Every finding on record at Lexington Premier Nursing & Rehab

Based on observation, interview, and review of the facility's policies, the facility failed to provide the residents or family group with a private space to have a monthly scheduled Resident Council meeting. Observation and resident interviews on 08/05/2025, during the Resident Council meeting, revealed the meeting's designated space to be a non-private area of the dining room accessed by nursing staff to communicate with kitchen staff.The findings include:Review of the facility's policy titled, Resident Rights, undated, revealed the resident had a right to personal privacy which included meetings with family and the resident group.Review of the facility's policy titled, Facility Responsibilities, undated, revealed the facility must ensure that the resident could exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Per the policy, the facility must provide a resident or family group, if one existed, with private space, and take reasonable steps, with the approval group, to make residents or family members aware of the upcoming meetings in a timely manner.Observation on 08/05/2025 at 10:30 AM revealed the Resident Council (resident group) meeting was held in the dining hall that employees walked through to have access to the kitchen. Further observation revealed the meeting location was not a private space, as employees entered and exited without acknowledging the residents' right to meet in a private space. During an interview with Resident (R) 5 on 08/05/2025 at 11:12 AM during the Resident Council meeting, she stated the Resident Council meetings were held in the dining hall, and staff walked in, disrupting the meeting by being loud and noisy.During an interview with R8 on 08/05/2025 at 11:18 AM during the Resident Council meeting, she stated the Resident Council meetings were held in the dining hall, and staff was constantly walking through the meeting trying to access the kitchen. She stated staff had another door they could use to access the kitchen that would not cause them to interfere with the Resident Council meeting. During an interview with R14 on 08/05/2025 at 11:43 AM during the Resident Council meeting, he stated he attended the Resident Council meetings every month. He stated every time there was a meeting it was held in the dining hall, and employees came in to pass to the kitchen or just came in and sat in the meeting without getting the residents' approval. He stated employees entered the meeting at their own pleasure, disregarding the residents' right to meet in a private space. During an interview with the Activities Director on 08/06/2025 at 9:12 AM, he stated he held Resident Council meetings for the residents once a month. He stated at one time the Resident Council meetings were going to be held in what now was his office. He stated due to the facility having limited space, it had been an ongoing issue to find a private space for residents to meet monthly. He stated finding the residents a private space to express their concerns was important and should be treated as so. He stated residents not having a private space to discuss concerns with one another could result or lead to frustrations within residents. He stated he would continue to advocate for residents to have a private space to enjoy the company of their fellow residents and provide them with a private space to express concerns. During an interview with the Director of Nursing (DON) on 08/06/2025 at 11:00 AM, she stated she was unaware Resident Council meetings were being disrupted by staff. She stated she thought signs were posted on the doors to inform staff the Resident Council meeting was in progress. She stated she could communicate with and educate staff on not to walk through or cause any unnecessary disruption while the Resident Council meeting was being held in the dining hall. She stated it was important for residents to feel respected while they were here at the facility, as this was their home, and staff wanted them to reside in a home like environment. During an interview with the Administrative Assistant on 08/07/2025 at 4:22 PM, he stated he was unaware of the Resident Council not having a private space to meet for their monthly meetings. He stated now that he was aware of a private area being requested from the residents for the Resident Council meeting, he would ensure it was provided. He stated the facility did not have a lot of space, especially for those residents in wheelchairs, but he would do his best, even if he must monitor the dining hall entrance to ensure staff did not interrupt. During an interview with the Chief Executive Officer (CEO) on 08/06/2025 at 10:33 AM, he stated he was unaware of residents requesting to meet in a private space for their monthly Resident Council meetings. He stated if the residents were requesting a private space to meet, then the facility should provide the residents a space where they could feel safe and have privacy.

Based on observation and interview, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment. Observations on 08/04/2025 and 08/07/2025 of three areas of the facility revealed stained and unraveled carpet. The findings include:The State Survey Agency (SSA) Surveyor requested an environmental policy from the Director of Nursing (DON) on 08/08/2025 at 8:46 AM; however, the only documents provided were blank cleaning logs.Observation upon the initial entry to the facility on [DATE] at 3:00 PM revealed the carpet in the front lobby was overall dirty, visibly stained in multiple areas, and unraveling near the front reception desk.Observation on 08/04/2025 at 3:19 PM revealed the carpet on the North Hall was visibly stained in multiple areas throughout the unit. Observation on 08/07/2025 at 3:57 PM revealed the carpet on the South Hall was visibly stained in multiple areas throughout the unit. During an interview with Registered Nurse (RN) 4 on 08/08/2025 at 9:59 AM, she stated it was important the carpets were clean in the facility, so dust and dirt were eliminated; and it was just overall unhealthy. RN4 further stated it made a bad first impression when people walked into the facility, and the first thing they noticed were visibly stained and dirty carpets.During an interview with the Assistant Director of Nursing (ADON) on 08/08/2025 at 10:04 AM, she stated it was important the facility and the carpets were clean because the facility was home for the residents, and it should be clean. Additionally, she stated it left a bad impression when visitors or family walked into the facility, and the first thing they noticed were the carpets needed to be cleaned. During an interview with the Administrative Assistant (AA) on 08/08/2025 at 11:48 AM, he stated the facility's carpets should be clean, as well as the entire facility for resident safety related to infection prevention concerns. During an interview with the Chief Executive Officer (CEO) on 08/06/2025 at 10:33 AM, he stated he was not clinical and was unaware of any standard practices for infection control. He stated he had recently replaced carpeting in the resident rooms, but the entire carpet replacement was a two-phase project that had not yet been completed due to the facility's financial trouble when he took over leadership a few years ago. The CEO further stated he had received three or four quotes from different companies to replace the carpet at the facility.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide food and drink that was palatable and at a safe and appetizing temperature. Observation on 08/06/2025 at 8:15 AM of the breakfast test tray on the South 200 Unit revealed the food at point of service was at unappetizing temperatures. The findings include:Review of the facility's policy titled, In-Room Dining, dated 2020, revealed hot foods served on room trays were preferred to be at 120 degrees Fahrenheit (F) or greater to promote palatability for the resident. Review of the facility's Food Temperature Chart, dated 08/06/2025, revealed cooked cereal had a temperature of 184 degrees (F) initially and continued to a temperature of 180 degrees (F) at the conclusion of the tray line. Further review revealed eggs had a temperature of 179 degrees F and continued to a temperature of 176 degrees F at the conclusion of the tray line. Further review revealed sausage had a temperature of 179 degrees F initially and continued to a temperature of 177 degrees at the conclusion of the tray line.Observation on 08/06/2025 of the breakfast service on the South 200 Unit revealed a trolley of 20 trays and a smaller cart with six trays arrived at 7:55 AM. Staff was observed to deliver trays to residents, with the last tray delivered at 8:15 AM. Further observation revealed the Dietary Manager (DM) at 8:15 AM, took the temperature of food items, with a sausage patty measuring 77 degrees F, cheesy eggs measuring 104 degrees F, and oatmeal measuring 144 degrees F. Additional observation revealed, with tasting by the State Survey Agency (SSA) Surveyor, the sausage was not warm enough to be palatable, the cheesy eggs would have tasted better if warmer, and the oatmeal was palatable. Observation on 08/06/2025 at 10:45 AM of the kitchen during meal preparation revealed the plate warmer in the kitchen was overflowing with plates. Further observation at 11:00 AM revealed the Dietary Manager (DM) attempted to close the plate warmer and was able to close one side with effort, but the other side was too full to close. During interviews as part of the Resident Council meeting on 08/05/2025 at 10:30 AM, residents stated food items were sometimes cold when delivered to rooms, with breakfast cited as cold more often than the other meals.During interview with the DM on 08/06/2025 at 8:42 AM, he stated everything coming out of the kitchen was hot for breakfast, with temperatures taken of the food items when placed on the tray line and temperatures taken again at the completion of the tray line to ensure temperatures held. He stated the kitchen had plate warmers, and the bottom plate holder was insulated. He stated when the cooks arrived in the morning, they turned on the plate warmer and coffee pot first thing. He stated there were more residents in the facility than there was room for plates in the plate warmer. The DM stated his expectation was that temperatures be no less than 105 degrees F at the point of service, and if he went into a restaurant and his sausage was served at 80 degrees F, he would be upset.During interview with the Director of Nursing (DON) on 08/07/2025 at 9:27 AM, she stated when a resident complained about food temperatures, staff immediately alerted the DM and the Administrator. The DON stated the plate warmer in the kitchen was purchased by a recent Administrator to help ensure food was warm at point of service.The DON stated her expectation was when food was delivered to the floor, floor staff delivered trays as soon as they arrived to ensure they were distributed quickly. She stated her expectation was that food was at the correct temperature when residents received it. During interview on 08/08/2025 at 10:10 AM with the Administrative Assistant (AA), he stated he had been acting as the temporary Administrator for two months. The AA stated he grew up knowing breakfast was the most important meal of the day, and his expectation was that food temperatures would be warm enough, so residents enjoyed their meals.

Based on interview, record review, review of the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 5 of 5 sampled staff, Registered Nurse (RN) 2, Licensed Practical Nurse (LPN) 2, State Registered Nurse Aide (SRNA) 10, SRNA11, and SRNA12.The findings include:Review of the CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, dated 05/01/2021, revealed Long-term Care (LTC) facilities must offer staff vaccination against COVID-19 when vaccine supplies were available to the facility. LTC facilities must screen staff prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination. Per the guidance, the vaccine might be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity.Review of the facility's policy titled, Infection Control, revised 09/2021, revealed the facility would plan control activities and manage potential outbreaks of disease. The facility did not provide a COVID-19 Immunization Policy.1. Review of RN2's employee file revealed no documented evidence noting RN2 was offered the COVID-19 vaccination. Additionally, there was no documentation that education regarding the benefits, risks, and potential side effects of the vaccine was provided to the employee. RN2 was unavailable for interview.2. Review of LPN2's employee file revealed no documented evidence the facility had provided LPN2 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination. LPN2 was unavailable for interview.3. Review of SRNA10's employee file revealed no documented evidence the facility had provided SRNA10 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination. During an interview with SRNA10 on 08/07/2025 at 10:53 AM, he stated he had not been educated about or asked regarding his COVID-19 vaccination status. The SRNA further stated he had not signed any forms related to this issue and was not required to present a COVID-19 vaccination card or sign any documentation.4. Review of SRNA11's employee file revealed no documented evidence the facility had provided SRNA11 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination. During an interview with SRNA11 on 08/07/2025 at 10:53 AM, he stated he had not been educated about or asked regarding his COVID-19 vaccination status. The SRNA further stated he had not signed any forms related to this issue and was not required to present a COVID-19 vaccination card or sign any documentation.5. Review of SRNA12's employee file revealed no documented evidence the facility had provided SRNA12 with education regarding the benefits, risks, and potential side effects of the COVID-19 vaccination. SRNA12 was unavailable for interview.During an interview with the Human Resources Director (HRD) on 08/07/2025 at 2:56 PM, she stated the facility did not provide COVID-19 vaccinations in-house. Instead, she stated, the facility would offer information on external resources for obtaining vaccines. She stated the facility would provide educational materials to staff, utilizing the CDC's Vaccine Information Statement (VIS) dated January 2025. Additionally, she stated the facility did not require employees who chose to decline the vaccine to submit a declination form. During an interview with the Infection Preventionist (IP) on 08/07/2025 at 4:00 PM, she stated the facility did not have a COVID-19 Immunization Policy. The IP further stated she could not provide documentation to support staff signature on declination forms and education related to the COVID-19 vaccine. She stated the facility followed the Infection Control policy and CDC guidelines to prevent the spread of infection and disease. During an interview with the Director of Nursing (DON) on 08/08/2025 at 10:05 AM, she stated the facility followed the recommendation of the CDC for all immunizations and vaccines but had not provided education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine immunization education to its employees. Furthermore, she stated she did not have documentation for the staff regarding the employee's COVID-19 vaccine education. The DON stated it was important for the facility to educate staff about and offer the COVID-19 vaccine. Additionally, the DON stated the facility should maintain documentation of each staff member's immunization status or their decision to decline the vaccine in their personnel files. She stated the importance of adhering to the CDC's guidelines for infection prevention and control was to help prevent the spread of diseases and infections within the facility.During an interview on 08/08/2025 at 10:10 AM with the Administrative Assistant (AA), he stated he had been acting as the interim Administrator for two months. The AA stated it was important that the facility maintained the appropriate documentation to reflect that it provided the required COVID-19 vaccine education to employees to comply with CDC recommendations and adhere to the facility's infection control program. He further stated that following policy and CDC guidelines was important for the safety of residents and staff.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 4 sampled residents, Resident (R) 54. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response-Physical Environment, dated 01/2024, revealed with each interaction in the resident's room or bathroom, staff would ensure the call light was within reach of the resident and secured, as needed. Review of the facility's policy titled, Facility Responsibilities, dated 01/2024, revealed the resident had a right to a dignified existence, self-determination, and communication and access to persons and services inside and outside the facility. Review of R54's admission Record revealed the facility admitted the resident on 02/20/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and age-related cognitive decline. Review of R54's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated the resident was cognitively intact. Observation on 08/04/2025 at 4:29 PM revealed R54 lying in bed in her room. Further observation revealed R54's call light was located on the floor on the right side of the bed and out of the resident's reach. During an interview with State Registered Nurse Aide (SRNA) 10 on 08/07/2025 at 10:53 AM, he stated call lights were always placed within a resident's reach, and the resident should be aware of the call light's location. SRNA10 further stated it was important residents were able to always reach the call light, so they could contact staff when they needed help. During an interview with SRNA7 on 08/08/2025 at 8:55 AM, she stated the facility's call light policy was to answer lights as soon as possible, even if the resident was not assigned to that staff member. SRNA7 further stated she ensured the call light was within a resident's reach before she left a room, and it should not be located on the floor. SRNA7 stated if a resident needed help or had an emergency, they could not call for help if their call light was on the floor. During an interview with SRNA18 on 08/08/2025 at 9:01 AM, she stated call lights and television remotes were placed within a resident's reach before she left a room. She stated it was important for residents to be able to reach staff if they required assistance. During an interview with SRNA19 on 08/08/2025 at 9:08 AM, she stated call lights were answered as soon as possible so residents' needs were addressed. SRNA19 stated call lights were located within a resident's reach and never on the floor. She further stated residents depended on their call lights as a form of communication so staff could be reached when needed. During an interview on 08/08/2025 at 9:35 AM, Registered Nurse (RN) 3 stated she rounded on residents in between SRNA rounds. She further stated she expected residents' call lights were always accessible. RN3 stated it was important residents were able to reach their call light when they needed staff assistance. During an interview on 08/08/2025 at 10:04 AM, the Assistant Director of Nursing (ADON) stated it was her expectation residents were able to always reach their call light, so residents had access to staff when needed. During an interview on 08/08/2025 at 10:56 AM, the North Unit Manager (UM) stated it was her expectation that residents' call lights were in their reach always and/or pinned to their clothing or bed linens. The North UM stated it was important staff ensured call lights were in reach, so resident needs were met when they required assistance. During an interview on 08/08/2025 at 11:08 AM with the Director of Nursing (DON) and the Administrative Assistant, the DON stated the purpose of the call light was so residents had access to staff when they needed assistance, and it was her expectation a resident's call light was always within their reach and not located on the floor.

