32 PM, she stated she had concern regarding R13's falls and injuries. She stated assessments and documentation related to the resident's falls were fragmented across multiple areas of the system, including risk management, post-fall packets, and progress notes, making information difficult to locate and contributing to inconsistencies in documentation and review. The Administrator stated she expected staff to complete thorough post-fall documentation, including a comprehensive assessment of the resident, a root cause analysis, and clear narrative documentation of the circumstances of the fall. She stated nursing staff should monitor residents, continue physical assessments, and implement appropriate interventions to ensure residents received quality care and maintained their safety and well-being. Additionally, she stated it would have been appropriate for nursing staff to escalate concerns to the Medical Director if they were unable to contact the primary physician.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 25 sampled residents, Resident (R) 6, R13, R14, R26, and R93.Observations on 04/27/2026 and 04/28/2026 revealed in five resident rooms the privacy curtain was in disrepair. Further observation revealed trash on a bedside table and the floor, including used mouth swabs and a contaminated dressing and gloves; debris accumulation around the baseboards; and soiled bed linens on a bed.The findings include:Review of the facility's undated policy titled, Resident's Rights, revealed the resident had the right to be treated with consideration, respect, and recognition of their dignity and individuality.The State Survey Agency (SSA) Surveyor requested a policy on housekeeping from the Administrator on 04/29/2026 at approximately 10:00 AM. The Administrator provided the Cleaning and Disinfecting policy. Review of the facility's policy titled, Cleaning and Disinfecting, dated 08/01/2024, revealed housekeeping staff cleaned floors and tabletops regularly, when spills occurred, and when surfaces were visibly soiled1. Observation of R14's room on 04/27/2026 at 9:04 AM revealed trash and debris on the floor. There were straw wrappers and a napkin on the floor. Food crumbs were also scattered around the room.During an interview with R14 on 04/27/2026 at 9:04 AM, she stated housekeeping did not sweep and mop her room daily. She stated the floor was often covered with crumbs and trash, and the trash cans were not emptied until they overflowed. R14 stated she preferred a clean and tidy room and did not like seeing trash or debris on the floor.2. Observation of R6's and R13's room on 04/27/2026 AM at 10:13 AM revealed multiple trash items found on the floor, including a wound dressing, dated 04/26/2026, on the floor behind the trash can. The area along the wall and baseboard contained visible debris accumulation. A pair of contaminated gloves were observed under the bed, rolled up inside out. There were multiple pairs of gloves on top of the bedside table. Additionally, trash, used tissues, and debris were observed on the floor. During an interview with R6 on 04/27/2026 at 11:45 AM, she stated her room had not been cleaned over the weekend. She stated nursing staff threw discarded gloves on the floor and sometimes left extra supplies in her room, which made it cluttered and untidy. She stated the condition of the room made her feel uncomfortable.3. Observation of R26's room on 04/27/2026 at 11:35 AM revealed the resident's bed was visible from the hallway. The bed was unmade, and the bed linens were visibly soiled. [NAME] and yellow stains were present on both the top sheet and fitted sheet. The pillowcase contained a large stain on one corner. Crumbs were observed across the fitted and draw sheets, along with what appeared to be fecal smearing on the draw sheet. Used tissues were also present in the bed.During an interview with State Registered Nurse Aide (SRNA) 1 on 04/27/2026 at 11:35 AM, she stated she had gotten R26 dressed and out of bed and had not yet cleaned the room. She stated she tried to make the bed and straighten up the room after getting the residents up for the day. SRNA1 stated it was important because this is their home and it should be clean.4. Observation of R93's room on 04/28/2026 at 8:10 AM revealed the resident was in bed resting. The privacy curtain was pushed back near the head of the bed. A portion of the privacy curtain was lying on the floor. Further observation revealed multiple hooks were missing, which prevented the curtain from hanging properly on the track. Additionally, there was trash on the bedside table and the floor, including used mouth swabs.During an interview with Family (F) 15 on 04/29/2026 at 7:45 AM, she stated resident rooms were not always kept as tidy as she would like, especially during staff call-ins or on weekends. She stated the facility appeared cleaner since the State Survey Agency (SSA) Surveyors entered the building.During an interview with Housekeeper (HSK) 1 on 04/30/2026 at approximately 10:45 AM, she stated two housekeepers worked weekends compared to four during the week. She stated she believed housekeeping staff had call-ins over the weekend and arrived late for work on Monday, resulting in normal cleaning duties not being completed on time. She stated it was important to keep curtains and personal items off the floor to prevent the spread of germs.During an interview with the Housekeeping Supervisor on 04/29/2026 at 9:10 AM, she stated the facility employed four full time housekeepers during the week and two housekeepers on weekends. She stated housekeeping staff was responsible for maintaining a clean, safe, and sanitary environment. She stated daily tasks included cleaning resident rooms, bathrooms, and common areas. She stated housekeeping staff performed dusting, sweeping, mopping, and disinfection of high touch areas such as handrails and doorknobs. Additionally, the Housekeeping Supervisor stated housekeeping staff should ensure privacy curtains were clean and in proper working order. She stated they could be taken down and replaced with new ones or repaired by adding new hooks. The Housekeeping Supervisor stated nurse aides were responsible for emptying trash and putting linen and trash in the Dirty Utility Room.During an interview with SRNA12 on 04/29/2026 at 10:00 AM, she stated SRNAs were responsible for keeping rooms tidy throughout the day and for cleaning up after themselves. She stated housekeeping was available if there were large spills or messes. She stated beds should have been made daily, and if they were soiled, the sheets should have been changed immediately. Furthermore, SRNA12 stated staff should take trash out of the room throughout the day to prevent the trash receptacle from overflowing. SRNA12 stated, This is their home, and we need to take care of our residents.During an interview with the Administrator on 04/29/2026 at 10:13 AM, she stated that four housekeeping staff worked Monday through Friday, and two worked on weekends. She stated the facility provided housekeeping services seven days per week. The Administrator stated weekend staffing was adequate because not every resident room required cleaning every day. She stated staff was expected to clean spills and remove any debris or trash observed during rounds or resident care. The Administrator stated she expected resident rooms to remain clean, tidy, and maintained in a home like environment. She stated maintaining a clean and safe facility was important because it was the residents' home.

Based on interview, record review, and review of the facility's document and policy, the facility failed to send a written notice of transfer to the resident's representative, including the reason for the transfer, the effective date of the transfer, the duration of the bed hold, and the facility's bed hold policy, for 2 of 3 residents sampled for Admission, Transfer, and Discharge, Resident (R) 13 and R96.Record review and interviews revealed the facility failed to provide responsible parties with written notification of hospitalization for R13 on 03/10/2026 and for R96 on 04/16/2026.The findings include:Review of the facility's policy titled, Transfer/Discharge Policy, dated 08/01/2024, revealed resident transfers would be conducted in accordance with resident rights, physician orders, and regulations to maintain continuity of care. Further review revealed a written notice form would be placed in the clinical record and provided to the resident or resident representative. Furthermore, the policy revealed that at the time of a resident's transfer for hospitalization, written notice of the facility's bed hold policy was to be provided to the resident or resident's representative.Review of the facility's undated document Skilled Nursing admission Agreement revealed if a resident left the facility for a hospital stay or therapeutic leave overnight, the facility could hold the resident's bed for a limited period of time. Additionally, the agreement stated, Medicare generally did not pay for bed holds, but Medicaid may pay depending on state rules. It further stated the facility would notify the resident's representative about holding a bed. The facility might also require authorization forms and payment if the leave extended beyond three days.1. Review of R13's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 02/03/2024. R13's diagnoses included Parkinson's disease with dyskinesia, repeated falls, and cognitive communication deficit. Review of R13's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/02/2026 and found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, indicating moderate cognitive impairment. Review of R13's electronic medical record (EMR) revealed no transfer in writing or a copy of the transfer notice/bed hold documented in her medical record. Review of an eINTERACT Transfer Form, dated 03/10/2026 at 4:59 PM, revealed the resident was transferred to a local emergency department (ED) by emergency medical services (EMS) after radiology reports revealed R13 had a fractured femur. During a telephone interview with Family (F) 13 on 04/29/2026 at 11:16 AM, she stated the facility did not inform her of the transfer/discharge paperwork or the facility's bed hold policy related to R13's 03/10/2026 hospitalization. She stated she did not receive a written copy of her mother's transfer/discharge documentation or bed hold information, in person or by mail following R13's hospitalization. 2. Review of R96's admission Record, found in the resident's eEMR under the Profile tab, revealed the facility admitted the resident on 04/15/2026 with diagnoses to include Alzheimer's disease; dementia in other diseases unspecified without behavioral disturbances, psychotic disturbances, or mood disturbances; and anxiety. Review of a Social Services Note, dated 04/23/2026, revealed the resident had a BIMS score of three out of 15, indicating severe cognitive impairment. Review of R96's EMR revealed the resident was transferred to a local ED by EMS for evaluation after a fall on 04/16/2026. No transfer information was documented in the record, nor was there a copy of the transfer notice/bed hold in her medical record.The State Survey Agency (SSA) Surveyor attempted a telephone interview with R96's Family (F) 14 on 04/30/2026 regarding R96's ED visit on 04/16/2026. However, there was no answer, and a voicemail was left. F14 did not return the call. During an interview with Licensed Practical Nurse (LPN) 15 on 05/01/2026 at 5:01 PM, she stated when the facility transferred a resident to a local hospital, staff printed a transfer form from the resident's EMR and provided the form to EMS at the time of the transfer. She stated she notified F13 of R13's transfer by telephone. However, LPN15 stated she was not aware of a written notice mailed to the resident's representative documenting the transfer and discharge paperwork or bed hold information.During an interview with the Director of Nursing (DON) on 04/29/2026 at 11:00 AM, she stated nursing staff completed a transfer form and provided the paperwork to EMS at the time of the resident's transfer to the hospital. The DON stated F13 was notified of the transfer. However, she stated she could not confirm documentation reflected R13's representative (F13) received written notification regarding the reason for the transfer, transfer and discharge information, or bed hold rights. The DON further stated she could not identify where the facility maintained notification documentation. Additionally, she stated staff sent a transfer form and other pertinent discharge paperwork with the resident to the hospital and expected hospital staff to provide the paperwork to the resident's representative.During an interview with the Admissions Director on 04/29/2026 at 11:12 AM, she provided R13's Discharge Summary, dated 03/14/2026, as documentation of the transfer and discharge paperwork related to R13's 03/10/2026 hospitalization. The admission Director stated the facility did not provide any additional written forms or notices to the residents' representatives regarding transfers. She further stated she did not mail written notices of transfer/discharge information or the facility's bed hold policy to the residents' representatives.During an interview with the Administrator on 05/01/2026 at 6:32 PM, she stated a transfer form was given to EMS to give to the resident's representative at the local hospital. She stated the facility did not mail written notifications to the residents' representatives. Additionally, she stated the facility reviewed the bed hold conditions with residents or their representatives during the admission process as part of the admission packet, which was signed upon admission. She stated admission paperwork explained how the facility could hold a resident's bed during a temporary hospitalization and outlined potential payment responsibilities when the bed was held for an extended period of time. She further stated the bed hold policy did not apply to R13 because she was covered under the Medicaid program.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to promote and maintain resident dignity for 1 of 2 sampled residents, Resident (R) 93.Observations on 04/27/2026, 04/28/2026, and 04/29/2026 revealed staff failed to ensure R93's urinary catheter drainage bag remained covered with a dignity cover. The urinary drainage bag remained visible to individuals passing by R93's room.The findings include:Review of the facility's undated policy titled, Resident's Rights revealed the resident had the right to be treated with consideration, respect, and recognition of their dignity and individuality.Review of R93's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/23/2026. R93's diagnoses included unspecified protein-calorie malnutrition, benign prostatic hyperplasia, and aphasia following cerebral infarction.Review of R93's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/23/2026, found in the resident's EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating moderate cognitive impairment. Continued review of the MDS revealed R93 had an indwelling urinary catheter.Review of R93's Care Plan Report, dated 04/25/2026, found in the resident's EMR under the Care Plan tab, revealed a focus for a urinary catheter, initiated on 04/25/2026. According to the Care Plan, there were no interventions related to R93's refusal of a dignity bag cover.1. Observation of R93 on 04/27/2026 at 9:53 AM revealed the resident's urinary catheter drainage bag was attached to the bed frame while the dignity cover hung beside the bag. However, staff did not place the urinary drainage bag inside the dignity cover. The drainage bag remained visible from the hallway. 2. Observation of R93 on 04/28/2026 at 8:10 AM revealed the resident's urinary catheter drainage bag was secured to the bed without a dignity cover in place. Continued observation outside R93's room revealed staff had left the urinary drainage bag visible to individuals passing by the room. 3. Observation on 04/29/2026 at 9:28 AM, outside R93's room, revealed R93's urinary catheter drainage bag was visible from outside the resident's room. The urinary drainage bag was not in the dignity bag cover.During an attempted interview with R93 on 04/27/2026 at 9:35 AM, the resident was unable to answer questions. Resident 93 had aphasia following a cerebral infarction and difficulty communicating during the interview. Due to the resident's communication impairment, the State Survey Agency (SSA) Surveyor was unable to determine whether the resident refused care or how the resident felt about the catheter collection bag being visible.During an interview with State Registered Nurse Aide (SRNA) 12 on 04/29/2026 at 10:00 AM, she stated staff placed dignity covers over urinary catheter drainage bags to maintain resident privacy and dignity unless the resident or family requested not to use a cover. SRNA12 stated staff monitored residents with catheters during care and rounds to ensure dignity covers remained in place.During an interview with Licensed Practical Nurse (LPN) 2 on 04/29/2026 at 11:45 AM, he stated SRNAs kept urinary catheter drainage bags covered with a dignity cover to protect resident privacy. LPN2 further stated he checked to ensure drainage bags remained covered during nursing rounds. He stated he was not sure why R93's catheter bag was not covered.During an interview with the Medical Director on 04/30/2026 at 3:50 PM, he stated residents should have a dignity cover placed over urinary catheter drainage bags to protect the resident's privacy and dignity.During an interview with the Director of Nursing (DON) on 05/01/2026 at 6:00 PM, she stated staff was expected to keep urinary catheter drainage bags covered with a dignity cover to maintain resident dignity and privacy.During an interview with the Administrator on 05/01/2026 at 6:32 PM, she stated the facility expected staff to ensure urinary catheter drainage bags remain covered to protect resident privacy and preserve dignity.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 1 out of 10 sampled residents, R93.Observation on 04/27/2026 at 9:16 AM revealed Licensed Practical Nurse (LPN) 3 exited R93's room. The resident was on enhanced-barrier precautions (EBP) for wounds and gastrostomy tube (G-tube). The nurse failed to remove gloves upon exit. She then obtained a cup from the medication cart with the contaminated gloves and re-entered the room.Observation on 04/28/2026 at 8:10 AM revealed Unit Manager (UM) 1 performed oral care for R93 and then held the resident's G-tube. Further observation revealed there was an enteral syringe containing a pink colored liquid on the resident's overbed table. UM1 failed to don (put on) the required personal protective equipment (PPE), including a gown, when providing high-risk direct care for a resident on EBP.The findings include:Review of the CDC's guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. According to the guidelines, staff should ensure the proper selection and use of PPE based on the nature of the patient (resident) interaction and potential for exposure to blood, body fluids, and/or infectious materials.Review of the facility's policy titled, Enhanced Barrier Precautions [EBP], revised 09/09/2025, revealed EBP were implemented to reduce the transmission of multi-drug-resistant organisms (MDRO) through the use of gowns and gloves during high-contact resident care. The policy stated high-contact resident care included device care involving feeding tubes, including gastrostomy tubes (G-tube), and required staff to use gowns and gloves during care. Additionally, the policy stated staff were expected to discard personal protective equipment (PPE) prior to exiting the resident's room.Review of the facility's policy titled, Personal Protective Equipment [PPE], dated 08/01/2024, revealed staff was expected to remove PPE in a manner that avoided contamination and remove all PPE before exiting the resident's room. Review of the policy further revealed used gloves were expected to be discarded in the waste receptacle inside the room.Review of the facility's policy titled, Hand Hygiene, dated 08/01/2024, revealed staff must adhere to hand hygiene practices to reduce transmission of pathogens. According to the policy, staff must use an alcohol-based hand rub (ABHR) before and after direct care with residents, and after removing gloves.Review of R93's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/23/2026. R93's diagnoses included unspecified protein-calorie malnutrition, benign prostatic hyperplasia, and aphasia following cerebral infarction.Review of R93's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/20/2026 found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating moderate cognitive impairment. Continued review of the MDS revealed R93 had an indwelling urinary catheter and a G-tube.Review of R93's Order Report, dated 04/2026, found in the resident's EMR under the Orders tab, revealed the resident was under EBP related to the presence of a wound, a G-tube, and an indwelling urinary catheter. 1. Observation on 04/27/2026 at 9:16 AM revealed LPN3 exited R93's room wearing gloves after providing care. Signage on R93's door indicated the resident was under EBP. LPN3 exited the room wearing gloves and did not remove her gloves or perform hand hygiene. She touched the top surface of the medication cart with one contaminated gloved hand, then used the other gloved hand to remove a plastic cup from the stack of cups, and returned to the resident's room. LPN3 did not remove her gloves or perform hand hygiene.During an interview with LPN3 on 04/27/2026 at 9:17 AM, she stated she did not remove her gloves because they were not dirty. When interviewed whether she had provided care to R93 prior to exiting the room, LPN3 did not answer. She turned around, reentered R93's room wearing the same gloves, and closed the door.2. Observation in R93's room on 04/28/2026 at 8:10 AM revealed Unit Manager (UM) 1 was leaning up against the resident's bed while she performed oral care for R93 and then handled the resident's G-tube. Further observation revealed the cap to the G-tube was open while UM1 handled the device. R93 was on EBP related to the presence of a G-tube. UM1 failed to wear the required gown while providing the high-contact direct care to the resident. Furthermore, there was an enteral syringe containing a pink colored liquid on the resident's overbed table.During an interview with UM1 during the time of the observation, she stated she was only holding R93's G-tube and was not going to administer medications or an enteral feeding or flush the tube. UM1 denied she intended to administer the pink liquid though the G-tube. The UM stated she did not believe a gown was necessary because she was not providing high-contact care.During an interview with the Infection Preventionist (IP) on 04/29/2026 at 10:36 AM, she stated all staff received infection prevention education upon hire, with ongoing reinforcement through in-services and town hall meetings. She stated education included hand hygiene before and after entering residents' rooms and use of gown and gloves for direct care to prevent cross-contamination, including EBP rooms and activities such as dressing changes, tube feedings, and resident transfers. She stated a gown, and gloves should be used when handling a G-tube. Additionally, the IP stated gloves should not be worn in the hall. She stated staff should remove all PPE before they exited a resident's room, followed by hand hygiene. The IP stated she conducted daily rounds to audit compliance and completed annual competency checkoffs and skills validations for hand hygiene and PPE use. Furthermore, the IP stated she expected nurses, unit managers, and nursing leadership to reinforce infection prevention practices. The IP stated she expected all staff to follow the CDC's guidelines and the facility's policies to prevent the spread of disease and protect the safety of residents and staff.During an interview with the Director of Nursing (DON) on 04/29/2026 at 11:00 AM, she stated she expected staff to follow the facility's infection control and enhanced barrier precaution policies to prevent the spread of infection and protect the health and safety of residents and staff.During an interview with the Medical Director on 04/30/2026 at 3:50 PM, he stated staff was expected to use proper hand hygiene before and after resident care. The Medical Director stated enhanced barrier precautions required gowns and gloves when handling a G-tube during feedings and medication administration. The Medical Director further stated staff was expected to gown and glove appropriately, especially when performing high-contact direct care to residents who met the criteria for EBP to help prevent cross-contamination and the spread of disease within the facility.During an interview with the Administrator on 05/01/2026 at 6:32 PM, she stated staff received training on infection control policies and protocols. The Administrator stated she expected staff to follow posted precaution signage before entering resident rooms and providing care. Furthermore, she stated adherence to the facility's policy and state and federal guidelines was necessary to protect residents from the spread of infection and maintain a safe environment.

Based on observation, interview, review of the United States Department of Agriculture (USDA) web page, review of the facility's signage, and review of the facility's procedure, the facility failed to prepare and serve food under sanitary conditions as determined by observations during the initial kitchen tour and return tours. Observation on 04/01/2025 and on 04/02/2025 revealed dome lids were stacked wet. Observation on 04/01/2025 of food temperatures for the lunch service revealed an inaccurate temperature for puree food, but it was placed on the tray line for service. Additionally, observation on 04/02/2025 revealed staff changed gloves and performed tasks without proper hand hygiene. The findings include: Review of the facility's procedure titled, Dishwashing Procedure, dated 12/15/2022, revealed to air-dry dishes and keep them in a clean area to avoid contamination. Review of the facility's sign posted in the kitchen Use Disposable Gloves Properly, not dated, revealed to wash hands before and after use of disposable gloves and to change gloves frequently and between tasks. Review of the United States Department of Agriculture (USDA) web page https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-thermometers#:~:text=The%20food%20thermometer%20should%20be,reached%20the%20safe%20internal%20temperature revealed using a food thermometer was the only reliable way to ensure foods had been cooked to a safe minimum internal temperature to destroy any harmful microorganisms that might be in the food. Per the web page, the temperature danger zone was 40 degrees Fahrenheit (F) to 140 degrees F. It also stated the safe practice was to place the thermometer into the thickest part of the food item or for thin foods through the side which reached the middle. Per the web page, always check each piece of food to ensure it had reached the safe internal temperature. In addition, size, quantity, and distribution of food when cooking caused the pieces of food to reach a safe internal temperature at different times. It did not state the food could have a cover, such as plastic, when taking the temperature. Observation on 04/01/2025 at 10:00 AM during the initial tour of the kitchen with the Food and Beverage Director (FBD), revealed dome lids for the resident plates were not aired dried. The inside of the dome had condensation with beads of water. Observation on 04/01/2025 at 11:50 PM of the lunch meal service revealed at 11:57 AM, the FBD was taking the temperature of the food on the steam table. She pushed the thermometer through the plastic wrap over the peas and carrots. In an interview with the Food and Beverage Director (FBD) on 04/01/2025 at 11:57 AM, she stated she on occasion inserted the thermometer through the plastic to take the temperature. She asked the State Survey Agency (SSA) Surveyor if she should not put the thermometer through the plastic wrap. Observation on 04/01/2025 at 12:00 PM of food temperatures on the steam table revealed the temperature of the puree chicken taken by the FBD was 168 degrees F. The SSA Surveyor asked for the FBD to retake the temperature. The puree chicken recheck temperature was 119 degrees F. So, the FBD asked the cook to reheat the puree chicken. Continued observation of the FBD on 04/01/2025 at 12:00 PM, revealed she asked [NAME] 1, Where are the french fries? The cook did not know the location of the french fries, and both left the tray line to find them in the walk-in freezer. Further observation of the FBD and [NAME] 1 revealed they removed their gloves and entered the walk-in freezer. However, they did not wash their hands after changing tasks and the glove change. Observation on 04/02/2025 at 8:19 AM and 11:51 AM revealed the dome lids and bottoms were left wet on the rail near the tray line. In an interview with the FBD on 04/02/2025 at 8:20 AM, she stated the dome lids and bottoms were air-dried on the rack in the dishroom, and then she stacked the dome lids and bottoms together. In an interview with [NAME] 1 on 04/03/2025 at 10:09 AM, she stated hand washing and glove use was important for controlling bacteria. She stated the french fries were not prepared for the tray line. She stated she felt rushed and had to hurry to have time to prepare all the food. She stated she dried the dishes with a towel or let them air dry for a moment before putting them away. In another interview with the FBD on 04/03/2025 at 1:54 PM, the FBD stated the process was to leave dishes in the rack to drain and air dry in the dish room, and the dome lids should be placed in the rack in single file to air dry. The FBD stated there was the potential for bacteria to grow and cause cross contamination if the dome lids were left wet. The FBD stated the proper method to take food temperatures was to swab the stick of the thermometer, check the temperature, and clean between each food. The FBD stated to ensure an accurate temperature, the food should be stirred, and double checked if needed. The FBD stated to prevent the potential of food borne illness, food should be served at the correct temperature. The FBD stated staff did not use gloves on the tray line with serving utensils, and gloves should be changed when staff interrupted tasks to prevent the potential for cross contamination. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 04/03/2025 at 3:37 PM, she stated she expected staff to take care of residents through safe food handling practices. In an interview with the Administrator on 04/03/2025 at 9:18 AM and 3:49 PM, she stated the concern with the dome lids stacked together wet was bacterial growth. She stated she expected staff to take accurate food temperatures to prevent the growth of bacteria. Also, she stated she expected staff to perform proper hand hygiene and to change gloves as directed to prevent the potential for cross contamination.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage for enhanced barrier precautions (EBP), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 19 sampled residents, Resident (R) 18, R41, R56, R68, and R73. R18, R41, R56, R68, and R73 all had active orders to be on EBP. However, observations on 04/01/2025 to 04/03/2025 revealed none of the residents had EBP signage posted on their room doors of what the infection control requirements were when entering and exiting their rooms, for the resident, staff, and visitors. The findings include: Review of the facility's policy titled, Infection Prevention and Control, Transmission Based Precautions, dated 08/01/2024, revealed descriptions for the indications and measures for contact, droplet, and airborne precautions but no description of enhanced barrier precautions. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), undated, revealed EBP were enacted to prevent the transmission of multi-drug resistant organisms. Per the policy, EBP employed targeted gown and glove use during high contact resident care activities. The policy stated the same gown and gloves should not be worn for the care of more than one person. Further review of the policy revealed an order for EBP would be obtained for residents with a wound or indwelling medical device. Review of the facility's signage utilized for EBP, undated and labeled as obtained from the CDC revealed: 1) everyone must clean their hands, including before entering and when leaving the room; and 2) providers and staff must also wear gloves and a gown for the following high-contact resident care activities, such as dressing; bathing/showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device use or care with a central line, urinary catheter, feeding tube, and tracheostomy; or wound care for any skin opening that required a dressing. 1. Review of R18's Admission Record revealed the facility admitted R18 on 12/17/2020 with diagnoses of cerebral vascular disease, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of R18's Clinical Orders, dated 03/24/2025 and entered by the Minimum Data Set (MDS) Nurse, revealed R18 had an active order for EBP related to a wound located on the left inner upper thigh. However, observation on 04/01/2025 at 10:00 AM and 04/02/2025 at 9:02 AM revealed no EBP signage was posted outside R18's room. 2. Review of R41's Admission Record revealed the facility admitted R41 on 07/25/2022 with diagnoses of unspecified dementia, anorexia, and contractures. On 03/07/2025 a diagnosis of squamous cell carcinoma of the skin of the left upper limb was added. Review of R41's Clinical Orders, dated 02/17/2025 and entered by the MDS Nurse, revealed R18 had an active order for EBP related to a wound. Review of R41's Clinical Orders, dated 03/06/2025, revealed an order to apply oil emulsion gauze to the left arm biopsy site daily. Observation on 04/01/2025 at 10:06 AM revealed no EBP signage was posted outside R41's door, and on 04/02/2025 at 9:08 AM and 04/03/2025 at 8:54 AM signage for Contact Precautions was posted outside R41's room. However, during an interview on 04/03/2025 at 2:07 PM with the Infection Preventionist Nurse (IPN), she stated R41 did not have an order for Contact Precautions, she had an order for EBP because of a wound, and that was the signage that should have been posted outside her room. 3. Review of R56's Admission Record revealed the facility admitted R56 on 08/16/2024 with diagnoses of adult failure to thrive and dysphagia (swallowing difficulties). Review of R56's Clinical Orders, dated 03/28/2025 and entered by the MDS Nurse, revealed R56 had an active order for EBP related to a wound located on his coccyx. However, observation on 04/01/2025 on 10:06 AM revealed no EBP signage was posted outside R56's room. 4. Review of R68's Admission Record revealed the facility admitted R68 on 02/28/2025 with diagnoses of fracture of the left humerus, congestive heart failure, and a pressure ulcer to the right lower back. Review of R68's Clinical Orders, dated 03/11/2025 and entered by the MDS Nurse, revealed R68 had an active order for EBP related to a wound and an indwelling urinary catheter. However, observation on 04/01/2025 at 10:08 AM revealed no EBP signage was posted outside R68's room. 5. Review of R73's Admission Record revealed the facility admitted R73 on 10/22/2024 with diagnoses of unspecified dementia, need for assistance with personal care, cognitive communication deficit, and neck fracture. Review of R73's Clinical Orders, dated 03/10/2025 and entered by the MDS Nurse, revealed R68 had an active order for EBP related to a wound on his sacrum (lower back). However, observation on 04/01/2025 at 10:10 AM revealed no EBP signage was posted outside R73's room. During an interview on 04/03/2025 at 3:30 PM with Certified Nurse Assistant (CNA) 4, she stated this was her second week working at the facility, and she relied on the signage posted outside the residents' rooms to guide her in what personal protective equipment (PPE) to wear into the residents' rooms to provide care. She stated if there was no signage outside the resident's room, she would not know what she needed to do and to wear to care for the resident, which could place all the residents at risk for infection. CNA4 stated the residents' precautions were not indicated on the Kardex (the list of resident needs for care and assist generated by the nursing care plan), so she would only be aware of the need for PPE, like a gown or a mask, if it was posted outside the resident's room. During an interview on 04/03/2025 at 3:35 PM with CNA5, she stated she had worked at the facility since 01/2025, and she looked at signage outside the resident's room to guide her as to what PPE she required to provide resident care. CNA5 further stated she would use a gown or mask as the sign posted outside the resident's room instructed. She stated if there was no sign, she would always use gloves as needed and perform hand hygiene with either soap or hand sanitizer as needed. She stated the sign was important so staff and visitors would know what to do before entering the room to keep everyone safe and infection free. During an interview on 04/03/2025 at 3:40 PM with CNA6, she stated she had worked at the facility for two years and was also a Kentucky Medication Aide (KMA). She stated as a KMA she was able to see if a resident was on infection control precautions as she administered medications because it was visible on the resident's dashboard on the electronic medical record (EMR). She stated she would also observe the signage which should be posted outside the residents' rooms indicating what PPE was required to perform resident care. She stated this was important to prevent the spread of infection and in some cases, protect a resident from getting an infection. During an interview on 04/03/2025 at 3:45 PM with the Staff Development Coordinator (SDC), she stated infection control precaution signage should be posted outside a resident's room immediately after an order was received by the nurse to ensure staff and visitor compliance with the precautions. The SDC stated if there was no signage posted outside the resident's room, staff would not know what PPE to wear to provide care. She also stated the signage would instruct staff on PPE the resident needed to wear to exit the room and would instruct visitors on what PPE they needed to wear to enter the room. She stated if staff and visitors did not have the signage information, everyone could be at risk for infection and the spread of infection. During an interview on 04/03/2025 at 3:53 PM with the Physical Therapist (PT), she stated she had worked at the facility for [AGE] years. She stated if a resident was on infection control based precautions, and there was not a sign posted outside the resident's room indicating the resident was on precautions, staff and visitors would not know which PPE to wear into the room. She stated the therapy department would not be aware if a resident could leave their room for therapy or if the resident's condition required therapy be performed in the resident's room. She stated this was important to protect the resident, staff, and any visitors. During an interview on 04/03/2025 at 2:44 PM with the Minimum Data Set (MDS) Nurse, she stated she had been at the facility for six years and had been in the role of MDS Nurse for one year. The MDS Nurse stated if she received an order for a resident for infection control precautions, she would usually let the resident's nurse or the IPN know about it. She stated she had never placed signage outside the resident's room and was not sure how soon after an order was received the signage should be placed, but it would be whatever the policy stated. She further stated the signage being placed on the door was not important as long as staff knew what the orders were, that would be okay. She stated she felt since staff was pretty consistent at the facility, they knew the residents well and would remember what infection control precautions they were on. When asked how visitors would be made aware of the precautions, the MDS Nurse stated she was not sure but agreed staff and visitors knowing if a resident was on ordered infection control precautions was important for the safety of the resident, staff, and visitors to prevent the spread of infection. During continued interview on 04/03/2025 at 2:07 PM with the IPN, she stated she had become certified as an IPN in July 2024. She stated it was her expectation the nurse that entered an order for a resident for any transmission-based precautions (TBP) or EBP then placed signage outside the resident's door immediately. She stated the placement of infection precaution signage outside the resident's room was important for the resident, visitors, and staff to prevent the spread of infection. During an interview on 04/03/2025 at 2:07 PM with the Director of Nursing (DON), she stated she had worked at the facility in the role of DON for a little less than a month and had worked as a floor nurse prior to that. She stated it was also her expectation the nurse that entered an order for a resident for any TBP or EBP ensured signage was placed outside the resident's room immediately whether that nurse placed it or asked another nurse to do so. She stated signage on the door was important for the safety of the resident, visitors, and staff to prevent the spread of infection. The DON also stated R41 should have been on EBP for a biopsy site to her left upper arm. During an interview on 04/03/2025 at 4:30 PM with the Administrator, she stated she had been at the facility for twenty-two (22) years. The Administrator stated signage indicating what infection control precautions were ordered for a resident should be posted outside the resident's room, and that signage should posted as soon as possible after the order was received. She further stated her expectation was the nurse that received the order would be responsible for ensuring the signage was posted so all staff and visitors would comply with the infection precautions. The Administrator stated compliance with ordered infection control precautions for a resident was important to protect all residents, staff, and visitors.

Based on interview, record review, and review of facility Policies, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and to State Agencies as per State Law for one (1) of three (3) sampled residents (Resident #1). On 02/16/19 at approximately 8:00 AM, Resident #1 reported to State Registered Nurse Aide (SRNA #2), a man had climbed into the resident's bed and raped him/her. SRNA #2 notified the Registered Nurse (RN) #1, the nurse on duty, of an allegation of sexual abuse made by Resident #1. However, RN #1 failed to notify the Director of Nursing (DON) and/or Administrator of the alleged abuse until Resident #1 made the allegation a second time to SRNA #2 and a Licensed Practical Nurse (LPN) #3, on 2/16/19 at approximately 11:30 AM. SRNA #2 and LPN #3 then notified RN #1 of the allegation, and RN #1 reported the allegation of abuse to the DON on 02/16/19 at 12:30 PM. The DON notified the Administrator of the allegation on 02/16/19 at 12:30 PM, which was approximately four (4) and one half (1/2) hours after the allegation was made. In addition, there was no documented evidence State Agencies were notified of the allegation until 02/20/19, four (4) days after the facility learned of the allegation. The findings include: Review of facility Policy titled, Abuse, Neglect, and Exploitation Prohibition and Prevention Program, with an effective date of 09/01/18, revealed all employees are informed of their responsibility to immediately report any allegation of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to the Community's administration for investigation, remediation, and reporting to the appropriate state agencies. Review of the facility Policy titled, Resident Rights, with an effective date of 09/01/18, revealed each resident has the right to be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life and that recognizes the resident's individuality. Review of Resident #1's medical record revealed the facility admitted the resident on 07/14/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of seven (7) out of fifteen (15) indicating severe cognitive impairment. Review of the facility's Investigation Report, dated 02/16/19, completed by the Director of Nursing (DON), revealed Resident #1 reported an allegation of sexual abuse to SRNA #2 and LPN #3 as they attended to the resident, first thing in the morning on 02/16/19. SRNA #2 and LPN #3 reported the allegation to RN #1 immediately. Further review revealed Resident #1 made the allegations of sexual abuse again at 11:30 AM on 02/16/19, and RN #1 notified the DON of the abuse allegations on 02/16/19 at 12:30 PM. Review of the Combined Incident Report/Final Report which was emailed to the Office of Inspector General (OIG) on 02/20/19, revealed Resident #1 alleged he/she was reaped during the night. Per the Report, the resident had no visible injuries and was transferred to the Hospital for a rape exam. Further review of the Report, revealed a report was made to the OIG, Adult Protective Services (APS) and Local Police Department. However, there was no documented evidence State Agencies were notified of the allegation within two (2) hours of the allegation being made. Interview with SRNA #2, on 03/06/19 at 1:50 PM, revealed on 02/16/19 at 8:30 AM, Resident #1 reported to her that a man had climbed in bed with him/her and raped the resident. SRNA #2 stated she immediately reported the allegation to RN #1. SRNA #2 stated after the abuse allegation was reported to RN #1, RN #1 went into the resident's room. Further interview with SRNA #2, revealed Resident #1 got out of bed on 02/16/19 at 11:30 AM, and at that time again reported the rape allegation. SRNA #2 stated she and LPN #3 then reported the allegation again to RN #1. Interview with LPN #3, on 03/06/19 at 2:05 PM, revealed an abuse allegation was reported to her by Resident #1, on 02/16/19 at 11:30 AM. She stated Resident #1 reported that a man was in bed with him/her, and spermed on {his/her} stomach. LPN #3 stated she immediately reported the allegation to RN #1. Further interview revealed RN #1 stated she was already aware of the allegation. LPN #3 stated she suggested to RN #1, that she notify the DON of the allegation. Telephone interview with RN #1, on 03/07/19 at 8:00 AM, revealed the allegation of rape by Resident #1 was reported to her during breakfast, by SRNA #2 on 02/16/19. RN #1 stated she had already seen Resident #1 that morning and the resident's only complaint was back pain. RN #1 further stated she related the allegation to a bad dream and did not take the allegation seriously at the time. Continued interview revealed RN #1 did not report the allegation at that time, or investigate the allegation and only tried to redirect the resident. RN #1 further revealed that on 02/16/19 at 11:30 AM, the resident made the same abuse allegation with more details. Further interview revealed she then called the DON to report the allegation, but the DON's voicemail was full. RN #1 stated she then texted the DON on 02/16/19 at 12:07 PM, and the DON called her back on 02/16/19 at 12:30 PM. RN #1 stated she had been trained to immediately notify the Director of Nursing of any allegations of abuse. Interview with the DON, on 03/07/19 at 11:00 AM, revealed she was informed of the abuse allegation on 02/16/19 at 12:30 PM by RN #1, and she (DON) conducted the investigation into the abuse allegation made by Resident #1. Continued interview revealed due to Resident #1's cognition and behaviors, RN #1 did not take the allegation seriously when it was reported to her on 02/16/19 at approximately 8:00 AM, and failed to report the allegation to the DON and Administrator immediately, as per facility policy. Further interview revealed she had called the OIG office and left a message related to the allegation of abuse on 02/16/19 at 2:10 PM and had also called Adult Protective Services on that date. However, the DON was unable to provide documented evidence of the notification to State Agencies, prior to 02/20/19. Interview with the facility Administrator, on 03/07/19 at 11:30 AM, revealed she was not at the facility on 02/16/19, but she was notified of the abuse allegation made by Resident #1 via phone call from the DON, on 02/16/19 at 12:30 PM. She further stated, per facility policy, RN #1 should have reported the abuse allegation to the DON or Administrator immediately after the SRNA reported the allegation to her the morning of 02/16/19. She stated it was extremely important for the DON and Administrator to be notified of abuse allegations immediately for the safety of the residents, and State Agencies were also to be notified of allegations of abuse within the two (2) hour timeframe. Further interview revealed facility policy was not followed related to reporting Resident #1's allegation of abuse.

Based on observation, interview and review of facility Policies, it was determined the facility failed to prepare and store food under sanitary conditions. Observation on 01/29/19, during initial kitchen tour, revealed there were no paper towels available at the kitchen sink. In addition, scoops were found lying in the food product, inside three (3) of the four (4) ingredient bins. Furthermore, observation on 01/29/19, revealed the nutrition refrigerator located in the Medication room on the Magnolia Unit was soiled. The findings include: 1. Review of the facility Policy titled Handwashing, dated 10/01/17, revealed instructions to turn the water off using a paper towel to prevent the hands from becoming contaminated. Review of the facility Policy titled Food Safety in Receiving and Storage, dated 09/01/18, revealed all food storage bins or containers should be maintained in clean condition and labeled with the contents. Scoops are not to be stored inside bins. Observation on 01/29/19 at 6:05 AM, upon initial tour of the kitchen, revealed there were no paper towels available at the hand sink in the pot and pan area. After washing hands, the State Agency Representative asked Dietary Aide #1 for paper towels and was told there was another hand sink in the kitchen. The State Agency Representative again requested paper towels and Dietary Aide #1 located the paper towels in dry storage and filled the paper towel holder. Continued observation during initial kitchen tour, revealed scoops were left inside three (3) of four (4) white storage bins containing sugar, rice and food thickener. Interview on 01/30/19 at 9:48 AM, with Dietary Aide #1 revealed she did not know the paper towel holder was out of paper towels. Continued interview revealed paper towels should always be available to access at the sinks in order for staff to dry their hands after hand washing. Further interview revealed scoops should be hung inside the storage bin lid and should not be left in the food product in order to prevent cross contamination. Interview on 01/30/19 at 8:05 AM, with the Dietary Supervisor, revealed all staff were responsible to fill the paper towel holder because staff were to use paper towels to dry wet hands after hand washing instead of using hand towels to prevent cross contamination. Further interview revealed the bin scoops were to be placed inside the scoop holder located inside the lid because if the scoops were left in the food product, the handle of the scoop could cause cross contamination. Interview on 01/30/19 at 3:05 PM, with the Registered Dietitian (RD), revealed paper towels should be accessible in the paper towel holder in order for staff to dry hands after handwashing for infection control purposes. Further interview revealed scoops should be placed in the scoop holder and should not be left inside the ingredients in the bins as this could cause cross contamination from the scoop to the food ingredients. Interview on 01/31/19 at 2:33 PM, with the Director of Nursing (DON), revealed it was important for staff to wash hands and to turn off the water faucets with paper towel and not by bare hand to prevent infection control concerns. Per interview, all Dietary staff were responsible for restocking the paper towel holder. Further interview, revealed scoops should be placed in the proper holder and not left in the ingredients in the bins in order to prevent cross contamination. Interview on 01/31/19 at 2:53 PM, with the Administrator, revealed after handwashing faucets were to be turned off with paper towels to prevent the spread of bacteria or germs, and paper towels should always be available at the kitchen sinks. He further stated scoops should not be left in the ingredients inside the kitchen bins, but should be properly stored in the scoop holders. Continued interview revealed it was his expectation for dietary staff to follow the facility policies regarding hand washing and the storage of scoops. 2. Review of the facility Policy titled, Sanitation and Infection Control Standards for Food and Dining, dated 09/01/18, revealed employees were trained on sanitation and cleaning procedures. Interview on 01/31/19 at 4:14 PM, with the Director of Nursing (DON), revealed the Nursing Department did not have a policy for cleaning the residents' nutritional refrigerators in the Medication Rooms. Observation on 01/29/19 at 10:52 AM, revealed the nutrition refrigerator in the Medication Room, located on the Magnolia Unit, had dried pudding running down the wall of the refrigerator to the bottom of the refrigerator, and the pudding had pooled in the corner of the bottom drawer. Interview with Licensed Practical Nurse (LPN) #9, on 01/29/19 at 10:52 AM, who also observed the nutrition refrigerator, revealed the residents' nutritional snacks and supplements were stored in the refrigerator, and the refrigerator should be kept clean. She agreed the refrigerator needed to be cleaned. Interview with LPN #2, on 01/31/19 at 7:30 AM, revealed night shift staff was responsible for cleaning the nutrition refrigerators each night. However, she stated staffing on night shift had been low, so there were times the refrigerator did not get cleaned. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for the Magnolia Unit, revealed night shift was responsible for cleaning the nutrition refrigerators in the Medication Room nightly. She stated there was no policy or protocol to govern the cleaning; however, cleaning was important for infection control. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed it was her expectation for the nutrition refrigerators in the Medication Rooms to be kept clean as this was important for infection control. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for nursing staff to maintain clean nutritional refrigerators for infection control purposes.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 01/29/19, revealed the temperature of the Magnolia Unit medication refrigerator was out of range. In addition, observation on 01/30/19, revealed loose pills which were not packaged or labeled in three (3) of six (6) medication carts. The findings include: Review of the facility Policy titled, Medication Management Guidelines, dated 09/01/18, revealed no guidelines for checking medication carts for unlabeled medications nor for ensuring medication refrigerator temperatures were in range. 1. Observation on 01/29/19 at 10:52 AM, of the Magnolia Unit Medication Room, , revealed the medication refrigerator temperature gauge was out of range. The temperature was in the red out of range area at forty two (42) degrees. Interview with Licensed Practical Nurse (LPN) #9, on 01/29/19 at 10:52 AM, revealed night shift normally checked refrigerator temperatures. She stated she did not normally address any issues related to the refrigerator temperatures because she did not work night shift. Interview with the Unit Manager for the Magnolia Unit, on 01/31/19 at 1:58 PM, revealed it was her expectation for night shift nursing staff to check medication refrigerator temperatures each night and record the readings in a log book. Per interview, if nursing staff recognized the temperature was out of range, she expected staff to move the medications to a regulated refrigerator and notify Maintenance of the malfunctioning refrigerator. She stated it was important to maintain correct temperatures to preserve the medications. 2. Observation on 01/30/19 at 10:00 AM, revealed the Medication Cart for Hall B, on the Rehabilitation to Home Unit, contained eight (8) loose pills in the medication drawers. The pills were not packaged or labeled and were scattered in the drawers. Interview with Licensed Practical Nurse (LPN) #10 on 01/30/19 at 10:00 AM, revealed the medication cart for Hall B on the Rehabilitation Unit had eight (8) loose, unlabeled pills in the medication drawers. She stated the unlabeled pills should not be left in the cart, and should have been discarded for safety reasons. 3. In addition, observation on 01/30/19 at 10:15 AM, revealed the Medication Cart for Hall A, on the Rehabilitation to Home Unit , contained two (2) loose pills which were not packaged or labeled in the cart drawers. Interview with LPN #11, on 01/30/19 at 10:15 AM, revealed the medication cart for Hall A, on the Rehabilitation to Home Unit, had two (2) unlabeled, loose pills in the drawers. She stated the pills should have been discarded because they were unidentified medications. 4. Furthermore, observation on 01/30/19 at 11:34 AM, revealed the Medication Cart for the 210 Magnolia Hall had three (3) loose pills which were not packaged or labeled in the cart drawers. Interview with LPN #7, on 01/31/19 at 1:17 PM, revealed the medication cart for the 210 Hall on the Magnolia Unit, had three (3) loose unlabeled pills in the drawers. Per interview, these unidentified pills should have been discarded as they were not safe for administration. Further interview with the Unit Manager for Magnolia Unit, on 01/31/19 at 1:58 PM, revealed loose, unlabeled medications were not to be in the Medication Cart, and staff were to discard such medications. Interview with the Director of Nursing (DON), on 01/30/19 at 10:25 AM, and on 01/31/19 at 4:30 PM, revealed medication carts should not have loose, unlabeled medications present in the drawers as these medications were not safe to administer and should be discarded. Further interview revealed the night shift nursing staff was to check medication refrigerator temperatures and record results on a temperature log. Per interview, if medication refrigerator temperatures were out of range, this should be immediately reported to the Unit Managers for resolution. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for nursing staff to check medication refrigerator temperatures, and report out of temperatures to the DON. Per interview, medication refrigerator temperatures should be maintained at appropriate temperatures to maintain the integrity of the medications. The Administrator further stated she would not expect to find loose, unlabeled medications in the medication carts. She stated loose pills should be discarded.