Based on interview, record review, and review of the facility's policy, the facility failed to provide documentation they notified the resident and/or the resident's representative in writing of the reason for the transfer/discharge to the hospital or of the facility's bed hold policy, including reserve bed payment. Additionally, the facility failed to notify or send a copy of the notice to the ombudsman for 3 of 4 sampled residents, Resident (R) 9, R37 and R54. The findings include:Review of the facility's policy titled, Transfer and Discharge from the Facility, dated 01/2024, revealed the resident and representative would receive timely notification, adequate preparation, orientation, and information about the transfer as orderly and safely as possible, and the notice contained information about the transfer and information about the resident's right to appeal. Further review revealed the facility forwarded a copy of all discharge notices to the Office of the State Long-Term Care Ombudsman and required state agencies. Additional review revealed the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood. Review of R9's, R54's, and R37's electronic health record (EHR), on 08/06/2025, revealed there was no documentation in the residents' EHR that the facility notified the residents and/or the residents' representatives of the reason for the transfer/discharge to the hospital or of the facility's bed hold policy, including reserve bed payment. Additionally, the facility failed to notify the residents and/or the residents' representatives in writing of the reason for the transfer/discharge to the hospital or send a copy of the notice to the ombudsman. 1. Review of R9's admission Record revealed the facility admitted the resident on 08/16/2024 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of R9's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/29/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15, indicating the resident was moderately cognitively impaired. Review of R9's, Progress Note, dated 07/31/2025, revealed the resident was sent to an outside hospital for evaluation following complaints of abdominal pain on that date.2. Review of R54's admission Record revealed the facility admitted the resident on 02/20/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and age-related cognitive decline. Review of R54's quarterly MDS, with an ARD of 03/07/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R54's Progress Note, dated 05/17/2025, revealed the resident was sent out to the hospital due to altered mental status and decreased urine output on that date. 3. Review of R37's admission Record revealed the facility admitted the resident on 09/09/2022 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, dementia, and pneumonia. Review of R37's significant change in status MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of eight out of 15, which indicated the resident was moderately cognitively impaired.Review of R37's Progress Note, dated 05/06/2025 at 4:27 AM, revealed R37 was sent out by emergency services for a possible stroke. According to the progress note, the nurse assessed the resident and found her to have droop to the left side and slurred speech. Per the progress note, the nurse gave report to the local emergency department. Review of R37's Progress Note, dated 05/17/2025, revealed the resident was sent to the hospital due to altered mental status and decreased urine output on that date. During a telephone interview with R37's legal guardian on 08/07/2025 at 1:10 PM, she stated she was assigned to the resident on 07/31/2025. She stated the resident's files indicated that R37 had been hospitalized ; however, she could not confirm whether the communication regarding this was written or verbal. The guardian also stated there was an after-hours hotline available where messages could be left, but the guardian's office and ombudsman required written documentation. She stated to her knowledge, the state guardian's office had not received any written notification, bed hold, or reason for R37's transfer from the facility. During an interview on 08/07/2025 at 10:28 AM with the Administrative Assistant (AA), he stated bed hold information was provided to the resident and the resident's representative in the admission packet. The AA stated when a resident was sent to the hospital, their representative was notified the following day via telephone, the bed hold was discussed, and the representative was mailed a copy of the bed hold information. He further stated he thought the transfer/discharge summary information was part of the bed hold form. During an interview on 08/07/2025 at 3:32 PM, Licensed Practical Nurse (LPN) 12 stated the nurses filled out the transfer/discharge information that went with the resident when they were transferred or discharged to the hospital, and their representative was notified by telephone. During an interview on 08/08/2025 at 9:35 AM, Registered Nurse (RN) 3 stated the resident was given a copy of the transfer/discharge summary at the time of their transfer or discharge. She stated transfer/discharge information went with the resident to the hospital and included a Situation, Background, Assessment, Recommendation (SBAR) form, a demographics sheet, medication list, advance directive, pertinent progress notes or labs, and a medication administration record (MAR). During a follow-up interview with the AA on 08/08/2025 at 11:48 AM, he initially stated that both the discharge/transfer and bed hold information was mailed out to the resident's representative. The AA stated family was notified by phone that day or the following morning and asked about the bed hold, and the bed hold information was mailed to the representative. When asked again about the discharge/transfer summary, the AA stated he was uncertain about the discharge/transfer summary, and the Director of Nursing (DON) should be contacted for that information. On 08/08/2025 at 12:09 PM, the State Survey Agency (SSA) Surveyor requested proof from the DON that the facility sent written notification to the resident, resident's representative, and the ombudsman when a resident was transferred or discharged ; that information was not received.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 sampled residents, Resident (R) 76.R76 was prescribed scheduled narcotics for pain but did not have a care plan developed for effective pain management. The facility failed to create a care plan to address the resident's chronic pain with assessment-based goals and interventions.The findings include:Review of the facility's policy titled, Care Plan Process, revised 09/2019, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident to meet the needs as identified in the comprehensive assessment to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of R76's admission Record, found in R76's electronic health record (EHR), revealed the facility admitted the resident on 08/22/2022 with diagnoses to include unspecified dementia, severe, with other behavioral disturbance; chronic obstructive pulmonary disease (COPD); and dysphagia following cerebral infarction. Review of R76's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/30/2025, revealed the resident was not assessed by the facility for the Brief Interview for Mental Status [BIMS] due to issues with both long and short-term memory, as well as difficulties in being understood.Review of R76's Comprehensive Care Plan [CCP], revised 06/24/2025, and found in the resident's EHR, revealed the facility did not care plan the resident for pain based on her assessment to address the resident's chronic pain, including goals and interventions for pain management.Review of R76's Pain Evaluation, dated 07/09/2025, and found in the resident's EHR, revealed the resident expressed pain non-verbally. R76's pain was rated as hurts even more on the Wong-Baker Faces Pain Rating Scale. The assessment noted several nonverbal indicators of pain, including moaning and grimacing facial expressions. It was assessed that the resident's pain increased with movement during care and dressing changes. According to the evaluation, pain medications effectively relieved the discomfort. Per the evaluation, the current pain management regimen included narcotics, and the plan of care indicated that satisfactory pain management was achieved with narcotics.Review of R76's Physician Orders, found in the resident's EHR, revealed an order, dated 04/25/2025, instructing staff to observe the resident for any signs or complaints of pain. According to this order, all instances of pain must be addressed with appropriate interventions, and any uncontrolled pain should be reported to the physician during each shift. Additionally, there was an order, dated 08/05/2025, for oxycodone (narcotic pain reliever) 10 milligrams (mg) to be given four times a day for pain. Furthermore, R76's orders included an order, dated 04/24/2025, for acetaminophen (pain reliever) 500 mg tablet, give two tablets by mouth two times a day for pain. R76 was also prescribed acetaminophen 325 mg, to be taken as two tablets by mouth every four hours as needed for pain relief.Review of R76's Medication Administration Record [MAR], for 08/05/2025, found in the resident's EHR, revealed R76 received one oxycodone 10 mg and two tramadol (pain reliever) 50 mg tablets at 8:00 AM, as ordered. Further review of the MAR and narcotic count sheets revealed the resident received her medications as ordered. Observation of R76 on 08/05/2025 at 9:15 AM revealed she was lying in bed in her room. R76 displayed non-verbal signs of pain, including intermittent crying and moaning. Further observation revealed facial expressions indicative of discomfort; R76 was grimacing and had a furrowed brow. Additionally, she exhibited protective body movements, such as bracing with her arms, and frequently changed her position, moving her head back and forth. R76 was unable to participate in an interview and could not express her needs. There were noticeable signs of discomfort.Observation of R76 on 08/05/2025 at 9:38 AM revealed she was lying in bed in her room, and she continued to cry out and moan. The State Survey Agency (SSA) Surveyor requested that the unit manager check on the resident. Both Licensed Practical Nurse (LPN) 1 and the South Unit Manager (SUM) attended to the resident. During an interview with LPN1 on 08/05/2025 at 9:55 AM, he stated he and the SUM repositioned the resident, and he administered as needed (PRN) pain medication at 9:45 AM. He stated the resident was non-verbal, but staff could ask questions, and R76 would respond by nodding. He stated the resident was assessed as having pain, and she received scheduled and PRN pain medications as ordered. He stated he left a message with the provider to discuss R76's pain.During an interview with the SUM, she stated pain medications were administered to the resident. The SUM also stated the facility had requested that the State Guardian place the resident in Hospice, due to her recent decline. The SUM stated the facility had not heard back from the State Guardian. Resident 76 was non-interviewable due to severe cognitive impairment. During an interview with R76's appointed State Guardian on 08/08/2025 at 10:06 AM, she stated she had recently been assigned to R76. She stated she was not yet familiar with all aspects of the resident's case and was not aware of the request for a Hospice consultation. She stated she would immediately advance the request to the department's nurse navigators for review. She further stated she would call the facility and discuss current plans of care. During an interview with the Director of Nursing (DON) on 08/08/2025 at 10:05 AM, she stated R76 should have a care plan for pain management, as the resident had displayed behaviors indicating discomfort, occasionally crying out or moaning. She stated care plans must be based on the resident's assessment to address chronic pain, including specific goals and interventions for pain management. Furthermore, the DON stated staff should respond to the resident's non-verbal cues and assess for non-pharmacological interventions promptly. She stated it was her expectation that State Registered Nurse Aides (SRNA) inform the nurse about observations indicating pain. She stated nurses needed to assess pain effectively. The DON stated pain medication should be administered as ordered and promptly. During an interview on 08/08/2025 at 10:10 AM with the Administrative Assistant (AA), he stated he had been acting as the interim Administrator for two months. The AA stated it was his expectation that a comprehensive person-centered care plan was developed for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, review of the facility's job description, and review of the facility's policy, the facility failed to ensure nursing staff followed the standard of care for medication administration for 1 of 4 sampled residents, Resident (R) 57. Observation on 08/07/2025 revealed the North Unit Nurse Manager prepared medications for R57. She then transferred the cup of pills to Licensed Practical Nurse (LPN) 2, who administered the medications to the resident. The findings include: Review of the facility's policy titled, Medication Administration by Route or Dosage Form, undated, revealed no specific guidelines for more than one nurse administering medications to a single resident. Review of the facility's job description Licensed Practical Nurse (LPN), undated, revealed LPNs were expected to only administer medications personally prepared and did not leave medications at the bedside without an order to do so.Observation of medication administration with the North Unit Manager (UM) on 08/06/2025 at 8:30 AM revealed she prepared 14 medications for R57. R57's assigned staff nurse, LPN2, walked to the storage room twice during this time to obtain a nutrition supplement. After the North Unit UM had placed the pills in the medication cup, she handed it to LPN2, who had returned to the room entrance and immediately administered the medications to the resident, who was sitting just inside the door to the room. During interview with the North Unit UM on 08/06/2025 at 8:41 AM, she stated she would have to check the policy to determine whether one nurse preparing medications to be administered by another nurse was appropriate. During interview with LPN6 on 08/07/2025 at 8:50 AM, she stated it was not the acceptable standard of care to prepare medication and hand it to another staff to give or to administer medications prepared by another nurse. During interview with LPN10 on 08/07/2025 at 10:00 AM, she stated it was never an accepted standard of practice to prepare medications and hand them to someone else to give. She stated it was also unacceptable for staff to give medications they did not prepare because they did not know what was in the cup if they did not prepare the medications. She stated that was not a safe practice.During interview with LPN12 on 08/07/2025 at 10:45 AM, she stated it was not accepted practice to prepare and then hand medications to someone else to give due to safety issues.During a joint interview with the Director of Nursing (DON) and the Administrative Assistant (interim Administrator) on 08/08/2025 at 1:45 PM, the DON stated her expectation was that nursing staff would prepare and administer medications to residents individually and would not hand medications to another staff member to give to a resident. She stated if a nurse received medications prepared by someone else, it was not safe because they would not know if it was the right medication for the right resident. The Administrative Assistant stated his expectation was that staff would follow the facility's policies.

Based on observation, interview, review of the Food and Drug Administration's document, review of the facility's job descriptions, and review of the facility's policy, the facility failed to correctly label opened medications and dispose of expired medications and supplies to prevent resident use for 1 of 3 medication rooms and 3 of 8 medication and treatment carts.Observation of the Rehab Unit Medication Room and Treatment Cart on 08/06/2025 revealed expired medications and supplies available for resident use.Observation of North Unit Medication Cart 3 on 08/07/2025 revealed a vial of insulin with no opened date on the box or the vial and available for resident use.Observation of South Unit Medication Cart 3 on 08/07/2025 revealed an expired inhaler was on the cart and available for resident use.The findings include:The State Survey Agency (SSA) Surveyor made a written request to the Director of Nursing, on 08/06/2025 and 08/07/2025, for the facility's policy on medication storage. A written response was received that medication storage was included as part of the Medication Administration policy. Review of the facility's policy titled, Medication Administration, undated, revealed no details of medication storage requirements.Review of Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions, both undated, revealed job duties included to dispose of drugs appropriately, to check in medications when delivered, to order medications in a timely manner, to restock medication carts, to maintain clean and orderly medication rooms, and to maintain proper storage of medications.Review of the document Food and Drug Administration's Expiration Dates - Questions and Answers, most recent update 01/21/2025, found on the website www.fda.gov, revealed the importance of drug expiration dates was they reflected the time period during which the product had been shown to remain stable, such that it retained strength, quality, and purity when stored in accordance with labeled conditions. Further review revealed the risk of taking an expired medicine or one that might have degraded because it was not stored according to the labeled conditions. Per the document, if a drug had expired or degraded, subsequent review revealed it might not provide the intended benefit because it had a lower strength than intended. Observation of the Rehab Unit Medication Room on 08/06/2025 at 12:40 PM revealed expired medications and supplies as follows: one Biopatch (a wound dressing), expired 3/31/2024; 31 lubricating jelly, 0.9 ounce, expired 10/28/2023; one box of Surgilube lubricant 0.9-ounce, expired June 2023; and nine DermaFoam dressings, 4-inch x 4.25-inch, expired 02/20/2024.Observation of the Rehab Treatment Cart on 08/06/2025 at 1:34 PM revealed Resident (R) 88's 30-gram tube of Santyl ointment for wound care, expired 05/2025; one Hydrocellular Foam Dressing, 6-inch x 6-inch, expired 06/2020; and one nonbordered Mepilex dressing, 8.3-inch x 8.3-inch, expired 04/01/2023.Observation of the North Unit Medication Cart 3 on 08/07/2025 at 3:04 PM revealed an opened vial of Admelog insulin, 100 unit/milliliter, with no opened date on the box or vial.Observation of the South Unit Medication Cart 3 on 08/07/2025 at 3:47 PM revealed one opened Ellipta inhaler, 100/25 micrograms (mcg), with an opened date of 03/17/2025 and noted to discard after six weeks.During an interview with LPN6 on 08/06/2025 at 12:48 PM, she stated the pharmacy consultant audited the medication carts, and nursing staff and Kentucky Medication Aides (KMA) audited at least once per week. She stated medication rooms were audited weekly. She stated it was important to discard items/medications before expiration because they might not be safe and effective. During an interview with LPN11 on 08/07/2025 at 3:17 PM, he stated the pharmacy conducted medication storage audits, and the Unit Manager did audits, but he did not know the frequency.During an interview with the Rehab Unit Manager on 08/06/2025 at 12:51 PM, she stated it was important not to use medications after expiration because they might not be effective. During a joint interview with the Director of Nursing (DON) and the Administrative Assistant (interim Administrator) on 08/08/2025 at 1:45 PM, the DON stated her expectation was that the nursing staff would ensure appropriate labeling with medications, and discarded medications would be returned to pharmacy or discarded. The Administrative Assistant stated his expectation was that staff would follow the facility's policies.