Based on observation, interview, and review of facility policy, it was determined the facility failed to maintain patient care equipment in a safe operating condition. The facility failed to ensure glucometer control solutions were dated when opened as directed by Manufacturer's Recommendations. Observation on [DATE], of the Magnolia Unit Medication Room, revealed a [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solution box containing two (2) glucometer testing solutions which had been opened and were not marked with the open date. In addition, observation on [DATE], of the Rehabilitation to Home Unit Medication Room, revealed a [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solution box containing two (2) glucometer testing solutions which had been opened and were not marked with the open date. The findings include: Review of the facility Policy titled, Blood Glucose Calibration/Quality Control Testing dated [DATE], revealed the policy's purpose was to set forth the procedures to be followed to test the accuracy of the blood glucose monitoring devices. Policy guidelines included testing when test results were questionable and use of a calibrator packaged with the box of test strips to be used. No guidelines in accordance with manufacturer's recommendations were included relative to dating the glucose control testing solutions ([MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solutions) when opened. Review of the package insert for [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solutions, published by Abbott and dated Rev. A ,[DATE], revealed the solution was stable for ninety (90) days after opening. Further recommendations for product usage revealed the open date of the solution should be written on the vial at the time it is first opened. The recommendations stated the vials should be discarded ninety (90) days from the open date on the vial or on the expiration date, whichever occurred first. 1. Observation on [DATE] at 11:11 AM, of the Magnolia Unit Medication Room, revealed a [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solution box with two (2) glucometer testing solutions which had been opened and were not marked with the open date. 2. Observation on [DATE] at 10:00 AM, of the Rehabilitation to Home Unit Medication Room, revealed a [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solution box with two (2) glucometer testing solutions which had been opened and were not marked with the open date. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 1:17 PM, revealed night shift performed the glucometer control testing . She stated she generally did not work nights and thus, did not usually perform the testing. LPN #7 further stated new control solution vials should have the open date marked on the vial. Interview with LPN #3, on [DATE] at 1:37 PM, revealed although she usually did not work night shift, she knew how to perform glucometer checks using the [MEDICATION NAME] control solutions. She stated it was very important to date the vials when new testing solution was opened. She stated control testing was important to ensure accurate glucometer readings. Interview with the Unit Manager for Magnolia Unit, on [DATE] at 1:58 PM, revealed night shift performed glucometer testing each night and recorded readings in a log book. She stated when new testing solution was opened, the open date of the vial should be written on the vial itself. She stated accuracy of the glucometer readings was dependent on using testing solution that was not expired. She further stated the glucometer readings were the determinant in administering accurate sliding scale insulin doses. Interview with Registered Nurse (RN) #1, on [DATE] at 7:40 AM, revealed she worked night shift and performed glucometer testing at night. She stated when she opened a new box of [MEDICATION NAME] Glucose and [MEDICATION NAME] Control solution vials, she dated the box. She further stated she should date the vials and not the box in case the vials were separated from the box. Interview with the Director of Nursing (DON), on [DATE] at 11:11 AM, and on [DATE] at 4:14 PM, revealed the [MEDICATION NAME] Glucose and [MEDICATION NAME] Control Solution vials should be dated when opened. Further interview revealed she expected the [MEDICATION NAME] Glucose and [MEDICATION NAME] Control solution vials to be dated both on the vials and on the box. She stated glucometer testing helped ensure accurate blood glucose readings which determined sliding scale insulin dosing. She stated using expired testing solution could compromise the integrity of the glucometer results and impact resident safety negatively. Continued interview revealed following manufacturer's recommendations was an important component to ensure correct glucometer results. Interview with the Administrator, on [DATE] at 5:02 PM, revealed she expected nursing to manage glucometer control testing. She stated the DON should manage the process and ensure staff were following facility policy. The Administrator stated the control solution vials should be dated when opened. Further interview revealed glucose testing solution should not be expired to ensure the accuracy of glucometer readings, which in turn determined sliding scale insulin dosing.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframe to meet the residents' mental and psychosocial needs that are identified in the comprehensive assessment related to Dementia for one (1) of twenty-two (22) sampled residents (Resident #10). Resident #10's Comprehensive Care Plan was not developed and implemented related to the resident's symptom and rate of progression of dementia (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks) or related to meaningful activities to address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. The findings include: Review of the facility Care Plan Development and Communication Policy, revised 01/04/19, revealed care planning processes allow for the delivery of comprehensive, coordinated, quality care designed to meet the ongoing individualized needs of residents. The Care Plan should be developed to include measurable objectives and timetables to meet a residents medical, nursing, and mental and psychosocial well-being. Review of Resident #10's clinical record revealed the facility admitted the resident on 01/04/19 with [DIAGNOSES REDACTED]. Review of Resident #10's Admission Minimum Data Set (MDS) Assessment, dated 01/14/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) revealing the resident was cognitively intact. Review of Section I, titled Active Diagnoses, revealed the facility assessed Resident #10 as having an active [DIAGNOSES REDACTED]. Also, it was somewhat important for him/her to keep up with the daily news, to listen to the music he/she likes, to participate in his/her favorite activities, to do things with groups of people, and to participate in religious services. Review of the Comprehensive Care Plan, initiated 01/15/17, revised 01/20/19, revealed Resident #10 experienced short term cognition and recall problems. The goal revealed the resident would continue to make needs known through next review. Interventions listed included: administer cognition medication as ordered; observe for changes in condition that could impact mental status; and provide with cues and reminders as needed. Further review of the Comprehensive Care Plan, initiated 08/24/17, revised 10/08/18, revealed the resident had alteration in communication related to decreased cognition due to [DIAGNOSES REDACTED]. Interventions included: allowing ample amount of time to respond, and repeat if necessary; ask yes and no questions if possible; notify physician as needed; observe for non-verbal signs and symptoms of communication; obtain diagnostic testing as ordered; and Speech therapy to treat and evaluate as ordered. Additional review of the Comprehensive Care Plan, initiated 02/28/19, revealed the resident was at risk for activity participation deficit related to a decrease in health and physical ability; and enjoyed church services, talking on the phone, watching TV, outings with grandson and time with family. The goal revealed the resident would attend two (2) activities through the review date of 04/04/19. The interventions included: inviting the resident to scheduled activities and providing the resident with an activities calendar. However, there was no documented evidence the facility developed and implemented an individualized Care Plan with interventions to address the resident's symptom and rate of progression of dementia (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks). In addition, there was no documented evidence the Care Plan was developed and implemented to include individualized, purposeful and meaningful activities that addressed the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Observation of Resident #10 on 01/29/19 at 10:15 AM, revealed he/she was lying in bed in with eyes closed, with no interaction from staff; observation on 01/29/19 at 2:05 PM, revealed the resident was seated at the side of the bed reading with no interaction from staff; observation on 01/30/19 at 10:30 PM, revealed the resident was lying in bed talking on his/her cellular phone; and observation on 01/31/19 at 11:00 AM, revealed the activity assistant entered the resident's room and placed and activity calendar for (MONTH) 2019 on the resident's bed side table and then exited the room. Interview with the Activity Director, on 01/31/19 at 2:30 PM, revealed it was her duty to implement activities specific to residents diagnosed with [REDACTED].#10's Activity Care Plan needed to be more specific and person centered with individualized interventions to be implemented to ensure the resident was socializing and taking part in activities of choice. Interview with the Interim Director of Nursing, on 01/31/19 at 4:00 PM, revealed it residents with dementia needed to receive more of staff's attention. She stated residents with Dementia usually needed more assistance from staff with Activities of Daily Living; however, Resident #10 was in the early stages of Dementia and was more independent, and his/her main issue was mental health. Additional interview revealed it was important for Resident #10 to receive person centered care through individualized approaches, and therefore the resident's Care Plan should have been developed and implemented with specific approaches related to the [DIAGNOSES REDACTED]. Interview with the Administrator, on 01/31/19 at 5:15 PM, revealed it was important for the Comprehensive Care Plan to be developed and implemented with goals and interventions to receive appropriate treatment and services related to individualized dementia care needs.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure a resident with an indwelling urinary catheter, receives the appropriate care and services to prevent urinary tract infections for one (1) of (1) sampled residents observed for catheter placement out of twenty two (22) sampled residents (Resident #18). Observation on 01/29/19, of indwelling urinary catheter care for Resident #18, revealed during the procedure the catheter became dislodged, and State Registered Nurse Assistant (SRNA) #2 attempted to re-insert the catheter. SRNA #2 was unsuccessful at re-inserting the catheter and went to get the nurse. Further observation revealed Licensed Practical Nurse (LPN) #2 failed to use sterile technique when inserting the indwelling urinary catheter for Resident #18, and also failed to to test the retention balloon prior to inserting the catheter. The findings include: 1. Review of the facility Policy titled, Indwelling Urinary Catheter- General Information dated 06/03/06, revealed urinary catheters were a common source of infection and should be used only with clinical rationale. The policy did not have procedure guidelines for insertion and maintenance of the catheter. Review of the facility Policy titled, Indwelling Urinary Catheter General Information with effective date 09/01/18, revealed guidelines for appropriate urinary catheter use, but not procedural guidelines for catheter insertion. Review of Perry and Potter Clinical Nursing Skills and Techniques, Chapter Thirty Three (33), Eighth Edition, used by the facility's nursing staff, revealed urinary catheters should be inserted using sterile procedure. Review of the Kentucky Board of Nursing Advisory Opinion (AOS) #15, revised 12/2018, revealed Registered Nurses could delegate urinary catheter care to unlicensed personnel; however, insertion of the catheters remained a function for licensed nursing staff. Review of Resident #18's clinical record revealed the facility admitted the resident on 08/16/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/05/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having a Foley catheter in place for [MEDICAL CONDITION] and benign prostate hypertrophy, requiring care and maintenance of the catheter. Observation on 01/29/19 at 9:09 AM, of catheter care for Resident #18, revealed during provision of catheter care the indwelling urinary catheter dislodged with the retention balloon deflated. SRNA #2 attempted to reinsert the catheter without success and then went to find the nurse. Licensed Practical Nurse (LPN) #2 entered the resident's room with the indwelling urinary catheter in one package with an outer wrapping and a sterile inner wrapping along with another package containing all other supplies, again with an outer package wrapping with sterile supplies inside. LPN #2 then set up the sterile field, donned sterile gloves, and picked up the outer package of the indwelling urinary catheter and opened it to reach the inner sterile catheter packaging. LPN #2 did not take off the contaminated gloves and don another pair of sterile gloves during the procedure of inserting the indwelling urinary catheter. LPN #2 also did not test the retention balloon prior to inserting the catheter. Interview with SRNA #2, on 01/31/19 at 11:25 AM, revealed he was assigned to care for Resident #18 on 01/29/19, when the Foley catheter came out during catheter care. SRNA #2 stated he knew he should not have reinserted Resident #18's catheter when it dislodged, but this was his immediate reaction. Further interview revealed catheters should be placed per sterile procedure by a licensed nurse. Interview with LPN #2, on 01/31/19 at 1:17 PM, revealed indwelling urinary catheters should be inserted using sterile technique. She revealed she was aware the outer packaging of the catheter should not be touched once sterile gloves were donned in order to maintain the sterile field. She further revealed she normally inflated the catheter balloon prior to insertion to ensure it was operational, deflated the balloon, and then inserted the catheter. Further interview revealed when she inserted the new urinary catheter for Resident #18, she forgot to test inflate the balloon prior to insertion of the catheter, and she failed to use sterile technique. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for the Magnolia Unit where Resident #18 resided, revealed SRNAs should never insert indwelling urinary catheters as this was not in their scope of practice. She revealed only licensed nurses were trained to insert indwelling catheters. She further revealed nursing staff should always maintain sterile technique during catheter insertions to minimize infection risks. Continued interview revealed nursing staff should not touch the outer packaging of a catheter with sterile gloves during the procedure, and if that were to occur, the nurse would need to doff the contaminated gloves, wash hands, and don sterile gloves again. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed only licensed nursing staff were to place indwelling urinary catheters, as per nursing practice guidelines. Per interview, SRNAs were not trained on catheter insertion and should never perform this procedure. The DON revealed sterile technique should be followed by nursing staff when inserting indwelling urinary catheters to help prevent infection. The DON stated licensed nurses should maintain sterile technique and not touch the outer packaging of a catheter after sterile gloves were applied. The DON further stated the nurse should have tested the urinary catheter balloon prior to insertion, deflated, and then inserted the catheter. Further interview revealed the nursing staff used Perry and Potter guidelines for clinical procedures. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for the nursing staff to follow sterile procedures in accordance with accepted standards of practice and facility adopted guidelines in inserting indwelling urinary catheters. She revealed her expectation was consistent with good infection control practices. Continued interview revealed it was never acceptable for a nursing assistant (SRNA) to insert a urinary catheter because the skill was beyond the scope of practice.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who is diagnosed with [REDACTED].#10). The facility failed to ensure necessary care and services were person-centered and reflected the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, and choice for Resident #10, related to the resident's [DIAGNOSES REDACTED]. The findings include: Review of Resident #10's medical record revealed the facility admitted the resident on 01/04/19 with the [DIAGNOSES REDACTED]. Review of Resident #10's Admission Minimum Data Set (MDS) Assessment, dated 01/14/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Section I, titled Active Diagnoses, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. It is somewhat important for him/her to keep up with the daily news, to listen to the music he/she likes, to participate in his/her favorite activities, to do things with groups of people, and to participate in religious services. Review of Resident #10's Comprehensive Care Plan, initiated 01/15/17, revised 01/20/19, revealed the resident experienced short term cognition and recall problems. The goal stated the resident would continue to make needs known through next review. Interventions were listed as: administer cognition medication as ordered; observe for changes in condition that could impact mental status; and provide with cues and reminders as needed. Continued review of the Comprehensive Care Plan, initiated 08/24/17, revised 10/08/18, revealed the resident had alteration in communication related to decreased cognition due to [DIAGNOSES REDACTED]. Interventions included: allow ample amount of time to respond, and repeat if necessary; ask yes and no questions if possible; notify physician as needed; observe for non-verbal signs and symptoms of communication; obtain diagnostic testing as ordered; and Speech therapy to treat and evaluate as ordered. Further review of the Comprehensive Care Plan, initiated 02/28/19, revealed the resident was at risk for activity participation deficit related to a decrease in health and physical ability. Per the Care plan, the resident enjoyed church services, talking on the phone, watching TV, outings with grandson and time with family. The goal stated the resident would attend two (2) activities through the review date of 04/04/19. The interventions included inviting the resident to scheduled activities and providing the resident with an activities calendar. However, there was no documented evidence the facility developed individualized Care Plan interventions related to the resident's symptom and rate of progression (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks) or related to meaningful activities to address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Observation of Resident #10 on 01/29/19 at 10:15 AM, revealed he/she was lying in bed in with eyes closed, with no interaction from staff. Observation of Resident #10 on 01/29/19 at 2:05 PM, revealed the resident was seated at the side of the bed reading with no interaction from staff. Observation of Resident #10 on 01/30/19 at 10:30 PM, revealed the resident was lying in bed talking on his/her cellular phone. Observation on 01/31/19 at 11:00 AM revealed the activity assistant entered the resident's room and placed and activity calendar for (MONTH) 2019 on the resident's bed side table and then exited the room. Interview with the Activity Director, on 01/31/19 at 2:30 PM, revealed she was new to the facility, but it was her duty to implement activities specific to residents diagnosed with [REDACTED].#10's Activity Care Plan needed to be more specific and person centered with individualized interventions to be implemented to ensure the resident was socializing and taking part in activities of choice. Interview with the Interim Director of Nursing, on 01/31/19 at 4:00 PM, revealed it was her expectation residents with dementia receive more of staff's attention. Per interview, residents with Dementia usually needed more assistance from staff with Activities of Daily Living; however, Resident #10 was in the early stages of Dementia and was more independent, and his/her main issue was mental health. Further interview revealed it was important for Resident #10 to receive person centered care through individualized approaches, and therefore the resident's Care Plan should have reflected the resident's care needs related to Dementia. Interview with the Administrator, on 01/31/19 at 5:15 PM, revealed it was her expectation staff be aware of residents' cognitive impairments due to Dementia. Per interview, it was important for residents with Dementia to receive appropriate treatment and services to ensure the residents' individualized dementia care needs were met.

Based on interview and record review, it was determined the facility failed to ensure medical records are maintained that are complete and accurately documented, per accepted professional standards and practices for one (1) of twenty-two (22) sampled residents (Resident #10). Resident #10 was being seen by a Wound Consultant Company and also a separate Wound Clinic. However, there was no documented evidence the physician's orders [REDACTED]. In addition, there were conflicting physician's orders [REDACTED]. These concerns were not discovered by the facility until State Agency Representative intervention. The findings include: Review of the facility Medical Records Policy, dated 01/01/07, revealed medical records are to be maintained in a complete, readily accessible, and systematically organized manner in accordance with federal and state regulations, facility policies, and accepted professional standards of practice. The medical record will contain complete and accurate documentation that clearly identifies the resident, justifies the diagnosis, conditions, and treatment and care approaches. Review of Resident #10's medical record revealed the facility admitted the resident on 01/04/19 with [DIAGNOSES REDACTED]. Review of the Wound Consultant physician's orders [REDACTED]. In addition, physician's orders [REDACTED]. Review of the Treatment Administration Record dated 01/11/19, revealed these orders were implemented starting 01/11/19. Review of the Hospital Wound Care Clinic Patient Care Instructions, dated 01/17/19, revealed physician's orders [REDACTED]. However, record review revealed there was no documented evidence these Orders/Instructions were inputted into the Electronic Medical Record (EMR) as physician's orders [REDACTED]. Review of the Wound Consultant Companies Wound Physician's Evaluation and Management Summary, dated 01/17/19, revealed a Treatment Plan for order changes as follows: Diabetic Wound of the Right Medial Ankle: sterile ADB pad, sterile gauze roll, Alginate calcium, apply once daily for thirty (30) days. Diabetic Wound of the Left, Lateral Foot: sterile ABD pad, sterile gauze roll, [MEDICATION NAME], apply once daily for thirty (30) days. However, record review revealed there was no documented evidence this Treatment Plan was inputted into the EMR as physician's orders [REDACTED]. Review of the Hospital Wound Care Clinic Note, dated 01/24/19, revealed physician's orders [REDACTED]. Record review of the (MONTH) 2019 TAR, on 01/031/19, revealed Resident #10's physician's orders [REDACTED]. Also, the Right Medial Ankle wound was still being dressed with [MEDICATION NAME]. In addition, the MAR indicated [REDACTED]. There was conflicting orders on the MAR indicated [REDACTED]. These discrepancies in physician's orders [REDACTED]. on 01/31/19, when watching wound care for Resident #10. Interview with the Wound Care Nurse, on 01/31/19 at 10:35 AM, revealed physician's orders [REDACTED].#10's Electronic Medical Record. She stated due to the resident visiting different wound clinics, it was hard to keep up with both clinics and their orders. She stated she had oversight over the wounds and should have identified physician's orders [REDACTED]. Interview with the Interim Director of Nursing, on 01/31/19 at 4:41 PM, revealed it was her expectation orders were inputted into the EMR timely and accurately. Further interview revealed it was important physician's orders [REDACTED]. Interview with the Administrator, on 01/31/19, revealed it was her expectation physician's orders [REDACTED]. She stated it was important for physician's orders [REDACTED].

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure proper sterile technique was used during indwelling urinary catheter placement for one (1) of (1) sampled residents observed for catheter placement out of twenty two (22) sampled residents (Resident #18). Observation of indwelling urinary catheter care for Resident #18, on 01/29/19, revealed during the procedure the catheter became dislodged, and the State Registered Nurse Assistant (SRNA) attempted to re-insert the catheter. The SRNA was unsuccessful at re-inserting the catheter and went to get the nurse. Further observation revealed the licensed nurse failed to use sterile technique when inserting the indwelling urinary catheter for Resident #18, and also failed to to test the retention balloon prior to inserting the catheter. In addition, the facility failed to review the Infection Control Plan and other infection control policies on an annual basis. The findings include: 1. Review of the facility Policy titled, Indwelling Urinary Catheter- General Information dated 06/03/06, revealed urinary catheters were a common source of infection and should be used only with clinical rationale. The policy did not have procedure guidelines for insertion and maintenance of the catheter. Review of the facility Policy titled, Indwelling Urinary Catheter General Information with effective date 09/01/18, revealed guidelines for appropriate urinary catheter use, but not procedural guidelines for catheter insertion. Review of Perry and Potter Clinical Nursing Skills and Techniques, Chapter Thirty Three (33), Eighth Edition, used by the facility's nursing staff, revealed urinary catheters should be inserted using sterile procedure. Review of the Kentucky Board of Nursing Advisory Opinion (AOS) #15, revised 12/2018, revealed Registered Nurses could delegate urinary catheter care to unlicensed personnel; however, insertion of the catheters remained a function for licensed nursing staff. Review of Resident #18's medical record revealed the facility admitted the resident on 08/16/17 with [DIAGNOSES REDACTED]. Observation of catheter care for Resident #18, on 01/29/19 at 9:09 AM, revealed during provision of catheter care the indwelling urinary catheter dislodged with the retention balloon deflated. SRNA #2 attempted to reinsert the catheter without success and then went to get the nurse. Licensed Practical Nurse (LPN) #2 entered the resident's room with the indwelling urinary catheter in one package with an outer wrapping and a sterile inner wrapping along with another package containing all other supplies, again having an outer package wrapping with sterile supplies inside. LPN #2 set up the sterile field, donned sterile gloves, and then picked up the outer package of the indwelling urinary catheter and opened it to reach the inner sterile catheter packaging. She did not take off the contaminated gloves and don another pair of sterile gloves during the procedure of inserting the indwelling urinary catheter. LPN #2 also failed to test the retention balloon prior to inserting the catheter. Interview with SRNA #2 on 01/31/19 at 11:25 AM, revealed he was educated about indwelling urinary care during orientation. He stated he was assigned to care for Resident #18 on 01/29/19, when the Foley catheter came out during catheter care. He further stated he had never had a catheter fall out during catheter care. SRNA #2 stated he knew he should not have reinserted Resident #18's catheter when it dislodged, but this was his immediate reaction. Continued interview revealed catheters should be placed per sterile procedure by a licensed nurse. Interview with LPN #2, on 01/31/19 at 1:17 PM, revealed urinary catheters should be inserted using sterile technique. She stated she was aware the outer packaging of the catheter should not be touched once sterile gloves were donned in order to maintain the sterile field. She further stated she normally inflated the catheter balloon prior to insertion to ensure it was operational, deflated the balloon, and then inserted the catheter. Continued interview revealed when she inserted the new urinary catheter for Resident #18, she forgot to test inflate the balloon prior to insertion of the catheter, and she failed to use sterile technique. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for Magnolia Unit where Resident #18 resided, revealed SRNAs should never insert indwelling urinary catheters because it was not in their scope of practice. She stated only licensed nurses were trained to insert indwelling catheters. She further stated nursing staff should always maintain sterile technique during catheter insertions to minimize infection risks. The Unit Manager stated nursing staff should not touch the outer packaging of a catheter with sterile gloves during the procedure, and if that were to occur, the nurse would need to doff the contaminated gloves, wash hands, and don sterile gloves again. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed only licensed nursing staff were to place indwelling urinary catheters, as was consistent with nursing practice guidelines. Per interview, SRNAs were not trained on catheter insertion and should never perform the procedure. The DON stated sterile technique should be followed by nursing staff when inserting indwelling urinary catheters to help prevent infection. Per interview, licensed nurses should maintain sterile technique and not touch the outer packaging of a catheter after sterile gloves were applied. She further stated the nurse should have tested the urinary catheter balloon prior to insertion, deflated, and then inserted the catheter. Continued interview revealed the nursing staff used Perry and Potter guidelines for clinical procedures. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for the nursing staff to follow sterile procedures in accordance with accepted practice and facility adopted guidelines in inserting indwelling urinary catheters. She stated her expectation was consistent with good infection control practices. She further stated it was never acceptable for a nursing assistant (SRNA) to insert a urinary catheter because the skill was beyond the scope of practice. 2. Review of the facility Policy titled, Infection Prevention and Control Program Overview, with a prior revision date of 10/15/14 and an effective date of 10/01/17, revealed the facility had not updated the policy on an annual basis. Review of the facility Policy titled Influenza with revision date of 02/15/11, revealed no current review date. The policy sponsor was clinical/infection control. Review of the facility Policy titled, Pneumonia with revision date 02/15/11, revealed no current review date. The policy sponsor was clinical/infection control. Interview with the facility Infection Control Practitioner, on 01/31/19 at 3:27 PM, revealed she had assumed the infection control role in (MONTH) (YEAR). She stated the Infection Prevention and Control Program Overview policy had not been reviewed or updated in (YEAR). She further stated she was unable to produce an infection control policy with a current date. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed the Infection Control Plan and Policies should be reviewed at least annually. She stated she was new in her role and was unable to produce current infection control policies. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed she was aware of the requirement to review infection control policies and plans on an annual basis. She stated she thought that was done, but could not locate or produce any evidence to support her assertion.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure a [MEDICAL CONDITION] drug (defined as any drug that affects brain activities associated with mental processes and behavior) when ordered PRN (as needed), was limited to fourteen (14) days for one (1) of twenty-one (21) sampled residents (Resident #66). Review of Resident #66's physician's orders [REDACTED]. The findings include: Review of the facility's [MEDICAL CONDITION] Medication Use Policy, revised 11/28/16, revealed the facility would comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual (SOM), and all other applicable law relating to the use of psychopharmacological medications including gradual dose reductions (GDR). Continued review revealed as needed (PRN) orders for [MEDICAL CONDITION] drugs would be limited to fourteen (14) days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond the fourteen (14) days, he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for [MEDICAL CONDITION] drugs would be limited to fourteen (14) days and would not be renewed unless the attending physician or practitioner evaluated the resident for the appropriateness of that medication. Review of Resident #66's medical record revealed facility admitted the resident on 12/15/17 with [DIAGNOSES REDACTED]. Review of Resident #66's Admission Minimum Data Set (MDS) Assessment, dated 12/22/17, revealed the facility assessed the resident as having a Brief Interview for Mental (BIMS) score of seven (7) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #66's physician's orders [REDACTED]. There was no stop date for the medication. Further review of Resident #66's medical record revealed no documented evidence the resident's PRN anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) had been re-evaluated after fourteen (14) days. Continued review revealed no documented evidence the attending physician or the prescribing practitioner had documented the rationale for extending the PRN [MEDICAL CONDITION] medication after fourteen (14) days. Review of Resident #66's Medication Administration Records (MARs), dated December 2017 and January 2018, revealed orders for [MEDICATION NAME] 0.5 milligram (mg) tablet, give one (1) tablet by mouth every eight (8) hours as needed for anxiety, with an order date of 12/15/17. Continued review of the MARs, revealed the resident had been given one (1) dose of [MEDICATION NAME] on 12/15/17, which was the only dose of medication received in December 2017. Further review revealed the resident did not receive the medication in January 2018. Interview on 01/17/18 at 2:14 PM, with Licensed Practical Nurse (LPN) #1, who worked the Rehab to Home Unit and administered medications to Resident #66, revealed she was not aware PRN orders for [MEDICAL CONDITION] drugs needed to be re-evaluated by the attending physician or prescribing practitioner after fourteen (14) days, or that the attending physician or prescribing practitioner needed to document the rationale for extending the medication beyond fourteen (14) days. LPN #1 revealed Resident #66 had only received one (1) dose of the medication during the resident's rehab stay. Interview on 01/17/18 at 3:42 PM, with the Advanced Practice Registered Nurse (APRN), who oversaw the care of Resident #66, revealed she was unaware PRN orders for [MEDICAL CONDITION] medications needed to be reviewed after fourteen (14) days, and was also unaware if the medication needed to be extended after fourteen (14) days, a rationale needed to be documented in the resident medical record. Interview on 01/17/18 at 2:17 PM, with the Interim Director of Nursing (DON), revealed she was unaware PRN [MEDICAL CONDITION] medications needed to be reviewed by the attending physician or prescribing practitioner and a new order obtained after fourteen (14) days. The DON further stated she was unaware the physician needed to write a justification for extending the medication past the fourteen (14) days. Continued interview revealed she was also unaware of the facility's Policy regarding PRN [MEDICAL CONDITION] medication use. After reviewing the Policy, the DON stated the nurses should have contacted Resident #66's attending physician to review the resident's PRN [MEDICATION NAME] order and obtained an order to continue the medication or the medication should have been discontinued after fourteen (14) days. Post Survey interview, on 01/22/18 at 1:20 PM, with the Consulting Pharmacist who provided pharmaceutical services to the facility, revealed the pharmacist was responsible for reviewing each residents' medications on admission and monthly thereafter. She stated when the resident had an order for [REDACTED]. Per interview, it was important for the Pharmacist to review and monitor high risk medications to ensure correct dosing; monitor for drug interactions; monitor lab results for certain medications; monitor GDR; monitor medications related to falls and loss of appetite; monitor for frequency of use of the medication if PRN; monitor for the need to discontinue the medication; and monitor for effectiveness or side effects of the medication. The Consulting Pharmacist revealed without the record in front of her, she was unable to state if she had written a recommendation to stop Resident #66's [MEDICATION NAME] after fourteen (14) days. Interview on 01/17/18 at 4:00 PM, with the Administrator, revealed she expected nurses to communicate with the physician and pharmacy when new orders were received for a PRN [MEDICAL CONDITION] medication requiring the fourteen (14) day timeframe. She stated it was her expectation the pharmacy review the residents' medications and make recommendations to the nurses and physicians as appropriate. The Administrator stated she expected staff to follow the facility's [MEDICAL CONDITION] Medication Use Policy and review orders after fourteen (14) days, and document a rationale for extending the use of the [MEDICAL CONDITION] Medication. She further stated she expected nursing staff to utilize non-pharmaceutical approaches prior to using medication for mood and behavior. .