Based on observation, interview, record review, review of bleach germicidal wipe instructions, review of the facility's job descriptions, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) document and signage related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), 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 for 3 out of 24 sampled residents, Resident (R) 16, R28, and R32. 1. Observation on 08/04/2025 revealed Licensed Practical Nurse (LPN) 2 performed a blood sugar fingerstick for R28, then went to perform a fingerstick on R32. LPN2 failed to follow infection control practices while performing the procedure and failed to put on the appropriate personal protective equipment (PPE) for the resident under EBPs. Further observation revealed LPN2 failed to properly clean and disinfect the blood glucose meter (used to obtain blood sugar results) before storage. 2. Observation on 08/04/2025 revealed R16 was under Contact precautions due to colonization from carbapenem-resistant acinetobacter baumannii ([NAME]). Staff interviews revealed they were unaware of the reasons for the TBP. Further observation on 08/05/2025, revealed staff members entered the room without first donning (putting on) required PPE. The findings include:Review of the CDC's document Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms [MDROs], updated 04/22/2024, revealed due to the increase in MDRO transmission in skilled nursing facilities, EBPs were indicated for nursing home residents. EBPs were an infection control intervention designed to reduce transmission of MDROs, which employed targeted gown and glove use during high contact resident care activities to include: 1) wounds or indwelling medical devices, regardless of MDRO colonization status; and 2) infection or colonization with an MDRO. Review of the CDC's signage on Contact Precautions, undated, revealed everyone must clean their hands before entering and when leaving the room. Additional instructions for providers and staff were to put on gloves and gown before room entry, and discard gloves and gown before room exit, not wearing the same gown and gloves for the care of more than one person. In addition, the signage stated to clean and disinfect reusable equipment before use on another person. Review of the facility's policy titled, Infection Control, revised 09/2021, revealed the facility would plan infection control activities and manage potential outbreaks of disease. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 01/2024, revealed resident-care equipment, including reusable items and durable medical equipment, would be cleaned and disinfected according to current CDC recommendations for disinfection. Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised 01/2024, revealed EBP was an infection control measure that reduced the transmission of resistant organisms by requiring gowns and gloves during high-contact resident care. Additionally, staff would also follow standard precautions for all residents, regardless of infection or colonization status. According to the policy, staff should wear a gown and gloves to provide high-contact resident care. Review of the facility's policy titled, Infection Control Standard Precautions- Handwashing, revised 01/2024, revealed the facility considered hand hygiene the primary means to prevent the spread of infection. Further review revealed all personnel would follow the hand-hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Review of the MicroKill bleach germicidal wipes instructions, Cleaning and Disinfecting Recommendations, no date, revealed to thoroughly clean the glucometer surface then wrap the glucometer with a bleach wipe, covering all surfaces of the glucometer, and ensure the surface remained wet for the entire contact time. Per the instructions, These wipes are EPA-registered and effectively eliminate Clostridium difficile spores in just 3 minutes and Candida auris in 2 minutes.Review of the Certified Nursing Assistant/State Registered Nurse Aide (SRNA) job description, undated, revealed aides were expected to conduct proper hand hygiene and use of PPE and sanitize surfaces when needed.Review of the Licensed Practical Nurse (LPN) job description, undated, revealed LPNs were expected to conduct proper hand hygiene and use of PPE and sanitize surfaces when needed. Review of the Registered Nurse (RN) job description, undated, revealed RNs were expected to conduct proper hand hygiene and use of PPE and sanitize surfaces when needed.Review of R16's admission Record found in R16's electronic health record (EHR), revealed the facility admitted the resident on 08/02/2023 with diagnoses to include dementia, dysphagia, and [NAME].Review of R16's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/29/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight out of 15, indicating the resident was moderately cognitively impaired.Review of R28's admission Record found in R28's EHR, revealed the facility admitted the resident on 07/11/2024 with diagnoses to include type 2 diabetes, cancer, and neurogenic bladder. Review of R28's quarterly MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of 10 out of 15, indicating the resident was moderately cognitively impaired.Review of R32's admission Record found in R32's EHR, revealed the facility admitted the resident on 10/31/2024 with diagnoses to include congestive heart failure, type 2 diabetes, and convulsions.Review of R32's quarterly MDS, with an ARD of 06/26/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. 1. Observation of LPN2 on 08/04/2025 at 6:25 AM revealed he performed a blood sugar fingerstick for R28. LPN2 entered the room and did not don the appropriate PPE for R28 who was in EBP. Furthermore, LPN2 did not perform hand-hygiene prior to entering the room. LPN2 then came out of the room holding a contaminated glucometer. He then entered R32's room with the glucometer in his hand and without performing hand-hygiene. LPN2 then exited R32's room and went back to the medication cart, where he placed the contaminated glucometer down without a barrier cloth. When asked by the State Survey Agency (SSA) Surveyor what the facility policy was regarding the cleaning and disinfection of shared equipment, he pulled out disinfectant wipes and wiped the glucometer for 15 seconds and placed it back down on the medication cart without a barrier.During an interview with LPN2 on 08/04/2025 at 6:36 AM, he stated glucometers were cleaned after each use to prevent the spread of blood-borne pathogens. He further stated he should have performed hand-hygiene before and after providing R28's care. Additionally, he stated he should have worn the appropriate personal protective equipment (PPE) when providing direct care to a resident under enhanced-barrier precautions (EBP). Further discussion with LPN2 revealed he was unable to articulate what dwell-time meant or the required dwell-time for the disinfecting wipes he used to clean the glucometer. During an interview with R28 on 08/04/2025 at 7:06 AM, he stated staff rarely put on a gown or gloves to provide his care. He stated he did not want to make waves so he did not say anything when staff failed to follow infection control procedures such as washing their hands or putting on a gown and gloves.During an interview with the North Unit Manager on 08/04/2025 at 10:25 AM, she stated staff should follow CDC guidance for residents under EBP if they provided direct care to the resident. She stated PPE for EBP rooms were inside the room. She stated hand-hygiene was done when entering and exiting a resident's room. She stated nursing staff should follow the disinfecting wipes manufacturer's instructions for proper cleaning and disinfection of all shared equipment. She further stated it was her expectation that all staff followed facility polices to prevent the spread of disease and infection. 2. Observation of R16's room on 08/04/2025 at approximately 3:45 PM revealed the resident was placed under Contact isolation precautions. CDC signage on the door provided detailed instructions for staff regarding appropriate PPE, supplies, and the necessary actions while providing care to R16. During an interview with SRNA1 on 08/04/2025 at 4:05 PM, she stated she did not know the source of R16's infection. She stated she did not receive that information in shift report. Additionally, SRNA1 stated staff entered R16's room without donning the appropriate PPE. Observation of R16's room on 08/05/2025 at 8:47 AM revealed Housekeeping 1 entered the room and did not don (put on) gloves or gowns. During an immediate interview with Housekeeping 1, she stated she had not been trained to don gloves and a gown when entering R16's room, and she did not know anything about precautions for R16. During an interview with SRNA15 on 08/07/2025 at 8:30 AM, she was able to explain when hand hygiene was necessary, such as when entering and exiting resident rooms, and when it was required to wash with soap and water. SRNA15 stated she followed the guidelines for PPE use for contact precautions based on the instructions posted on the signage at the resident's doors. Additionally, the SRNA stated she understood the importance of following EBP as indicated by the signage, particularly for residents who had a catheter or a feeding tube.During an interview with SRNA16 on 08/07/2025 at 8:35 AM, she stated the importance of hand hygiene when entering and exiting resident rooms, as well as when passing out meal trays. SRNA16 stated staff was to wash hands with soap and water after providing personal care or if hands became soiled for any reason. Additionally, she stated that residents with any type of TBP isolation had signage indicating the appropriate PPE required, and staff should strictly adhere to these guidelines.During an interview with LPN12 on 08/07/2025 at 10:15 AM, she stated she was R16's assigned nurse. She stated she believed R16's isolation was due to having a catheter port. However, LPN12 was unsure why that would require contact precautions. According to LPN12, contact precautions required staff to wear gowns and gloves, but she was uncertain about EBPs related to R16's isolation precautions. LPN12 stated she did not receive information about the resident's isolation precautions during the shift report.During an interview with the South Unit Manager on 08/07/2025 at 10:25 AM, she stated the reason for R16's isolation was due to [NAME] colonization, which was a multi-drug resistant organism. She stated staff was educated regarding isolation precautions and updated daily in report. During an interview with the Infection Preventionist (IP) on 08/07/2025 at 2:06 PM, she stated the facility provided generalized education related to isolation precautions. She stated staff received infection prevention and control training upon hire and periodically thereafter. The IP stated it was important for staff to know about the resident's condition. She stated her expectation was for staff to follow the posted CDC signage. She stated all staff should follow the facility's policies and procedures related to infection control to provide a safe and healthy environment for residents, staff, and visitors. She stated staff was trained to clean and disinfect all shared equipment between residents. She stated nurses were educated on the proper cleaning and disinfection process for shared glucometers to prevent the spread of blood-borne pathogens. Additionally, she stated it was her expectation that all nurses cleaned, disinfected, and stored shared glucometers according to the manufacturer's instructions. She stated the dwell time for MicroKill germicidal bleach wipes was three minutes. She stated the glucometer must remain wet for the full three minutes to ensure complete disinfection, and after cleaning and disinfection, the glucometer should be stored in a container to keep it clean.During an interview with the Director of Nursing (DON) on 08/05/2025 at 9:00 AM, she stated R16 had been under Contact precautions since staff learned, after admission, he was colonized with [NAME]. She stated it was her expectation that staff members who cared for a resident understood the type of infection the resident had and the reasons for enhanced or transmission-based precautions.During an additional interview with the DON on 08/08/2025 at 10:05 AM, she stated the facility followed the recommendations of the CDC for isolation precautions and for shared equipment cleaning and disinfection. She stated her expectation was for staff to adhere to posted signage when entering an EBP or TBP isolation room. Additionally, the DON stated it was her expectation that staff cleaned and disinfected shared equipment according to the facility's policy and manufacturer's guidelines. The DON stated it was important to follow infection prevention and control guidelines and policies to prevent the spread of infection and disease to residents, staff, and visitors. During an interview with the Administrative Assistant (AA) on 08/08/2025 at 10:10 AM, he stated he had been acting as the interim Administrator for two months. The AA stated it was his expectation that staff adhered to the facility's policies related to infection control. He stated that was important to ensure the safety and health of the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to develop and implement care plans with individualized person-centered interventions, to include adequate supervision and monitoring for residents at risk for elopement; and for residents with a history of falls, for seven (7) of thirty-three (33) sampled residents (Residents #1, #3, #18, #22, #24, #25, and #26). 1. Resident #1 eloped from the facility on 07/27/2023 without staffs' knowledge. The resident disabled a window alarm in his/her room and climbed out the window. Resident #1 was found at a nearby convenience store approximately forty-five (45) minutes later. Resident #1 had to cross two (2) busy roads with heavy traffic to get to the convenience store. 2. In addition, the facility failed to have an effective system to develop and implement comprehensive care plans with individualized person-centered interventions to evaluate falls and perform root cause analysis of the falls in order to implement individualized interventions, and to monitor the effectiveness of the interventions to prevent additional falls for six (6) of thirty-two (32) sampled residents (Residents #3, #18, #22, #24, #25, and #26). a). Resident #3 sustained a fall on 06/20/2023, from a wheelchair while unattended. The resident was transferred to a local hospital for evaluation, where he/she was evaluated to have a nasal fracture and a subdural hematoma. However, there were no intervetions in place to address the resident's impaired cognition and need to increase supervision and monitoring. b). Resident #24 was found by staff sitting in a chair on 06/25/2023, with pain and swelling to his/her right knee. The resident reported he/she had fallen from the bed during a self-transfer. Resident #24 was transferred to a local hospital where he/she was diagnosed with a right femur fracture. Resident #24 had to have surgery to repair the right femur fracture. c). Resident #26 sustained falls on 06/14/2023, 06/17/2023, 07/02/2023, 07/25/2023, 07/28/2023, two (2) falls on 08/02/2023; and, on 08/15/2023, a total of eight (8) falls. The fall on 07/02/2023 was due to a self-transfer attempt which resulted in fractures to Resident #26's right radius and ulna (bones of the forearm), as well as a fracture to radius ulna and nasal bone. However, Resident #26's care plan revealed no docuemted evidence of person-centered interventions to prevent falls related to the root cause of each fall. d). Resident #22 had falls on 07/07/2023, 07/15/2023, and 07/22/2023, which resulted in a right orbital blowout fracture. Review of the care plan revealed no documeted evidence of person-centered care plan interventions to address Resident #22's implaired cognition and need for increased supervison and monitoring. e). Resident #18 sustained falls from his/her bed twice while attempting to self-transfer from the bed to the wheelchair. On 07/09/2023, Resident #18 was found lying face down on the floor next to his/her bed, with swelling and blood to his/her lip and pain under the left arm. Resident #18 was transferred to the local hospital for evaluation, with no significant injuries evaluated. On 07/29/2023, Resident #18 was again found lying on the floor between the head of the bed and the wheelchair, soiled with feces, injuries noted. f). Resident #25 reported on 07/30/2023, that he/she had fallen the night before, rolling out of bed during care. The resident sustained a knot to the right hip and skin tear to the right elbow as a result of the fall; however, he/she was not sent to the hospital for evaluation. Immediate Jeopardy (IJ) was identified on 08/11/2023 and again on 09/05/2023 and was determined to exist on 06/14/2023 at 42 CFR 483.25 Quality of Care (F689) Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656); 42 CFR 483.70 Administration (F835); and 42 CFR 483.75 Quality Assurance and Performance Improvement, QAPI/QAA program (F867). The IJ is ongoing. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 09/05/2023. The findings include: Review of the facility's policy titled, Baseline and Comprehensive Care Plan Development, Implementation, and Revisions, dated 08/01/2019, revealed care plans were used to direct effective and person-centered care that focused on personal preferences, goals, medications, active diagnoses, and services to be received by the resident. Further review revealed if there was a conflict between the resident's rights and safety, the facility would explore care alternatives through a thorough care planning process in which the resident might participate. 1. Review of Resident #1's Admission Record revealed the facility admitted the resident on 03/31/2023, with diagnoses of Unspecified Dementia, Type II Diabetes, and Polyneuropathy. Review of Resident #1's Admission MDS dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated moderate cognitive impairment. Review of Resident #1's Quarterly MDS dated [DATE], revealed the facility failed to complete the Cognitive Patterns Section of the MDS and failed to conduct a BIMS' assessment of the resident. Review of Resident #1's Care Plan dated 08/07/2023, revealed the facility care planned the resident for elopement risk on 04/21/2023, with interventions that included: placement of a Wander Guard bracelet; staff to be aware of the resident's location; and family to provide energy drinks for the resident to discourage wandering. Further review revealed the facility resolved the elopement area of the care plan on 08/04/2023, following the Nurse Practitationer''s determination that Resident #1 was competent to make his/her own decisions. Continued review revealed the care plan was updated on 08/07/2023 to include the resident signing himself/herself out to go to businesses in the surrounding area. However, there was no documented evidence the facility included interventions outlining assessment of Resident #1's current mental status; measures to be taken for the resident's safety while out of the facility; time frames he/she was permitted to be out of the facility; or interventions for diabetes management, such as blood sugar checks and insulin administration scheduling around times the resident was absent from the facility. Observation on 08/09/2023 at 2:14 PM, revealed no visual evidence of energy drinks in Resident #1's room. In an interview at the time of the observation revealed Resident #1 stated he/she did not know what interventions were in his/her care plan. Resident #1 stated he/she made multiple requests for the facility to buy energy drinks for him/her out of the money in his/her account. However, the facility failed to honor the requests. In an interview on 08/12/2023 at 6:46 PM, Certified Nursing Nurse (CNA) #9 stated she did not know what interventions were in Resident #1's care plan as far as elopement preventions, other than placement of a Wander Guard bracelet. Per CNA #9, she did not know if providing Resident #1 with an energy drink was an intervention in his/her care plan to prevent elopement. However, she did know the Physician had approved the resident to have one (1) sugar free energy drink per day upon request. CNA #9 further stated the importance of developing and following a care plan was to make sure the resident was safe, and for facility staff to know the resident's needs. In an interview on 08/08/2023 at 4:31 PM, Licensed Practical Nurse (LPN) #1 stated prior to Resident #1's elopement on 07/27/2023, his/her care plan included interventions such as having a sugar-free energy drink available for the resident and keeping a Wander Guard bracelet in place. She stated Resident #1 had not been care planned for specific monitoring such as fifteen (15) minute checks or 1:1 observation prior to his/her elopement. LPN #1 further stated the importance of care planning was to provide resident-centered care to meet the resident's needs. In an interview on 08/15/2023 at 4:49 PM, LPN #11, who was the Unit Manager of the South Hall, stated on the evening of 08/14/2023, staff reported to her that Resident #1 was attempting to go to the courtyard and they did not know if he/she was allowed to do that. LPN #11 stated she did not know if Resident #1's care plan had been updated to include that the resident was allowed to go to the courtyard without a staff member present. She stated she believed staff were confused with all the changes to Resident #1's care plan because he/she had worn a Wander Guard bracelet for months, then climbed out the window and was under 1:1 observation, and then was allowed to sign himself/herself out of the building. LPN #11 further stated the importance of care planning was to promote resident safety and communicate the residents' needs to staff. In an interview on 08/10/2023 at 10:46 AM, the Activities Director (AD) stated one (1) of her job duties was to go to the store for residents who had specific requests for items to be purchased with money from their resident account. The AD stated she rotated which residents she went to the store for each week because there were too many to go for all of them at once. She stated Resident #1 was not on her list of residents for whom she was to shop. The AD further stated she did not know Resident #1's preferences, as he/she was a newer (Resident was admitted in March, 2023) resident in the facility. However, she stated she planned to add the resident to the list of residents she would shop for in the future. In an interview on 08/21/2023 at 3:49 PM, the MDSC (Minimum Data Set Coordinator) stated Resident #1's care plan for exit seeking, prior to his/her elopement on 07/27/2023, was vague and failed to communicate resident specific interventions that would prevent elopement and ensure the safety of the resident. In interview on 08/24/2023 at 4:24 PM, the MDS Nurse stated all residents were identified as fall risks when admitted to the facility and basic interventions were implemented such as non-skid foot wear, and call light within reach at that time. The MDS Nurse further stated more interventions were put in place once a resident sustained falls. In an interview on 08/14/2023 at 8:23 AM, the Medical Director stated he did not know if providing energy drinks was included in Resident #1's care plan as an intervention to prevent elopement. He stated he believed Resident #1 was also motivated to go to the gas station for socialization, as well as for the energy drinks and cigarettes. The Medical Director further stated he should have been more proactive in contributing to care plan interventions for Resident #1, such as setting a time limit on the resident's absences to ensure the resident received his/her prescribed insulin doses and blood sugar monitoring for Diabetes. In an interview on 08/11/2023 at 9:46 AM, the Director of Nursing (DON) stated the facility told Resident #1's daughter she could bring in energy drinks for her parent; however, the facility did not provide those beverages. She stated the IDT (Interdiscplinary Team) discussed safety interventions for Resident #1 when he/she signed out of the facility independently to include signing out at the nurse's station and/or front desk, telling staff where he/she was going, and ensuring the resident had his/her cell phone in his/her pocket. However, the DON stated the IDT team had failed to include those interventions in Resident #1's care plan as a means to communicate the interventions to staff. She stated therefore, not everyone would have been aware of the safety measures which should have been in place for Resident #1. In an additional interview on 08/24/2023 at 12:19 PM, the DON stated her expectation was for residents' care plans to contain any focus assessments or conditions pertaining to the resident so the facility could have a plan and interventions to communicate the plan of care. In an interview on 08/24/2023 at 3:03 PM, the Administrator stated her expectation was for care plans to be comprehensive and resident centered. She stated the purpose of residents' care plans was to communicate the resident's care needs to staff. The Administrator stated care plan interventions for exit-seeking residents should be developed to address the root cause of the exit-seeking behavior for that particular resident. 2. Review of Resident #3's face sheet revealed the facility admitted the resident on 09/08/2022, with diagnoses that included Hemiplegia to the right side, Diabetes, and Cerebral Infarction. Review of the Admission Minimum Data Set (MDS) Assessment, dated 09/08/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) which indicated moderately impaired cognition. Continued review revealed the facility assessed Resident #3's Activities of Daily Living (ADL's) as one (1) person assist with his/her unsteady balance. Further review revealed the facility assessed Resident #3's mobility assist device as a manual wheelchair with substantial assistance needed. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #3 to have a BIMS' score of seven (7) out of fifteen (15) which indicted severely impaired cognition. Continued review revealed the facility assessed Resident #3's ADL status as requiring one (1) to (2) person extensive assistance. Further review revealed the facility assessed Resident #3's mobility as totally dependent per a manual wheelchair. Review of Resident #3's comprehensive care plan (CCP) dated 09/09/2022, revealed the facility identified the resident as a fall's risk with interventions which included: anticipate and meet the resident's needs; call light within reach and encourage use of assistance as needed; and wear proper footwear. Per review of the CCP, Resident #3 was identified on 06/12/2023 as a fall's risk due to right sided weakness and impulsiveness related to Cardiovascular Accident (CVA/stroke) with a revision date of 06/22/2023. Continued review revealed interventions which included: educating the family to alert staff when leaving if the resident was in the chair, and not to close the room door. Further review of the CCP revealed the facility identified Resident #3's safety insight as poor, with interventions implemented on 06/21/2023 for staff to conduct routine visual rounding per routine care task; however, there was no documented evidence of interventions for closer monitoring prior to the resident's fall on 06/20/2023. Additional review of the CCP revealed the facility identified Resident #3 as being cognitively impaired with poor decision-making skills on 06/13/2023. Further review revealed the interventions included observing Resident #3 for mental status changes; however, there was no documented evidence of interventions noted to guide direct care staff on what actions to take if observations of mental status changes were made; how often to make observations; or who to report their observations to. In interview, on 08/10/2023 at 1:30 PM, the Director of Nursing (DON) stated care plans were maps of care for residents and everyone should be looking at them. She stated the Kardexes (direct care staff plans of care) were updated, and all staff were taught to check those each day. The DON further stated there was no process for auditing to determine if staff were checking the care plans and Kardexes as instructed; however, there was ongoing training and in-services provided. Review of the Nursing Admission Data Collection form, dated 09/08/2022, revealed the facility assessed Resident #3 as a fall risk due to falls within three (3) months of admission, elimination with assistance, ambulated with problems/devices, and could not achieve balance without physical help. Review of the Fall Risk Assessment for Resident #3 dated 06/20/2023 at 3:57 PM, revealed the facility scored the resident as a six (6), which indicated he/she was a high risk for falls. Review of the Progress Notes for Resident #3 dated 06/14/2023 through 06/19/2023 revealed the resident was documented to have confusion. Continued review revealed no documented evidence the Physician was notified of Resident #3's confusion. Review of the Occupational Therapy (OT) note dated 06/14/2023, revealed during Activities of Daily Living (ADL) retraining Resident #3 required maximum assist with verbal cues. Review of the facility's Fall Scene Investigation Report dated 06/20/2023 at 4:02 PM, revealed Resident #3 was found lying on the floor in his/her room after ambulating alone and unattended. Continued review revealed Resident #3's mental status prior to the fall was confused and having decreased awareness. Further review revealed the Fall Prevention Book was to be updated. In an interview on 08/29/2023 at 2:25 PM, with the Assistant Director of Nursing (ADON) at 2:25 PM, and Licensed Practical Nurse (LPN) #2 at 2:40 PM, revealed the facility had no Fall Intervention Books which were noted on the 06/20/2023, Fall Scene Investigation Report. Review of Resident #3's Progress Note dated 06/20/2023 at 3:12 PM, revealed the Unit Manager was called to the resident's room after a CNA found him/her lying on the floor at the foot of the bed. Review of the Progress Note, dated 06/20/2023 at 4:03 PM, revealed the Primary Care Provider (PCP) was notified with a recommendation to send Resident #3 to the Emergency Department (ED). The facility transferred the resident to the ED. Review of the Progress Note, dated 06/21/2023 at 11:03 AM, revealed Resident #3 had been admitted to the hospital with a broken nose and subdural hematoma. Review of the Pain Evaluation dated 06/20/2023 at 4:02 PM, for Resident #3 revealed the Wong-Baker face scale for pain was utilized for assessing the resident's pain. Continued review of the Pain Evaluation revealed hurts even more with moaning and facial grimacing were marked on the form as well as, pain increasing with movement with the likely cause of the pain being the fall. Review of the local hospital records for Resident #3 dated 06/20/2023, revealed a Computerized Tomography (CT) scan was performed on the resident at 4:56 PM, of his/her head and facial bones. Review of the findings revealed an acute thin subdural hematoma and acute minimally displaced fracture of the nasal bone indicated from a frontal head injury. Observation of Resident #3 on 08/08/2023 at 9:25 AM and at 1:50 PM; and on 08/29/2023 at 2:30 PM revealed the resident alone in his/her room without supervision of staff nearby. Continued observation on 08/31/2023 at 11:55 AM, revealed Resident #3 sitting in the common area alone and unattended and no device observed to call for assistance if needed. In interview on 08/09/2023 at 12:55 PM, Certified Nurse Aide (CNA) #38 stated she went by what she was told in shift report and did not always look at residents' Kardex for their care needs. In interview on 08/08/2023 at 9:30 AM with CNA #2 and at 4:30 PM with LPN #1 they stated Resident #3 could only respond to yes and no questions. In interview on 08/28/2023 at 4:06 PM, LPN #7 stated she had been told in report by night shift staff that during the night on 06/19/2023, Resident #3 had attempted to get out of bed two (2) times by placing his/her feet on the floor. She stated staff were constantly needing to remind Resident #3 to not get up and to call for help. The LPN stated on 06/20/2023, she thought Resident #3 had simply just stood up and tried to walk when he/she sustained the fall. She further stated that day staff had brought Resident #3 had brought him/her out into the common area to keep an eye on him/her until his/her daughter arrived. In interview with CNA #20 on 08/29/2023 at 1:15 PM, she stated she attempted to round more often on residents who had low BIMS scores; however, got busy and could not always do that. In an interview with CNA #16 on 08/28/2023 at 4:46 PM, she stated due to staffing shortages she no longer worked at the facility. She stated there were other residents besides Resident #3 who needed closer supervision residing at the facility. In an interview on 08/30/2023 at 9:55 AM, the Activities Director (AD) stated Resident #3 would not be safe to self-transfer and was seated in the common area due to concerns of his/her getting up without staff. She stated Resident #3 probably needed closer supervision due to his/her inability to remember instructions. In an interview with the ADON on 08/31/2023 at 2:11 PM, she stated the facility's documentation did not reveal a root cause analysis for Resident #3's fall sustained on 06/20/2023. She stated she was not that familiar with the incident since it had happened on the Rehabilitation Unit. 3. Review of Resident #24's medical record revealed the facility admitted the resident on 02/02/2022, with diagnoses that included Dementia, Repeated Falls, Atrial Fibrillation, and urinary and bowel incontinence. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #24 to have a BIMS score of five (5) out of fifteen (15) which indicated he/she was severely cognitively impaired. Continued review revealed the facility assessed Resident #24's ADLs status as requiring the assistance of one (1) staff for transfers, walking, and toilet use. Further review revealed the facility assessed Resident #24's balance as unsteady and the resident was only able to stabilize with human assistance. In addition, record review revealed the facility assessed the resident to utilize a wheelchair for mobility. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of three (3) out of fifteen (15), also indicating severely impaired cognition. Further review revealed the facility assessed the resident's balance as being only able to stabilize with human assistance. Review of Resident #24's Comprehensive Care Plan (CCP) dated 02/04/2022, revealed the facility identified the resident as a fall risk with interventions implemented on 02/07/2023, anti-roll back devices to his/her wheelchair for safety. Per review, additional interventions included toileting the resident every two (2) to three (3) hours with CNA rounds; however, with no revision date noted. Continued review revealed on 08/15/2023, Resident #24's care plan was revised with anti-roll-back devices, encourage, and remind the resident to use the call light. Further review of Resident #24's CCP revealed the facility also identified the resident as having impaired cognition related to Dementia on 06/30/2023, with interventions which included observations for any changes in the resident's cognitive function. However, there was no documented interventions informing staff what action to take if observations were made of changes resident's cognition. Further review of Resident #24's CCP revealed the facility identified the resident as having bowel and bladder incontinence which had been initiated on 02/17/2022 and revised on 01/18/2023. Review of the bowel and bladder incontinence care plan further revealed interventions implemented on 02/22/2022, and revised on 04/20/2023, which included to check and change the resident every two (2) hours. Review of the Progress Note, dated 03/21/2023, revealed Resident #24's Dementia was a contributing factor for his/her recurrent falls as he/she was uneducable and unable to remember to lock his/her brakes on the wheelchair, use the call light, or ask for assistance. Review of Resident #24's Fall Risk Assessments dated 03/19/2023 and 04/21/2023, revealed the facility assessed the resident to have a score of twelve (12) indicating he/she was a high fall risk. Review of the facility's Incident Report dated 06/25/2023 at 3:00 PM, revealed Resident #24 had been found to be sitting on his/her bottom on the floor by the bed with injury to his/her right knee. Continued review of the Report revealed the facility identified predisposing factors included for Resident #24 which included confusion, incontinence, gait imbalance, impaired memory, and ambulating without assistance. Review of the Fall Risk Assessment for Resident #24, dated 06/25/2023, revealed the facility assessed the resident to have a score of ten (10) indicating he/she was a high fall risk. Review of the facility's Fall Risk Evaluation dated 06/25/2023 at 3:31 PM, revealed Resident #24's cognition was baseline. Continued review revealed the resident had sustained falls since admission; required staff assistance with elimination; and was only able to stabilize for toilet use with staff's assistance. Review of the Progress Note dated 06/25/2023 at 3:30 PM, revealed upon assessment of Resident #24's right knee the resident complained of pain, and the knee was observed to be very swollen, with the resident unable to bear weight on that leg. Continued review revealed Resident #24 was transported to a local hospital for evaluation. Review of Resident #24's Progress Note, dated 06/27/2023 at 9:19 AM, provided by the DON, revealed right before the resident sustained the fall, he/she had been lying on his/her bed asleep. Continued review revealed the resident self-reported falling from his/her bed. Review of the hospital records, dated 06/25/2023, revealed Resident #24 received right knee/femur imaging performed at 7:35 PM, with the findings of the imaging noted as a fracture to the right femur. Continued review of the hospital records revealed Resident #24 underwent surgery for right femur nailing (procedure to stabilize the femoral bone) on 06/26/2023. Further review revealed Resident #24 was discharged and returned to the facility on [DATE]. Observation on 08/31/2023 at 2:15 PM, revealed Resident #24 sitting up unattended in a wheelchair with anti-roll back devices which he/she was moving about throughout facility. In interview on 08/31/2023 at 10:15 AM, CNA # 29 stated Resident #24 did not have a device to his/her wheelchair to prevent it from tilting, such as anti-roll backs. She stated the resident was confused and she tried to check on him/her frequently due to confusion. In interview on 08/30/2023 at 9:55 AM, the AD stated Resident #24 would just get up when he/she wanted to, and she felt the resident would never be safe enough to self-transfer. She further stated she would instruct staff regarding that information. In interview on 08/31/2023 at 2:11 PM, the ADON stated the RCA (Root Cause Analysis) for Resident #24's fall on 06/25/2023 was determined to have been his/her attempting to self-transfer and rolled out of bed while doing so. She further stated the RCA for Resident #24's other falls had been his/her attempting to self-transfer and his/her impulsiveness. In interview on 09/05/2023 at 11:35 AM, the DON stated a Fall Scene Investigation Report had not been performed on 06/25/2023, for Resident #24 fall. However, the entries documented in the Progress Notes was how the event occurred. 4. Review of Resident #26's Admission Record revealed the facility admitted the resident on 05/12/2023, with diagnoses that included Alzheimer's Disease, Parkinson's Disease, and Repeated Falls. Review of Resident #26's Admission MDS Assessment, dated 05/22/2023, revealed no documented evidence the facility assessed the resident with a BIMS' score. Continued review revealed the facility assessed Resident #26 to require one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of seven (7) out of a possible fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility again assessed Resident #26 to require one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Care Plan dated 08/15/2023, revealed the facility identified the resident at risk for falls on 05/12/2023. Interventions included: Physical and Occupational Therapy (PT/OT) evaluations and treatment; conduct rounds per routine care task to determine additional safety cueing; ensure the resident used a walker for ambulation; and ensure the resident wore nonskid footwear during transfers. Continued review revealed the interventions included: placing a nightlight in his/her room; offering toileting before meals; and applying red tape to call light to remind resident to ask for assistance. Review of Resident #26's medical record revealed the resident sustained falls on 06/14/2023; 06/17/2023; 07/02/2023; 07/25/2023; 07/28/2023; on 08/02/2023 at 5:33 PM and 9:15 PM; and on 08/15/2023. Review of the facility's Fall Scene Investigation Report dated 06/14/2023 at 1:36 PM, revealed Resident #26 attempted to self-transfer back into the bed from too far away, causing the resident to fall to the floor. Continued review revealed the facility's initial interventions were to re-educate Resident #26 on asking for assistance when needed, and educating the resident on checking to make sure he/she was close enough to the object before sitting down. Review of Resident #26's Care Plan revealed no documented evidence of the interventions the facility identified for the resident after the 06/14/2023 fall. The interventions were to re-educate the resident to ask for assistance when needed; and, to check to ensure he/she was close enough to the object he/she was transferring to. Review of the facility's Fall Scene Investigation Report dated 06/17/2023 at 2:05 PM, revealed Licensed Practical Nurse (LPN) #4 witnessed Resident #26 walking in the hallway with a cane, lose his/her balance and fall to the floor. Continued review revealed Resident #26 sustained no injury. Review of Resident #26's Care Plan revealed on 06/19/2023, the facility implemented an intervention for staff to ensure the resident had a walker when ambulating. Review of the facility's Fall Scene Investigation Report dated 07/02/2023 at 11:45 PM, revealed CNA #36 and LPN #8 found Resident #26 lying on the floor at the foot of his/her roommate's bed, near the bathroom, covered in blood. Review of Resident #26's hospital records dated 07/09/2023, revealed the resident was admitted to the hospital on 07/03/2023, for fractures to his/her left radius and ulna, as well as nasal fractures due to a fall. Review of Resident #26's Care Plan revealed on 07/03/2023, the facility implemented an intervention of a night light to the resident's room for safety. Review further revealed however, no documented evidence the facility developed Resident #26's care plan to include interventions to address the resident's attempt to self-toilet. Review of Resident #26's Fall Scene Investigation Report dated 07/25/2023 at 2:06 AM, revealed LPN #14 found the resident sitting on the floor, leaning against the bathroom door. Review of Resident #26's Care Plan revealed on 07/25/2023, the facility implemented an intervention for having Resident #26 wear nonskid footwear when transferring. However, continued review revealed no documented evidence the facility developed interventions to address the resident's attempt to self-toilet as the cause of the fall. Review of the facility's Fall Scene Investigation Report dated 07/28/2023 at 2:30 PM, revealed LPN #3 found Resident #26 lying on the floor beside his/her bed after the resident attempted to self-transfer. Review of Resident #26's Progress Note documented dated 07/28/2023 at 2:41 PM, documented by LPN #3 revealed the resident told her he/she slid out of the lift chair while attempting to transfer to his/her bed. Continued review revealed LPN #3 re-educated Resident #26 to ask for assistance