Based on observation, interview, record review, and review of the facility's guidelines, it was determined the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised after completion of Minimum Data Set (MDS) Resident Assessment Instruments (RAI) for two (2) of four (4) sampled residents, Residents #2 and #4. Resident #4 was assessed as requiring supervision and setup for ADLs (activities of daily living) including transfers, walking in room, walking in corridor, eating, and toilet use, on the 11/15/17 Annual assessment, and supervision and one-person physical assist with dressing and personal hygiene. Resident #2 was assessed as requiring extensive assistance with two-person physical assist with dressing, extensive assistance with one-person physical assist with eating, total dependence with one-person physical assist with bathing, and no impairment in functional limitation in Range of Motion (ROM), on the 10/31/17 Quarterly Assessment; however, the resident's comprehensive care plan, was not updated with new interventions after completion of the MDS Furthermore, when a change was made to the residents care plan after updates related to the MDS Assessment, there were no interdisciplinary notes indicating why the changes were made per the facility's policy. The findings include: Review of the facility's Process for Care Plan Development and Communication policy, revision 09/25/14, revealed that the facility shall follow a care planning process to ensure timely development and updating of the resident's plan of care. The facility must develop a plan of care specific to each resident which help to attain or maintain the residents' highest practical level of function. The care plan should be viewed as a work in progress and changes made as the residents' needs change. It is a process that evolves to meet the needs of the resident over the course of their stay (3.0 Fundamental Information). Changes to any section of the resident care plan must be dated by the discipline making the change. Sections of the care plan include problem statement, approaches/interventions and measurable goals. When there is a change made to the residents care plan, there needs to be an update in the interdisciplinary notes as well. Notes should indicate the changes that were made and why. Nursing summary notes should include progress or lack of progress the resident is making toward the goals. If the resident is not progressing toward the goals the note should address the reason(s) and identify the interventions or approaches to be changes (5.0 Documentation). 1. Review of Resident #4's Annual MDS Assessment, dated 11/15/17, revealed the facility assessed the resident as requiring supervision and set up for ADLs including transfers, walking in corridor, eating, and toilet use. Further review of the MDS, revealed the facility assessed as Resident #4 as requiring supervision and one (1) person physical assist with dressing and personal hygiene. The MDS coded bathing as did not occur. Further review revealed the facility assessed Resident #4 to have a Brief Interview of Mental Status (BIMS) of a six (6) out of fifteen (15) indication the resident was moderately impaired in cognition. Review of Resident #4's Care Area Assessment (CAA) for the Annual MDS Assessment, dated 11/15/17 revealed ADL Function/Rehab Potential and Bathing were triggered conditions and Care planning decision was yes (Y). The CAA further revealed Care plan will be developed due to resident does need assist with his/her ADL's related to decreased mobility, weakness, decrease cognition and debility. Review of Resident #4's Comprehensive Care Plan revised 11/2/17, revealed the resident had increased risk for potential Limitation(s) in the ability to perform ADLs related to decreased mobility with weakness. The goal, revised 11/22/17, stated; I will maintain current level of function through my next review date. The intervention, Transfer: I am independent with transfers, revision date 01/25/17, did not specify need for supervision. The intervention, I require use of a walker and am independent with ambulation, revision date 08/09/17, did not specify need for supervision and setup. The intervention, Eating, provide me with meal tray setup, revision date 11/10/16, did not specify need for supervision and setup. Observation of Resident #4, on 01/03/18, at 1:15PM, revealed Resident #4 was sitting at dining room table by nursing station, eating/sucking on his/her roast beef. Resident #4 verbalized he/she could not eat roast beef. Resident #4 stated, I told them before, I have asked for soup, but I did not get it. Review of the meal ticket revealed Soup was written on meal ticket, on the tray. Licensed Practical Nurse (LPN) #2, brought the resident's lower denture to the table. Resident #4 stated the denture did not fit right and had been missing a long time. Resident #4 put denture in mouth as instructed by LPN #2. Resident #4 took a bite of the roast beef and LPN #2 asked if that was any better. Resident #4 stated no, and declined the denture. When LPN #2 was asked who was responsible for assisting resident with dentures, LPN #2 advised resident was Independent. Further observation revealed soup was provided to the resident before the meal ended. Interview with State Registered Nursing Assistant (SRNA), #4, on 01/05/18, at 1:10PM, revealed Resident #4 did require routine setup and supervision assist with meal trays; cut meat, open drinks, open straws. SRNA #4 stated the resident mostly goes on his/her own but does require occasional, prompts and cues and stated the resident asked for different foods from time to time. The Intervention, Toilet use: I am independent with toileting. Bedside commode elevator to be used as ordered, revision date 01/25/17, did not specify need for supervision and setup. The intervention, I am independent with my dressing, grooming, hygiene and oral care needs after setup, revision date 08/09/17, did not specify need for supervision with one-person physical assist. Comprehensive Care Plan initiated on 6/20/16, revealed the resident utilized dentures secondary to all his/her teeth being gone. The goal, revised 11/22/17, stated; I will be free from complications thru my next review. Interventions, I will wear upper and lower dentures; revised 6/20/2016. The intervention, take me to the shower room two (2) times a week and as needed. I will often decline showers, as I prefer bed baths, revision 11/10/2016, did not specify need for level of assist need for bathing. Further review of Resident #4's medical record, ADL- EATING INTAKE, dated 12/03/17 through 01/04/18, revealed Resident #4 usually ate fifty percent (50%) of meals. Review of Physician orders, dated 01/09/17, revealed orders for Nutritional Supplement, Ensure, two (2) times a day related to weight loss or wound healing. 2. Review of Resident #2's Quarterly MDS Assessment, dated 10/20/17, revealed the facility assessed the resident as requiring extensive assist with two-person physical assistance for dressing; extensive assistance with one-person physical assistance for eating: total dependence with one-person physical assistance for bathing. Further review of the MDS, revealed coding for Functional Limitation in Range of Motion: No impairment. Review of the BIMS status revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) indicating the resident had no cognitive impairment. Review of Resident #2's Comprehensive Care Plan, revised 04/24/17, revealed the resident was at at risk for alteration in ADL functioning related to decreased mobility with weakness and decreased cognition. The goal, revised 10/17/2017, stated; I will improve current level of function thru my next review. The intervention: I require assist of one (1) with my dressing, revision date 06/23/2017, did not specify need for two-person physical assistance. The intervention: Provide me with meal tray setup, revision 06/23/2017, did not specify need for extensive assist with one-person physical assistance. Review of Resident #2's medical record revealed ADL- EATING, dated 12/01/17 through 01/04/18, revealed Resident #2 usually ate greater than fifty percent (50%) of meals. The intervention: Take me to the shower room two (2) times a week and as needed, revision 06/23/2017, did not specify need for total dependence with one-person physical assistance. Review of Resident #2's Comprehensive Care Plan, revised 08/09/17, revealed the resident required Restorative Programming, related to need for bilateral upper extremity strengthening and wheelchair positioning. The goal, revised 10/19/17, stated: I will be stronger and more independent and have improved wheelchair positioning. Further review of Resident #2's medical record, NUR FUNCTIONAL EVALUATION-V2, revealed a change in Functional Limitation in Range of Motion: bilateral upper and lower extremity impairment, dated 07/18/17 and 04/25/17, and no impairment on evaluation dated 10/18/17. Observations of Resident #2, on 01/03/18, at 4:15 PM, revealed Resident #2 sitting in room with bedside table in front of wheelchair, call bell within reach. Noted tremor to right hand, right hand postured with first and second fingers partially closed. Resident needing assistance with getting cordless phone from middle of beside table and repositioning left leg up on wheelchair foot rest with calf support. Assistance was provided by Registered Nurse (RN) #1. Interview with Resident #2, on 01/03/18, at 4:15 PM, revealed the resident had difficulty doing things with his/her hands and arms related to a serious spinal accident. Interview with Resident #2's Private Sitter #1, on 01/04/18, at 6:10 PM, revealed the resident required extensive to total assistance with meals related to his/her hands and the sitter stated the resident ccould eat finger food independently; however, it took him/her a long time. Private Sitter #1 stated he/she helps the resident four (4) days a week from 5:00 PM to 9:00 PM. Interview with Resident #2's Private Sitter #2, on 01/08/18, at 1:00PM, revealed that Resident #2 required extensive to total assistance with meals related to the resident's poor hand mobility. Private Sitter #2 revealed he/she assists the resident daily with breakfast and lunch meals, approximately twenty-five (25) hours a week. Interview with SRNA #4, on 01/05/18, at 1:10 PM, revealed Resident #2 had a private sitter at almost every meal to assist the resident and that occasionally staff assist the resident during meals. SRNA #4 stated staff did more than resident when assisting with meals and that Resident #2 could help a little but staff fed the resident for the most part. Interview with Licensed Practical Nurse (LPN) #1, Unit Coordinator, on 01/04/18 at 5:25 PM, and 01/05/18, at 3:52 PM, revealed the MDS assessments and comprehensive care plans should be individualized for each resident related to their ongoing needs and followed by all staff. It was expected that assessments and revisions of the comprehensive care plan were ongoing and should be updated/revised timely. Care plans and ADL coding, should match the resident's care needs. If it did not match, the care plan should be updated to match the resident care needs. Interview with Registered Nurse (RN)/MDS #1, on 01/04/18 at 6:37 PM and 01/05/18, at 3:09 PM, revealed data was gathered during MDS assessment periods and ongoing by chart review, staff interviews, and observation of individual residents on the unit during hands on care. Care plans were revised with new orders, changes in condition, Quarterly and Comprehensive MDS assessments and as necessary. RN #1 stated that Resident #4 was pretty independent with his/her ADLs. It was not necessary, to change the ADL care plan from supervision to Independent with eating because staff always supervise residents; it was not a big difference. Interview with LPN/MDS, #2, on 01/05/18, at 4:35 PM, revealed Care Plans were revised with changes in condition, new orders, observations of change, reports of change from staff, with Quarterly and Comprehensive MDS assessments. The Resident Assessment Instrument (RAI) manual, interview of direct care staff, chart reviews and direct observation are used to accurately assess residents. The Rule of 3 (three) was used to code to the highest level of assistance when fluctuating ADLS are noted during the Assessment Reference Date (ARD) period. LPN stated that Resident # 2 is cognitively able to ask for assistance and is able to eat independently. That is why there were no changes to the care plan; It is accurate. During the ARD the level of assistance fluctuated. Interview with the Director of Nursing (DON), on 01/04/18 at 6:20 PM, and 01/05/18 at 5:06 PM, revealed it was expected that the Comprehensive Care Plan was updated with each MDS Assessment, resident individualized preferences, physician's orders [REDACTED]. Per interview, it was expected that MDS nurse's communicate to the floor staff routinely related to changes/revisions to the comprehensive assessment and care plan. The resident, MDS assessment, and care plan should all match after completion of MDS assessment. The ADL assessment reflects the true level of assistance the resident requires and should be based on observations and interviewing and match the current care plan. The Care plan is ongoing and should be a current, true reflection of the resident. Interview with the Administration, on 01/05/18, at 5:32PM, revealed Care plan revisions are expected as changes to residents occur as needed. Per interview, Assessments and Care Plans should reflect the resident's current needs.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans were reviewed and revised to implement interventions to provide adequate supervision for one (1) of ten (10) sampled residents (Resident #1) who was assessed at risk for wandering and/or exit seeking behaviors. The facility assessed Resident #1 to have wandering and exit seeking behaviors. On 08/08/14, Resident #1 was agitated and exhibited increased wandering and exit seeking behavior. At approximately 5:45 PM, Resident #1 pushed open the fire exit door on the Magnolia Unit setting off the alarm and went through the door onto the small concrete porch area. Staff responded to the alarm and Resident #1 was returned to the Magnolia Unit day area and placed on fifteen (15) minute checks. However, staff was not aware they needed to have Security Staff come and re-set the fire exit door and ensure the alarms were functioning appropriately. Between 7:45 PM and 8:00 PM on 08/08/14, Resident #1 eloped from the facility without staff's knowledge through the unsecured fire exit door on the Magnolia Unit. Resident #1 was found by the Social Services Director (SSD) at approximately 8:15 PM lying on the sidewalk approximately seven (7) feet from a busy city road, with skin tears to the left forearm and right knee. In addition, interviews revealed Resident #1 had increased behaviors of wandering, exit seeking, and agitation on the days the resident's daughter did not visit. However, the facility failed to revise the resident's care plan to address these behaviors to ensure the resident remained safe. (Refer to F-323) The facility's failure to have an effective system in place to ensure residents' Comprehensive Care Plans were reviewed and revised to implement interventions to provide adequate supervision was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/12/14 and was determined to exist on 08/08/14. An acceptable credible Allegation of Compliance (AOC) was received on 09/16/14 which alleged removal of the Immediate Jeopardy on 09/16/14. The Immediate Jeopardy was verified to be removed on 09/16/14 with remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment (F-280) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure residents' Comprehensive Care Plans are reviewed and revised to implement interventions to provide adequate supervision of residents. The findings include: Review of the facility's policy titled, "Resident Safety Program: Wandering and Elopement", revised 10/31/07, revealed Policy's purpose for provision of a system to identify residents at risk for "unsafe wandering and elopement". The Policy stated if a resident was determined to be at risk for wandering potentially leading to elopement, an individualized care plan was to be immediately implemented and reviewed with staff to ensure the resident's safety. Per the Policy the care plan was to include interventions to minimize the potential for resident elopement, and the frequency and responsibility for monitoring the resident's location in the facility would be identified in the care plan. Further review of the Policy revealed if a resident was missing the care plan was to be updated. Review of the facility's policy titled, "Process for Plan of Care Development and Communication" dated 07/01/10, revealed the facility should follow a care planning process to ensure timely development and updating of residents' care plans. The Policy revealed the Registered Nurse (RN) was responsible to review all aspects of residents' care plans. Per the Policy, the care plan was to be viewed as a "work in progress" and changes made to it as residents' needs changed. Per the Policy, the direct care nurse was to update residents' care plans as resident's needs changed, with a note made in the Interdisciplinary Notes of the resident's medical record. Record review revealed the facility admitted Resident #1's on 01/26/12, with [DIAGNOSES REDACTED]. Review of the 06/24/14 Annual Minimum Data Set (MDS) Assessment, revealed the facility assessed Resident #1 to be severely cognitively impaired. Review of the Wandering/Elopement Risk Review Tool, dated 06/24/14 revealed the facility assessed Resident #1 as at risk for elopement. Review of Resident #1's Comprehensive Care Plan (CCP), dated 05/11/12, revealed Resident #1 was care planned for the risk for wandering/exit seeking behavior, mainly at night with interventions which included offering snacks of choice and trying to redirect to other activities, offering to call the resident's family when behaviors escalated, offering reassurance his/her family would come to visit, soothing the resident by talking to him/her about his/her "kids" and observing the resident for exit seeking behaviors. Review of the facility's "Self-Reported Incident Form, 5 Day Follow Up/Final Report" form, dated 08/13/14, revealed on 08/08/14 an attempt to elope from the facility was made by Resident #1 through the Magnolia Unit fire exit door. Review revealed Resident #1 successfully opened the door and stepped outside the door onto the small porch area. Per the Form, Resident #1 was hard to re-direct, was taken for a walk outside around the facility and returned to the Magnolia Unit where he/she was given a snack. The Form revealed Resident #1 continued to be "agitated" and wandered to another unit and brought back to the Magnolia Unit where he/she resided. Per the Form, at approximately 8:00 PM, Resident #1 was missing and RN #1 searched the Magnolia Unit and other units, but was unable to locate the resident. According to the Form, at approximately 8:15 PM, Resident #1 was observed lying on the sidewalk outside the facility with skin tears to his/her left forearm and right knee. Interview with Resident #1's daughter and Power of Attorney (POA) on 09/12/14 at 10:28 AM and on 09/17/14 at 6:35 PM, revealed she did not visit the resident on Tuesdays and Fridays and on those days Resident #1 didn't do "very well at all" and tried to go home "constantly". Per interview, she was notified, on 08/08/14, Resident #1 successfully eloped from the facility without staff knowledge, and was found outside on the sidewalk. She stated this was one (1) of the days she didn't visit Resident #1. Per interview, sometimes on the days she didn't visit, staff would call her and let the resident talk to her which calmed calmed the resident down. However, she did not receive a call on 08/08/14 prior to the elopement. Resident #1's daughter/POA was concerned with Resident #1's successful elopement on 08/08/14, and wondered what would have happened had the resident made in onto the busy road near where he/she was found. Interview, on 09/11/14 at 11:09 AM and on 09/12/14 at 7:17 PM, with RN #1 revealed Resident #1's behaviors were worse on days his/her daughter did not visit, and on Friday 08/08/14, a day the resident's daughter didn't visit, Resident #1 was distressed, very anxious, and more agitated. Per interview, on the days Resident #1's daughter did not visit it was "usually harder" to care for Resident #1. Interview with State Registered Nursing Assistant (SRNA) #4 on 09/11/14 at 5:45 PM, revealed on days his/her daughter did not visit the resident was "worse", wandering "a lot" more, "hard to keep an eye on" and trying to get out the doors. Interview, on 09/11/14 at 11:40 AM, with Licensed Practical Nurse (LPN) #5 revealed she knew on the days Resident #1's daughter did not visit the resident's behaviors were worse, and he/she was "more anxious". Interview, on 09/11/14 at 11:45 AM, with LPN #3 revealed on Tuesdays and Fridays when the resident's daughter didn't visit his/her behaviors were "worse", usually more confused and wandered more, and staff had to keep a closer eye on the resident. Interview, on 09/11/14 at 4:15 PM, with LPN #6 revealed she was very familiar with Resident #1 and knew when his/her daughter didn't visit the resident experienced increased wandering, agitation and would be searching for "people" like his/her "kids". Interview, on 09/11/14 at 8:45 PM, with RN #4/House Supervisor revealed she knew on Tuesdays and Fridays when Resident #1's daughter did not visit he/she became "really agitated", and roamed about much "worse" on those days. She stated on those days Resident #1 needed "increased supervision". However, record review revealed no documented evidence Resident #1's care plan interventions were revised to address the resident's increased behaviors of exit seeking on days the resident's daughter did not visit. Interview, on 09/12/14 at 5:17 PM and 5:37 PM, with MDS #1 and MDS #2 revealed MDS #1 was responsible for Resident #1 MDS Assessments and care plans. MDS #2 stated the MDS nurses were "constantly updating" residents' care plans, and the nurses and Unit Coordinators could also update the care plans. MDS #1 stated she was aware Resident #1 had behaviors of exit seeking, wandering, getting confused, "calling" out for family, and stated staff had reported Resident #1 was "worse" on days his/her daughter didn't visit with increased wandering and agitation, but she had not witnessed these behaviors. According to MDS #1, she had heard staff say "that for quite awhile"; however, without witnessing this herself she would not know if the resident required increased supervision on those days. MDS #1 stated she guessed increased supervision on the days Resident #1's daughter didn't visit might have been an appropriate intervention; however, the care plan was not revised to include increased supervision. MDS #2 and MDS #1 stated also, if a resident had experienced an elopement attempt previously the care plan should have been revised to include more frequent monitoring than every fifteen (15) minute checks, such as one on one (1:1) supervision. The MDS Nurses stated Resident #1's care plan should have been updated and revised on 08/08/14 for increased supervision after the first elopement attempt, and to address the increased behaviors on days his/her daughter didn't visit. Interview, on 09/11/14 at 10:10 AM and on 09/12/14 at 7:42 PM, with the Director of Nursing (DON) revealed on 08/08/14 after Resident #1's elopement his/her care plan would not have been revised if staff felt it met the resident's needs, but stated in looking back it should have been revised with increased supervision after the first elopement attempt. She stated she was not aware of Resident #1's increase behaviors when his/her daughter did not visit; however, indicated the resident's care plan should have been updated to include this information, and if necessary for increased supervision of Resident #1 on those days. Interview, on 09/11/14 at 10:10 AM and on 09/12/14 at 8:42 PM, with the Administrator revealed prior to 09/11/14, he had not been aware on days Resident #1's daughter did not visit the resident had increased behaviors, and indicated the care plan could have been revised for increased supervision on those days. The Administrator reported staff should revise residents' care plans anytime it was necessary. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 09/16/14, which alleged removal of the Immediate Jeopardy (IJ), effective 09/16/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on one on one (1:1) supervision by the Director of Nursing (DON) at 11:00 PM on 09/12/14. Ongoing 1:1 assignment would be determined by the licensed nurse and identified on the daily staffing sheet. A sign in log was to be used to record the time each assigned staff member assumed responsibility for the resident for tracking purposes. 2. The Wandering Risk Care Plan problem was updated on 09/12/14 at 11:00 PM by the DON for Resident #1 to include increased 1:1 supervision. Resident #1's daughter was notified on 09/12/14 at 11:05 PM by the licensed nurse that the resident's care plan had been updated with this information. The Advanced Practice Registered Nurse (APRN) was made aware on 09/13/14 by the licensed nurse of the need to change the resident's care plan. 3. Resident #1 would remain on 1:1 supervision until Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and State Registered Nurse Aides (SRNA's) had been re-educated by the DON and Staff Development Coordinator on consistently implementing the care planned interventions to decrease risk of further elopement events. Any RN, LPN, or SRNA not receiving this education by 09/15/14 would receive the education prior to working their next scheduled shift. 4. The Care Plan for Resident #1 was reviewed on 09/15/14 by the Interdisciplinary Team which included the DON, Minimum Data Set (MDS) Nurse, Social Worker, Unit Coordinator, and Therapy to re-evaluate current interventions related to wandering and behavior episodes. Resident #1 received showers on Tuesdays and Fridays and this intervention was updated to reflect additional showers as needed since showers had been effective in the past to help calm behaviors. 5. A total of thirteen (13) additional residents identified with increased wandering risk behaviors based on their most recent Wandering/Elopement Review Form, were reviewed on 09/15/14 by the Interdisciplinary Team (IDT) that included the DON, MDS Nurse, Social Worker (SW), Unit Coordinator (UC), and Therapy to re-evaluate current interventions, problems and goals related to wandering and behavior episodes. These care plans were updated with any changes to the identified problem, goals and interventions for direct care staff to implement when residents exhibit increased wandering behavior. 6. Staff education was initiated by the DON on 09/12/14 at 11:00 PM for direct care nursing staff, which included RN's, LPN's, and State Registered Nurse Aides (SRNA's), in reference to; Resident #1 must remain in visual contact of the assigned staff member at all times. This education also included instructions that in the event of any resident's attempt to exit the facility they must immediately notify the DON or Administrator and interventions must be initiated per the resident's individualized plan of care to decrease risk of another elopement attempt. This re-education also included information that in the event a door alarm was triggered, a staff member was to be stationed at the doorway until security was notified and the alarm returned to normal operation. A sign had been placed on each exit door stating "if an alarm sounds you must call security to reset". Staff members verbalized understanding of these instructions at the time of the education. Out of seventy-nine (79) full time employees, sixty-five (65)would receive the above education by 09/15/14. Out of eight (8) part time employees, four (4) would receive the education by 09/15/14. Out of thirty-nine (39) as needed (prn) employees, twenty (20) would receive the above education by 09/15/14. This training would continue to be provided by the DON, House Supervisor, UC's, and Staff Development Coordinator for RN's, LPN's, and SRNA's prior to their next scheduled shift until all have been educated on this information. A bulleted point sheet containing this education was developed by the DON and placed in the new hire packets for ongoing training for all newly hired employees. Lexington Country Place did not utilize agency staff. 7. Ongoing monitoring included a daily Quality Assurance Performance Improvement (QAPI) review of Nurse's Notes, Care Plans, and any new physician's orders [REDACTED].#1. This audit would be conducted and documented daily, including weekends, on an audit tool by the DON, UC, and/or House Supervisor to identify any new elopement attempts and to monitor that staff was documenting care planned interventions for increased behaviors of anxiety or agitation and for the effectiveness of these interventions. Any issues identified in these audits would be addressed as indicated, based on the direction of the DON. 8. The evening and night shift security staff was educated on parameters for testing the secondary red box alarms ("Stop" back up alarm) located on the fire safety doors on 09/12/14 and 09/13/14 by the Administrator. These instructions included to allow the red box's audible alarms to sound for a minimum of fifteen (15) seconds when being tested to ensure they maintain a sustained volume level within normal range. Instructions also included, in the event of a low or weak sounding alarm, a staff member was to be stationed at the doorway until the Administrator was notified and the battery was replaced and the alarm was returned to normal operation. These tests would be documented on the Door Inspection of three (3) times a day by Security and Maintenance Staff. A sign was placed on each exit door stating "if alarm sounds you must call security to reset". Staff members verbalized understanding of these instructions at the time of the educations. 9. Other security and maintenance staff would be educated on the minimum fifteen (15) second testing parameter procedure prior to working their next scheduled shifty by the Administrator or Director of Security and Transportation. Seven (7) of twelve (12) Maintenance and Security employees would have received this education by end of day on 09/15/14 and there was five (5) additional Security and Maintenance employees who would receive this education prior to working their next scheduled shift. Education on this door testing parameter procedures would be included as part of the new hire orientation provided to new Security and Maintenance Staff which was conducted by the Director of Security and Transportation and the procedure would be reviewed annually ongoing with Security and Maintenance staff by the Director of Security and Transportation and Director of Plant Operations under the direction of the Administrator. 10. Door alarms, including the delayed egress on the fire safety door and the secondary red box alarms located on the fire safety doors would continue to be checked by Security and Maintenance Staff a minimum of three (3) times each day, including on weekends. Testing would be conducted on each shift by sounding the alarm for a duration of at least fifteen (15) seconds. In the event the alarm does not sound at at sustained volume level within range, a staff member would be posted at the door and the problem would be immediately reported to the Administrator. A staff member would remain at the door until Maintenance and the Administrator were notified and the battery was replaced and the alarm was returned to normal operation. Batteries in the secondary red box alarms would be changed a minimum of monthly. This battery change would be documented in the facility's TELS system. The Administrator would verify this on at least a monthly basis. 11. Elopement /Missing Resident Drills would be conducted daily on alternating shifts, including weekends, for a minimum of two (2) weeks by the Staff Development Coordinator and Administrator. An Elopement/Missing Person Drill Evaluation Form would be completed with each drill. 12. Ongoing monitoring would also include completion of Elopement/Missing Resident Drills at a minimum of four (4) times a year. One (1) drill would be held on each shift and on a weekend day. An Elopement/Missing Person Drill Evaluation Form would be completed for each drill held. The facility would develop an action plan for staff education and correction of issues if encountered during the drills. Monitoring would also include a daily QAPI review of the Door Inspection Logs by the Administrator and/or Director of Security and Transportation. The Administrator would initial these logs to indicate review. Any issues identified would be addressed as indicated by the Administrator and documented on the QAPI tool. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the One on One Staff Observation Log, revealed Resident #1 was placed on 1:1 observation on 09/12/14 at 11:00 PM. Continued review of the One on One Staff Observation Log revealed Resident #1 was still on 1:1 observation as of 09/18/14 at the time of the survey. Per the Observation Log the date and time was recorded for each staff member who was resuming responsibility for the resident. Review of the daily staffing sheets from 09/12/14 through 09/18/14 revealed the person responsible for the 1:1 observation of Resident #1 was identified. 2. Review of Resident #1's Wandering Risk Care Plan revealed an update on 09/12/14 with an intervention for 1:1 observation. Review of the Nurse's Note dated 09/12/14 at 11:05 PM, revealed Resident #1's daughter was informed of the resident being on 1:1 care and was agreeable. Review of the Nurse's Note dated 09/13/14 at 1:14 PM, revealed the APRN was notified of the resident being placed on 1:1 observation continuously. 3. Interview on 09/18/14 at 2:30 PM with SRNA #9 and at 2:45 PM with LPN #1 who worked the Magnolia Unit where Resident #1 resided, verified Resident #1 was still on 1:1 observation. Interview with the DON on 09/18/14 at 6:00 PM revealed staff was not allowed to work until they received inservices including implementing care plan interventions to decrease risk of further elopement events and Resident #1 would remain on 1:1 until all staff had been educated. 4. Review of Resident #1's Care Plan revealed it was revised on 09/15/14 to include an intervention for showers Tuesdays, Fridays and as needed. Interview, on 09/18/14 at 7:20 PM, with the DON revealed the Interdisciplinary Team (IDT) met and reviewed Resident #1's care plan to re-evaluate current interventions related to wandering. 5. Review of the Care Plans for the thirteen (13) residents who were identified with increased wandering behaviors based on their most recent Wandering/Elopement Review Form, revealed the care plans were reviewed and revised on 09/15/14 by the IDT. Changes were made to the care plans with additional interventions for direct care staff to implement when the resident exhibited increased wandering behaviors. Also, some of the Care Plans problems and goals were updated related to the resident's wandering behaviors. 6. Review of the inservice information and Attendance Record revealed inservices began on 09/12/14 and continued each day and were still taking place for nursing staff including RN's, LPN's and SRNA's related to the following; 1) Resident #1 to remain in visual contact at all times and a sign in sheet must be completed by each staff member who was assigned to the resident for one on one observation, 2) in the event of any resident's attempt to exit the facility the DON or Administrator must be notified immediately and interventions must be initiated per the resident's individualized plan of care to decrease the risk of another elopement attempt, 3) if there was a weak or low sounding battery or if a door was opened for any reason, a staff member must be stationed at the doorway until the alarm was returned to normal. Observation of the facility exit doors on 09/18/14 from 5:00 PM until 5:30 PM revealed signs on the doors or beside the doors which stated "if an alarm sounds you must call security to reset". As of 09/18/14 all employees but three (3) full time employees, two (2) part time, and thirteen (13) employees had not received the education. Further review revealed a total of seventy-four (74) full time, six (6) part time, and twenty-seven (27) prn staff had received the inservice education. Interview with the DON on 09/18/14 at 7:20 PM, revealed the inservice education started on 09/12/14, and is ongoing. She stated at change of shift, administrative staff stand by the time clock, and anyone who has not received the inservice was not allowed to work until they had been educated. Further interview revealed the Staff Development Coordinator, and House Supervisors assisted with the education. Interview on 09/18/14 at 11:56 AM with the Staff Development nurse revealed a bullet point sheet containing the inservice education was placed in the new hire packet for all newly hired employees. She confirmed the facility did not utilize agency staff. Interview on 09/18/14 with SRNA #9 at 2:30 PM, with LPN #1 at 2:45 PM, LPN #8 at 3:23 PM, with SRNA #16 at 4:00 PM, with SRNA #17 at 4:17 PM, revealed they had been inserviced and trained ensuring Resident #1 remained in visual contact, they must immediately notify the DON or Administrator of any other residents' attempt to exit and that interventions must be initiated, to ensure someone was stationed at any fire exit door alarm which had been triggered until Security returned the door alarm to normal operation. 