Based on observation, 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 adequate supervision and monitoring to prevent elopements for one (1), Resident #1; and falls for six (6), Residents #3, #18, #22, #24, #25 and #26, of thirty-three (33) sampled residents. 1. On 04/20/2023, Resident #1 attempted to exit the building by walking out of the front door of the facility. At that time, the facility failed to assess the resident's cognition and placed a Wander Guard bracelet on the resident, as a measure to prevent elopement. Further, the facility failed to have a system in place to ensure the resident's window alarm, which alerted staff when opened, was checked routinely. Subsequently, the resident exited the facility, without staff knowledge, by disabling a window alarm in his/her room and climbed out of the window, on 07/27/2023. The resident was missing from the facility for approximately forty-five (45) minutes and was found at a nearby convenience store. The resident had to cross two (2) roads with heavy traffic to get to the store. Additionally, the facility failed to ensure the Interdisciplinary Team (IDT) met to discuss the resident's cognition and his/her ability to make decisions related to his/her safety. On 08/02/2023, the resident was assessed utilizing the St. Louis University Mental Status (SLUMS) exam, which determined the resident was not safe to leave the facility unsupervised, based on his/her score which indicated the resident had dementia. However, on 08/04/2023, the resident was assessed utilizing the Min-Mental State Examination (MMSE), which determined the resident was cognitively intact (according to SLUMS Test For Dementia: What It Is and How It Works (verywellhealth.com), updated 09/13/2022, the SLUMS was a more sensitive test than the MMSE, which meant it was more reliable in determining the various levels of cognitive decline). Therefore, approximately eight (8) days after the resident's elopement, the facility determined the resident was cognitively intact and capable of leaving the facility unsupervised without taking into account the results of the SLUMS examination and staff's concerns for the resident's safety. In addition, the facility failed to have an effective system to determine the root cause: evaluate falls: implement individualized interventions, and to monitor their effectiveness to prevent additional falls for six (6) of thirty-three (33) sampled residents (Residents #3, #18, #22, #24, #25, and #26) 2. Resident #3 had a fall from a wheelchair on 06/20/2023, while unattended. The facility transferred the resident to a local hospital for evaluation. The hospital assessed Resident #1 to have a nasal fracture and a subdural hematoma. 3. The facility found Resident #24 sitting in a chair on 06/25/2023. The resident was noted to have pain/swelling to his/her right knee. Resident #24 reported he/she had fallen from the bed during a self-transfer. The resident was transferred to a local hospital; the radiology findings revealed a right femur fracture. The resident had surgery to repair the right femur fracture. 4. Resident #26 had falls on 06/14/2023, 06/17/2023, 07/02/2023, 07/25/2023, 07/28/2023, twice on 08/02/2023 and 08/15/2023. The fall on 07/02/2023 was due to a self-transfer attempt which resulted in fractures to the resident's right radius and ulna, as well as a fracture to the nasal bone. 5. Resident #22 had falls on 07/07/2023, 07/15/2023, and 07/22/2023, which resulted in a right orbital blowout fracture. The fall on 07/22/2023 occurred while the resident was unattended and attempted to self-transfer. 6. Resident #18 had a fall from the bed twice while attempting to self-transfer from the bed to the wheelchair. On 07/09/2023, the facility found the resident face down on the floor next to the bed. The fall resulted in swelling and blood to the resident's lip and pain under his/her left arm. The facility transferred Resident #18 to the local hospital for evaluation, with no significant injuries found. Subsequently, on 07/29/2023, Resident #18 was found on the floor between the head of the bed and the wheelchair, soiled with feces. 7. Resident #25 reported, on 07/30/2023, that he/she had fallen the night before, on 07/29/2023, rolling out of the bed while staff assisted with the resident's care. The resident sustained a knot to the right hip and a skin tear to the right elbow. The incident; however, was not reported until 07/30/2023. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring to prevent an elopement and falls is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/11/2023 and again on 09/05/2023, and was determined to exist on 06/14/2023 at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Person-Centered Care Plans ( F656), 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement QAPI/QAA program (F867). The IJ is ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on08/11/2023 and again on 09/05/2023. The findings include: Review of the facility's policy titled, Elopement/Unsafe Wandering Risk Evaluations, not dated, revealed the facility ensured each resident received adequate supervision to prevent accidents, including elopement. Further review revealed elopement was defined as when a resident left the facility without authorization or supervision, usually without staff knowledge. 1. Record review revealed the facility admitted Resident #1, on 03/31/2023, with diagnoses of Unspecified Dementia, Type II Diabetes, and Polyneuropathy. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/10/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) of fifteen (15) which indicated moderate cognitive impairment. Review of Resident #1's Quarterly MDS Assessment, dated 07/05/2023, revealed the facility failed to assess the resident with a BIMS score, a cognitive assessment. Review of Resident #1's Comprehensive Care Plan (CCP), dated 08/07/2023, revealed the facility care planned Resident #1 for an elopement risk, on 04/21/2023. Interventions included: placement of a Wander Guard bracelet, staff to be aware of resident's location, and family to provide energy drinks to resident to discourage wandering. Review of Resident #1's Progress Note, dated 04/20/2023, revealed the facility identified Resident #1 as an elopement risk when he/she attempted to exit the front door. Further review revealed the resident stated he/she wanted to go to the store to purchase cigarettes and an energy drink. Review of the Note revealed the facility failed to perform a cognitive assessment at that time. However, the facility placed a Wander Guard bracelet (a device placed on the resident that would trigger an alarm to sound if the resident exited a door equipped with an alarm) on Resident #1 as an elopement prevention measure. Review of Resident #1's Incident Report, dated 07/27/2023, revealed on 07/27/2023 at approximately 9:30 PM, Certified Nursing Assistant (CNA) #10 noted Resident #1 was not in his/her bed and initiated a Code Green. This code was used for a missing resident. Further review revealed CNA #9 located Resident #1 at a local gas station and brought him/her back to the facility at 10:15 PM, approximately forty-five (45) minutes after Resident #1 was noted to be missing. Further review revealed Resident #1 disabled the window alarm so staff would not hear him/her leave. Continued review revealed the facility assessed the resident to be free from injury upon return to the facility. Review of the weather data, according to www.weatherunderground.com, revealed on 07/27/2023 at 9:54 PM, the temperature in the area was eighty-six (86) degrees Fahrenheit with clear skies. Observation of the route to the gas station revealed it was seven-tenths (0.7) of a mile from the facility, crossing two (2) roads with heavy traffic. Observation on 08/10/2023 at 6:02 AM, revealed Resident #1 was returning to the facility, smelling of cigarette smoke and dressed in a black sweater and jeans. Resident #1 stated he/she had gone outside to smoke a cigarette and signed out with the nurse before leaving. Observation on 08/10/2023 at 8:29 AM, revealed Resident #1 signed himself/herself out of the facility with the Administrator at the front desk. Further observation revealed the Administrator asked the resident yes/no questions, such as Are you going to the gas station? which would not provide information on the resident's cognitive status. In an interview on 08/09/2023 at 2:14 PM, Resident #1 stated, on 07/27/2023, he/she turned off the alarm on the window of his/her room and climbed out the window to get an energy drink and some cigarettes from the local gas station. He/she stated that prior to the night he/she climbed out the window, he/she had asked facility staff to take his/her money and buy him/her an energy drink, but they never provided the energy drink as requested. Resident #1 stated the first time he/she tried to exit the facility through the front door, facility staff told him/her that he/she was not allowed to leave the facility but did not explain why he/she was not allowed to leave. Per the interview, the nurses talked to the resident a few days after he/she came back to the facility and told the resident that he/she was allowed to leave the facility if he/she signed out and told staff where he/she was going. In an interview on 08/08/2023 at 10:45 AM, CNA #1 stated she was aware of Resident #1's elopement, though it did not happen while she was working. She stated she was concerned about the resident's safety while walking to the gas station, due to the heavy traffic on the roads between the facility and the gas station. Per the interview, Resident #1 was alert and oriented but had days where he/she became confused. CNA #1 stated those were the days she worried about the resident being allowed to sign himself/herself out of the facility without supervision. In an interview on 08/14/2023 at 4:42 PM, CNA #10 stated she was working the night Resident #1 eloped and had seen him/her in the courtyard at approximately 8:30 PM on 07/27/2023. She further stated she went to Resident #1's room while conducting routine resident care rounds at approximately 9:30 PM and noted the resident was not in his/her bed, so CNA #10 checked the courtyard. Per the interview, when she did not see Resident #1 in the courtyard, she informed the nurse, and they called the Code Green, the code for a missing resident. In further interview, CNA #10 stated Resident #1 often asked for an energy drink and cigarettes, and she believed if the resident had those items available in the facility, he/she would not have eloped. In an interview on 08/12/2023 at 6:46 PM, CNA #9 stated Resident #1 frequently asked for cigarettes and an energy drink, so when CNA #9 heard Resident #1 was not found in the building or on the grounds on 07/27/2023, she told Licensed Practical Nurse (LPN) #1 that she believed the resident might be at the local gas station. She stated she drove her car down to look for him/her. CNA #9 stated she found Resident #1 sitting on the curb at the gas station, smoking a cigarette, and drinking an energy drink. In further interview, CNA #9 stated the physician approved Resident #1 to receive one (1) sugar-free energy drink per day, due to his/her diabetes and heart conditions. However, she stated she was not sure how the energy drinks were made available to the resident or what was in the care plan about the process. CNA #9 stated Resident #1 had worn a Wander Guard bracelet as long as she had worked at the facility. However, she stated she was not sure why Resident #1 wore the Wander Guard bracelet. CNA #9 stated after Resident #1 climbed out the window on 07/27/2023, the facility performed a mental examination and determined the resident would be allowed to sign himself/herself out of the building independently. In an interview on 08/10/2023, LPN #3 stated she was working on 04/20/2023 and recalled Resident #1 attempting to exit through the front doors. She stated she redirected Resident #1 back to his/her room and, after consulting with management, placed a Wander Guard bracelet on Resident #1 to alert staff if he/she attempted to exit through the doors. In further interview, she stated she did not know who made the decision on whether residents could safely sign themselves out of the facility for a leave of absence, nor did she know of a policy describing the criteria for determining if a resident could sign themselves out. LPN #3 stated there was not an official assessment she would perform for a resident asking to sign themselves out, but she would talk to the resident to see if he/she could describe where he/she was going and how long he/she would be gone. In an interview on 08/08/2023 at 4:31 PM, LPN #1 stated she was working on the South Hall on 07/27/2023 when Resident #1 eloped. She further stated when CNA #10 told her Resident #1 was not in his/her bed and the window was open, staff called a Code Green. She stated CNA #9 drove to the gas station where she found Resident #1 and brought him/her back to the facility. In an interview on 08/21/2023 at 3:23 PM, the Maintenance Director stated he did not perform routine inspections of window alarms, because that duty was assigned to housekeeping. In an interview, on 08/21/2023 at 3:31 PM, the Housekeeping Supervisor stated it was the responsibility of the housekeeping staff to check the window alarms. In further interview, she stated, prior to 07/27/2023, the housekeeping staff checked the batteries and the function of the window alarms twice per year by raising the window to check if the alarm sounded. The Housekeeping Supervisor stated the current owners of the facility did not have a policy on how often the batteries should be checked. Record review revealed the facility resolved the elopement area of the care plan on 08/04/2023 following the Nurse Practitioner's determination that the resident was competent to make his/her own decisions. Continued review revealed the CCP was updated, on 08/07/2023, to include the resident could sign himself/herself out to go to businesses in the surrounding area but failed to include any interventions outlining further assessment or any measures to be taken for the resident's safety while out of the facility. However, in an interview on 08/09/2023 at 11:27 AM, the Speech Therapist stated she performed a BIMS assessment and assigned Resident #1 a score of fourteen (14), which indicated the resident was cognitively intact. She further stated she also conducted a St. Louis University Mental Status (SLUMS) assessment with Resident #1. She stated the SLUMS assessment was a more detailed assessment that evaluated for dementia. The Speech Therapist stated Resident #1 scored fifteen (15) of a possible thirty (30), which indicated signs of dementia. In a further interview, the Speech Therapist stated she was concerned about Resident #1 consistently being able to navigate safely to and from the gas station while unsupervised, and she had expressed those concerns to the Director of Rehabilitation. In an interview on 08/11/2023 at 9:06 AM, the Director of Rehabilitation (DOR) stated she gave the documentation of the Speech Therapist's assessment findings to the Director of Nursing (DON) and the Administrator, who made the decision to allow Resident #1 to sign himself/herself out of the facility based on those assessments, as well as the cognitive assessment performed by the Nurse Practitioner. In an interview on 08/09/2023 at 8:13 AM, the Nurse Practitioner (NP) stated she was informed of Resident #1's elopement on 07/27/2023 and she conducted a mini mental exam with Resident #1 on 08/04/2023. She stated this examination consisted of asking the resident questions to determine his/her orientation to person, place, and time; asking the resident to follow three (3) step simple commands, such as folding a piece of paper; and sequential counting. The NP stated Resident #1 scored a twenty-seven (27) of thirty (30) on this examination. Per the interview, the NP stated she determined, based on this assessment and her assessment of the resident, that the resident was competent to make his/her own decisions. She stated she recommended the resident be allowed to sign out of the facility to go to the gas station. In an interview on 08/14/2023 at 8:23 AM, the Medical Director (MD) stated the facility contacted him when Resident #1 eloped on 07/27/2023. He further stated his recommendations at that time were to ensure the resident remained in the building until the IDT discussed the resident's ability to sign himself/herself out and let staff know he/she was leaving, versus climbing out the window. Per the interview, the MD stated he was not closely involved in the discussions around allowing Resident #1 to sign out of the facility independently to walk to the gas station. In further interview, the MD stated he should have been more involved in safety measures for Resident #1's sign-out procedure, such as setting time limits for Resident #1's absences because the facility was ultimately responsible for Resident #1 while he/she was a resident there. In an interview on 08/11/2023 at 9:46 AM, the Director of Nursing (DON) stated Resident #1 first tried to exit the front door of the facility on 04/20/2023 to go to the gas station the resident was familiar with from the neighborhood near the facility where his/her daughter lived. The DON stated she told Resident #1 and his/her daughter, at that time, that the resident would not be allowed to walk out of the facility on his/her own due to his/her admission BIMS assessment that indicated cognitive impairment. The DON further stated the facility's process for determining if a resident was capable of making his/her own decisions was to look at the BIMS' score. The DON stated if the BIMS score was an eight (8) or below, the facility would not consider the resident to be mentally competent. In further interview, the DON stated when staff members noted Resident #1 was not in his/her bed on 07/27/2023, they knew where to look for the resident because the resident had previously stated he/she had frequented that gas station prior to admission to the facility. The DON stated the facility decided to let Resident #1 sign out of the facility independently after the MD and NP determined the resident was mentally competent to do so. However, the Medical Direction in his interview on 08/14/2023 at 8:23 AM stated he was not involved in the discussions around allowing Resident #1 to sign out of the facility independently and should have been more involved in safety measures surrounding Resident # 1's sign-out procedure. The DON further stated she worried about Resident #1 when he/she was out of the facility. In an interview, on 08/24/2023 at 3:03 PM, the Administrator stated the facility determined Resident #1 eloped from the facility on 07/27/2023 through the window in his/her room to go get energy drinks and cigarettes. She further stated, that prior to the resident's admission to the facility, the facility was not aware that Resident #1's daughter allowed the resident to go to the gas station independently, a habit which she stated could have been a contributing factor in his/her elopement. Review of the facility's policy titled, Falls Protocol, revised 03/18/2019, revealed the facility would assess residents for fall risks upon admission, readmission, and with a significant change in medical condition. Per the policy, in the event of an actual fall, an attempt would be made to eliminate the causal factors and prevent further falls. Residents experiencing an actual fall would have the following interventions: neurological checks performed and documented for falls that involved a possible head injury or were unwitnessed, incident investigation completed to determine the root cause of the fall and/or if the event was isolated in nature. Further review revealed implementation of preventative measures prior to the end of the shift based on the incident investigation findings, request of primary care physician (PCP) for x-ray order for any resident alert to self, only with any external signs of an injury after a fall to rule out a possible fracture, and review of the fall at the next Interdisciplinary Team (IDT) meeting to assure that the interventions were appropriate, to evaluate the need for any additional preventative measures, and to verify appropriate interventions had been implemented. Further review of the facility's policy titled, Falls Protocol, revised 03/18/2019, revealed the care plan would be revised for any new fall prevention interventions, and the Fall Intervention Book would be updated immediately for staff reference. The policy stated a resident with two (2) falls within a ninety (90) day period would have a review conducted by the IDT regarding all documentation and findings related to previous falls and would discuss this with the resident/family and physician. Per the policy, additional educational interventions utilized for prevention and any refusals related to recommended safety interventions would be documented. The policy stated a resident with three (3) falls within a ninety (90) day period would additionally have a request made to the attending physician/pharmacist or other clinical designee to review falls, medications, and plan of care for additional recommendations. 2. Review of Resident #3's Admission Record revealed the facility admitted the resident, on 09/08/2022, with diagnoses to include Hemiplegia to the Right Side, Diabetes, and Cerebral Infarction (Stroke). Review of Resident #3's Admission MDS Assessment, dated 06/16/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) of fifteen (15), indicating cognition to be severely impaired. A manual wheelchair was assessed on 06/16/2023 for an assistive device with the resident being totally dependent. Review of Resident #3's Comprehensive Care Plan (CCP), dated 09/09/2022, revealed he/she was identified as a fall risk with interventions in place which included anticipating and meeting the resident's needs, call light within reach and encourage usage for needed assistance, wear proper footwear, and the resident needed a prompt response for assistance, not indicating what defined prompt. Additional review of Resident #3's CCP revealed the resident was identified on 06/12/2023 as a fall risk due to right sided weakness and impulsiveness due to stroke with revision date of 06/22/2023. Interventions were placed for educating family to alert staff when leaving if resident was in his/her chair and not to close the door. Continued review of the CCP revealed the resident's safety insight was poor, with interventions placed on 06/21/2023 for staff to conduct routine visual rounding per routine care task; however, no interventions for closer monitoring were indicated on the CCP prior to the fall on 06/20/2023. Further review of Resident #3's CCP revealed Resident #3 was identified as being cognitively impaired with poor decision-making on 06/13/2023 with interventions of observing for mental status changes. Review of Occupational Therapy Notes, dated 06/14/2023, revealed during ADL retraining, Resident #3 required maximum assist with verbal cues. Review of Resident #3's Fall Scene Investigation Report (FSIR), dated 06/20/2023 at 4:02 PM, revealed Resident #3 was found on the floor in his/her room after ambulating while alone and unattended. The Fall Scene Investigation Report revealed Resident #3's mental status prior to the fall was confused, and the resident had decreased awareness, with psychological status charted as having decreased awareness and confused. The FSIR revealed the Fall Prevention Book would be updated. However, per interview on 08/29/2023 at 2:25 PM with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #2 on 08/29/2023 at 2:40 PM, both stated there were no Fall Intervention Books, to update staff on new fall prevention interventions, as noted in the Fall Scene Investigation Report. Review of Resident #3's Progress Note, dated 06/20/2023 at 3:00 PM, revealed Resident #3 was transported to the Emergency Department (ED). Review of Resident #3's Progress Note, dated 06/21/2023 at 11:03 AM, revealed Resident #3 had been admitted to the hospital with a broken nose and a subdural hematoma. Review of Resident #3's Progress Note, dated 06/24/2023 at 10:00 AM, revealed Resident #3 returned to the facility from the hospital. Review of Resident #3's hospital records, dated 06/20/2023, revealed a Computed Tomography (CT) scan of the head and facial bones was performed on 06/20/2023 at 4:56 PM. The findings were an acute thin subdural hematoma and an acute minimally displaced fracture of the nasal bone indicated from a frontal head injury. Observation of Resident #3 on 08/08/2023 at 9:25 AM and at 1:50 PM; and on 08/29/2023 at 2:30 PM, revealed the resident was alone in his/her room without nearby staff. Continued observation on 08/31/2023 at 11:55 AM, revealed Resident #3 was sitting in the common area alone and unattended. In an interview with CNA #2 on 08/08/2023 at 9:30 AM and LPN #1 at 4:30 PM, they stated Resident #3 could only respond to yes and no questions. In an interview with LPN #7, on 08/28/2023 at 4:06 PM, she stated she had been told in report by night shift staff that Resident #3 had attempted to get out of bed two (2) times through the night by placing his/her feet on the floor on the night of 06/19/2023. Review of Resident #3's Medical Record; however, revealed no documented evidence to support staff assessed the resident to determine if his/her interventions were appropriate, to include providing increased supervision and monitoring of the resident when he/she attempted to get out of bed on 06/19/2023. In continued interview, the LPN stated staff constantly needed to remind Resident #3 to not get up and to call for help. She stated she thought Resident #3 had simply stood up and tried to walk when he/she fell . She stated, that on the day of the fall, staff had brought the resident to the common area to keep an eye on him/her until the resident's daughter arrived. In an interview with CNA #20 on 08/29/2023 at 1:15 PM, she said she attempted to round more often on residents who had a low BIMS score. However, she stated when she became busy, she could not always do that. In an interview with the Activities Director on 08/30/2023 at 9:55 AM, she stated Resident #3 would not be safe to self-transfer and would be seated in the common area due to concerns of getting up. She stated Resident #3 probably needed closer supervision because the resident was not able to remember instructions. In an interview with the Assisted Director of Nursing (ADON), on 08/31/2023 at 2:11 PM, she stated documentation did not reveal a root cause analysis for the fall sustained by Resident #3 on 06/20/2023. She stated she was not that familiar with the incident since it had happened on the Rehabilitation Unit. 3. Review of Resident #24's Admission Record revealed the facility admitted the resident, on 02/02/2022, with diagnoses to include Dementia, Repeated Falls, and Urinary and Bowel Incontinence. Review of Resident #24's Quarterly MDS Assessment, dated 04/28/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating cognition to be severely impaired. Review of the facility's assessment revealed the resident required assistance of one (1) for transfers, walking, and toileting. In addition, the assessment revealed the resident's balance was unsteady, and he/she was only able to stabilize with human assistance. Continued review revealed the facility assessed the resident to require a wheelchair for mobility. Review of Resident #24's CCP, dated 02/04/2022, revealed Resident #24 was identified as a fall risk with interventions placed on 02/07/2023 for antiroll-backs for the wheelchair, with a revision date of 08/15/2023. Additional interventions included toileting every two (2) to three (3) hours with CNA rounds, no revision date noted. The CCP revealed staff were to encourage and remind the resident to use the call light with a revision date of 08/15/2023. Continued review of the CCP revealed Resident #24 was identified as having bowel and bladder incontinence initiated on 02/17/2022 and revised on 01/18/2023. Interventions placed on 02/22/2022 included check and change every two (2) hours with a revision date of 04/20/2023. A review of Resident #24's Falls Risk Assessment, dated 03/19/2023 and 04/21/2023, both revealed a score of twelve (12), indicating a High Fall Risk. A Falls Risk Assessment, dated 06/25/2023 revealed a score of ten (10), indicating a High Fall Risk. Review of Resident #24's Progress Note by the Physician's Assistant, dated 03/21/2023, revealed under assessment and plan, Resident #24's dementia was a contributing factor for recurrent falls as he/she was uneducable and unable to remember to lock the brakes on his/her wheelchair, use the call light and ask for assistance. Review of the resident's care plan; however, revealed staff were to encourage and remind the resident to use his/her care light. There was no documented evidence to support the facility reviewed the resident's care plan, on 03/21/2023, to ensure that the interventions were appropriate, evaluated for the need for additional preventative measures, and verified that appropriate interventions were implemented, as the resident was uneducable and was unable to remember. Review of Resident #24's Incident Report, dated 06/25/2023 at 3:00 PM, revealed Resident #24 was noted to be sitting on his/her bottom on the floor by his/her bed with an injury to the right knee. The report identified predisposing factors included confusion, incontinence, gait imbalance, impaired memory, and ambulating without assistance. Review of Resident #24's Progress Note, dated 06/25/2023 at 3:30 PM, revealed upon assessment of the right knee, the resident complained of pain. The note stated the right knee was noted to be very swollen, and the resident was unable to bear weight to the right leg. The note stated Resident #24 was transported to the local hospital for evaluation. Review of Resident #24's Fall Risk Evaluation, dated 06/25/2023 at 3:31 PM, revealed cognition was baseline, had sustained falls since admission, required staff assistance with elimination, and was only able to stabilize for toilet use with staff assistance. Review of Resident #24's hospital record, dated 06/25/2023, revealed a right knee/femur image series was performed at 7:35 PM with findings of a fracture to the right femur. Continued review revealed Resident #24 underwent surgery of the right femur nailing on 06/26/2023, was discharged , and returned to the facility on [DATE]. Review of a copy of Resident #24's Progress Note, dated 06/27/2023 at 9:19 AM, and provided by the DON, after the SSA Surveyor requested a copy of the FSIR, revealed the resident self-reported he/she had fallen from bed and right before the fall, Resident #24 had been sleeping in bed. Observations of Resident #24 from 08/08/2023 to 09/05/2023 , revealed the resident was unattended in a wheelchair mobilizing throughout the facility with an anti-rollback device on the wheelchair. In an interview with CNA #29, on 08/31/2023 at 10:15 AM, she stated Resident #24 did not have a device to the wheelchair to prevent tilting. She added Resident #24 was con [TRUNCATED]