7. Review of the Daily QAPI Chart Review Tool, revealed daily audits starting 09/13/14 through 09/18/14 of physician's orders [REDACTED]. Interview with the DON on 09/18/14 at 7:20 PM, revealed administrative nursing staff was checking new physician's orders [REDACTED]. She stated she reviewed all the audits and was checking for any escalating behaviors she was unaware of, so she could address the behaviors. She further stated the audits would continue until it was decided in the QAPI meeting that the audits could stop. 8. Review of the Staff Inservice Summary and Attendance Record revealed the Administrator educated Maintenance and Security staff on 09/12/14 through 09/16/14 related to the following; allow audible door alarms (red boxes) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door checks daily every shift, the Door Alarm Inspection Form must have the timing of these tests documented (document the seconds the door alarm sounds), any problems noted during the door inspections must be reported immediately to the Administrator and Maintenance, and in the event of a weak or low sounding alarm a staff member was to be stationed at the doorway until the Administrator was notified and the battery was replaced and the alarm was returned to normal operation. Observation of the facility exit doors revealed a sign on the door or beside the door which stated, "if alarm sounds you must call security to reset". Interview, on 09/18/14 with Security Guard #3 at 6:00 PM revealed he was educated on the minimum fifteen (15) second testing parameter procedure to ensure the alarm maintained a sustained volume within normal range, and in the event of a low or weak sounding alarm a staff member was to be stationed at the doorway until the Administrator was notified and the battery replaced. 9. Interview with the Administrator on 09/18/14 at 8:00 PM revealed Security and Maintenance staff had been educated related to allowing audible door alarms (red boxes) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door checks daily every shift. He stated if the alarm did not work or had a low volume, security or maintenance was to notify him and someone was to guard the door until the alarm was fixed. He further stated maintenance was checking the door alarms on the day shift and security was checking the alarms on 2nd and 3rd shifts. Continued interview revealed maintenance and security was documenting checking the door alarms on separate door inspection logs, and he verified this was being done by checking the logs daily. He stated there was one (1) more security employee to educate because he was on vacation; however, the rest of the maintenance and security staff had been educated by him or the Director of Security. Further interview revealed this training would be provided as part of the new hire orientation provided to new hires for maintenance and security and would also be reviewed at least annually ongoing with maintenance and security staff. Interview with the Maintenance Director on 09/18/14 at 5:30 PM, revealed he was educated on the testing of the door alarms by the Administrator. He stated maintenance staff checked the doors each day on day shift. Continued interview revealed they were to allow the audible door alarms (red box) to sound for at least fifteen (15) seconds when being tested . He stated if the door alarms did not work, they were to have staff guard the door until the alarm was fixed. He further stated if there was a concern with the door alarms they were to notify the Administrator. Interview with Security Guard #3 on 09/18/14 at 6:00 PM, revealed he had received education on 09/13/14 related to allowing the audible door alarms (red box) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door on evening and night shift. Continued interview revealed if the alarm did not work or had a low volume, the Administrator was to be notified, and a staff member was to guard the door until it was fixed. He stated security checked the door alarms on evening and night shift. 10. Review of the Door Inspections Log revealed the door alarms including the delayed egress on the fire safety door and the secondary red box alarms were being checked three (3) times a day 09/12/14 through 09/18/14. Review of the Red Box Emergency Door Battery Change Log, revealed the batteries were changed on 08/09/14 for the secondary red box alarms. Continued interview with the Administrator on 09/18/14 at 8:00 PM, revealed the batteries on the secondary Red Box alarms would be changed monthly and documented on the battery change log. 11. Review of the Elopement/Missing Resident Drill Evaluation Forms revealed drills were performed on 08/13/14, 08/19/14, 08/20/14 for all three (3) shifts and weekend personnel, and on 09/15/14 at 6:45 PM, 09/17/14 at 6:36 AM. Interview on 09/18/14 at 11:56 AM with the Staff Development Nurse revealed since the Immediate Jeopardy was called, they were doing elopement drills more frequently and at different times of the day. She stated she had done one (1) of the drills and was told on 09/15/14 they would be doing the drills daily. Interview on 09/18/14 at 7:20 PM, with the DON, and the Consultant DON, revealed they had been participating in the elopement drills which were being done daily, on different shifts and on weekends as well which were being done by the Staff Development Coordinator and the Administrator. Interview on 09/18/14 with SRNA #9 at 2:30 PM, with LPN #1 at 2:45 PM, with Laundry Worker #1 at 3:10 PM, with Housekeeper #1 at 3:20 PM, LPN #8 at 3:23 PM, with SRNA #16 at 4:00 PM, with SRNA #17 at 4:17 PM, revealed they had been inserviced and trained on elopement and elopement drills had been taking place since 09/12/14. 12. Interview with the Administrator on 09/18/14 at 8:00 PM, revealed education started on 09/12/14 and was ongoing related to elopement drills, elopement policy, and door alarms. He stated the elopement drills were to be performed every day for two (2) weeks, then depending on if there was opportunity for improvement they may be done monthly. He stated after a drill and Evaluation was completed and the results were summarized. He stated if there was a problem identified with the drills, an action plan would be developed and staff would be re-educated. He further stated there would be a daily QAPI review of the Door Inspection Logs and he would initial the logs to indicate they were reviewed. The Administrator further stated if a concern was identified with the door alarms, re-education would be done and the problem would be addressed. Continued interview revealed through the QAPI process, they would identify weak areas and issues identified would be addressed and documented on the QAPI tool.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans were implemented to ensure monitoring, safety and supervision for one (1) of ten (10) sampled residents (Resident #1) who was assessed at risk for wandering and/or exit seeking behaviors. On 08/08/14, Resident #1 was agitated and exhibited increased wandering and exit seeking behavior. At approximately 5:45 PM, Resident #1 pushed open the fire exit door on the Magnolia Unit setting off the alarm and went through the door onto the small concrete porch area. Staff responded to the alarm and Resident #1 was returned to the Magnolia Unit day area and placed on fifteen (15) minute checks. However, staff was not aware they needed to have Security Staff come and re-set the fire exit door and ensure the alarms were functioning appropriately. Between 7:45 PM and 8:00 PM on 08/08/14, Resident #1 eloped from the facility without staff's knowledge through the unsecured fire exit door on the Magnolia Unit. Resident #1 was found by the Social Services Director (SSD) at approximately 8:15 PM lying on the sidewalk approximately seven (7) feet from a busy city road, with skin tears to the left forearm and right knee. Interviews with staff revealed the resident exhibited agitation, was hard to redirect, and had increased exhibit seeking behavior on days the daughter did not visit. Review the care plan revealed interventions to call the daughter to calm the resident. However, staff failed to implement this intervention on 08/08/14. (Refer to F-323) The facility's failure to have an effective system in place to ensure residents' Comprehensive Care Plans were implemented to ensure monitoring, safety and supervision for residents assessed as at risk for wandering and/or exit seeking behaviors was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/12/14 and was determined to exist on 08/08/14. An acceptable credible Allegation of Compliance (AOC) was received on 09/16/14 which alleged removal of the Immediate Jeopardy on 09/16/14. The Immediate Jeopardy was verified to be removed on 09/16/14 with remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment (F-282) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure to ensure residents' Comprehensive Care Plans were implemented to ensure monitoring, safety and supervision for residents assessed as at risk for wandering and/or exit seeking behaviors. The findings include: Review of the facility's policy titled, "Resident Safety Program: Wandering and Elopement", revised 10/31/07, revealed if a resident was determined to be at risk for wandering and/or elopement, the facility would develop an individualized care plan which should be reviewed with staff and immediately implemented for ensuring safety of the resident. Review of the facility's policy titled, "Process for Plan of Care Development and Communication" dated 07/01/10, revealed the purpose of the Policy was to ensure effective delivery of comprehensive, coordinated quality care in an organized manner designated to meet the ongoing individualized needs of residents. The Policy revealed the Registered Nurse (RN) was responsible to review all aspects of residents' care plans, and direct care staff should be "directly" involved in the care planning process as they spent the most time with residents. Review of the facility's "Self-Reported Incident Form, 5 Day Follow Up/Final Report" form, dated 08/13/14, revealed Resident #1 attempted to exit the facility on 08/08/14 at about 6:15 PM through the Magnolia Unit fire exit door. The Form noted Resident #1 was hard to re-direct, so State Registered Nursing Assistant (SRNA) #5 took the resident for a walk, and every fifteen (15) minute checks were implemented when the resident returned to the Magnolia Unit. Per the Form, Resident #1 remained "agitated", wandered to another unit and had to be brought back to the Magnolia Unit. Continued review of the Form revealed Resident #1 was missing again from the Magnolia Unit at about 8:00 PM, and Registered Nurse (RN) #1 searched the unit and other units. The Form noted Resident #1 was found outside the facility at approximately 8:15 PM, by the Social Service Director (SSD), and the resident had sustained skin tears. Review of Resident #1's record revealed the facility admitted Resident #1 on 01/26/12, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/24/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was severely cognitively impaired. Review of the Wandering/Elopement Risk Review Tool, revealed Resident #1 was assessed to be at risk for elopement on 06/24/14. Review of Resident #1's Comprehensive Care Plan (CCP), dated 05/11/12, revealed Resident #1 was care planned to be at risk for wandering/exit seeking behavior, mainly at night with interventions in place which included calling family if behaviors escalated, soothing the resident by talking to him/her about his/her children, observing Resident #1 for exit seeking behaviors, trying to redirect to other activities and offering snack of his/her choice. Interview, on 09/12/14 at 10:28 AM and on 09/17/14 at 6:35 PM, with Resident #1's daughter/Power of Attorney (POA) revealed on Tuesdays and Fridays when she didn't visit the resident, he/she did not do "very well at all", and staff had a "hard time" with him/her on days she didn't visit. Per interview, on those days Resident #1 "constantly" tried to go home, and on 08/08/14 she was notified the resident had eloped from the facility without staff's knowledge. Continued interview revealed 08/08/14 was a Friday, and "of course was one (1) of the nights" she didn't visit Resident #1; however, if they had called her as they sometimes did and let her talk to the resident in might have calmed him/her down and prevented the elopement. Resident #1's daughter/POA was concerned after learning of the successful elopement, and wondered "what would have happened if" he/she "had gotten onto" the busy road near where he/she was found on 08/08/14. Interview, on 09/11/14 at 2:55 PM, with SRNA #5 revealed he walked Resident #1 around the facility outside after his/her first elopement attempt on 08/08/14. SRNA #5 stated after the walk he took Resident #1 back to the Magnolia Unit, had him/her sit in the day area and gave the resident a snack. SRNA #5 revealed he was not aware of Resident #1's care plan interventions and had not attempted to call the resident's family. Interview on 09/11/14 at 3:34 PM with SRNA #10, who worked on Resident #1's hall on 08/08/14, and at 5:45 PM with SRNA #4, who was assigned to Resident #1's care on 08/08/14, revealed they were not aware of Resident #1's care plan interventions or if the interventions had been followed on 08/08/14 after the resident's first elopement attempt around dinner time as they were busy providing care for other residents. Interview with RN #1 on 08/21/14 at 5:15 PM, on 09/11/14 at 11:09 AM and on 09/12/14 at 7:17 PM, revealed Resident #1's behaviors were usually increased on days his/her daughter didn't' visit, which was on Tuesdays and Fridays. She stated on 08/08/14, Resident #1 had been very anxious, distressed and more agitated that night which was a Friday and the daughter was not there visiting. RN #1 reported on 08/08/14, Resident #1 attempted to elope from the facility and was placed on every fifteen (15) minute checks, but continued to be agitated and eloped from the facility later on that evening at approximately 8:15 PM. Per interview, after Resident #1's first elopement attempt, she had not implemented other interventions, such as calling the resident's daughter and letting the resident talk to her, talking to the resident about his/her children, or trying to redirect him/her to other activities. Continued interview revealed she should have followed Resident #1's care plan interventions, such as calling the daughter which might have helped decrease his/her exit seeking behaviors on 08/08/14. RN #1 stated Resident #1 might not have successfully eloped from the facility on 08/08/14, if she had ensured the care plan interventions were carried out. Interview, on 09/11/14 at 10:10 AM and on 09/12/14 at 7:42 PM, with the Director of Nursing (DON) revealed on 08/08/14 after Resident #1's first elopement attempt his/her care plan interventions should have been implemented to try to decrease the exit seeking behaviors. The DON revealed if staff was aware of Resident #1's increased behaviors when his/her daughter did not visit implementing the intervention to call family might have helped decrease his/her behaviors. Interview, on 09/11/14 at 10:10 AM and on 09/12/14 at 8:42 PM, with the Administrator revealed the expectation was staff should always follow residents' care plans. He stated if staff was aware Resident #1 had increased behaviors when his/her daughter didn't visit, calling the daughter and letting the resident talk to her, after the first elopement attempt, might have helped to calm him/her. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 09/16/14, which alleged removal of the Immediate Jeopardy (IJ), effective 09/16/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on one on one (1:1) supervision by the Director of Nursing (DON) at 11:00 PM on 09/12/14. Ongoing 1:1 assignment would be determined by the licensed nurse and identified on the daily staffing sheet. A sign in log was to be used to record the time each assigned staff member assumed responsibility for the resident for tracking purposes. 2. The Wandering Risk Care Plan problem was updated on 09/12/14 at 11:00 PM by the DON for Resident #1 to include increased 1:1 supervision. Resident #1's daughter was notified on 09/12/14 at 11:05 PM by the licensed nurse that the resident's care plan had been updated with this information. The Advanced Practice Registered Nurse (APRN) was made aware on 09/13/14 by the licensed nurse of the need to change the resident's care plan. 3. Resident #1 would remain on 1:1 supervision until Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and State Registered Nurse Aides (SRNA's) had been re-educated by the DON and Staff Development Coordinator on consistently implementing the care planned interventions to decrease risk of further elopement events. Any RN, LPN, or SRNA not receiving this education by 09/15/14 would receive the education prior to working their next scheduled shift. 4. The Care Plan for Resident #1 was reviewed on 09/15/14 by the Interdisciplinary Team which included the DON, Minimum Data Set (MDS) Nurse, Social Worker, Unit Coordinator, and Therapy to re-evaluate current interventions related to wandering and behavior episodes. Resident #1 received showers on Tuesdays and Fridays and this intervention was updated to reflect additional showers as needed since showers had been effective in the past to help calm behaviors. 5. A total of thirteen (13) additional residents identified with increased wandering risk behaviors based on their most recent Wandering/Elopement Review Form, were reviewed on 09/15/14 by the Interdisciplinary Team (IDT) that included the DON, MDS Nurse, Social Worker (SW), Unit Coordinator (UC), and Therapy to re-evaluate current interventions, problems and goals related to wandering and behavior episodes. These care plans were updated with any changes to the identified problem, goals and interventions for direct care staff to implement when residents exhibit increased wandering behavior. 6. Staff education was initiated by the DON on 09/12/14 at 11:00 PM for direct care nursing staff, which included RN's, LPN's, and State Registered Nurse Aides (SRNA's), in reference to; Resident #1 must remain in visual contact of the assigned staff member at all times. This education also included instructions that in the event of any resident's attempt to exit the facility they must immediately notify the DON or Administrator and interventions must be initiated per the resident's individualized plan of care to decrease risk of another elopement attempt. This re-education also included information that in the event a door alarm was triggered, a staff member was to be stationed at the doorway until security was notified and the alarm returned to normal operation. A sign had been placed on each exit door stating "if an alarm sounds you must call security to reset". Staff members verbalized understanding of these instructions at the time of the education. Out of seventy-nine (79) full time employees, sixty-five (65)would receive the above education by 09/15/14. Out of eight (8) part time employees, four (4) would receive the education by 09/15/14. Out of thirty-nine (39) as needed (prn) employees, twenty (20) would receive the above education by 09/15/14. This training would continue to be provided by the DON, House Supervisor, UC's, and Staff Development Coordinator for RN's, LPN's, and SRNA's prior to their next scheduled shift until all have been educated on this information. A bulleted point sheet containing this education was developed by the DON and placed in the new hire packets for ongoing training for all newly hired employees. Lexington Country Place did not utilize agency staff. 7. Ongoing monitoring included a daily Quality Assurance Performance Improvement (QAPI) review of Nurse's Notes, Care Plans, and any new physician's orders [REDACTED].#1. This audit would be conducted and documented daily, including weekends, on an audit tool by the DON, UC, and/or House Supervisor to identify any new elopement attempts and to monitor that staff was documenting care planned interventions for increased behaviors of anxiety or agitation and for the effectiveness of these interventions. Any issues identified in these audits would be addressed as indicated, based on the direction of the DON. 8. The evening and night shift security staff was educated on parameters for testing the secondary red box alarms ("Stop" back up alarm) located on the fire safety doors on 09/12/14 and 09/13/14 by the Administrator. These instructions included to allow the red box's audible alarms to sound for a minimum of fifteen (15) seconds when being tested to ensure they maintain a sustained volume level within normal range. Instructions also included, in the event of a low or weak sounding alarm, a staff member was to be stationed at the doorway until the Administrator was notified and the battery was replaced and the alarm was returned to normal operation. These tests would be documented on the Door Inspection of three (3) times a day by Security and Maintenance Staff. A sign was placed on each exit door stating "if alarm sounds you must call security to reset". Staff members verbalized understanding of these instructions at the time of the educations. 9. Other security and maintenance staff would be educated on the minimum fifteen (15) second testing parameter procedure prior to working their next scheduled shifty by the Administrator or Director of Security and Transportation. Seven (7) of twelve (12) Maintenance and Security employees would have received this education by end of day on 09/15/14 and there was five (5) additional Security and Maintenance employees who would receive this education prior to working their next scheduled shift. Education on this door testing parameter procedures would be included as part of the new hire orientation provided to new Security and Maintenance Staff which was conducted by the Director of Security and Transportation and the procedure would be reviewed annually ongoing with Security and Maintenance staff by the Director of Security and Transportation and Director of Plant Operations under the direction of the Administrator. 10. Door alarms, including the delayed egress on the fire safety door and the secondary red box alarms located on the fire safety doors would continue to be checked by Security and Maintenance Staff a minimum of three (3) times each day, including on weekends. Testing would be conducted on each shift by sounding the alarm for a duration of at least fifteen (15) seconds. In the event the alarm does not sound at at sustained volume level within range, a staff member would be posted at the door and the problem would be immediately reported to the Administrator. A staff member would remain at the door until Maintenance and the Administrator were notified and the battery was replaced and the alarm was returned to normal operation. Batteries in the secondary red box alarms would be changed a minimum of monthly. This battery change would be documented in the facility's TELS system. The Administrator would verify this on at least a monthly basis. 11. Elopement /Missing Resident Drills would be conducted daily on alternating shifts, including weekends, for a minimum of two (2) weeks by the Staff Development Coordinator and Administrator. An Elopement/Missing Person Drill Evaluation Form would be completed with each drill. 12. Ongoing monitoring would also include completion of Elopement/Missing Resident Drills at a minimum of four (4) times a year. One (1) drill would be held on each shift and on a weekend day. An Elopement/Missing Person Drill Evaluation Form would be completed for each drill held. The facility would develop an action plan for staff education and correction of issues if encountered during the drills. Monitoring would also include a daily QAPI review of the Door Inspection Logs by the Administrator and/or Director of Security and Transportation. The Administrator would initial these logs to indicate review. Any issues identified would be addressed as indicated by the Administrator and documented on the QAPI tool. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the One on One Staff Observation Log, revealed Resident #1 was placed on 1:1 observation on 09/12/14 at 11:00 PM. Continued review of the One on One Staff Observation Log revealed Resident #1 was still on 1:1 observation as of 09/18/14 at the time of the survey. Per the Observation Log the date and time was recorded for each staff member who was resuming responsibility for the resident. Review of the daily staffing sheets from 09/12/14 through 09/18/14 revealed the person responsible for the 1:1 observation of Resident #1 was identified. 2. Review of Resident #1's Wandering Risk Care Plan revealed an update on 09/12/14 with an intervention for 1:1 observation. Review of the Nurse's Note dated 09/12/14 at 11:05 PM, revealed Resident #1's daughter was informed of the resident being on 1:1 care and was agreeable. Review of the Nurse's Note dated 09/13/14 at 1:14 PM, revealed the APRN was notified of the resident being placed on 1:1 observation continuously. 3. Interview on 09/18/14 at 2:30 PM with SRNA #9 and at 2:45 PM with LPN #1 who worked the Magnolia Unit where Resident #1 resided, verified Resident #1 was still on 1:1 observation. Interview with the DON on 09/18/14 at 6:00 PM revealed staff was not allowed to work until they received inservices including implementing care plan interventions to decrease risk of further elopement events and Resident #1 would remain on 1:1 until all staff had been educated. 4. Review of Resident #1's Care Plan revealed it was revised on 09/15/14 to include an intervention for showers Tuesdays, Fridays and as needed. Interview, on 09/18/14 at 7:20 PM, with the DON revealed the Interdisciplinary Team (IDT) met and reviewed Resident #1's care plan to re-evaluate current interventions related to wandering. 5. Review of the Care Plans for the thirteen (13) residents who were identified with increased wandering behaviors based on their most recent Wandering/Elopement Review Form, revealed the care plans were reviewed and revised on 09/15/14 by the IDT. Changes were made to the care plans with additional interventions for direct care staff to implement when the resident exhibited increased wandering behaviors. Also, some of the Care Plans problems and goals were updated related to the resident's wandering behaviors. 6. Review of the inservice information and Attendance Record revealed inservices began on 09/12/14 and continued each day and were still taking place for nursing staff including RN's, LPN's and SRNA's related to the following; 1) Resident #1 to remain in visual contact at all times and a sign in sheet must be completed by each staff member who was assigned to the resident for one on one observation, 2) in the event of any resident's attempt to exit the facility the DON or Administrator must be notified immediately and interventions must be initiated per the resident's individualized plan of care to decrease the risk of another elopement attempt, 3) if there was a weak or low sounding battery or if a door was opened for any reason, a staff member must be stationed at the doorway until the alarm was returned to normal. Observation of the facility exit doors on 09/18/14 from 5:00 PM until 5:30 PM revealed signs on the doors or beside the doors which stated "if an alarm sounds you must call security to reset". As of 09/18/14 all employees but three (3) full time employees, two (2) part time, and thirteen (13) employees had not received the education. Further review revealed a total of seventy-four (74) full time, six (6) part time, and twenty-seven (27) prn staff had received the inservice education. Interview with the DON on 09/18/14 at 7:20 PM, revealed the inservice education started on 09/12/14, and is ongoing. She stated at change of shift, administrative staff stand by the time clock, and anyone who has not received the inservice was not allowed to work until they had been educated. Further interview revealed the Staff Development Coordinator, and House Supervisors assisted with the education. Interview on 09/18/14 at 11:56 AM with the Staff Development nurse revealed a bullet point sheet containing the inservice education was placed in the new hire packet for all newly hired employees. She confirmed the facility did not utilize agency staff. Interview on 09/18/14 with SRNA #9 at 2:30 PM, with LPN #1 at 2:45 PM, LPN #8 at 3:23 PM, with SRNA #16 at 4:00 PM, with SRNA #17 at 4:17 PM, revealed they had been inserviced and trained ensuring Resident #1 remained in visual contact, they must immediately notify the DON or Administrator of any other residents' attempt to exit and that interventions must be initiated, to ensure someone was stationed at any fire exit door alarm which had been triggered until Security returned the door alarm to normal operation. 7. Review of the Daily QAPI Chart Review Tool, revealed daily audits starting 09/13/14 through 09/18/14 of physician's orders [REDACTED]. Interview with the DON on 09/18/14 at 7:20 PM, revealed administrative nursing staff was checking new physician's orders [REDACTED]. She stated she reviewed all the audits and was checking for any escalating behaviors she was unaware of, so she could address the behaviors. She further stated the audits would continue until it was decided in the QAPI meeting that the audits could stop. 8. Review of the Staff Inservice Summary and Attendance Record revealed the Administrator educated Maintenance and Security staff on 09/12/14 through 09/16/14 related to the following; allow audible door alarms (red boxes) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door checks daily every shift, the Door Alarm Inspection Form must have the timing of these tests documented (document the seconds the door alarm sounds), any problems noted during the door inspections must be reported immediately to the Administrator and Maintenance, and in the event of a weak or low sounding alarm a staff member was to be stationed at the doorway until the Administrator was notified and the battery was replaced and the alarm was returned to normal operation. Observation of the facility exit doors revealed a sign on the door or beside the door which stated, "if alarm sounds you must call security to reset". Interview, on 09/18/14 with Security Guard #3 at 6:00 PM revealed he was educated on the minimum fifteen (15) second testing parameter procedure to ensure the alarm maintained a sustained volume within normal range, and in the event of a low or weak sounding alarm a staff member was to be stationed at the doorway until the Administrator was notified and the battery replaced. 9. Interview with the Administrator on 09/18/14 at 8:00 PM revealed Security and Maintenance staff had been educated related to allowing audible door alarms (red boxes) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door checks daily every shift. He stated if the alarm did not work or had a low volume, security or maintenance was to notify him and someone was to guard the door until the alarm was fixed. He further stated maintenance was checking the door alarms on the day shift and security was checking the alarms on 2nd and 3rd shifts. Continued interview revealed maintenance and security was documenting checking the door alarms on separate door inspection logs, and he verified this was being done by checking the logs daily. He stated there was one (1) more security employee to educate because he was on vacation; however, the rest of the maintenance and security staff had been educated by him or the Director of Security. Further interview revealed this training would be provided as part of the new hire orientation provided to new hires for maintenance and security and would also be reviewed at least annually ongoing with maintenance and security staff. Interview with the Maintenance Director on 09/18/14 at 5:30 PM, revealed he was educated on the testing of the door alarms by the Administrator. He stated maintenance staff checked the doors each day on day shift. Continued interview revealed they were to allow the audible door alarms (red box) to sound for at least fifteen (15) seconds when being tested . He stated if the door alarms did not work, they were to have staff guard the door until the alarm was fixed. He further stated if there was a concern with the door alarms they were to notify the Administrator. Interview with Security Guard #3 on 09/18/14 at 6:00 PM, revealed he had received education on 09/13/14 related to allowing the audible door alarms (red box) to sound for a minimum of fifteen (15) seconds when being tested as part of routine door on evening and night shift. Continued interview revealed if the alarm did not work or had a low volume, the Administrator was to be notified, and a staff member was to guard the door until it was fixed. He stated security checked the door alarms on evening and night shift. 10. Review of the Door Inspections Log revealed the door alarms including the delayed egress on the fire safety door and the secondary red box alarms were being checked three (3) times a day 09/12/14 through 09/18/14. Review of the Red Box Emergency Door Battery Change Log, revealed the batteries were changed on 08/09/14 for the secondary red box alarms. Continued interview with the Administrator on 09/18/14 at 8:00 PM, revealed the batteries on the secondary Red Box alarms would be changed monthly and documented on the battery change log. 11. Review of the Elopement/Missing Resident Drill Evaluation Forms revealed drills were performed on 08/13/14, 08/19/14, 08/20/14 for all three (3) shifts and weekend personnel, and on 09/15/14 at 6:45 PM, 09/17/14 at 6:36 AM. Interview on 09/18/14 at 11:56 AM with the Staff Development Nurse revealed since the Immediate Jeopardy was called, they were doing elopement drills more frequently and at different times of the day. She stated she had done one (1) of the drills and was told on 09/15/14 they would be doing the drills daily. Interview on 09/18/14 at 7:20 PM, with the DON, and the Consultant DON, revealed they had been participating in the elopement drills which were being done daily, on different shifts and on weekends as well which were being done by the Staff Development Coordinator and the Administrator. Interview on 09/18/14 with SRNA #9 at 2:30 PM, with LPN #1 at 2:45 PM, with Laundry Worker #1 at 3:10 PM, with Housekeeper #1 at 3:20 PM, LPN #8 at 3:23 PM, with SRNA #16 at 4:00 PM, with SRNA #17 at 4:17 PM, revealed they had been inserviced and trained on elopement and elopement drills had been taking place since 09/12/14. 12. Interview with the Administrator on 09/18/14 at 8:00 PM, revealed education started on 09/12/14 and was ongoing related to elopement drills, elopement policy, and door alarms. He stated the elopement drills were to be performed every day for two (2) weeks, then depending on if there was opportunity for improvement they may be done monthly. He stated after a drill and Evaluation was completed and the results were summarized. He stated if there was a problem identified with the drills, an action plan would be developed and staff would be re-educated. He further stated there would be a daily QAPI review of the Door Inspection Logs and he would initial the logs to indicate they were reviewed. The Administrator further stated if a concern was identified with the door alarms, re-education would be done and the problem would be addressed. Continued interview revealed through the QAPI process, they would identify weak areas and issues identified would be addressed and documented on the QAPI tool.

Based on observation, interview, record review and review of the facility's Incident Reports, Investigations and policies, it was determined the facility failed to have an effective system in place to ensure a safe environment and adequate supervision for residents who had been assessed at risk for wandering and/or exit seeking behaviors for one (1) of ten (10) sampled residents (Resident #1). On 08/08/14, Resident #1 was agitated and exhibited increased wandering and exit seeking behavior. At approximately 5:45 PM, Resident #1 pushed open the fire exit door on the Magnolia Unit setting off the alarm and went through the door onto the small concrete porch area. Staff responded to the alarm and Resident #1 was returned to the Magnolia Unit day area and placed on fifteen (15) minute checks. However, staff was not aware they needed to have Security Staff come and re-set the fire exit door and ensure the alarms were functioning appropriately. Between 7:45 PM and 8:00 PM on 08/08/14, Resident #1 eloped from the facility without staff's knowledge through the unsecured fire exit door on the Magnolia Unit. Resident #1 was found by the Social Services Director (SSD) at approximately 8:15 PM lying on the sidewalk approximately seven (7) feet from a busy city road, with skin tears to the left forearm and right knee. The facility's failures to have an effective system in place to ensure a safe environment and adequate supervision was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/12/14 and was determined to exist on 08/08/14. An acceptable credible Allegation of Compliance (AOC) was received on 09/16/14 which alleged removal of the Immediate Jeopardy on 09/16/14. The Immediate Jeopardy was verified to be removed on 09/16/14 with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care (F-323) at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure a safe environment and adequate supervision of residents. The findings include: Review of the facility's policy titled, "Resident Safety Program: Wandering and Elopement", revised 10/31/07, revealed the facility would provide a "proactive" program of supervision and interventions to minimize the risk for elopement, and provide a program for staff education in effective wandering/elopement management through "in-services and drills". The Policy revealed the person who identified a resident was missing was to immediately notify the Administrator and/or Director of Nursing (DON) or designee who would immediately mobilize staff to initiate a search. Review of the facility's, "Missing Person/Elopement Tips" form, undated, revealed staff were to initiate an overhead page of "Dr. Hunt" with the resident's name and room number of the missing resident to notify other staff. Review of the facility's policy titled, "Resident Safety Program: Wandering & Elopement: Resident Security Systems and Devices", revised 10/31/07, revealed the purpose of the Policy was to provide a security system to enhance the safety of the residents in the facility, and to ensure the resident signaling device and door alarm equipment was tested , used and maintained properly to reduce the risk associated with wandering. Record review revealed the facility admitted Resident #1 on 01/26/12, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/24/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #1 to require supervision and one (1) person assist with a walker for ambulation. Further record review revealed the facility assessed Resident #1 as an elopement risk on the facility's Wandering/Elopement Risk Review Tool, when he/she was readmitted in March 2014, again on 04/21/14 and also on 06/24/14. Review of Resident #1's Comprehensive Care Plan (CCP), dated 05/11/12, revealed Resident #1 was care planned for at risk for wandering/exit seeking behavior, mainly at night, related to his/her [DIAGNOSES REDACTED].#1 for exit seeking behaviors, calling family if behaviors escalated, soothing the resident by talking to him/her about his/her children, offering snacks and trying to redirect to other activities. Review of the facility's "Self-Reported Incident Form, 5 Day Follow Up/Final Report" form, dated 08/13/14, revealed Resident #1 was observed "around 6:15 PM" attempting to exit the building at the fire exit door on the Magnolia Unit (where he/she resided). Review of the Form revealed Resident #1 was "able to open the fire exit door by pressing the bar and activating the delayed egress" (magnetic locking device system which prevented doors from being opened for protection of residents inside and outside to prevent entrance through the door). The Form noted the alarm was sounding and staff heard the alarm and responded attempting to re-direct Resident #1. According to the Form, Resident #1 was "difficult" to re-direct, so State Registered Nursing Assistant (SRNA) #5 took the resident for a walk, brought him/her back into the building where every fifteen (15) minute checks were implemented. The Form revealed Resident #1 "continued to be agitated", wandered to another unit and was brought back to the Magnolia Unit. Continued review of the Form revealed Registered Nurse (RN) #1 administered Ativan (anti-anxiety medication) PRN (as needed) to Resident #1, and the resident became "sleepy" while sitting in the "day area" of the Magnolia Unit after the Ativan was given. Review revealed RN #1 observed Resident #1 "at a table in the day area" of the Magnolia Unit at 7:55 PM, left to "go give another resident medication", and when she returned "around 8:00 PM" the resident was no longer in the "day area". The Form noted RN #1 searched the unit and other units, returned to the Magnolia Unit "around 8:15 PM", where a Security Guard informed her she had found the fire exit door "unlocked and not alarmed while doing her nightly rounds". Review of the Form revealed the Security Guard informed RN #1 she had "just" re-set the fire exit door and locked it. Further review of the Form revealed "it was around 8:15 PM" when the Social Services Director (SSD) "spotted" Resident #1 on the "sidewalk outside the door of" the Magnolia Unit. The Form noted Resident #1 had "tripped and sustained minor skin tears", was assessed and took "back into the facility" where he/she received first aid. Record review revealed a Nurse's Note dated 08/08/14 at 10:00 PM, which stated Resident #1 got outside the facility by himself/herself and had an unwitnessed fall on the sidewalk. Continued review of the Note revealed Resident #1 sustained one (1) skin tear to the left forearm (LFA) and two (2) skin tears to the right knee. Review of the Note revealed Resident #1 was returned to his/her room and assessment and first aid was administered by a nurse. Further review of the Nurse's Note revealed Resident #1's family and Physician were notified. Observation of the area Resident #1 was found, on 09/11/14 at 4:27 PM, with LPN #6, and on 09/12/14 at 4:10 PM, with the SSD, revealed it was approximately six and a half feet to seven feet from the busy city road. Observation, on 09/12/14 at 3:45 PM, of the Maintenance Director measuring the distance from the Magnolia Unit's fire exit door to where Resident #1 was found revealed it was one hundred and sixty-six (166) feet. Continued observation of the Maintenance Director revealed he measured the distance from where the SSD reported finding Resident #1 as seven (7) feet from the busy city road. Interview, on 09/11/14 at 3:34 PM, SRNA #10 revealed she was working on the Magnolia Unit on 08/08/14 when Resident #1 eloped from the facility. According to SRNA #10, that night Resident #1 was really confused, "frustrated", going in and out of other residents' rooms and being redirected and stating he/she "wanted to go home". Per interview, Resident #1 was "convinced" he/she was a "little girl" and kept wanting to go out the fire exit door "to go home to" his/her "parents". She stated when Resident #1 opened the fire exit door on 08/08/14, she was the first to respond as she saw the resident pushing on the door and opening it. SRNA #10 stated the alarms sounded when Resident #1 pushed on the fire exit door and the resident stepped outside the fire exit door onto the small porch area. SRNA #10 had to step in front of the resident to prevent him/her from going onto the long ramp leading to the sidewalk. Continued interview revealed she and RN #1 tried quite awhile to redirect Resident #1 back into the building; however, he/she would not go. She reported SRNA #5 came and volunteered to take Resident #1 ahead down the ramp and around the facility for a walk. SRNA #10 stated it took approximately twenty-five (25) minutes to get Resident #1 back inside the facility. Per interview, SRNA #5 brought Resident #1 back to the Magnolia Unit and sat him/her in a chair in the day area where the nurse kept an eye on the resident. She stated she was not "entirely sure after" the first elopement attempt staff had performed every fifteen (15) minute checks. The SRNA stated she had gone to a resident's room to give a bed bath, and when she was finished RN #1 had asked her if she had seen Resident #1. She stated she told RN #1 "no", and right after that she found out Resident #1 was found outside and she had seen RN #1 "jump over the fence" to get to where the resident was found outside. SRNA #10 stated even though she did hear alarms when Resident #1 first attempted to elope, she had not heard any alarms when the resident successfully eloped through the fire exit door the second time. Interview, on 09/11/14 at 2:55 PM, with SRNA #5 revealed he had not provided care for Resident #1 before; however, he did work on the Magnolia Unit where Resident #1 resided, and everyone on the unit knew to watch out for as Resident #1 "walked around all the time". SRNA #5 stated Resident #1 had increased restlessness and wandering on 08/08/14, and "after supper" went to the fire exit door on the Magnolia Unit, pushed on it and it opened. He stated he could not remember hearing "any kind of alarm at all"; however, observed RN #1 and SRNA #10 attempting to get Resident #1, who appeared frustrated, back inside the fire exit door. The SRNA stated he offered to walk the resident around outside and RN #1 agreed. According to SRNA #5, he walked Resident #1 around the outside of the facility and returned him/her to the Magnolia Unit day area and he/she was given a snack. SRNA #5 stated when Resident #1 eloped from the building "the second time" he was giving a resident a shower and did not remember hearing any kind of alarm. Additional interview, on 09/12/14 at 10:20 AM, with SRNA #5 revealed he did not know when the every fifteen (15) minute checks were started, and had not performed them or documented them anywhere. Interview with RN #1 on 08/21/14 at 5:15 PM, on 09/11/14 at 11:09 AM, and on 09/12/14 at 7:17 PM, revealed she usually worked on Resident #1's hall on the Magnolia Unit, and was assigned as the resident's nurse on 08/08/14. She stated Resident #1 had been very anxious, distressed and more agitated that evening, which was a Friday and his/her daughter was not there to visit on Tuesdays and Fridays. RN #1 reported on the evening of 08/08/14 it was "really busy", and right after supper, Resident #1 attempted to go outside by pressing the fire exit door bar which caused the door alarm to go off briefly; however, the "Stop" back up alarm only sounded faintly. RN #1 stated SRNA #5 then took Resident #1 outside for a walk to help calm the resident down, walked him/her around to the front door of the facility and back to the Magnolia Unit day area. Per interview, she stated Resident #1 got up from where SRNA #5 had sat him/her in the day area, and had experienced increased wandering and was still agitated, so she gave him/her a PRN dose of Ativan (medication used for Anxiety) at 7:15 PM. She stated her supervisor, RN #4 placed Resident #1 on every fifteen (15) minute checks sometime after the resident was returned to the unit which had been documented on a monitoring form. RN #1 stated she guessed the responsibility for doing the every fifteen (15) checks had fallen mainly on her because the SRNAs were busy providing care for residents. The RN stated she was unable to recall exactly what time the every fifteen (15) minute checks were started, and reported the monitoring form of 08/08/14, which had been completed by staff, was now missing and could not be located. She stated in hindsight Resident #1 should have been put on one on one (1:1) supervision since she had experienced the elopement attempt earlier. The RN stated she checked on Resident #1 at approximately 7:45 PM, and the resident was "less anxious" and becoming sleepy while sitting in the dayroom on the Magnolia Court unit. Continued interview with RN #1 revealed she left Resident #1 sitting in the day area of the Magnolia Unit at approximately 7:55 PM to 8:00 PM to go give another resident's medication and when she returned to the day area approximately five (5) minutes later, Resident #1 was no longer sitting there. However, review of RN #1 time clock punches revealed she clocked out for her lunch break at 7:35 PM and clocked back in at 8:05 PM. Further interview with RN #1 revealed she immediately checked Resident #1's room, and searched other areas of the facility in attempt to locate him/her; however, did not call the "Dr. Hunt" overhead page as per the facility policy. The RN stated she should have performed the "Dr. Hunt" overhead page as per facility policy when she didn't find Resident #1 in his/her room. However, she reported searching for Resident #1 for approximately fifteen (15) minutes, but was unsuccessful in locating the resident. Per interview, after returning to the Magnolia Unit interview revealed Security Guard #1 notified her the fire exit door was not secure on Magnolia Court and the alarms weren't working. RN #1 stated right after seeing Security Guard #1, RN #4/House Supervisor told her Resident #1 had been found on the sidewalk outside, and the resident "had gotten pretty far the down the sidewalk near the driveway". She stated she went to where Resident #1 was outside and Licensed Practical Nurse (LPN) #6 was with the resident who had skin tears to his/her left forearm and right knee. Interview, on 09/11/14 at 4:15 PM, with LPN #6 revealed was sitting at the nurse's station on 08/08/14 when she received a phone call from the SSD telling her Resident #1 was lying on the sidewalk outside the facility, and the SSD thought the resident was hurt. LPN #6 stated when she got to Resident #1 the resident was sitting up with his/her legs straight out in front of him/her on the grass by the sidewalk near the busy city road. Continued interview revealed she had assessed Resident #1 and found the resident to have "wounds" on his/her left forearm and right knee, which she administered first aid to and measured once the resident was returned to his/her room in the facility. LPN #6 stated the SSD pushed on the Magnolia Unit fire exit door that night after Resident #1 was returned to his/her room, and the "Stop" back up alarm only made a "little noise" and then quit which it was not supposed to do. Per interview, the "Stop" back up alarm was supposed to be very loud and stay on until the fire exit door was re-set by Security. She stated she knew the fire exit doors needed to be re-set, but didn't think the staff on the Magnolia Unit were aware of that information. LPN #6 stated the facility's process for locating missing residents was to search for "no more than five (5) minutes", then if the resident was not found, call the "Dr. Hunt" overhead page and each unit's staff searched the areas they were assigned to search. She stated, however, no "Dr. Hunt" overhead page was made the night of 08/08/14 when Resident #1 eloped from the facility. Interview, on 08/22/14 at 11:00 AM, on 09/12/14 at 4:15 PM and 6:20 PM, with the SSD revealed she was already clocked out from work on 08/08/14, and leaving the driveway of the facility at about 8:15 PM, when she observed a "bystander" bent over someone on the sidewalk and realized it was Resident #1, who was lying on his/her left side on the sidewalk near the busy road. She stated the "bystander" informed her she had witnessed Resident #1 fall onto the sidewalk when she was driving by the facility on the busy road, and had pulled her car over to check on the resident. Per interview, Resident #1's walker was standing up near the resident. Continued interview revealed the SSD called the facility and reached LPN #6 whom she informed of Resident #1 lying on the sidewalk outside the facility, and LPN #6 immediately came to assess the resident. The SSD stated she called the Administrator too, while outside with Resident #1, and then went into the building, and proceeded to the Magnolia Unit fire exit door. Further interview revealed RN #1 should have called a "Dr. Hunt" overhead page within minutes of discovering Resident #1 missing as per facility policy; however, had not done so. Interview, on 09/11/14 at 8:45 PM, with RN #4/House Supervisor revealed on 08/08/14, she was aware the resident had "tried to get out" of the facility "about 6:00 PM". Per interview, every fifteen (15) minute checks were initiated "right after" that incident, and she had assisted with the checks which were documented on a monitoring "sheet" which had now "disappeared". She stated after the first incident Resident #1 had remained "agitated", and the resident "probably" needed to be on one on one (1:1) supervision, but there had not been enough staff that night to have someone sit one on one (1:1) with Resident #1. RN #4/House Supervisor stated so she thought at the time the every fifteen (15) minute checks were appropriate; however, did not call the DON and was later told had she called the DON one on one (1:1) supervision could have been arranged. Continued interview revealed about 8:15 PM to 8:20 PM, RN #1 came to her and asked if she had seen Resident #1. RN #4/House Supervisor revealed RN #1 told her she had "just seen" Resident #1, but now couldn't find him/her and would continue searching for the resident. RN #4/House Supervisor stated the facility's process was for a "Dr. Hunt" overhead page to be made within five (5) minutes of discovering a resident missing; however, RN #1 had not done this. Further interview revealed "nobody was aware" that night Security was supposed to be called to re-set fire exit doors and alarms; however, she stated she was told by the DON later that night Security had to re-set it. Interview with RN #1 on 08/21/14 at 5:15 PM, on 09/11/14 at 11:09 AM, and on 09/12/14 at 7:17 PM, revealed she thought once the fire exit door was closed, the alarm "re-enabled itself", and she was not aware she needed a Security Guard to come and re-set the door. Further interview with RN #1 revealed she later learned the "Stop" back up alarm on the fire exit door should have sounded loudly until the fire exit door had been re-set. Interview, on 09/11/14 at 2:55 PM with SRNA #5, on 09/11/14 at 5:45 PM with SRNA #4, and on 09/11/14 at 3:34 PM with SRNA #10, revealed they did not realize the fire exit door and alarms needed to be re-set. Interview, on 09/11/14 at 2:25 PM and on 09/12/14 at 11:26 AM with Security Guard #1, revealed on 08/08/14 about 8:15 PM, during her rounds of the facility she checked the Magnolia Unit fire exit door and found it "not locked" as it "opened right up" when she pushed on it. She stated the "Stop" back up alarm did not sound. Security Guard #1 stated she locked the fire exit door. According to Security Guard #1, she had not realized the "Stop" back up alarm was not working as she thought the fire exit door and the back up alarm had not been re-set. She stated to re-set the "Stop" back up alarm she had to insert a key to re-set the alarm and thought that's all that was wrong until the Administrator called her later that evening. Security Guard #1 stated the Administrator asked her to check the fire exit doors and alarms every hour because he thought the batteries were not good in the "Stop" back up alarm on the Magnolia Unit. Interview, on 08/21/14 at 1:00 PM, and on 09/12/14 at 9:53 AM, with Maintenance Worker #1 revealed fire exit doors were monitored weekly by maintenance before 08/08/14; however, the monitoring did not include checking the door alarm batteries. Maintenance Worker #1 revealed he was notified by the Administrator on 08/08/14 at "around 8:30 PM to 9:00 PM" the Magnolia Unit fire exit door "Stop" back up alarm was not working. He stated the Administrator had requested the "re-set code" for the Magnolia Unit fire exit door, and said it had been "activated"; however, he was not told how it was "activated" until the next morning on 08/09/14. Maintenance Worker #1 reported the facility's Executive Director told him there was a "problem" with the "Stop" back up alarm on the Magnolia Unit's fire exit door, and asked him that morning to check that alarm, which he did, and discovered when he "activated" the alarm it "went off", but was "weak" and "almost dead", "buzzed and cut off after five (5) to ten (10) seconds". He stated when the fire exit door was activated, the "Stop" back up alarm was also and the back up alarm was "supposed to keep going off" loudly until it the door and alarm were re-set. Continued interview revealed he reported this information to the Executive Director after checking the alarm, and was told to check the rest of the facility's fire exit doors and replace all the batteries in the "Stop" back up alarms which he did. He reported another "Stop" back up alarm on the fire exit door by the employee lounge was also weak and "almost dead". Maintenance Worker #1 stated prior to 08/08/14, the facility had no process in place to check the batteries on the "Stop" back up alarms on a regular basis, and had only changed the batteries if they were notified one (1) of those alarms quit working. However, review of the manufacturer's recommendation for the fire safety door lock, "Exit Stopper STI-6400", revealed all fire safety door lock units were to be tested periodically to verify the life of battery, and the manufacturer recommended changing the fire safety door back up battery twice a year. The Maintenance Worker indicated he was unaware of that information until after 08/08/14. Review of the facility's security systems and devices maintenance logs from 04/28/14 through 08/06/14, revealed a maintenance worker checked the functioning of the fire safety doors once a week; however, there was no documented evidence as part of the checks performed the maintenance worker was checking or changing the batteries in the door alarms. Interview with the Administrator and Executive Director on 08/21/14 at 12:00 PM, revealed the policy regarding the security checks of the facility's fire exit doors, was for the maintenance department to check the functioning of the door alarm once a week, and the Security Guard to check the functioning of the doors and alarms daily one (1) time on the second shift around 8:00 PM, and one (1) time on the third shift around midnight daily. However, they indicated the functioning of the door alarm batteries for the fire exit doors was not routinely checked prior to the elopement of Resident #1 on 08/08/14. The facility's Executive Director revealed all of the employees had received the information during their orientation regarding the need to contact security to re-set the door, but the staff had forgotten to contact Security to re-set the Magnolia Unit fire exit door on 08/08/14 after Resident #1's first elopement attempt. According to the Executive Director, as a result of the fire exit door not being re-set the magnetic lock was not functioning, and the "Stop" back up alarm sounded only "very weakly" when Resident #1 walked out the door, unattended the second time on the evening of 08/08/14 around 8:00 PM. Further interview with the Administrator on 09/11/14 at 10:10 AM and on 09/12/14 at 8:42 PM, revealed staff had not known to have the fire exit door re-set by Security after the first attempt, and he had found out about the "Stop" back up alarm not working the "next day" when the investigation was being conducted. The Administrator the facility had no system or process in place prior to 08/08/14 to check the batteries in the "Stop" back up alarms on the fire exit doors, and no process for the "routine changing" of the batteries in the alarms. He stated Maintenance Worker #1 discovered on 08/09/14, two batteries in the "Stop" back up alarms on the facility's fire exit doors, batteries "were almost dead" and had to be replaced. Interview with the DON on 08/20/14 at 4:30 PM, on 09/11/14 at 10:10 AM and on 09/12/14 at 7:42 PM, revealed the Magnolia Unit had two (2) alarms on the door, one (1) of which was the "Stop" back up alarm. The DON indicated the "Stop" back up alarm was a battery alarm which alarmed when the door was opened, and the other was a sensor alarm for when the door was not locked with the magnetic lock. Per interview, on 08/08/14 staff had not realized after Resident #1 activated the door on his/her first attempt to elope, the fire exit door and "Stop" back up alarm needed to be re-set by Security staff. Further interview revealed she had seen the 08/08/14 fifteen (15) minute monitoring form on 08/11/14 during the morning meeting, as had the Administrator and SSD. However, she reported the monitoring form was misplaced on 08/11/14, and the facility had been unable to locate it. Continued interview revealed on 08/08/14 when Resident #1 successfully eloped from the facility without staff's knowledge, she was told by RN #1 she had last seen Resident #1 at approximately 7:55 PM; however, since then she had learned RN #1 had not clocked back in from her break yet at that time. The DON revealed if the resident wasn't located staff was to overhead page the "Dr. Hunt" code, and staff on each unit were to search their specified area. She stated RN #1 should have done this as per the facility policy, and in orientation staff was trained on doing the codes. Interview with the Administrator on 09/11/14 at 10:10 AM and on 09/12/14 at 8:42 PM, revealed Resident #1 was placed on every fifteen (15) minute checks on 08/08/14. He stated he had seen the 08/08/14 fifteen (15) minute check sheet on 08/11/14 during the morning meeting; however, since then the sheet had been misplaced and could not be located. According to the Administrator, he thought the every fifteen (15) minute checks had been an appropriate intervention to monitor Resident #1. Per interview, he was not aware of Resident #1's first elopement attempt until the investigation into the successful elopement and subsequent fall. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 09/16/14, which alleged removal of the Immediate Jeopardy (IJ), effective 09/16/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was placed on one on one (1:1) supervision by the Director of Nursing (DON) at 11:00 PM on 09/12/14. Ongoing 1:1 assignment would be determined by the licensed nurse and identified on the daily staffing sheet. A sign in log was to be used to record the time each assigned staff member assumed responsibility for the resident for tracking purposes. 2. The Wandering Risk Care Plan problem was updated on 09/12/14 at 11:00 PM by the DON for Resident #1 to include increased 1:1 supervision. Resident #1's daughter was notified on 09/12/14 at 11:05 PM by the licensed nurse that the resident's care plan had been updated with this information. The Advanced Practice Registered Nurse (APRN) was made aware on 09/13/14 by the licensed nurse of the need to change the resident's care plan. 3. Resident #1 would remain on 1:1 supervision until Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and State Registered Nurse Aides (SRNA's) had been re-educated by the DON and Staff Development Coordinator on consistently implementing the care planned interventions to decrease risk of further elopement events. Any RN, LPN, or SRNA not receiving this education by 09/15/14 would receive the education prior to working their next scheduled shift. 4. The Care Plan for Resident #1 was reviewed on 09/15/14 by the Interdisciplinary Team which included the DON, Minimum Data Set (MDS) Nurse, Social Worker, Unit Coordinator, and Therapy to re-evaluate current interventions related to wandering and behavior episodes. Resident #1 received showers on Tuesdays and Fridays and this intervention was updated to reflect additional showers as needed since showers had been effective in the past to help calm behaviors. 5. A total of thirteen (13) additional residents identified with increased wandering risk behaviors based on their most recent Wandering/Elopement Review Form, were reviewed on 09/15/14 by the Interdisciplinary Team (IDT) that included the DON, MDS Nurse, Social Worker (SW), Unit Coordinator (UC), and Therapy to re-evaluate current interventions, problems and goals related to wandering and behavior episodes. These care plans were updated with any changes to the identified problem, goals and interventions for direct care staff to implement when residents exhibit increased wandering behavior. 6. Staff education was initiated by the DON on 09/12/14 at 11:00 PM for direct care nursing staff, which included RN's, LPN's, and State Registered Nurse Aides (SRNA's), in reference to; Resident #1 must remain in visual contact of the assigned staff member at all times. This education also included instructions that in the event of any resident's attempt to exit the facility they must immediately notify the DON or Administrator and interventions must be initiated per the resident's individualized plan of care to decrease risk of another elopement attempt. This re-education also included information that in the event a door alarm was triggered, a staff member was to be stationed at the doorway until security was notified and the alarm returned to normal operation. A sign had been placed on each exit door stating "if an alarm sounds you must call security to reset". Staff members verbalized understanding of these instructions at the time of the education. Out of seventy-nine (79) full time employees, sixty-five (65)would receive the above education by 09/15/14. Out of eight (8) part time employees, four (4) would receive the education by 09/15/14. Out of thirty-nine (39) as needed (prn) employees, twenty (20) would receive the above education by 09/15/14. This training would continue to be provided by the DON, House Supervisor, UC's, and Staff Development Coordinator for RN's, LPN's, and SRNA's prior to their next scheduled shift until all have been educated on this information. A bulleted point sheet containing this education was developed by the DON and placed in the new hire packets for ongoing training for all newly hired employees. Lexington Country Place did not utilize agency staff. 7. Ongoing monitoring included a daily Quality Assurance Performance Improvement (QAPI) review of Nurse's Notes, Care Plans, and any new physician's orders [REDACTED].#1. This audit would be conducted and documented daily, including weekends, on an audit tool by the DON, UC, and/or House Supervisor to identify any new elopement attempts and to monitor that staff was documenting care planned interventions for increased behaviors of anxiety or agitation and for the effectiveness of these interventions. Any issues identified in these audits would be addressed as indicated, based on the direction of the DON. 8. The evening and night shift security staff was educated on parameters for testing the sec