Based on interview, record review, review of the facility's Plan of Correction (POC) from the 01/28/2023 Recertification Survey, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the 01/28/2023 Recertification Survey's Plan of Correction (POC), revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 09/05/2023 survey had repeat deficiencies that had been cited on the 01/28/2023 survey. Review of the falls' list, dated 04/11/2023 through 08/15/2023 revealed the residents had a total of fifty-seven (57) falls, four (4) of which resulted in major injury. The facility's administration failed to have an effective system to investigate the root cause of the residents' falls; failed to develop and implement an action plan after each fall; and, failed to accurately assess the resident and/or residents' environment to determine whether adequate supervision was necessary to prevent accidents. The facility's failure to to have an effective system to ensure it was administered in a manner to prevent elopement and falls; and to prevent repeat deficient practice at actual harm and Immediate Jeopardy levels is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/11/2023 and again on 09/05/2023, and was determined to exist on 06/14/2023 at 42 CFR 483.25 Quality of Care, (F689) Free from Accident Hazards/Supervision/Devices at a S/S of a K; 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at a S/S of a K; 42 CFR 483.70 Administration (F835) at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement QAPI/QAA Program (F867) at a S/S of a K. The IJ is ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689) Free from Accident Hazards/Supervision/Devices. The facility was notified of the IJ on 08/11/2023 and again on 09/05/2023. Refer to F656; F689; F837; and F867 The findings include: Review of the Administrator's job description, not dated, revealed the primary function of the Administrator was to manage the facility in accordance with federal, state, and local regulations. Further review revealed the Administrator was to conduct departmental meetings to ensure goals were being met and to implement an effective Quality Assurance program. Continued review revealed the Administrator was responsible for identification, investigation, and follow up on concerns identified. Review of the 01/28/2023 Recertification Survey's POC revealed F689, Quality of Care, Free from Accident Hazards/Supervision/Devices was cited. The POC stated the facility failed to have an effective system to consistently investigate the root cause of the residents' falls and elopement; and failed to develop and implement care plan interventions to address a root cause if one was identified. Review of the POC revealed the facility Administration/QAPI would conduct observations and review monthly to ensure residents who experienced a fall had an added intervetion and the intervention had been implemented and this would occur for each fall; however, review of the facility's monthly meeting documetation revealed no documented evidence this was occuring with each fall as per the POC. Additioanly the POC indicated findings would be reported to the Administrator with each review. However, observations, interview, and record review, during the 09/05/2023 survey revealed the facility failed to ensure F689 remained in compliance. F689 was a repeat deficiency cited at the IJ level. The facility's administration failed to develop and/or implement an effective system to ensure person centered care plans which were specific to each resident to address the causes of the residents' falls, specifically the need for increased supervision for cognitively impaired residents. Further the facility failed to provide effective administrative oversite of day-to-day operations of the facility; and failed to ensure an effective Quality Assurance Program to provide quality care and services to meet the needs of the residents. In interview on 08/30/2023 at 1:03 PM, the Assistant Director of Nursing (ADON) stated she met with the Interdisciplinary Team (IDT), where she was responsible for tracking and trending fall data. In further interview, the ADON was unable to produce analysis of the root cause of the residents' falls to develop systemic changes to ensure appropriate care plans were implemented for residents with repeat falls. The ADON stated they did not have a specific program to identify root case analysis. In an interview, on 09/01/2023 at 1:46 PM, the Director of Nursing (DON) stated she was a member of the IDT and Quality Assurance and Performance Improvement (QAPI) teams. She further stated her expectation when a resident fell was for the IDT to analyze the root cause of the fall and implement interventions specific to that resident. She stated the IDT identified that the fall investigation forms were not being completed correctly. However, she stated she believed the facility was following the correct process, just not documenting it correctly. In an additional interview on 09/05/2023 at 1:33 PM, the DON stated she and the Administrator comprised the Governing Body because the facility did not have a corporate structure. In continued interview, the DON stated the QAPI committee continued action from the POC by randomly reviewing care plans of one (1) to two (2) residents, which might include residents with repeated falls but not all residents with recurrent falls and not all residents at high risk for fall. Per interview, the DON they were reviewing residents' care plans in QAPI, but were not currently focusing on resident at high risk or with repeated falls. In an interview on 09/01/2023 at 8:44 AM, the Medical Director (MD) stated it was the goal of the administration of the facility to prevent falls, and especially falls with injury. He further stated he was not concerned about the facility's increased number of falls since June 2023. The MD stated he would expect to see as many as thirty (30) falls per month in a facility of approximately one hundred twenty (120) beds (the size of this facility) without it indicating a problem because nursing home residents were prone to falls. The MD stated he did not recall specific measures put in place for residents with a high fall risk without reviewing notes. He did recall discussing educating staff on the importance of monitoring residents and answering call lights timely. In interview on 09/05/2023 at 2:08 PM, the Administrator stated when she started at the facility in June of 2023, she was surprised to find the Quality Assurance and Performance Improvement (QAPI) process was based on reacting to falls that had already occurred, rather than taking action to prevent falls. The Administrator further stated the conversation about falls in the first two (2) QAPI meetings she attended focused on raw numbers, not analysis of patterns and instituting systemic changes to protect residents from accidents and hazards. The Administrator stated she knew that needed to change and was introducing a new QAPI process at the next meeting that would address data analysis and taking preventative action. In continued interview, the Administrator stated that because the facility was independently owned and did not have a separate governing body, there was no one to ensure continuity of care and maintain adherence to consistent policies through changes in administration. The Administrator further stated she was still reviewing the previous accptable POC, and was unsure if the facility monitoring include reporting all monitoint of intervetion for falls were in place and being implemented.