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Physician was notified when there was a significant change in a resident's physical status and a need to alter treatment for [REDACTED]. On 09/25/13 Resident #2's left heel Pressure Ulcer was noted to have progressed from a Suspected Deep Tissue Injury (SDTI) with no open areas to a SDTI with an open area which was observed during a skin assessment by the surveyor. However, there was no documented evidence the nurse, who completed the skin assessment, recognized the change in the Pressure Ulcer and notified the Physician for further treatment orders. As a result, there was no new treatment orders for the open wound until 09/26/13 after surveyor intervention. The findings include: Review of the facility's policy, "Resident Condition Changes that Require Physician Notification Guidelines", revised 12/19/12, revealed the urgent category of condition change notification was a condition that would require Physician notification and a Physician response within four (4) to six (6) hours. This included pressure ulcers notifications for treatment orders. Continued review of the policy revealed licensed nurses were expected to recognize situations/conditions that require Physician notification. Further review revealed documentation of residents' condition change and proper notification were the responsibility of the nurse who observed and assessed the condition change. Review of Resident #2's medical record revealed the facility admitted the resident on 09/03/13, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) which indicated the resident was alert and oriented. Further review of the MDS revealed the facility assessed Resident #2 to require extensive assistance with transfers, and to have ambulated only once or twice during the assessment period. Review of the Weekly Wound Progress Note, dated 09/19/13, untimed completed by the Wound Nurse, revealed Resident #2's right heel had a Stage I Pressure Ulcer (a nonblanchable redness that persists when fingertip pressure was applied indicating tissue damage had occurred) which measured 2.5 centimeters (cm) in length by 2.5 cm width; and, the left heel had a Stage I Pressure Ulcer with measurements of 2.0 cm in length by 2.0 cm width. Review of the Weekly Wound Progress Note, dated 09/25/13, untimed completed by the Wound Nurse, revealed Resident #2's right heel had a "healing" Stage I area which measured 2.5 cm in length by 2.5 cm width. Continued review of the Note revealed the resident's left heel had an "oval" shaped Suspected Deep Tissue Injury (SDTI) with "soft red/nonblanchable center" which measured 2.0 cm by 1.0 cm width. The Note stated, staff would treat the Pressure Ulcers with [MEDICATION NAME] every shift and use a heel lift cushion. Observation, on 09/25/13 at 3:00 PM, of a skin assessment on Resident #2 with Registered Nurse #1/Unit Manager (UM) and interview revealed the resident's right heel was described as "slightly" red and blanchable (this means a reddened area that temporarily turned white or pale when pressure was applied with a fingertip which was an early indication of pressure). Continued observation and interview revealed the nurse described an area on Resident #2's left heel as a 1.6 cm in length by 0.6 cm width, purplish SDTI area which she described as "slightly" open. Review of the medical record on 09/26/13 revealed RN #1/UM had not documented her findings of Resident #2's skin assessment performed on 09/25/13 in the medical record. Continued record review revealed no documented evidence RN #1/UM had notified the Physician of the Pressure Ulcer on Resident #2's left heel being open. Interview, on 09/26/13 at 1:25 PM, with RN #1/UM revealed the first time she had seen the wound was on 09/25/13 during the skin assessment. She stated she had not notified the Physician of the change in the wound as she had not realized the open area was a change in the Pressure Ulcer. Observation, on 09/26/13 at 1:10 PM, of a skin assessment on Resident #2 with the Director of Nursing (DON), revealed the DON described the right heel as having a "healed" appearance. She described the left heel as having an open area measuring 0.9 cm in length by 0.5 cm width, surrounded by a purple area which measured 2.2 cm in length by 1.5 cm width. She stated this area was an SDTI. Interview, on 09/26/13 at 10:10 AM and 6:15 PM, with the Director of Nursing (DON) revealed the Physician should have been notified of the worsening of Resident #2's left heel Pressure Ulcer on 09/25/13, as the [MEDICATION NAME] that was in use, was not an appropriate treatment for [REDACTED]. Record review revealed the Physician was not notified of the worsening of Resident #2's left heel until 09/26/13 after surveyor intervention. Interview with the Attending Physician on 09/26/13 at 5:15 PM revealed if Resident #2's Left Heel Pressure Ulcer had progressed to an open area they would need to look at further pressure relief and attempt to find out why the wound was opening such as possible shearing. He stated if this was a significant change in the Pressure Ulcer, he would need to be notified.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure the Comprehensive Plan of Care was revised for two (2) of seventeen (17) sampled residents (Resident #2 and #6). Resident #2 was admitted to the facility on [DATE] with Stage 1 Pressure Ulcers to the bilateral heels; however, the Comprehensive Plan of Care, undated, addressed the resident's right heel ulcer only. There was no documented evidence of specific individualized interventions to heal the Bilateral Pressure Ulcers to the heels and prevent further skin breakdown. In addition, the Wound Nurse's recommendations from 09/03/13 to float the heels was not added to the Comprehensive Care Plan and there was no evidence this intervention was consistently implemented. On 09/23/13 the resident's left heel Pressure Ulcer progressed to a Suspected Deep Tissue Injury (SDTI) and a treatment was initiated for [MEDICATION NAME] and a heel lift cushion; however, there was no documented evidence of a revision to the Care Plan to address the resident's SDTI on the left heel with the new interventions. On 09/25/13 the Pressure Ulcer to the left heel further progressed with an open area noted during a skin assessment observed by the surveyor; however, there was no documented evidence the Care Plan was again revised related to the progression of the wound. Resident #6's had a [DIAGNOSES REDACTED]. The findings include: Review of the facility's, "Wound Documentation Policy", dated 06/01/07, revealed the purpose of the policy was to document the assessment, intervention, evaluation and care planning process of the skin care/wound program within the facility. Review of the facility's, "Process for Care Plan Development and Communication Policy", dated 01/15/12, revealed the purpose of the policy was to ensure the effective delivery of comprehensive, coordinated, quality care in an organized manner designated to meet the ongoing individualized needs of the residents. Further review revealed the facility should follow a care planning process to ensure timely development and updating of the resident's plan of care. The Policy stated, the facility was to develop a plan of care specific to each resident which helped attain or maintain the residents' highest practical level of function and should identify residents' strengths, risk factors and measurable goals. Per the policy, the care plan was a work in progress and changes were made as the residents' needs changed. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 09/03/13, with admission [DIAGNOSES REDACTED]. Review of the Initial Wound Evaluation dated 09/03/13, revealed Resident #2 was admitted with a Stage I Pressure Ulcers to the left and right heels. The Initial Wound Summary, which was a part of the Initial Wound Evaluation form dated 09/03/13, revealed it was completed by the Wound Nurse. Review of the Summary revealed Resident #2's left and right heels had irregular shaped Stage I areas with soft, boggy, red non-blanchable centers and pink periwound tissue (skin surrounding a wound). Continued review of the Summary revealed Resident #2 had refused heel boots. Further review of the Wound Summary revealed the Wound Nurse recommended to float Resident #2's heels and to monitor the resident for further treatment as indicated. Review of the 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 thirteen (13) which was an indication Resident #2 was cognitively intact. Further review of the record revealed the facility assessed Resident #2 to require extensive assistance with transferring and to have only ambulated once or twice during the assessment period. Review of the Comprehensive Plan of Care, undated, with a problem onset date of 09/03/13, revealed Resident #2 had an alteration in skin Integrity and was admitted with a Stage I Pressure Ulcer to his/her right heel. However, review of the Care Plan revealed no documented evidence it had been revised to include the Wound Nurse's recommendation to float Resident #2's heels for the bilateral heel Pressure Ulcers. Continued review of the Comprehensive Plan of Care revealed no documented evidence of a Care Plan for the Stage I Pressure Ulcer on the resident's left heel. Interview, on 09/25/13 at 3:50 PM, with the Wound Nurse revealed she had completed the Initial Wound Assessment on 09/03/13, and was aware both of Resident #2's heels had Stage I Pressure Ulcers. She stated she had made the recommendation to float the resident's heels. She stated she and the MDS Nurses were responsible for the care plans related to the wounds. She indicated the Left Heel Ulcer should have been on the Comprehensive Care Plan and there should have been an intervention to float the heels. Interview, on 09/26/13 at 10:50 AM, with the MDS Nurse, revealed after reviewing Resident #2's record, she stated she did not see any reference to the resident's Left Heel Pressure Ulcer on the Comprehensive Plan of Care. She further stated the Wound Nurse was responsible for developing and revising the Comprehensive Plan of Care related to residents' wounds. Interview with LPN #2 on 09/26/13 at 10:48 AM, revealed she had been notified by the resident's daughter that the left heel looked like it had been scraped. She stated she checked the left heel and noted it was pink and white and did not look normal and she had notified the Wound Nurse who said the description sounded like a SDTI. She stated she notified the Physician for an order for [REDACTED]. Review of a physician's orders [REDACTED]. Review of the Weekly Wound Progress Note completed 09/25/13, by the Wound Nurse, revealed the right heel had a healing Stage I area 2.5 cm x 2.5 cm and the left heel had a SDTI with measurements at 2 cm x 1 cm. The Note stated, will treat with [MEDICATION NAME] and a heel lift cushion. However, further review of the Comprehensive Plan of Care revealed no documented evidence the Care Plan indicated the resident's left heel had a SDTI with interventions for [MEDICATION NAME] and a heel lift cushion. Further interview with the Wound Nurse on 09/25/13 at 3:50 PM revealed the Care Plan should have been updated related to the SDTI with interventions per physician's orders [REDACTED]. Observation, of Resident #2's skin assessment performed on 09/25/13 at 3:00 PM, with Registered Nurse #1/Unit Manager (UM), revealed Resident #2's right heel was described as slightly red and blanchable and the left heel was described as a 1.6 cm in length by 0.6 cm in width, purplish SDTI area. RN #1/UM described the SDTI to have a "slightly" open area. Observation, on 09/26/13 at 1:10 PM, of a skin assessment with the Director of Nursing (DON), revealed she described Resident #2's right heel as healing and the resident's left heel as having an open area which measured 0.9 cm's in length by 0.5 cm's in width, surrounded by a purple area measuring 2.2 cm's in length by 1.5 cm's in width. She described this area as a SDTI. Interview, on 09/26/13 at 10:10 AM and 6:15 PM, with the DON revealed Resident #2's left heel Pressure Ulcer should have been documented on the Comprehensive Plan of Care to include the Wound Nurse's recommendation to float Resident #2's bilateral heels. Further interview revealed the Care Plan should have been reviewed and revised again after the left heel wound was noted to have worsened on 09/23/13, and again on 09/25/13, with intervention to prevent further deterioration of the area. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 04/08/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/03/13, revealed the facility assessed the resident as being severely cognitively impaired. Continued review of Resident #6's medical record revealed on the Admission MDS, dated [DATE], the Care Area Assessment triggered for Psychosocial Well-Being and the resident was care planned for mood related to a [DIAGNOSES REDACTED]. Review of Resident #6's mood care plan revealed on 05/24/13, the care plan for Depression was revised by the Social Worker, due to the resident's inability to express feelings. Review of the Physician Order's dated 07/29/13, for Resident #6 revealed [MEDICATION NAME] 0.25 milligrams (mg) was ordered as needed (PRN) every eight (8) hours for anxiety and restlessness. Continued review of the Physician order [REDACTED]. Review of the Behavior/Intervention Monthly Flow Record (August) for Resident #6 revealed behaviors of restlessness/agitation were recorded in August on the following dates: August 14th, 15th, 16th and 18th. Review of the Medication Record for August revealed the resident got PRN [MEDICATION NAME] for Anxiety on: 08/13/13 (one time), 08/14/13 (two times), on 08/15/13 (one time), and on 08/16/13 (one time). Further review, revealed on 08/19/13 the mood care plan was again revised to include a [DIAGNOSES REDACTED]. However, the care plan was not revised to include the anxious behaviors demonstrated by the resident or, any additional interventions for the prevention and management of the anxiety Interview with Licensed Practical Nurse (LPN) #2, on 09/26/13 at 3:36 PM, revealed she had frequently taken care of the resident when she worked on that Unit and Resident #6 did display anxious behaviors. The LPN stated the resident appeared nervous and would rub himself/herself especially his/her eyes frequently. She stated they would try non-pharmacological interventions when the resident appeared anxious such as one on one with the resident and put her up front. The LPN further stated the family had asked if the Physician could prescribe something for the anxious behavior. Interview with LPN/Unit Manager #1, on 09/26/13 at 4:15 PM, revealed the [MEDICATION NAME] medication was originally ordered as needed for anxiety and restlessness. Continued interview with LPN #1 revealed anxiety interventions should have been added to the care plan because the practice was to try non-pharmacological interventions first before giving as needed anxiety medications like [MEDICATION NAME]. She stated they were supposed to look at what may trigger the resident's behavior. Interview with Social Worker (SW) #1, on 09/26/13 at 2:56 PM, revealed he had updated the care plan when the order for the [MEDICATION NAME] was given. The SW stated the care plan should have included the type of anxiety behaviors the resident was having. He stated he should have discussed the resident's anxiety behavior with the family to determine possible triggers. In addition, the SW further stated the care plan definitely could have been revised to include more interventions to address the anxiety behaviors such as moving the resident to a calm environment. Interview with the Director of Nursing (DON), on 09/26/13 at 4:32 PM, revealed Resident #6's care plan should have been revised to include the type of anxiety behavior he/she displayed. She stated a lot of the resident's anxious behaviors occurred when the resident was having increased pain. The DON stated the care plan also should have been revised to add interventions to reduce the behavior.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure a resident having Pressure Sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one (1) of seventeen (17) sampled residents (Resident #2). Resident #2 was admitted to the facility on [DATE], with Stage 1 Pressure Ulcers to the bilateral heels. There was no documented evidence the Wound Nurse's recommendations from 09/03/13, to float the heels, was consistently implemented. In addition, there was no documented evidence of a treatment order to the Pressure Ulcers although, the Weekly Wound Evaluations completed by the Wound Nurse on 09/12/13 and 09/19/13, revealed Resident #2 was receiving [MEDICATION NAME] treatment to the bilateral heels. However, there was no documented order for the [MEDICATION NAME] treatment until 09/23/13. On 09/23/13, the left heel Pressure Ulcer had progressed to a Suspected Deep Tissue Injury (SDTI) per interview with staff and a treatment was initiated; however, there was no documented evidence of a measurement and description of the wound. On 09/25/13 the Pressure Ulcer to the left heel was noted to have an open area noted during a skin assessment observed by the surveyor; however, there was no documented evidence the nurse completing the skin assessment recognized the progression of the Pressure Ulcer, documented the measurement and description of the wound, or notified the Physician for further treatment orders. The findings include: Review of the facility's, "Wound Documentation Policy", dated 06/01/07, revealed the purpose of the policy was to document the assessment, intervention, evaluation and care planning process of the facility's skin care/wound program. Continued review of the Policy revealed all findings of the skin assessment were to be documented utilizing the appropriate documentation form. According to the Policy, examples of the appropriate documentation forms included the Nursing Admission Assessment, Weekly Skin Check Form and, if appropriate the Wound Care Program documentation was to be initiated. Further review of the Policy, revealed a Interim Care Plan must be completed by a licensed nurse upon admission; and, a Minimum Data Set (MDS) Assessment and permanent Plan of Care were to be completed within the regulatory guidelines to encompass each resident's individual needs. Review of Resident #2's medical record revealed the facility admitted the resident on 09/03/13, with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #2 as having a Brief Interview for Mental Status (BIMS) score of a thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #2 to require extensive assistance with transfers and ambulation only occurred once or twice during the assessment period. Review of the Data Collection Tool dated 09/03/13, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #2 was admitted with Stage I Pressure Ulcers to his/her bilateral heels. Review of the Braden Scale dated 09/03/13, revealed Resident #2 was at risk for Pressure Ulcers with a score of fifteen (15). Continued review of the Braden Scale revealed Resident #2 was at risk related to his/her skin was often moist, he/she was chairfast, he/she had very limited mobility, probably inadequate nutrition, and had a potential problem of friction and shearing. Review of the Skin Risk Factors/Analysis and Interventions Form dated 09/03/13, revealed the Form was to be used as a guide to identify risk factors and temporary care plan interventions. Review of the Form revealed mobility was marked as a risk factor. However, the mobility interventions which included turning and repositioning the resident; a support surface when the resident was in the bed or chair; and, elevate the resident's heels off the bed were not marked for implementation. Review of the Initial Wound Evaluation dated 09/03/13, revealed Resident #2 had a Stage I Pressure Ulcer to the right heel which measured 2.5 centimeters (cm) in length by 2.5 cm width. Continued review of the Initial Wound Evaluation revealed Resident #2 also had a Stage I Pressure Ulcer to the left heel which measured 2.0 cm's in length by 2.0 cm's in width. Review of the Initial Wound Summary, which was part of the Initial Wound Evaluation, dated 09/03/13 and completed by the Wound Nurse, revealed the left and right heels presented with irregular shaped Stage I pressure areas with soft, boggy, red non-blanchable centers and pink periwound tissue (the skin surrounding an injury). Review of the Wound Summary revealed Resident #2 refused heel boots. Further review of the Initial Wound Evaluation revealed staff were to float the resident's heels off the bed and monitor for further treatment as indicated. Review of the Interim Plan of Care dated 09/03/13, revealed Resident #2 had an Alteration in Skin Integrity Care Plan that was related to a Stage I Pressure Ulcer to his/her right heel on admission. Interventions included the Registered Dietician was to assess Resident #2's protein and nutritional needs, a therapeutic or pressure reducing mattress was to be utilized, and treatment provided as ordered. However, there was no documented evidence of an intervention to float the resident's heels as per the Wound Nurse's recommendations; and, no documented evidence of a specific treatment for [REDACTED]. In addition, there was no documented evidence of a Stage I Pressure Ulcer to the resident's left heel on the Interim Plan of Care. Review of the Comprehensive Plan of Care, undated, revealed Resident #2 had an Alteration in Skin Integrity Care Plan and was admitted with a Stage I Pressure Ulcer to the right heel. However, there was no documented evidence of a Care Plan to address the Stage I Pressure Ulcer on Resident #2's left heel. Continued review of the Care Plan for the Stage I Pressure Ulcer on the resident's right heel revealed the interventions included treating the wounds per physician's orders [REDACTED]. Interview, on 09/26/13 at 1:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she had admitted Resident #2 on 09/03/13, and noted the resident had Stage I Pressure Ulcers to both heels. She stated when she called the Nurse Practitioner (NP) for admission orders [REDACTED]. Continued interview revealed she completed the Interim Plan of Care, along with the Minimum Data Set (MDS) Nurse. According to LPN #1, she was not sure why the left heel Pressure Ulcer was not documented on the care plan. She stated she was not sure why the intervention to float the resident's heels was also not on the Interim Plan of Care. The LPN stated she did not think a treatment was needed for the heel ulcers, staff would just need to elevate his/her heels. Further interview, on 09/26/13 at 1:30 PM, with LPN #1 revealed the intervention to float Resident #2's heels off of the bed would need to be documented on the Nursing Assistant's Report Sheet in order for the State Registered Nursing Assistants (SRNAs) to reference for Resident #2's care needs. However, review of the Nursing Assistant's Report Sheet dated 09/26/13, revealed there was no documented evidence of an intervention to float Resident #2's bilateral heels off the bed. Interview, on 09/26/13 at 2:30 PM, with SRNA #2 revealed he was consistently assigned to Resident #2's care on day shift. He stated he/she was up in a wheelchair during the day and, was assisted back to bed at 1:00 PM. He stated he had not elevated the Resident #2's heels off the bed until that week. Review of the Weekly Wound Progress Note dated 09/12/13, completed by the Wound Nurse, revealed the bilateral heel Stage I measurements were unchanged and staff would continue to treat with [MEDICATION NAME] every shift. Review of the Weekly Wound Progress Note dated 09/19/13, completed by the Wound Nurse, revealed the bilateral heel Stage I Pressure Ulcer areas were unchanged and continued to be irregular shaped, soft, red non-blanchable areas. Staff was to continue to treat the areas with [MEDICATION NAME] every shift as previously ordered, and re-evaluate the treatment and effectiveness as indicated. Interview, on 09/25/13 at 3:50 PM, with the Wound Nurse revealed she had completed the Initial Wound Assessment on 09/03/13, and had noted both heels had Stage I Pressure Ulcers which she described as red non- blanchable areas. She stated there had been no need to notify the Physician of the Stage I Pressure areas; staff just needed to float the resident's heels off the bed. The Wound Nurse stated she made the verbal recommendation to float Resident #2's heels off the bed to a nurse on the unit; however, she was unsure of which nurse she had informed. She stated the intervention should have been documented on the Nursing Assistant's Report Sheet which the SRNA's carried in their pockets for reference of resident's care needs. The Wound Nurse indicated she was unsure why she had written to continue a [MEDICATION NAME] treatment on the 09/12/13 and 09/19/13, Weekly Wound Progress Notes as this resident did not have an order for [REDACTED]. Review of the physician's orders [REDACTED].#2's bilateral heels. Review of these documents for that time period, revealed no documented evidence of any treatment for [REDACTED]. Interview, with LPN #2 on 09/26/13 at 10:48 AM, revealed she had been notified on 09/23/13, by Resident #2's daughter that the resident's left heel looked like it had been "scraped". She stated she assessed the left heel and noted it was pink and white and did not look normal. According to LPN #2, she notified the Wound Nurse who said the description sounded like a Suspected Deep Tissue Injury (SDTI). She stated she notified the Physician/Nurse Practitioner (NP) for an order for [REDACTED]. Review of a physician's orders [REDACTED].#2's bilateral heels related to SDTI and for a heel lift cushion to relieve pressure. Further review of the medical record revealed there was no documented evidence of a measurement or description of the bilateral heels for 09/23/13. Review of the Weekly Wound Progress Note dated 09/25/13, completed by the Wound Nurse, revealed Resident #2's right heel had a healing Stage I area 2.5 cm in length by 2.5 cm width. Review of the Note revealed the resident's left heel now had a SDTI with measurements at 2.0 cm in length by 1.0 cm width. Further review of the Weekly Wound Progress Note revealed the Wound Nurse documented "will treat with [MEDICATION NAME] and a heel lift cushion". Further review of the Comprehensive Plan of Care revealed there was no documented evidence of revision of the Care Plan indicating Resident #2's left heel now had a SDTI and no revision to indicate the treatment for [REDACTED]. Interview, on 09/26/13 at 10:50 AM, with the MDS Nurse revealed she did not see any reference to the resident's left heel Pressure Ulcer on the Interim Care Plan or on the Comprehensive Plan of Care. According to the MDS Nurse, the Wound Nurse was responsible for the development of the Comprehensive Care Plan in regards to wounds. She further stated the Pressure Ulcer should have been noted on the resident's care plan and there should have been appropriate interventions put in place to address this area. Observation, on 09/25/13 at 3:00 PM, during a skin assessment performed on Resident #2, by Registered Nurse #1/Unit Manager (UM), revealed the resident's right heel was described as slightly red and blanchable. Continued observation during the skin assessment, revealed the resident's left heel was described as a 1.6 cm in length by 0.6 cm in width, purplish SDTI area which the nurse described as "slightly open". Further observation revealed the nurse did not separately measure the open area and the purplish surrounding area on Resident #2's left heel. Review, of the medical record on 09/26/13, revealed no documented evidence of the skin assessment completed on 09/25/13by RN #1/UM. In addition, there was no documented evidence RN #1/UM had notified the Physician/NP Resident #2's left heel Pressure Ulcer now had an open area present. Interview, on 09/26/13 at 1:25 PM, with RN #1/UM revealed the first time she had seen the wound was 09/25/13 during the skin assessment. She stated she had not notified the Physician/NP of the change in the left heel Pressure Ulcer because she did not realize the open area was a change in the Pressure Ulcer. Observation, on 09/26/13 at 1:10 PM, of another skin assessment on Resident #2, with the Director of Nursing (DON) present, revealed the DON described the right heel as having a "healed" appearance. The DON described the left heel as having an open area which measured 0.9 cm in length by 0.5 cm width. She described skin surrounding the open area as a purple area which measured 2.2 cm in length by 1.5 cm in width. The DON stated she would describe this area as a SDTI. Interview, on 09/26/13 at 2:30 PM, with Resident #2, who the facility had assessed as interviewable, revealed facility staff had just started elevating her feet off the bed approximately two (2) to three (3) days ago. He/She stated, "I think it helps". Interview, on 09/26/13 at 3:30 PM, with Resident #2's daughter revealed she visited one (1) to two (2) times per day. She stated Resident #2's feet were elevated off the bed with pillows "off and on". However, she stated she felt this should have been done consistently all along due to the resident's history of pressure ulcers to the heels prior to admission. Interview, on 09/26/13 at 10:10 AM and 6:15 PM, with the DON revealed the admission nurse on 09/03/13, should have ensured there was a treatment order in place for Resident #2's bilateral heel Pressure Ulcers. She stated [MEDICATION NAME] or Skin Prep for Stage I Pressure Ulcers to the heels was what was usually ordered. She stated however, the facility had no wound protocol. She indicated the Wound Nurse should have reviewed the chart more thoroughly prior to the recommendations to continue [MEDICATION NAME] to the heels on 09/12/13 and 09/19/13, as Resident #2 had no orders for [MEDICATION NAME] at that time. Continued interview with the DON, revealed the left heel Pressure Ulcer should have been documented and care planned on the Interim Plan of Care, as well as, the Comprehensive Plan of Care. Further interview with the DON revealed when a nurse finds a worsened pressure ulcer, there should be documentation in the medical record in the Nurse's Notes or on the Weekly Skin Check Form. She stated the nurses should have measured and described the wounds when they were noted to have changed on 09/23/13, and again on 09/25/13. According to the DON, the Physician/NP should have been notified of the worsening of the Left Heel Pressure Ulcer on 09/25/13 because [MEDICATION NAME] was not an appropriate treatment for [REDACTED]. Interview, on 09/26/13 at 6:00 PM, with the Nurse Practitioner revealed the nurse did notify her of Resident #2's reddened heels, which indicated Stage I Pressure Ulcers, on 09/03/13. She stated she usually ordered [MEDICATION NAME] and to float the heels for Stage I Pressure Ulcers to the heels. The NP stated she was unsure why she had not ordered this treatment on 09/03/13 for Resident #2's Stage I Pressure Ulcers on his/her heels. She further stated the nurse should have re-iterated on 09/03/13, the need for a treatment order for Resident #2's heels. Review of the physician's orders [REDACTED]. Continue [MEDICATION NAME] to the right heel every shift.