Based on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoC) for the survey completed on 01/28/2023, with a compliance date of 04/11/2023, it was determined the facility failed to have an effective system to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement preventative action(s). The facility failed to ensure there was an effective system to regularly review and analyze and audit data, including data collected under the QAPI program; and, failed to act on available data to make improvements and maintain substantial compliance. The facility reported the number of falls with injuries between 02/14/2023 and 07/29/2023 was thirteen (13). However, there was no evidence the facility discussed the falls, reviewed previous falls, or analyzed the time of day and staff patterns for each fall to determine the root cause of the falls, and implemented person-centered interventions to prevent further falls. Immediate Jeopardy (IJ) was identified on 08/11/2023 and again on 09/05/2023, and was determined to exist on 06/14/2023 at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Person-Centered Care Plans ( F656), 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement QAPI/QAA program (F867). The IJ is ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 08/11/2023 and again on 09/05/2023. The findings include: Review of the POC for the 01/28/2023 survey, with a compliance date of 04/11/2023, revealed during the morning meetings the Interdisciplinary Team (IDT) would review residents who had experienced a fall or accident to ensure an appropriate intervention to assist in preventing further falls or accidents have been care planned and implemented, and the process was to occur indefinitely. During interview with the Minimum Data Set (MDS) Nurse on 08/24/2023 at 4:24 PM, she stated each resident was identified to be at risk for falls when admitted . The total census upon entrance on 08/08/2023 was one hundred and nine (109) residents. During an interview with the Social Worker on 08/31/2023 at 11:10 AM, she stated she was a member of the QAPI committee. She stated she presented information concerning psychotropic medications. The Social Worker stated the committee met every third Wednesday of the month and the meetings usually last thirty (30) to forty-five (45) minutes, but could not recall an Ad Hoc meeting related to falls. During an interview with the Assistant Director of Nursing (ADON) on 08/30/2023 at 1:05 PM, she stated she was a member of the QAPI committee and the committee met every third Wednesday of the month. She stated meetings last approximately forty-five (45) minutes, but could go longer if needed. The ADON stated expectation of the meeting was to work on areas of improvement processes and to discuss if that process was working well. She stated the process was to identify the problem, strategize, and come up with a solution. She stated QAPI could be discussed in the IDT meeting, which was held each morning. She stated the falls plan was to review the number of falls from the previous month and see if there were repeat falls for a pattern, but at this time, QAPI had not identified any patterns. The ADON stated falls for the month of June were ten (10); fifteen (15) falls in July; and in August there were nineteen (19). She stated she did not know if the QAPI committee had identified any patterns for falls increasing. During further interview with the ADON on 08/31/2023 at 2:11 PM, she stated she was responsible for tracking falls and for assessed for the root cause analysis (RCA). The ADON stated she was unable to identify an RCA for four (4) of eight (8) falls. During an interview with the Director of Nursing (DON) on 08/31/2023 at 1:45 PM, she stated she was a member of the QAPI committee and they met monthly for an hour. She stated discussions were held in the meeting for all present issues and to evaluate the effectiveness of their process. The DON stated the facility looked at everything, including staff and the time of day the falls occurred. She stated with falls, the QAPI committee looked for an RCA and then the care plans were updated, with the IDT then evaluating the effectiveness of the care plan. In continued interview, the DON stated the QAPI committee continued action from the POC by randomly reviewing care plans of one (1) to two (2) residents, which might include residents with repeated falls. Per interview, the DON stated residents with repeated falls were not an area of special focus in the care plan reviews. During an interview with the Medical Director (MD) on 08/31/2023 at 8:45 AM, he stated he was a member of the QAPI committee and they met monthly on the third Wednesday for about twenty (20) to thirty (30) minutes. In the meetings, discussions were held about falls, wounds, staffing, reportables, behavior issues with residents, and medications, including costs for medications. He stated he did not have any concerns with quality measures not being met, and he did not recall any injuries from falls in the tracking process. The Medical Director stated he would need to look at meeting notes for any correlations, such as staffing issues, for falls occurring. He stated there had been a fifteen (15) percent (%) reduction rate in staffing since the Coronavirus Disease 2019 (COVID-19). He stated he was not concerned about falls increasing since June. The MD stated falls change just like infections, one month they go up and another month they might go down. He stated falls could go as high as thirty (30) in a month since it was a nursing home. During further interview with the Administrator on 09/05/2023 at 1:39 PM, she stated she was a QAPI committee member and their tasks were to review policies, collaborate as a group to perhaps change processes but did not really use evidence-based information all the time. She stated the facility referred to other facilities to see what worked well for them. She stated their consultants used evidence-based information to add to the process. The Administrator stated the consultants also tracked and trended issues for policy changes when needed and usually she and the DON wrote the policies since they were the Governing Body. She stated she would speak with the Medical Director about falls if they were increasing. The Administrator stated QAPI was addressing falls by getting some things together now by using a new tracking tool that began in September. She stated they would discuss it more in the next QAPI meeting depending on the availability of the Medical Director. The Administrator stated one thing identified for the month of August was that more falls occurred on the three (3) to eleven (11) shift, but there was really no one to offer oversight during the transition since she was new and was still going through the POC manual. She stated she was not aware, per the POC, the DON was supposed to be reporting to her monthly regarding if care plan interventions were in place and her observations of the care plan interventions related to falls were being implemented for residents at high risk for falls.

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Census and Condition of Residents (Form 672), and review of the facility's assessment, it was determined the facility failed to provide adequate staff to provide nursing and related services. The facility failed to provide adequate supervision for cognitively impaired and incontinent residents; and failed to respond to residents' requests for assistance in a timely manner. Observation revealed call lights were not answered for extended periods of time with no staff members observed in the halls to answer them. Resident interviews revealed they had to wait for extended periods of time to have call lights answered on night shift. Staff stated there was not sufficient staff to complete resident care tasks and provide sufficient monitoring for cognitively impaired residents. The findings include: Review of the facility's assessment, dated 02/03/2023 revealed the facility was supposed to staff with twelve (12) Certified Nursing Assistants (CNAs) from 7:00 AM-3:00 PM, twelve (12) CNAs from 3:00 PM-11:00 PM and seven (7) CNAs from 11:00 PM-7:00 AM. Further review revealed the facility's assessment listed common conditions of residents the facility cared for included: Psychosis with Hallucinations and Delusions, Impaired Cognition, Schizophrenia, Bipolar Disorder, and Behaviors that Need Intervention. Continued review revealed the facility took those and other conditions into consideration when developing the facility's assessment to describe the resources, including staffing, needed to take care of residents. Review of the facility's schedule for 07/2023 revealed the facility did not staff according to its assessment for that month. Further review revealed the facility staffed each day with eleven (11) CNAs on first shift; should have had twelve (12). Ten (10) CNAs were scheduled on second shift instead of the assessed twelve (12) CNAs. Six (6) CNAs were scheduled on night shift, instead of the seven (7) CNAs per the facility's assessed needs. Review of the facility's time punch documentation revealed the facility was short staffed according to the facility's assessment for the month of 07/2023. Further review revealed the facility was short on CNA hours needed according to interviews with the Director of Nursing and Administrator for seventeen (17) of the thirty-one days. Review of the facility's CMS 672, dated 08/08/2023, revealed of a total census of one hundred and nine residents, fifty-nine (59) residents required one or two person assistance for transfers and thirty-six (36) were coded as dependent for transfers. Eighty-eight (88) residents were assessed as occasionally or frequently incontinent of bladder and seventy-three (73) were occasionally or frequently incontinent of bowel. 1. Observation on 08/16/2023 at 10:48 AM revealed Resident #33 calling, Hello, hello, repeatedly with increasing agitation. Continued observation revealed there was no staff member in the hallway until 10:59 AM, when Licensed Practical Nurse (LPN) #14 checked on the resident, who wanted to be pulled up in bed. Observation revealed LPN #14 told the resident she would have to get help, but she could not find another staff member in the hallway to help, so she went to another hall to find someone. Further observation revealed at 11:06 AM, LPN #14 returned with an aide from the therapy department and assisted the resident. In interview on 08/16/2023 at 11:20 AM, LPN #14 stated one of the CNAs on the South Unit was out at an appointment, another CNA was at lunch at that time, and the other two (2) were helping other residents, when Resident #33 needed help. The LPN stated she had to go find help. She stated the staff worked as a team and do their best to help the residents, but the residents might have to wait a few extra minutes if a CNA was out assisting a resident at an outside appointment. 2. Observation of the call light monitor screen at the North Nurse's Station on 08/30/2023 at 2:26 PM revealed the call light for Resident #31's room was activated at 1:59 PM and had not been answered. Further observation revealed no staff members were available in the hallway until 2:42 PM, when CNA #5 exited another room with dirty linens. Continued observation revealed CNA #5 entered Resident #31's room at 2:55 PM, twenty-nine minutes later. In an interview on 08/30/2023 at 2:38 PM, Resident #31 stated he/she was incontinent and needed staff to change his/her brief. Resident #31 further stated he/she activated his/her call light more than half an hour ago, and was still waiting for staff to respond. In an interview on 08/30/2023 at 2:58 PM, CNA #5 stated she turned off Resident #31's call light because the resident stated he/she activated it by accident. CNA #5 stated she had been busy with other resident care tasks, but she would return to change Resident #31's briefs immediately. Observation on 08/30/2023 at 3:04 PM revealed CNA #5 entered Resident #31's room with a package of briefs. In an interview on 08/11/2023 at 7:40 AM, Resident #5 stated he/she often had to wait over an hour for staff to answer his/her call light on night shift. The resident stated staff told him/her that the reason for the delay was short staffing. During an interview on 08/11/2023 at 3:10 PM, Resident #11 stated the facility worked short on CNAs multiple times a week on night shift. He/she stated, I lay here and pray nothing bad happens to me on night shift because they (do not) have enough people to help. In further interview, Resident #11 stated, on multiple occasions since he/she was admitted to the facility, there have only been three (3) CNAs in the entire building on night shift. In an interview on 09/01/2023 at 9:58 AM, Resident #31 stated the facility never had enough staff, especially on night shift. He/she stated the only thing night shift aides had time for was changing briefs. Resident #31 stated it was not uncommon to have to wait one (1) hour for staff to respond to his/her call lights. In an interview on 08/29/2023 at 2:36 PM, Resident #32 stated the facility did not have enough staff on night shift. Resident #32 further stated he/she made sure to ask the second shift aides to do everything he/she would need for the night before they left at 11:00 PM. Per interview, if Resident #32 needed anything after 11:00 PM, he/she would have to wait for up to an hour to get it. In an interview on 08/08/2023 at 10:45 AM, Certified Nursing Assistant (CNA) #1 stated there was never enough staff to give the residents the care they needed, such as timely incontinence care and timely answering of call bells. She stated the only time call bells were answered timely was when the State Survey Agency was in the building. In an interview on 08/13/2023 at 6:55 PM, CNA #14 stated the facility staffed too short on night shift to be able to provide the residents with their care needs, especially on the South Unit. She stated the facility did not take resident acuity into consideration with staffing and there were multiple dependent residents and residents with behaviors on the South Unit. CNA #14 stated she often could not find anyone to help while she was doing rounds, so she would get 2-person assist residents up by herself. She stated it was not possible to provide supervision to residents with behaviors or who were at risk for falls because there was not enough staff. In an interview on 08/15/2023 at 1:25 PM Certified Nursing Assistant (CNA) #16 stated the facility did not have enough staff to perform two (2) person assists for residents to transfer to the toilet according to their preference. The CNA stated she would have to use a bed pan if she could not find someone from the therapy department because it would be unsafe to get a resident up by herself if they required a two (2) person assist. She stated she was only able to give a limited number of residents a shower on a good day. In an interview on 08/16/2023 at 3:28 PM, CMA (Certified Medication Aide) #43 stated her work hours were primarily dedicated to medication administration, although she occasionally answered a call light or assisted a CNA with a transfer if she had time. In an interview on 08/31/2023 at 11:42 AM, LPN #9 stated the CNAs and nurses worked hard, but they had too many tasks to complete to be able to provide adequate supervision to cognitively impaired residents and residents with behaviors. In further interview, LPN #9 stated an additional CNA on each shift would make a significant impact for resident supervision. In continued interview, LPN #9 stated she did not express her concerns over staffing to management because she did not believe they would listen. In an interview on 08/19/2023 at 4:46 PM, LPN #11 stated the facility did not staff according to resident acuity and that caused residents not to be monitored appropriately, leading to the elopement and falls. In further interview, LPN #11 stated the facility's management did not increase staffing when a CNA was needed to accompany a resident to an appointment, or when a CNA was needed to do one-on-one (1:1) observation, so the number of aides working on the floor in those cases would decrease. LPN #11 further stated that on night shift, there were only two (2) aides for forty-five (45) residents, and staff worked as hard as they could, but that was not enough to provide care according to resident specific care plans. In an interview on 08/15/2023 at 11:21 AM, the scheduler stated she was told to staff with eleven (11) CNAs on first shift, ten (10) CNAs on second shift, and six (6) on night shift. She stated if the facility could not find enough regular staff to work a shift, they posted it for agency staff to pick up. She further stated the facility did not take resident acuity into consideration when deciding how many staff members were needed to work. The scheduler stated she had never seen the facility's assessment and did not know how the staffing pattern described in the assessment was developed. In an interview on 08/15/2023 at 10:27 AM, Registered Nurse (RN) #2, former Rehab Unit Manager, stated staffing at the facility was awful. She stated her staff frequently told her they did not have enough time to complete resident care tasks and answer call lights timely. RN #2 stated management staff was expected to be in meetings for most of the day, so she was not available to assist her staff with answering call lights or resident supervision. The RN stated she recalled residents' family members calling to complain about the amount of time residents had to wait for care, but she did not recall any specific names. In an interview on 08/24/2023 at 12:19 PM, the Director of Nursing (DON) stated the staffing pattern in the facility's assessment was written by the former Administrator. The DON stated she had no idea where those numbers came from. She further stated the staffing pattern the facility used was developed by the facility's consulting firm and was based on the facility's census. In further interview, the DON stated the staffing level for CNAs was set as: first shift (7:00 AM-3:00 PM) four (4) on both the North and South Units, and two (2) or three (3) CNAs on the Rehab Unit; second shift (3:00 PM-11:00 PM) was the same as first shift; third shift (11:00 PM-7:00 AM) was two (2) CNAs on each of the units. Per interview, the facility's staffing level for nurses was set as: day shift (7:00 AM-7:00 PM)- two nurses each on North and South, one nurse and one Certified Medication Assistant (CMA) on Rehab; second shift (3:00 PM-11:00 PM) one (1) CMA each came in for North and South; night shift (7:00 PM-7:00 AM) had one nurse each for North, South, and Rehab. In further interview, the DON stated she hoped staff realized if they needed help, they could ask for it and she could talk to the consultant about ways to adjust staffing, especially if the census was high. Per interview, the DON stated she expected management to be out on the floor to answer call lights when not in morning meetings. In continued interview, the DON stated the facility identified opportunities for improvement when auditing call light response times by observation. However, she stated that did not reflect a problem with staffing because the frequency with which residents asked for assistance was unpredictable. The DON further stated that analyzing resident acuity was not taken into consideration when deciding on staffing levels. In an interview on 08/24/2023 at 3:03 PM, the Administrator stated the staffing pattern the facility used was not based on acuity, but on facility census. The Administrator stated the facility would need more staff if the facility was full of residents who required two-person assist. However, the Administrator stated she had not analyzed the 672 data to see what overall resident needs were. In further interview, the Administrator stated she believed staff should be able to accomplish resident care tasks with the current staffing level. In interview on 08/24/2023 at 4:52 PM, the Nurse Consultant stated the consulting company supported the facility in whatever they needed. She further stated the current staffing model was developed with input from the Director of Nursing. In further interview, the Nurse Consultant stated that when she spoke with facility staff, some staff members told her the facility did not have enough staff; however, she stated this was because there would always be negative people who would complain no matter what.

Based on interview, record review, and review of the Medical Director's job description, it was determined the facility failed to have an effective system to ensure the Medical Director was responsible for identifying, evaluating and addressing health care issues as well as administration and governance on safety issues. Six (6) of thirty-three (33) sampled residents had falls with injuries (Residents #3, #18, #22, #24, #25, #26), and one (1) of thirty-three (33) sampled residents left the facility without staff knowledge (Resident #1). Between 06/14/2023 and 08/15/2023, six (6) cognitively impaired residents had falls. The six (6) residents had falls for a combined total of eighteen (18) times related to self-transfers and incontinence. Four (4) of the falls resulted in major injuries. The Medical Director to ensure the facility identified and addressed the root cause of the falls to prevent harm to residents. On 07/27/2023, Resident #1 left the facility without staff knowledge. The Medical Director stated he was not as involved as he should have been related to Resident #1's elopement to ensure the resident received adequate supervision following the elopement. The findings include: Review of the facility' job description titled, Role of Medical Director, no date given, revealed the facility will designate a licensed physician to serve as Medical Director and appointment will be by the Chief Executive Officer in consultation with the Director of Nursing. Further review of the policy revealed the Medical Director (MD) will provide clinical leadership by directing, coordinating and evaluating medical care, implementing elder medical care policies, identifying, evaluating and addressing health care issues and assuring elders have primary and backup physician coverage. Continued review revealed other responsibilities included services that reflected current standards of care and were consistent with regulatory requirements. Review of the Medical Director's job description revealed the Medical Director's responsibilities included addressing and resolving concerns and issues between physicians, health care practitioners and facility staff and resolving issues related to continuity of care and transfer of medical information between the facility and other care settings. Additional responsibilities included reviewing, discussing and intervening in individual elder cases for quality of care, consultants and medical care inconsistent with current standards of care. Record review revealed other job responsibilities included creation of policies and participating in provision of inservice trainings. The MD was responsible for coordinating physician services and medical services in the building, advise management, administration, governance on health and safety recommendations. The MD was also responsible for directing the Quality Assurance Performance Improvement and being familiar with the facility's process for the Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) and help the facility provide a safe environment. Record review revealed Resident #1 left the faciity on [DATE] without staff's knowledge. Further review revealed the facility assessed the resident as mildly cognitively impaired on 04/10/2023 and as at risk for elopement on 04/20/2023. Review of the electronic medical record (EMR) revealed on 06/20/2023 Resident #3 fell from a wheelchair while unattended. The facility transferred the resident to a local hospital for evaluation. The hospital assessed Resident #3 with a nasal fracture and subdural hematoma. Record review revealed Resident #18 fell from the bed twice attempting to self-transfer. On 07/09/2023, the resident was attempting to self-transfer. Staff found the resident face-down on the floor next to his/her bed. This fall resulted in swelling and blood to his/her lip, and pain under his/her left arm. The facility transferred the resident to the local hospital for evaluation. On 07/29/2023, the facility found Resident #18 on the floor between the head of the bed and wheelchair. The resident was soiled with feces. Record review revealed Resident #22 had a fall on 07/07/2023, 07/15/2023 and on 07/22/2023. The resident's fall resulted in the right orbital blowout fracture while attempting to self- transfer, unattended. Record review revealed Resident #24 was found sitting in a chair on 06/25/2023. The resident had complaints of pain/swelling to the right knee. Resident #24 self -reported that he/she had fallen from the bed during a self-transfer. Further record review revealed radiology findings that the resident had a right femur fracture. Record review revealed Resident #25 self-reported, on 07/30/2023, that he/she had fallen the night before. The resident stated that he/she rolled out of the bed during care. Further record review revealed the resident sustained a knot to his/her right hip and a skin tear to the right elbow. Record review revealed Resident #26 had falls on 06/14/2023, 06/17/2023, 07/02/2023, 07/25/2023, 07/28/2023, 08/02/2023, and 08/15/2023. Continued review revealed the fall on 07/02/2023 was due to the resident's self-transfer attempts. Further review revealed the resident's fall resulted in fractures to the resident's right radius and ulna, as well as a fracture to the nasal bone. In an interview on 08/14/2023 at 8:23 AM, the Medical Director (MD) stated he was made aware of Resident #1's elopement on 07/27/2023. He stated his recommendation at that time was to report the incident to the relevant state agencies; and to keep the resident in the building until the facility determined the resident's cognitive abilities related to signing out of the facility independently. The Medical Director stated he believed it was not a good idea to allow residents to sign out to do a walk about, because the facility was ultimately responsible for the resident. In further interview, the MD stated he was not as involved as he should have been in the discussion if Resident #1 should be allowed to sign out of the facility and what safety measures should have been in place for him/her. In an additional interview on 09/05/2023 at 8:44 AM, related to the Medical Director's job duties, the MD stated the facility had a copy of his job description and he did not provide his specific job duties during the interview. The MD stated he did not have any concerns about the effectiveness of the facility's Quality Assurance and Performance Improvement (QAPI) program. The MD stated in a facility of this size, he would expect to see as many as thirty (30) falls in a month without becoming concerned about it. He stated long term care residents were prone to falls. Per interview, the Medical Director stated they kept discussions of repeat falls to a high level during the QAPI meetings so the meeting would not last longer than forty-five (45) minutes. In an interview on 09/05/2023 at 2:08 PM, the Administrator stated she did not recall the Medical Director making contributions to any discussion of policy development or implementation. She further stated the MD was present for discussions of residents with repeated falls, but she could not recall any recommendations the MD made regarding the fall management program.

Based on interview, record review, and review of the facility's job description for the Medical Director, it was determined the facility failed to ensure residents were seen personally by a physician as required per regulation for an initial comprehensive visit, and once every thirty days after admission for seven (7) out of thirty-three (33) sampled residents (Residents #1, #3, #4, #5, #18, #22, and #26) The findings include: Review of the facility's policy titled, Role of Medical Director revealed the facility would designate a licensed physician to serve as Medical Director (MD). Continued review revealed the responsibilities of the MD would be defined with the organization to assure that elders have primary attending and backup physician coverage. However, the facility's policy did not speak of physician visits, timelines for the initial visit or required visits there after. 1. Record review revealed the facility admitted Resident #1 on 03/31/2023. Review of the Physician's Notes revealed the MD completed a regulatory visit for Resident #1 on 04/12/2023. However, the facility failed to produce any evidence the physician conducted any other visits with the resident. 2. Record review revealed the facility admitted Resident #3 on 06/16/2023. Review of Resident #3's medical record revealed the Nurse Practitioner completed the initial comprehensive visit on 06/16/2023. 3. Record review revealed the facility admitted Resident #4 on 01/25/2023. Review of the Physician's Notes revealed physician visits dated 02/01/2023, 03/22/2023, and 07/19/2023. However, the facility failed to produce evidence of any other visits by the physician. 4. Record review revealed the facility admitted Resident #5 on 02/21/2023. Review of Resident #5's medical record revealed the physician conducted a regulatory visit on 04/19/2023. However, the facility failed to produce evidence of any other visits by the physician. 5. Record review revealed the facility admitted Resident #18 on 03/22/2023. Review of the Physician's Notes revealed the physician failed to conduct regulatory visits every thirty (30) days for the first 90 days. Physician visits were conducted on 03/29/2023, 04/12/2023, 06/07/2023, and 08/16/2023 noted. 6. Review of Resident #22's Admission Record revealed the facility admitted the resident on 03/17/2023. Review of the Physician's Notes revealed the MD visited Resident #22 on 03/28/2023. However, the facility failed to produce any evidence the physician conducted any other visits with the resident. 7. Review of Resident #26's Admission Record revealed the facility admitted the resident on 05/12/2023. Review of the Physician's Notes revealed the MD visited Resident #26 on 07/19/2023 and 08/02/2023. However, the facility failed to produce any evidence the physician conducted any other visits with the resident. Unsuccessful attempt was made on 08/25/2023 at 10:25 AM to interview the Nurse Reactivation (NP). A message was left; however, the NP did not return the phone call. In an interview on 09/05/2023 at 8:44 AM, the Medical Director (MD) stated his process with scheduling regulatory visits was to have the Nurse Practitioner conduct the initial visit with the resident and get everything set up. Per interview, the MD would see the resident within the first thirty (30) days, then see the resident on an alternating basis with the nurse practitioner every thirty (30) days. 49051

Based on interviews, record review, and facility policy review, it was determined the facility failed to follow their policy regarding advanced directives for one (1) of thirty-three (33) sampled residents (Resident #1). Upon admission to the facility, Resident #1's daughter signed his/her Advanced Directives due to his/her impaired cognition. When the facility re-assessed Resident #1's cognition to be intact, they failed to provide Resident #1 with written information about forming and/or reviewing his/her advanced directives. The findings include: Review of the facility's policy titled, Advance Directive Policy and Procedure, not dated, revealed if a resident was incapacitated at the time of admission and was unable to receive information or articulate whether or not he/she had executed an advance directive, the facility would give advance directive information to the individual's resident representative. Further review revealed, in the event the resident's condition changed, based on regular comprehensive assessment, and the resident was able to receive information about advance directives, the facility would provide the resident with written information on the process to implement an advance directive. Continued review revealed the facility would periodically clarify and review the existing care instructions and encourage resident involvement in decision making. Review of Resident #1's Admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses of Unspecified Dementia, Type II Diabetes, and Polyneuropathy. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated moderate cognitive impairment. Review of the BIMS, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status score of thirteen (13) which indicated the resident was cognitively intact. Review of Resident #1's Care Plan, dated [DATE], revealed the facility care planned the resident as having a Do Not Resuscitate (DNR) status with interventions that included, following the resident's wishes in the Living Will, if applicable. Review of the facility's document, Advanced Directive Statement, dated [DATE], revealed Resident #1's Daughter, who had been designated as the resident's representative, signed the order for him/her to not receive cardiopulmonary resuscitation (CPR) if his/her heart stopped beating and/or he/she stopped breathing. The facility failed to produce evidence that Resident #1 had reviewed his/her advance directives after [DATE] when the nurse practitioner performed a mini mental exam, with a score of twenty-seven (27) out of thirty (30). According to the mini mental exam, Resident #1 was determined to be cognitively intact and competent to make his/her own choices. In an interview on [DATE] at 1:00 PM, Resident #1 stated the facility did not ask him/her about formulating an advanced directive. Resident #1 further stated his/her daughter signed the admission paperwork on his/her behalf. In an interview on [DATE] at 4:01 PM, Resident #1's Daughter stated she signed Resident #1's admission documents because he/she was confused at the time, but had previously expressed a desire to decline CPR. In further interview, the Daughter stated she was not aware of the facility going back to discuss the advanced directives with her parent after he/she had an improvement in mental status. In an interview on [DATE] at 10:35 AM, the Admissions Coordinator stated her role was to go over the admissions paperwork with the resident and family when the resident was admitted , but if changes needed to be made after that point, it would be the role of the management team to take care of it. In an interview on [DATE] at 11:14 AM, the Social Services Director (SSD) stated the process for a resident to review a previously signed Advanced Directive was for the resident to bring it up in a care plan meeting. In further interview, she stated she did not know if Resident #1 reviewed his/her Advanced Directives at the most recent care plan meeting. Per interview, the process during a care plan meeting was to discuss basic information such as Advanced Directives, but she did not have documented evidence that the facility provided Resident #1 with this information. In an interview on [DATE] at 12:19 PM, the Director of Nursing (DON) stated the Admissions Coordinator handled the signing of a resident's advanced directive upon admission. She further stated that if a resident was not of sound mind at the time of admission, the resident's representative would sign. In further interview, the DON stated if a resident's mental status improved after admission, she would expect someone to review the Advanced Directive with them, but she was not aware of anyone reviewing Resident #1's Advanced Directive with him/her after he/she was assessed by the Nurse Practitationer to be competent to make his/her own decisions. In an interview on [DATE] at 3:03 PM, the Administrator stated Resident #1 should have had the opportunity to review his/her Advanced Directives in a care plan meeting. 49051

Based on interview, record review, review of the facility's incident report form, and review of the facility's policy, it was determined the facility failed to ensure residents remained free from misappropriation of property for one (1) of thirty-three (33) sampled residents (Resident #6). Resident #6 reported he/she had money missing. The inding included: Review of the facility's policy, Abuse Protection, last revised 05/03/2022, revealed the resident had the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or funds without the resident's consent. Record review revealed the facility admitted Resident #6 on 03/21/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Depression and Anxiety. Review of the Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) examination, dated 03/21/2023. The facility assessed Resident #6 to have a BIMS' score of fifteen (15) out of fifteen (15) which indicated the resident's cognition was intact. Review of the Quarterly BIMS' Assessment, dated 07/19/2023, revealed the facility assessed Resident #6 to have a BIMS score of fifteen (15) out of fifteen (15) which indicated the resident's cognition was intact. Review of the Comprehensive Care Plan (CCP), dated 03/31/2023, revealed the facility assessed Resident #6 as having manipulative behaviors and to make false allegations. Further review revealed interventions that included: to allow Resident #6 to verbalize his/her feelings; intervene as necessary; and, monitor the resident's behavior. This was initiated on 05/24/2023. During an interview on 08/09/2023 at 8:38 AM, Resident #6 stated that he/she had lost one thousand dollars ($1,000) since admission. Resident #6 stated that his/her money was missing after his/her transfer from the rehabilitation unit to his/her current room. Resident #6 stated that upon transfer to his/her current room, the lock on the locked box was not operational. Resident #6 stated that he/she reported this to the Administrator, Activity Director, and the Social Services Director. Resident #6 stated that he/she gave his/her wallet to the Activity Director to keep locked up in the closet in the activity room upon moving from the rehabilitation unit before she noticed any money missing. Resident #6 stated that during this time, the Activity Assistants or Activity Director would bring his/her wallet upon request. The resident stated that on or around 07/06/2023, he/she gave Activity Assistant (AA) #1 seventy dollars ($70) to purchase both of them (the resident and Activity Assistant #1) jackets. However, Activity Assistant #1 returned with only a jacket for the resident. Resident #6 stated that Activity Assistant #1 did not return the balance of the money to him/her. The resident stated that when he/she asked Activity Assistant #1 why she did not purchase herself a jacket as originally agreed upon, the Assistant told resident that she had changed her mind. Resident #6 stated that AA #1 did not give an explanation for failure to return the balance of the $70.00. The receipt, dated 06/29/2023, listed Jean Jacket with a total amount of $20.14, a cash tendered amount of $70.00, and a change due amount of $49.86. Resident #6 could not account for the remainder of the four- hundred ($400.00) dollars missing. However reported that facility had returned $400 to him/her after report of loss of funds was completed. During an interview with the Business Office Manager on 08/11/2023 at 5:00 PM, he stated Resident #6 had reported he/she had money missing about a month ago. He stated that Resident #6 reported he/she had eighteen hundred ($1,800) dollars in a wallet and now it was missing. However, there was no record of the money. The Business Office Manager stated the resident had declined to open an account at the facility. During an interview on 08/12/2023 at 3:47 PM with Activity Assistant (AA) #1 she stated she was working as an activity assistant and as hospitality aide since her out of state Certified Nurse Aide (CNA) license (certification) could not transfer, but she had since been suspended. She stated one day the Activity Department was taking residents to the store and Resident #6 had forgotten his/her money and they turned around and returned to facility. She stated that was when the resident had discovered his/her money was missing. Activity Assistant #1 stated that the resident informed her that he/she had one thousand ($1,000) dollars missing, but no one had seen the money. When interviewed why she had been suspended, AA #1 stated Resident #6 had given her thirty ($30) dollars to go to a local store to buy him/her a jacket. She stated she told the resident she did not have enough gas, so the resident told her that the jacket was around twenty dollars, so use ten ($10) of the money for gas. AA#1 said she did just that. When she returned, she gave Resident #6 the jacket and the change left over from the jacket she purchased. She stated when asked if she knew the facility's policy for accepting gifts and or money from residents, she stated, I do now. The AA stated she was with the residents around 5:30 PM or 6:00 PM watching television when management asked her to come to the office. She stated she was asked about the one-thousand dollars ($1000.00). AA #1 stated at that time, she was informed she was not allowed to take money from residents, referring to the thirty dollars. She stated she was terminated and escorted out of the building. She stated this was sometime in July, but she was unable to give the exact day. In interview with CNA #13 on 08/13/2023 at 3:13 PM, she stated Resident #6 told her he/she had money missing but CNA #13 did not say if she had reported it. She stated she had quit right around that time. During interview with the Activities Director (AD), on 08/15/2023 at 1:05 PM, she stated she had placed Resident #6's wallet in the closet in the activity department. She stated that when the resident needed money, she would give the resident his/her wallet, and the resident would take the money out that he/she needed. Observation of the activity closet on 08/15/2023 at 1:05 PM revealed a door with lock and a key was in the lock. Continued observation, during the interview, revealed the AD opened the door to the closet. She stated the resident's wallet was placed on the top shelf. After the AD opened and closed the door, she placed the key behind a picture frame on the shelf next to the closet door, which was easily visualized. During a telephone interview with the Maintenance Director on 08/21/2023 at 10:30 AM he stated, he would replace the lock and provide the resident with a new key, and give the other key to the Social Worker. He stated he had not had any reports in months for a lock box that needed his service. The Maintenance Director stated that the Rehabilitation Unit had safes in the wall and he had nothing to do with those. He stated that he had known times when the resident forgot the combination and the facility had to call the company to get a new one. In interview with the Social Worker, on 08/10/2023 at 9:00 AM, she stated she was on leave when Resident #6 reported he/she had money missing and the investigation was already underway. She stated that each time she talked to Resident #6 he/she kept changing the amounts. During continued interview, she stated she had seen Resident #6 remove money from the safe in the wall and place it in his/her wallet, but she had not seen the money since that time. The Social Worker stated the money was not counted at that time with the resident. She stated the only time any money was seen and counted was on 05/30/2023 and that was when cash in the amount of nineteen hundred and ten dollars ($1,910.00) was given to the resident from the business office. The Social Worker stated that Resident #6 had kept forty ($40) dollars and had placed the rest in the wall safe. She stated this money was counted and witnessed by her, the Business Office Manager and the resident. During interview with the Director of Nursing (DON) on 08/10/2023 at 1:30 PM, she stated AA #1 had been terminated due to money that was reported per Resident #6 that was missing. In continued interview on 08/25/2023 at 1:33 PM the DON, stated when residents were admitted they offered to lock any valuables up in a facility safe, lock boxes or they let the family take the valuables home. The DON stated Resident #6 had been offered and educated on this system. She stated, We can't force a resident to do this. In an interview with the Administrator on 08/11/2023 at 3:55 PM she stated she had spoken to Resident #6 three (3) different times and during the conversations, the amount of money missing changed with the exception of four hundred ($400) dollars. The Administrator stated Resident #6 had reported to the Activity Director that he/she had money missing. She stated Resident #6 was re-imbursed four hundred ($400) dollars as good faith money since that was the amount that stayed consistent when asked about the one-thousand dollars missing. Review of the facility's investigation revealed it was incomplete, as some of the days were missing and there was no conclusion. Review of the investigation revealed a signed statement per the Business Officer Manager (BOM) that Resident #6 had declined a trust fund account, but had requested the BOM keep his/her money in the safe in the BOM's office. Review of the statement revealed when Resident #6 wanted money, the BOM would take it to him/her. However, no record was kept of the transactions. Further review of the investigation revealed the BOM was educated on 06/01/2023 by the previous Administrator to keep documentation of any money transactions. Review of the investigation revealed Resident #6 had reported on 05/26/2023, that one hundred and forty ($140) dollars was missing. The investigation stated staff had searched the resident's room and belongings and could not locate the money. On 06/22/2023, per the investigation Resident #6 had asked the Activities Director to lock up his/her wallet in the activity room. Continued review of the investigation revealed that on 07/05/2023 Resident #6 removed money for food, and on 07/06/2023, the resident reported there was money missing. Per the report, the police was called, but the facility was unable to locate the police report. Continued review of the facility's investigation revealed Activity Assistant #1 was terminated on 07/13/2023 for receiving a gift of money in the amount of twenty ($20) dollars. Review of the investigation revealed a copy of a check from the facility to Resident #6 in the amount of four hundred (400) dollars.

Based on interviews and record review it was determined the facility failed to have a system in place to communicate appropriate information to the receiving health care facility to ensure a safe and effective transition of care for one (1) of thirty-three (33) sampled residents (Resident #2) The facility transferred Resident #2 to an out of state facility on 03/23/2023 for the need of a locked dementia care unit. The resident had an elopement from the facility. The resident's daughter was informed the resident was to be transferred related to an elopement. The facility informed the Resident's Daughter that they could not provide sitters for 1:1 supervision unless the daughter paid for the sitters. The daughter stated she could not afford to pay for the sitters The facility failed to inform the Ombudsman of the transfer. The facility also failed to complete the Discharge Short Summary and failed to ensure the Primary Physician Summary was completed. The findings include: Review of the facility's policy titled, Discharging the Resident', dated 01/02/2018, revealed no resident would be discharged without a written order from the attending physician and timely notification of next of kin with the exception of medical reasons, his/her welfare, and non-payment. Guidelines included notice to be given within thirty (30) days with the exception if the safety of the resident would be endangered. Further review revealed a reference be made to Social Services policies for discharge planning documentation. Steps to be taken for discharging a resident included; if the resident was being discharged to another facility a transfer summary should be completed; and, assess and document the resident's condition and skin assessment at the time of discharge. Record review revealed the facility admitted Resident #2 on 11/12/2022 with diagnoses that included Dementia with Agitation, Repeated Falls, and Anxiety. Review of the Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) examination, dated 11/16/2022. Further review revealed the facility assessed Resident #2 to have a score of four (4) out of fifteen (15) which indicated severe cognitive impairment. Review of Quarterly BIMS' examination, dated 02/13/2023, revealed the facility assessed Resident #2 to have a BIMS' score of two (2) out of fifteen (15) which indicated the resident's cognition was severely impaired. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #2's functional status required the assistance of one (1) staff. Review of Resident #2 Comprehensive Care Plan (CCP) revealed the facility assessed Resident #2 as an elopement risk with goals set to have no injuries related to wandering with a revision date of 02/27/2023; and, a target date of 05/11/2023. Further review of the CCP revealed interventions that included 1:1 supervision related to elopement with a revision date of 12/15/2022. Continued review of Resident #2's CCP revealed a focus for potential to demonstrate physical/verbal behaviors with a goal of not harming self or others with revision date of 02/27/2023 and target date of 05/11/2023. Interventions included: 1:1 supervision related to behaviors with initiation date of 11/22/2022, revision date of 02/27/2023 and target date of 05/11/2023. However, no discharge CCP was noted in review. In interview with the Ombudsman on 08/15/2023 at 4:12 PM, she stated no notification was given to her office from the facility related to the discharge of Resident #2. In interview with Resident #2's daughter on 08/15/2023 at 4:12 PM, she stated a facility nurse, whom she thought was the Director of Nursing (DON), and the Social Worker (SW) called on 03/21/2023 and informed her that the only alternative for Resident #2 to stay at the facility was for her to pay for a sitter after the resident's second elopement. Resident #2's Daughter stated that she told them that she would not pay, because she could not afford it. During continued interview, she stated that back in December, the facility had discussed with her about the need to transfer the resident after his/her elopements. She stated that referrals had been sent but, they appeared to be to the same facilities. The Daughter stated she had found out when the Appeals Hearing Officer had requested her to obtain the referrals from the facility about a month ago. She stated the appeal's process was ongoing due to her requesting Resident#2 be closer to home. The Daughter stated that on 08/18/2023, she had voiced her objections of the transfer to the facility due to it being so far away from her. She stated the response from the DON and SW was the only alternative was for her to pay for sitters 24/7 not giving a reason why. She stated she did feel her parent needed to be on a locked memory care unit to meet his/her safety needs. In an interview with the Director of Nursing (DON) on 08/10/2023 at 1:30 PM, she stated she had spoken with Resident #2's Daughter and she was ok with the transfer. The DON stated the reason for the transfer was for the safety of the resident since the facility did not have a locked unit and could not provide sitters, not giving a reason. The DON did not say why the facility could not provide sitters. The State Survey Agency requested a Discharge Summary for Resident #2. However, the DON did not provide the summary. The State Survey Agency (SSA) made a request to the Social Worker for transfer and discharge papers sent to the receiving facility for Resident #2. The Social Worker provided a Discharge Short Summary, dated 03/23/2023. However the Discharge Short Summary was incomplete and did not include a discharge summary from the Primary Care Physician.