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Physician was notified when there was a change in a resident's physical health and a need to alter treatment for one (1) of sixteen (16) sampled residents (Resident #5). Resident #5 had poor fluid intake from admission on 10/04/12; however, there was no documented evidence the Physician or the Registered Dietician (RD) were notified of this resident's poor fluid intake. In addition, the results of laboratory data obtained on 10/08/12 for a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) were faxed to the facility on [DATE] at 6:04 PM; however, there was no documented evidence the Physician was notified of the laboratory values until 10/09/12, although the values were abnormal. On 10/09/12 orders were received to send Resident #5 to the hospital emergency room for evaluation related to abnormal labs and lethargy. Resident #5 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. In addition, there was no documented evidence the Physician and Registered Dietician (RD) were notified of Resident #5's weight loss of thirteen and four-tenth pounds (13.4 pounds) from 11/06/12 to 12/05/12 which was a significant weight loss of seven and one-half percent (7.5 %) in one (1) month. The findings include: Review of the facility's policy entitled, "Hydration/Fluid Management", dated 01/05/11, revealed the Physician was to be notified when there was a significant change in the resident's fluid intake or output. Review of Resident #5's medical record revealed the facility admitted the resident, on 10/04/12, with [DIAGNOSES REDACTED]. Resident #5 was also admitted with a current [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the Intake/Output Chart Detail Report revealed the following: On 10/05/12, 480 mls of fluids were consumed for the twenty-four (24) hours. Further review of the physician's orders [REDACTED]. On 10/06/12, 240 mls of fluids were consumed for breakfast; however, there was no documentation of fluids consumed for lunch and supper. On 10/07/12, 840 mls of fluids were consumed for the 24 hours. On 10/08/12, 720 mls of fluids were consumed for the 24 hours. Review of the Nurse's Notes from admission, 10/04/12 until 10/08/12, revealed there was no documented evidence the Physician was notified of the resident's low fluid intakes. Review of the Laboratory Report for the CMP and Blood Urea Nitrogen (BUN) drawn 10/08/12 revealed the BUN was High at 73 (reference 1-24), and the creatinine was High at 2.3 (reference 0.6-1.5). Further review revealed the Laboratory Report was faxed to the facility on [DATE], at 6:04 PM; however, there was no documented evidence the Physician or Nurse Practitioner were notified of the laboratory results until 10/09/12, although the laboratory data was abnormal. Review of the physician's orders [REDACTED]./12 and 10/12/12. Review of the Nurse's Notes, dated 10/09/12 at 12:00 PM, revealed Resident #5 complained of nausea, and tremors were noted to the resident's bilateral hands. The Nurse Practitioner was notified and orders were received to send the resident to the emergency room related to the abnormal labs and tremors. Resident #5 was sent to the hospital and admitted . Review of the Hospital Discharge Summary, dated 10/13/12, revealed the admitting [DIAGNOSES REDACTED]. Further review revealed upon arriving at the emergency room the resident was found to have a BUN of 86 (high) and creatinine of 3.1 (high). Per the Summary, the resident was admitted and started on IV hydration and a Renal Consult was obtained. Further review of the Summary revealed the resident's laboratory values improved after hydration with laboratory values within normal range before discharge from the hospital. The BUN was noted to be 28 and the creatinine level was 1. Interview, on 12/13/12 at 11:30 AM, with State Registered Nurse Aide (SRNA) #7, revealed she worked the day shift on the Unit where the resident resided, and she was assigned to the resident a lot recently. Further interview revealed SRNA #7 did not remember having to report to the nurse's that this resident was not eating or drinking well. She stated if the residents were not eating and drinking well she would let the nurses know. Interview, on 12/13/12 at 3:30 PM, with SRNA #6 revealed she worked the evening shift on the Unit where Resident #5 resided and was assigned to the resident at times. She stated the resident refused dinner a lot, although she could not remember how the resident's intake was in October 2012. She stated the SRNAs notified the nurses when the residents had poor intakes. Interview, on 12/13/12 at 11:30 AM and at 12:30 PM, with the Unit Coordinator on Resident #5's Unit revealed after reviewing the Intake/Output Detail Report, Resident #5 was consuming a low percentage 10/05/12 through 10/08/12. However, after reviewing the Nurses's Notes from admission 10/04/12 through 10/09/12, she stated there was only two (2) notes related to decreased intake and she did not see documentation of notification to the Physician or Dietitian related to the low intake. She stated the nurses did not routinely monitor food and fluid intakes and were not required to ensure residents met their estimated fluid requirement. Continued interview revealed they depended on the SRNAs to report when a resident had decreased intakes. The Unit Coordinator stated the Physician and Dietitian should have been notified of the decreased intakes. Further interview revealed it was important to immediately notify the Physician for abnormal labs received and the nurses were to look for faxes during their shift. She indicated the laboratory results for the CBC and CMP drawn 10/08/12 should have been called in to the Physician when the results were faxed to the facility on [DATE]. Phone interview, on 12/14/12 at 2:00 PM, with Registered Nurse (RN) #1, who was assigned to the resident on 10/05/12 and 10/08/12, revealed the SRNAs were to let the nurses know when a resident consumed less than fifty (50) percent and the nurses were to encourage the residents to eat and drink. She stated there was no protocol as to when the Physician or Dietitian was to be notified of decreased intakes but she would notify the Physician if there were a few shifts or a few days of low intakes, depending on the circumstances. She stated the nurses were responsible for monitoring intakes when there was a concern; however, she did not routinely monitor intakes because she did not have access to this information in the computer and would need to ask the Unit Coordinator for access. Continued interview revealed the Unit Coordinator monitored the meal intakes on the computer on a regular basis. Phone interview, on 12/14/12 at 2:30 PM, with Licensed Practical Nurse (LPN) #4, who was assigned to the resident on the day shift and evening shifts on 10/06/12 and 10/07/12, revealed she could not remember the specifics of how much Resident #5 was eating and drinking in October 2012, but she did not remember low intakes with Resident #5. Further interview revealed the nurses did not consistently monitor food/fluid intake documentation, but if there was a concern she could ask the Unit Coordinator for access to the information on the computer. Interview, on 12/13/12 at 3:45 PM, with LPN #5 revealed he had admitted Resident #5 on 10/04/12 and was also assigned to the resident on 10/05/12 and 10/08/12. He stated the SRNAs picked up the meal trays and were to report to the nurse if the residents had a low food/fluid intake. He further stated if a resident was eating 25% or less for 48-72 hours, or consumed less than 50% of the tray for two (2) days he would notify the Physician. Continued interview revealed he did not notify the Physician of Resident 5's low intakes or he would have documented the notification in the chart. Continued interview revealed he had notified the Physician of the results of the PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) (test used to monitor the effectiveness of anti-coagulation medications) on 10/08/12 at 5:05 PM as per his documentation on the Laboratory Report. According to the Laboratory Report for the PT/INR obtained on 10/08/12, the Report was faxed to the facility on [DATE] at 4:35 PM. Further interview revealed "for whatever reason" he did not receive the results of the labs over the fax machine for the CBC and CMP which was drawn 10/08/12 with results faxed to the facility on [DATE] at 6:04 PM. He stated the Laboratory Reports came in over the fax at different times and he always checked the machine several times a shift. Continued interview revealed if he had received the Laboratory Report for the CBC and CMP on 10/08/12, he would have notified the Physician immediately because of the abnormal BUN and Creatinine which was very high, and documented the notification in the Nurse's Notes as well as on the Laboratory Report. He further stated he did not necessarily check the "Lab Book" on the unit to see which labs were due back and when. Interview, on 12/14/12 at 3:00 PM, with the Attending Physician revealed Resident #5 did have low intakes on admission, especially considering he/she was receiving [MEDICATION NAME]. He stated Resident #5 was being over [MEDICATION NAME] and the dehydration was more a function of the [MEDICATION NAME] than the intakes. Further interview revealed the nurses should have alerted the Physician of the low intakes, especially considering the resident was on a large dose of [MEDICATION NAME]. He further stated the chart would reflect if he or the Nurse Practitioner, who worked with him had been notified, and there would have been new physician's orders [REDACTED]. Continued interview revealed he would anticipate quicker response to the Physician related to the abnormal laboratory results for the CBC and CMP as the values were high, and there would have been new physician's orders [REDACTED]. Interview and review of the intakes from 10/04/12 through 10/08/12 with the Registered Dietitian (RD), on 12/14/12 at 3:15 PM, revealed she should have been notified of the low intakes and if she had been notified she would have documented the notification in the chart as well as made recommendations for "Ensure" as a supplement at least one (1) time a day as well as an afternoon snack. She further stated she would have either done a calorie count or checked the meal intakes each meal for several days. Further interview revealed [MEDICATION NAME] 40 mg a day was a high dose for a small person, which placed this resident at risk for dehydration; and, also the [MEDICATION NAME] (an antibiotic) would decrease the appetite. Interview, on 12/14/12 at 4:20 PM, with the Director of Nursing (DON) revealed there was no one currently looking at what was input in the system for food and fluid intake on a regular basis, and staff relied on the weights to monitor; however, they needed to be more proactive. Further interview revealed the staff nurses did not have access to look back past the current day to see intakes and were unable to run a report currently because the computer blocked their access. After review of the medical record, she stated the Physician should have been notified of the low intakes for the time period 10/04/12 through 10/08/12. Further interview revealed the laboratory results for the CBC and CMP drawn on 10/08/12 should have been called into the Physician on the evening shift of 10/08/12 when the results were faxed to the facility and new orders would have been received that evening instead of waiting until 10/09/12. 2. Review of the Nutrition Management Program Policy, dated 06/03/10, revealed the nursing staff would notify Dietary Services if there was a weight loss of 5% more in one (1) month. The nurse would also review the resident's intake and notify the Physician. Review of the Weight Management Policy, dated 06/03/10, revealed a greater than 5% weight loss in one month would be considered severe. Further review revealed if there was an actual 5% or more weight loss in one month, nursing would notify the Physician, and dietary. Review of Resident #5's medical record revealed the "Weight Calender " indicated a weight of 177.7 pounds on 11/06/12 and a weight of 164.3 pounds on 12/05/12. This was a significant weight loss of 7.5 % in one (1) month; however, there was no documented evidence of a re-weight until 12/13/12. The resident's weight on 12/13/12 was 160.4 pounds, showing a further weight loss. However, there was no documented evidence the Physician or the RD was notified of the weight loss. Observation, by the surveyor, of a weight obtained on 12/14/12 at 5:00 PM in a weight chair revealed a weight of 161.6 pounds. Review of the Nutrition Note dated, 11/08/12, revealed the resident's average intakes were; breakfast 96%, lunch 82%, and dinner 89%. However, review of the Monthly Nutrition at Risk Note, dated 11/29/12, revealed the resident's meal intakes included 57% of breakfasts, 67% of lunches and 68% of supper with decreased intake values since the prior nutrition Note. Further review revealed Resident #5's weight was stable since admission at 177.7 pounds and the resident had an order for [REDACTED]. Interview, on 12/13/12 at 11:30 AM, with the Unit Coordinator (UC), revealed different SRNAs obtained weights with either a weight chair or a "Hoyer" (mechanical) lift. She stated when the SRNAs obtained the weights they documented the results in the weight book, and the licensed nurses then transcribed the weight from the weight book to the medical record on the "Weight Calender". She further stated if a weight discrepancy was noted, a re-weight would need to be done immediately, and the Physician notified at that time, if there was a weight gain or loss. Continued interview revealed a re-weight should have been done immediately on 12/05/12 instead of waiting eight days (8) for the re-weight. She stated she was unaware of Resident #5's weight loss although she was aware the resident was not eating well. She further stated there was a Nutrition at Risk meeting each Thursday where the Interdisciplinary Team (IDT) discussed weights and she was unsure if this resident had been discussed in the meetings. After reviewing the medical record, the UC stated there was no notification to the RD or the Physician related to the weight loss although they should have been notified. Interview, on 12/14/12 at 3:00 PM, with Kentucky Medication Aide (KMA) #1, revealed she normally got all the weights on the Unit where Resident #5 resided, although she did get some help at times from the SRNAs. She stated when she obtained the weights she turned them into the Unit Coordinator and was told by the Unit Coordinator when re-weights were needed. Continued interview revealed she had obtained the last few weights on Resident #5 including the 12/05/12 weight and the 11/06/12 weight and had documented them in the weight book. She stated she had not been asked to get a re-weight. She further stated there had been times when she was told to document the weights in the medical record on the Weight Calender. Further interview revealed KMA #1 had documented the resident's weights on the weight calender for the 11/06/12 and the 12/05/12 weights. Interview, on 12/14/12 at 3:15 PM, with the RD revealed re-weights were to be done the same day if there was a discrepancy; however, this did not always happen which caused lag time. She stated this had been talked about in the Nutrition at Risk (NAR) meetings and she had no concerns with the other two (2) units. Continued interview revealed she had been notified by one of her staff that Resident #5 was not eating well and she had notified the Nurse Practitioner and recommended [MEDICATION NAME] which was ordered 11/12 to increase the resident's appetite; however, she was unaware that the resident had actual weight loss from 11/12 to 12/12. She stated she would need to review the chart in order to make further recommendations. Review of the physician's orders [REDACTED]. Interview, on 12/14/12 at 4:20 PM and 5:30 PM, with the Director of Nursing (DON), revealed a re-weight for Resident #5 should have been obtained within twenty-four (24) hours. She further stated she had reviewed the medical record and there was no documentation the Physician had been notified of the weight loss from 11/06/12 to 12/05/12, or of the weight loss after the re-weight on 12/13/12. Interview, on 12/14/12 at 3:00 PM, with the Attending Physician for Resident #5, revealed a thirteen (13) pound weight loss in one month was a lot for that time period, and may have been due to the diuretic the resident was receiving. He stated he was unsure if he or the Nurse Practitioner he worked with was notified of the weight loss; however, he stated if there was no new orders and staff did not document the Physician was notified, he probably was not notified.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Plan of Care was sufficient to meet the needs of newly admitted residents for one (1) of sixteen (16) sampled residents (Resident #5). Resident #5 had poor fluid intake from admission on 10/04/12; however, there was no documented evidence the facility implemented their "Process for Care Plan Development and Communication Policy". Although the resident had risk factors for dehydration including poor fluid intake, was receiving a diuretic medication, and was admitted to the facility with a [DIAGNOSES REDACTED]. On 10/09/12, the facility transferred Resident #5 to the hospital where she/he was admitted to the hospital with [REDACTED]. The findings include: Review of the facility's policy entitled, "Process for Care Plan Development and Communication", dated 01/10/08, revealed the facility must develop a plan of care specific to each resident which helps to attain or maintain the residents' highest practical level of function. Further review revealed the resident's care plan shall identify the resident's needs, problems, strengths, risk factors and measurable goals. The policy further stated the admitting nurse would develop and initiate a written plan of care for the resident within twenty-four (24) hours of admission which would address physician's orders [REDACTED]. Review of Resident #5's clinical record revealed the facility admitted the resident on 10/04/12, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interim Plan of Care, dated 10/05/12, revealed there was no Plan of Care related to this resident's risk of dehydration, even though the resident was receiving a diuretic medication and an antibiotic medication for a [DIAGNOSES REDACTED]. Review of the Intake/Output Chart Detail Report, revealed the following documentation: On 10/05/12, the resident consumed 480 milliliters (mls) of fluids for the twenty four (24) hours. Review of physician's orders [REDACTED]. On 10/06/12, the resident consumed 240 mls of fluids for breakfast, and there was no documentation of fluids consumed for lunch and supper. On 10/07/12, the resident consumed 840 mls of fluids for the 24 hours. On 10/08/12, the resident consumed 720 mls of fluids for the 24 hours. Review of the laboratory data for the CMP drawn 10/08/12 revealed abnormal values for Blood Urea Nitrogen (BUN) at 73 High (reference 1-24), and creatinine at 2.3 High (reference 0.6-1.5). Further review of the physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. Resident #5 was admitted to the hospital. Review of the Hospital Discharge Summary, dated 10/13/12, revealed the admitting [DIAGNOSES REDACTED]. The resident was admitted to the hospital and started on IV hydration and a Renal Consult was obtained. Per the Summary, upon arriving at the emergency room the resident was found to have a BUN and creatinine of 86 and 3.1 (both values were high). According to the Summary, the resident's laboratory values improved after hydration with laboratory values before discharge from the hospital noted as BUN at 28 and creatinine at 1, both within normal levels. Review of the record revealed there was no documented evidence a Nutritional Assessment which included an estimated fluid requirement was completed until 10/16/12, after the resident was discharged from the hospital. The Nutritional Assessment, dated 10/16/12, revealed the resident's estimated fluid requirements were 2040-2400 milliliters per day. Interview, on 12/13/12 at 11:35 AM and 12:30 PM, with the Unit Coordinator on the Unit, where Resident #5 resided, revealed after reviewing the Intake/Output Chart Detail Report, Resident #5 was consuming a low percentage of food and fluids from 10/05/12 through 10/09/12. Further interview verified that the Report indicated all the fluids consumed for the twenty-four hours was included, not just meals. She stated she or the other nurses did not routinely monitor food and fluid intakes, or check to see if the resident's fluid requirements were met. Continued interview revealed the nurses did a head to toe assessment on each resident each day and checked for signs and symptoms of dehydration; however, the nurses had not recognized this resident as being dehydrated from the assessments per the Nurse's Notes. Further interview revealed it was the staff nurse's responsibility to initiate a nutrition/hydration care plan if a resident was not eating and drinking adequately. She further stated the admitting nurses should have looked at dehydration risk factors for this resident on admission, because the Data Tool Collection the nurse completed dated 10/04/12, indicated the resident had a recent history of weight loss, as well as the resident was on a diuretic medication which would place the resident at risk for dehydration. Continued interview revealed it was her responsibility to audit charts on new admissions to make sure assessments were complete and the medications were transcribed correctly to the Medication Administration Record; however, she did not do an in depth chart review to ensure the Interim Care Plans were accurate. Interview, on 12/14/12 at 3:00 PM, with the Attending Physician revealed Resident #5 did have low fluid intakes on admission, especially considering the dosage of [MEDICATION NAME] she/he was receiving. He stated the resident was being over [MEDICATION NAME] and the dehydration was more a function of the [MEDICATION NAME] medication than the fluid intakes. Further interview revealed the nurses should have alerted the Physician of the low intakes, especially considering the resident was on a large dose of [MEDICATION NAME]. The Physician stated the medical record would reflect if he or the Nurse Practitioner who worked with him had been notified, and there would have been new physician's orders [REDACTED]. Interview, on 12/14/12 at 3:15 PM, with the Registered Dietitian (RD) revealed she had seven (7) days from the date of a resident's admission to complete a Nutritional Assessment and assess the resident's estimated fluid requirement. After reviewing the intakes from 10/04/12 through 10/09/12, she stated if she had been notified of the low intakes she would have documented the notification in the medical record as well as made recommendations for "Ensure" as a supplement at least one (1) time a day as well as an afternoon snack, and would have either done a calorie count or checked the meal intakes each meal for several days. Further interview revealed [MEDICATION NAME] 40 mg a day was a high dose for a small person which placed this resident at risk for dehydration and also the [MEDICATION NAME] (an antibiotic) would decrease the appetite. Interview, on 12/14/12 at 4:20 PM, with the Director of Nursing (DON) revealed the RD was to assess the new admission's caloric count after seven (7) days and she did not interpret the policy as the Nutrition Assessment including the estimated fluid requirement needing to be completed on admission before the seven (7) days. After reviewing Resident #5's medical record, she stated the nurses should have taken the [MEDICATION NAME] in consideration, as well as the Pneumonia and antibiotics and completed a care plan to monitor this resident closely for the potential for dehydration.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health for one (1) of sixteen (16) sampled residents (Resident #5). Resident #5 had poor intake from admission on 10/04/12; however, there was no documented evidence the facility implemented their "Hydration/Fluid Management Policy". Although the resident had risk factors for dehydration including poor fluid intake, was receiving a diuretic medication, and was admitted to the facility with a [DIAGNOSES REDACTED]. There was also no documented evidence of a Nutritional Assessment completed on admission to identify this resident's estimated fluid needs. In addition, there was no documented evidence staff provided ongoing monitoring of the resident's fluid intake or notified the Physician or the Registered Dietitian (RD) of this resident's poor fluid intake. On 10/09/12, the facility transferred Resident #5 to the hospital where she/he was admitted to the hospital with [REDACTED]. The findings include: Review of the facility's policy entitled, "Hydration/Fluid Management", dated 01/05/11, revealed each resident's hydration/fluid needs would be determined by the nutritional professional upon admission, the Care Plan interventions related to proper hydration were to be developed according to the resident's needs, staff was to observe fluids provided to the resident to determine if the interventions identified in the Care Plan had been implemented, and the physician was to be notified when there was a significant change in the resident's fluid intake or output. Review of Resident #5's medical record revealed the facility admitted the resident on 10/04/12, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interim Plan of Care, dated 10/05/12, revealed there was no Plan of Care related to this resident's risk of dehydration on admission, or prior to the resident's hospitalization on [DATE] even though the resident was ordered a diuretic medication and an antibiotic medication for a [DIAGNOSES REDACTED]. Review of the Intake/Output Chart Detail Report revealed the following: On 10/05/12, the resident consumed 480 milliliters (mls) of fluids. Review of the physician's orders [REDACTED]. On 10/06/12, the resident consumed 240 mls of fluids for breakfast, and there was no documentation of fluids consumed for lunch and supper. On 10/07/12, the resident consumed 840 mls of fluids. On 10/08/12, the resident consumed 720 mls of fluids. Review of the laboratory data for the CMP obtained 10/08/12 revealed abnormal values for Blood Urea Nitrogen (BUN) at 73 High (reference 1-24), and creatinine at 2.3 High (reference 0.6-1.5). Further review of the physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. Review of the Hospital Discharge Summary, dated 10/13/12, revealed the admitting [DIAGNOSES REDACTED]. Further review revealed upon arriving at the emergency room the resident was found to have a BUN and creatinine of 86 and 3.1 (high levels). The patient was admitted and started on intravenous hydration and a Renal Consult was obtained. Per the Summary, the resident's laboratory values improved after IV hydration with laboratory values, returning go normal levels, before discharge from the hospital. The labs were noted as BUN at 28 and creatinine at 1. Review of the Nutrition Note written by the RD, dated 10/10/12, revealed the resident was discharged to the hospital prior to a full nutritional assessment being completed. Review of the Nutritional assessment dated [DATE], after the resident was discharged from the hospital revealed the resident's estimated fluid requirements were 2040-2400 mls per day. Interview, on 12/13/12 at 11:30 AM, with State Registered Nurse Aide (SRNA) #7 revealed she worked the day shift on the Unit where Resident #5 resided, and she was assigned to the resident a lot recently. She did not remember having to report to the nurse's that the resident was not eating or drinking well in the past. She stated the SRNAs passed drinks and snacks to all the residents between meals on the day shift at 9:30 AM and 2:00 PM. She further stated the SRNAs monitored how much the residents ate and drank at meals and documented it on the Kioske (computer system); however, she stated she was unable to view how much the resident was eating and drinking for prior days. She further stated if the residents were not eating and drinking well she would let the nurses know. Interview, on 12/13/12 at 3:30 PM, with SRNA #6, revealed she worked the evening shift on Resident #5's Unit and was assigned to the resident at times. She stated the resident refused dinner a lot, although she could not remember how the resident's intake was in 10/12. She stated the SRNAs documented the food and fluid intake on the Kioske and notified the nurses when residents had poor intakes. Interview, on 12/13/12 at 11:35 AM and 12:30 PM, with the Unit Coordinator on Resident #5's Unit, revealed after reviewing the Intake/Output Chart Detail Report, Resident #5 was consuming a low percentage, especially for breakfast and lunch from 10/05/12 through 10/09/12. She stated this Report indicated all the fluids consumed for the twenty-four hours, not just meals. After reviewing the Nurses's Notes from admission 10/04/12 through 10/09/12, she stated there were only two (2) Notes related to decreased intake and she did not see documentation of notification to the physician or dietician related to low intake. She stated she or the other nurses did not routinely monitor food and fluid intakes and they depended on the SRNAs to report when a resident had decreased intakes. She further stated dietary assessed the estimated fluid intake required per day; however, the nurses were not required to ensure the residents were meeting the fluid requirement. Continued interview revealed the nurses did a head to toe assessment on each resident each day and checked for signs and symptoms of dehydration which was noted on the Nurse's Notes; however, the nurses had not recognized this resident as being dehydrated from the assessments. Further interview revealed it was the staff nurses responsibility to initiate a nutrition/hydration care plan during a situation in which a resident was not eating and drinking well. She further stated the admitting nurses should have looked at dehydration risk factors for this resident on admission because the Data Tool Collection the nurse completed dated 10/04/12, indicated the resident had a recent history of weight loss. Continued interview revealed she was unaware this resident was dehydrated shortly after admission to the facility; however, she did not review hospital discharge summaries. The Unit Coordinator stated it was her responsibility to audit new admits to make sure assessments were complete and the medications were transcribed correctly to the Medication Administration Record; however, she did not do an in depth chart review to ensure the Interim Care Plans were accurate. Phone interview, on 12/14/12 at 2:00 PM, with Registered Nurse (RN) #1, who was assigned to Resident #5 on 10/05/12 and 10/08/12 revealed the SRNAs were to let the nurses know when a resident ate less than fifty (50) percent and the nurses would encourage the residents to eat and drink. She stated there was no protocol as to when the Physician or dietitian were to be notified of intakes but if there was a few shifts or a few days of low intakes, she would notify them depending on the circumstances. Further interview revealed all nurses were responsible for monitoring intakes when there was a concern, but she did not have access to this information in the computer and would need to ask the Unit Coordinator for access when needed. She further stated the Unit Coordinator monitored the meal intakes on the computer on a regular basis. Phone interview, on 12/14/12 at 2:30 PM, with Licensed Practical Nurse (LPN) #4, who was assigned to Resident #5 on the day shift and evening shifts on 10/06/12 and 10/07/12, revealed she could not remember the specifics of how much Resident #5 was eating and drinking in October 2012, but she did not recall low intakes with Resident #5. She stated the nurses did not consistently monitor food/fluid intake documentation, but if there was a concern she could ask the Unit Coordinator for access to the information on the computer. Interview, on 12/13/12 at 3:45 PM, with LPN #5 revealed he had admitted Resident #5 on 10/04/12 and was also assigned to the resident on 10/05/12 and 10/08/12. He stated the SRNAs picked up the meal trays and were to tell the nurses if the residents had a low food/fluid intake. He stated if a resident was eating 25% or less for 48-72 hours, or consumed less than 50% of the tray for two (2) days he would notify the Physician. LPN #5 stated he did not notify the Physician of Resident #5's low intakes or he would have documented the notification in the chart. Continued interview revealed he had completed this resident's Interim Care Plan on 10/05/12 and should have included a problem with potential for dehydration due to risk factors such as receiving antibiotics for Pneumonia and receiving a diuretic. Interview, on 12/14/12 at 3:00 PM, with the Attending Physician revealed Resident #5 did have low intakes on admission, especially considering she/he was receiving [MEDICATION NAME]. He stated the resident was being over [MEDICATION NAME] and the dehydration was more a function of the [MEDICATION NAME] than the intakes. Continued interview revealed the nurses should have alerted the Physician of the low intakes, especially considering the resident was on a large dose of [MEDICATION NAME]. He stated the chart would reflect if he or the Nurse Practitioner who worked with him had been notified, and there would have been new physician's orders [REDACTED]. Interview, on 12/14/12 at 3:15 PM, with the Registered Dietitian (RD), revealed she had seven (7) days from the day of a resident's admission to complete a Nutritional Assessment. After reviewing the intakes from 10/04/12 through 10/08/12, she stated if she had been notified of the low intakes she would have documented the notification in the chart as well as made recommendations for "Ensure" as a supplement at least one (1) time a day as well as an afternoon snack, and would have either done a calorie count or checked the meal intakes each meal for several days. Continued interview revealed [MEDICATION NAME] 40 mg a day was a high dose for a small person which placed this resident at risk for dehydration, and also the [MEDICATION NAME] antibiotic would decrease the appetite. Interview, on 12/14/12 at 4:20 PM, with the Director of Nursing (DON) revealed the RD was to assess the new admissions caloric count after seven (7) days and she did not interpret the policy as the Nutrition Assessment needing to be completed on admission before the seven (7)days. After reviewing Resident #5's food and fluid intakes, she stated the staff should have taken the [MEDICATION NAME] in consideration as well as the Pneumonia and antibiotics and completed a care plan to monitor this resident closely for potential for dehydration. She stated there was no one currently looking at what was input in the system for food and fluid intake on a regular basis, and staff relied on the weights to monitor; however, they needed to be more proactive. Further interview revealed the staff nurses did not have access to look back past the current day to see intakes and were unable to run a report currently because the computer blocked access. She further stated the Physician should have been notified of the low intakes for the time period 10/04/12 through 10/08/12.