Based on observation, interview, record review, review of the facility's policies, and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for six (6) of sixty-four (64) sampled residents (Residents #1, #23, #57, #71, #255, and #348). 1. The facility admitted Resident #1 on 11/12/2022 with a diagnosis of Dementia with Agitation. Resident #1's initial Nursing Assessment, dated 11/12/2022, revealed the facility assessed Resident #1 not to be an elopement risk. However, the facility assessed Resident #1 to have severe cognitive impairment and wandering behaviors. Review of Resident #1's Progress Notes, dated 11/18/2022, revealed Resident #1 had been wandering the hallways and attempting to go into other residents' rooms. However, there was no documentation the facility reassessed the resident for elopement risk. In addition, a care plan for wander and elopement risk was not developed at that time. Per the first Incident Report, dated 11/25/2022, on 11/22/2022 at approximately 1:15 PM, Resident #1 eloped from the facility and was returned to the facility by staff at 1:26 PM. Review of Resident #1's care plan revealed the facility care planned the resident as a wander and elopement risk after the resident's elopement on 11/22/2022. Review revealed following Resident #1's elopement, the facility placed the resident on one-to-one (1:1) supervision until placement at a psychiatric hospital on 11/29/2022. The facility readmitted Resident #1, from the hospital on 12/13/2022, with no report of exit seeking behaviors, and the 1:1 supervision was not resumed. Review of Resident #1's care plan, developed on 11/22/2022, revealed the risk for elopement care plan was continued, with interventions to include a room change (occurred on 11/22/2022), placement of a wander guard (a monitoring device placed on the resident's ankle that would cause an alarm to sound when the resident went through a door equipped with the wander guard alarm), and increased monitoring, which staff defined as increased awareness of the resident's location without documentation. Review of the Incident Report dated 12/14/2022, revealed Resident #1 eloped from the facility again without staffs' knowledge on 12/14/2022. The resident exited through the dining room emergency exit door, which was not equipped with a wander guard alarm, at approximately 6:35 PM and was not returned to the facility by staff until 7:02 PM. Additionally, the facility failed to develop and implement care plan interventions for: (a). Resident #23 related to his/her fall prevention interventions which included keeping a bedside commode at the resident's bedside and maintaining non-skid strips in the resident's bathroom. However, observation revealed those interventions were not being implemented. (b). Resident #57 related to his/her care plan interventions to manage edema and vascular wounds including performing dressing changes according to wound care recommendations. Observation of the resident revealed those interventions were not being implemented. (c). Resident #71 related to interventions for tube feeding care including to perform site care each shift. Observation of the resident revealed this intervention was not being implemented. (d). Resident #255 related to his/her care plan not having appropriate interventions developed for aspiration prevention; nor were his/her care plan interventions implemented according to the Physician's Orders. (e). Resident #348 related to his/her diagnosis of Dysphagia and requiring extensive assistance with eating which the facility failed to develop and have interventions in place for aspiration prevention. The facility's failure to have an effective system in place to ensure each resident's care plan was developed and implemented with interventions to reduce or prevent the likelihood of an elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/07/2023, and was determined to exist on 11/22/2022 in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F656, and at 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F689 both at a Scope and Severity (S/S) of a J along with Substandard Quality of Care (SQC). The facility was notified of the Immediate Jeopardy (IJ) on 01/07/2023. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/18/2023, alleging removal of the IJ on 12/20/2022. The State Survey Agency (SSA) validated removal of the IJ on 12/20/2020, as alleged prior to exit on 01/28/2023. The S/S was lowered to an G at F656 and a G at F689. The findings include: Review of the facility's policy titled, Care Plan Process, reviewed 10/01/2021, revealed the plan of care must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Policy review revealed the purpose of the policy was to ensure a care plan would be developed which was appropriate for each resident's needs based on the Resident Assessment Instrument (RAI) process. Further review revealed the comprehensive care plan was developed from the Minimum Data Set (MDS) Assessment data. Finally, the policy stated a care plan would be developed/reviewed within seven (7) days of the completion of the MDS Assessment. Review of the facility's policy titled, Elopement/Exit Seeking, revised 09/02/2019, revealed elopement risk would be care planned to reduce the potential for elopement and/or redirect the resident if an elopement attempt was made. 1(a). Review of Resident #1's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/12/2022, with diagnoses that included Dementia in Other Diseases Unspecified Severity with Agitation, Anxiety Disorder Unspecified, and Insomnia Unspecified. Continued review revealed the facility assessed Resident #1, in an Admission MDS Assessment, dated 11/16/2022, with a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated severe cognitive impairment. Further review of the Admission MDS Assessment revealed the facility also assessed Resident #1 as having wandering behaviors exhibited one (1) to three (3) days during the seven (7) day look-back period. Continued review of Resident #1's EMR revealed a Progress Note, dated 11/18/2022 at 1:00 PM, signed by Registered Nurse (RN) #1, the Unit Manager of Rehab. The Note stated the resident had been wandering in hallways, attempting to go into other residents' rooms, and demonstrating agitation or aggressiveness with redirection or assistance. Per review of the Note, RN #1 contacted the Advanced Practice Registered Nurse (APRN) and received an order for PRN (as needed) Ativan (an anti-anxiety medication). Review of Resident #1's Comprehensive Care Plan (CCP) revealed Resident #1's CCP was not reviewed until 11/22/2022, six (6) days after completion of Resident #1's Admission MDS Assessment. Continued review revealed the CCP did not include a care plan for Resident #1's wandering or elopement risk. Further review of the CCP revealed the facility failed to develop a care plan for Resident #1 regarding his/her wandering and elopement risk until after the resident eloped on 11/22/2022. Review of the facility's Incident Report for Resident #1, dated 11/25/2022, revealed Receptionist #1 received a phone call, on 11/22/2022 at 1:18 PM, regarding a potential missing resident walking on the sidewalk by a busy road next to the facility without shoes on. Continued review revealed Resident #1 had been located by staff while at 1:23 PM, and was returned by staff to the facility at 1:26 PM. Per review of the Report, Resident #1 had last been seen in his/her room by staff at approximately 1:15 PM. Further review of the Report revealed Resident #1 was placed on one-to-one (1:1) supervision; his/her room was changed; and, his/her care plan reviewed and updated. Continued review of Resident #1's Comprehensive Care Plan (CCP), initiated 11/12/2022, revealed no documented evidence of a care plan for elopement or wandering behaviors prior to the resident's elopement on 11/22/2022. Review of the CCP revealed on 11/22/2022 Resident #1's care plan was updated to include a care area related to elopement and wandering. Record review revealed the elopement/wandering interventions included: distracting the resident by offering pleasant diversions, and structured activities with a place to document the resident's preferences which had been left blank; monitor the resident throughout the shift, and document wandering behaviors and attempted diversions; provide structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; a Wander Guard alarm to person related to elopement; and 1:1 supervision related to the elopement. Review of the facility's,1:1 Monitoring documentation for Resident #1 revealed the resident remained on 1:1 supervision by staff from 1:30 PM on 11/22/2022 through 11/29/2022, when he/she was transferred to a psychiatric facility. Further review revealed the documentation revealed a break, from 11:45 AM on 11/26/2022 through 1:30 AM on 11/27/2022, during which time Resident #1 was out of the facility. Interview with Registered Nurse (RN) #2 on 01/06/2023 at 10:47 AM, revealed the staff had only what information the resident had on admission which included the hospital discharge summary and nursing admission assessment to base the residents' care plans on. She stated, if the nurse that received report upon admission had been given any indication Resident #1 had been a wanderer while at the hospital, facility nursing staff would have care planned for wandering. Continued interview revealed the nursing assessment could trigger an elopement assessment depending upon how the questions were answered. She stated if the elopement assessment was triggered and showed the resident was at risk for elopement, staff would initiate a care plan for elopement, and the electronic record system would trigger the resident's elopement care plan. Further interview revealed the triggers for elopement would include if a resident was to exhibit behaviors or make statements to the effect of leaving the facility. Interview, with RN #1 on 01/06/2023 at 2:18 PM, revealed nursing completed an Admission Nursing Assessment, which had an elopement risk question, which would be noted as a yes or no based on information available at the time of admission. She stated a resident should be care planned for wandering if wandering triggered on the resident's MDS Assessment. Further interview revealed she had not considered Resident #1 to be an elopement risk on 11/18/2022, when she completed a nursing note regarding the resident's behaviors. RN #1 further stated she had not considered Resident #1 as an elopement risk as his/her moods were all over the place, more like a back and forth and not a constant. Interview, with Certified Nursing Assistant (CNA) #2 on 01/04/2023 at 2:26 PM; with CNA #3 on 01/04/2023 at 2:45 PM; and with CNA #12 on 01/06/2023 at 10:20 AM and again on 01/10/2023 at 5:00 PM, revealed CNA #2 worked the Rehab Unit where Resident #1 resided and he/she had been very confused when initially admitted . CNA #2 and CNA #12 both stated Resident #1 constantly talked about wanting to go home, and he/she had wandered about the unit. Per CNA #2 and CNA #3, Resident #1 also talked about needing to go to the bank, or wanting to go pick up vehicles from the mechanic. CNA #2 stated Resident #1 went to the doors frequently; however, the resident stopped at the doors. CNA #3 stated Resident #1 would sometimes pack all his/her belongings, go to the door, yell about catching the bus and told staff he/she was going to catch the bus. CNA #3 further stated Resident #1 talked about leaving often, and made those comments in front of nursing staff. Interview with RN #1, the Manager of the Rehab Unit, on 01/05/2023 at 1:09 PM; 01/06/2023 at 2:18 PM; and 01/23/2023 at 2:48 PM, revealed she had not considered Resident #1 an elopement risk when she completed the Progress Note on 11/18/2022. Further interview revealed after Resident #1's elopement on 11/22/2022, the resident was moved to the South Unit, for increased monitoring, as that unit had a Wander Guard system. Interview with the Administrator, on 01/06/2023 at 10:47 AM, revealed she expected staff to alert her to residents that had behaviors of wandering or making statements about exiting the facility. The Administrator stated if staff had made her aware, the facility would have assessed Resident #1 and updated his/her care plan to place interventions for the resident's behavior of wandering at that time. Interview with RN #3, the MDS Coordinator on 01/23/2023 at 2:13 PM, revealed she was unaware of any exit seeking statements or behaviors made by Resident #1 prior to his/her elopement on 11/22/2022. She further stated on the evening of 11/22/2022, she had updated Resident #1's care plan to include 1:1 staff observation and placement of a Wander Guard. Additional review of Resident #1's EMR revealed a Progress Note dated 11/29/2022, noting the resident had been transferred to an inpatient psychiatric facility at 6:30 PM by ambulance. Continued review revealed a nursing readmission assessment completed by LPN #5 upon Resident #1's return to the facility on [DATE], indicated the resident was at risk for elopement. 1(b). Review of Resident #1's Comprehensive Care Plan revealed, upon the resident's readmission to the facility on [DATE], the 1:1 supervision had been removed from the resident's wandering/elopement risk care plan, with an intervention noted in its place, to monitor the resident's location throughout shift. Interview with the DON, on 01/06/2023 at 10:47 AM, revealed the intervention to monitor location throughout shift meant for staff members to know they needed to be aware of where Resident #1 was; however, it was not specifically for 1:1 supervision and was not documented as such. She further stated when Resident #1 returned from the psychiatric facility on 12/13/2022, he/she did not have any behaviors or indication he/she needed to go back on 1:1 supervision/observation. Review of the facility's Incident Report, dated 12/19/2022, revealed RN #4 arrived at the facility for work at 6:42 PM on 12/14/2022. Per review, when RN #4 pulled into the facility's parking lot, she observed Resident #1 standing at the entrance of the parking lot, facing the road with his/her thumb out. Continued review revealed RN #4 rolled her window down and asked Resident #1 if he/she needed a ride, and the resident stated yes, he/she did and needed to go to the bus stop. Further review revealed Resident #1 was escorted back into the facility at 7:02 PM, with a Wander Guard intact on his/her right ankle. Record review revealed during the investigation, Resident #1's wheelchair was observed in the doorway of the dining room, and it was determined the resident had exited the facility through the dining room emergency exit, with alarms sounding. However, the alarm was unable to be heard at the nearby nurses' station with the dining room doors closed. In addition, the Report stated Resident #1's care plan was reviewed and updated, and Resident #1 was placed on 1:1 observation. Additional review of Resident #1's Comprehensive Care Plan revealed following the resident's second elopement on 12/14/2022, his/her care plan had been updated with 1:1 supervision again on 12/14/2022. Record review revealed an additional revision was made on 12/15/2022, to check Resident #1's Wander Guard daily to ensure it was functioning properly. Interview with RN #3, the MDS Coordinator, on 01/23/2023 at 2:13 PM, revealed she updated Resident #1's care plan to include 1:1 supervision on 12/14/2022, after the resident's elopement. RN #3 further stated she also added an update on 12/15/2022, to check the functioning of Resident #1's Wander Guard daily. Interview, with CNA #6 on 01/05/2023 at 3:01 PM, revealed on 12/14/2022, when Resident #1 was brought back to the facility after his/her second elopement, the resident had a Wander Guard on, although the CNA had not heard any alarms going off. Further interview revealed after Resident #1's elopement on 12/14/2022, staff members were assigned to 1:1 supervision to keep an eye on the resident twenty-four hours a day, seven days a week (24/7). 46710 2. Review of Resident #23's EMR revealed the facility admitted the resident on 05/11/2021, with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Age-Related Debility. Review of Resident #23's Quarterly Minimum Data Set (MDS) Assessment, dated 11/06/2022, revealed the facility assessed the resident to have a BIMS' score of two (2) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility also assessed Resident #23 as requiring limited assistance for transferring between surfaces, walking in his/her room, and toileting; and needed substantial assistance to put on footwear. Review of Resident #23's Comprehensive Care Plan, dated 11/13/2022, revealed the facility identified the resident was at risk for falls and care planned him/her for the fall risk. Per review of the Care Plan, the interventions included: for staff to be sure the call light was within Resident #23's reach; place a bedside commode at his/her bedside; place nonskid strips in the bathroom; continue to re-educate the resident to ask for assistance with toileting; encourage the resident to wear appropriate footwear when up; and place a raised toilet seat in the resident's bathroom. Observation, on 01/17/2023 at 10:21 AM, revealed Resident #23 sitting on his/her bed with his/her walker out of reach of the bed, and a bedside commode placed directly outside the bathroom door, out of the resident's reach and with no receptacle in it for the resident to be able to use it. Further observation in Resident #23's bathroom revealed there was a raised toilet seat with grab bars; however, no nonskid strips were present in the bathroom as per the resident's care plan. Interview with Resident #23's Resident Representative (RR) on 01/18/2023 at 5:32 PM, revealed the resident had fallen on multiple occasions since admission to the facility. The RR stated Resident #23 had Dementia and forgot that he/she needed to use a walker when going to the bathroom. Per interview with the RR, the facility had been asked to keep a bedside commode at Resident #23's bedside so the resident would be able to urinate without needing to walk to the bathroom. Further interview revealed the RR stated the bedside commode was usually in the bathroom when the RR came to visit Resident #23, and not beside the bed as requested. Interview with CNA #40 on 01/23/2023 at 11:01 AM, revealed she was aware of Resident #23's history of falls, including a fall with an injury. CNA #40 stated when she cared for Resident #23, she knew if the resident tried to get up independently, he/she was at high risk for a fall with injury. Per CNA #40, she assisted Resident #23 with getting up to go to the bathroom in the morning and after meals, and assisted the resident to his/her recliner after toileting. Further interview revealed CNA #40 did not recall a bedside commode being located in the resident's room as per his/her care plan. She further stated Resident #23 did not like to use a walker or wheelchair, so she made sure she assisted the resident with ambulation to protect him/her from falling. Interview with LPN #11, South Unit Manager on 01/26/2023 at 2:07 PM, revealed she was aware of Resident #23's history of falls and his/her care plan interventions. LPN #11 stated there were nonskid strips in place in the resident's bathroom that the facility had reapplied when the strips showed signs of wear and tear. Per LPN #11, Resident #23 could not be educated due to the resident's Dementia diagnosis. Continued interview revealed staff had repeatedly educated Resident #23 about using his/her call bell and waiting for assistance to go to the bathroom; however, the resident continued to get up without assistance. LPN #11 stated Resident #23 did not like to use the bedside commode, and the facility attempted offering frequent toileting to the resident. According to the LPN, Resident #23 would tell staff he/she did not need help and a short time later would get up to go to the bathroom without staffs' assistance. Further interview revealed after that happened multiple times, the facility determined offering a toileting schedule was not an effective intervention for Resident #23 and therefore, discontinued the intervention. 3. Review of Resident #57's EMR revealed the facility admitted the resident on 10/04/2019, with diagnoses which included Type II Diabetes, Peripheral Vascular Disease, Cellulitis of Bilateral Lower Limbs, and Stage III Chronic Kidney Disease. Review of Resident #57's Quarterly Minimum Data Set (MDS) Assessment, dated 11/07/2022, revealed the facility assessed the resident to have a BIMS score of a fourteen (14) out of fifteen (15), indicating the resident was cognitively intact and interviewable. Further review of the MDS Assessment revealed the facility assessed Resident #57 as having five (5) venous and/or arterial ulcers. Review of Resident #57's Care Plan, dated 01/06/2023, revealed the facility care planned the resident for impaired skin integrity with interventions including: to provide treatments to the bilateral lower extremities as per the Physician's Orders, and to encourage the resident to elevate his/her legs during the day. Observation of Resident #57 on 01/03/2023 at 2:08 PM, revealed gauze dressings on the resident's legs with a foul odor noted in the resident's vicinity. Continued observation revealed the gauze dressings were loose with yellow areas in multiple places on the dressings on each leg. Further observation of Resident #57 on 01/03/2023 at 3:50 PM, revealed the dressings remained with an odor and the appearance of the dressings was unchanged from the previous observation. Review of Resident #57's Physician's Orders, dated 01/17/2023, revealed staff were to daily clean the resident's bilateral lower extremities with wound cleanser, apply calcium alginate with silver to open lymph wounds, and secure with gentle tubi-grip (a pressure bandage). Review of Resident #57's wound note, dated 01/17/2023 at 7:08 AM, revealed the wound doctor's recommendation were to cover the topical medication on the resident's leg wounds with an absorbent pad, held in place by a stretchy gauze roll, covered by an ACE bandage, which was to be changed every day for thirty (30) days. Review of Resident #57's Treatment Administration Record (TAR) dated 01/2023, revealed the dressings on the resident's legs were not documented as having been changed as required on 01/22/2023 or 01/23/2023. Observation of Resident #57 on 01/23/2023 at 10:56 AM, revealed yellow areas observed on the gauze dressings bilaterally with no ACE bandage or tubi-grip in place as ordered. Observation further revealed Resident #57 was sitting up in his/her wheelchair with his/her eyes closed and his/her feet on the floor with no footrests for elevating his/her feet as per the care plan. Interview with Resident #57 on 01/23/2023 at 10:57 AM, revealed the dressings on his/her bilateral legs were only changed twice per week after his/her showers. Interview with CNA #40 on 01/23/2023 at 11:01 AM, revealed in her experience when caring for Resident #57, the dressings on his/her legs were only changed twice per week with showers, even if the resident had urinated on the dressings while trying to use a urinal, which she had witnessed multiple times. CNA #40 stated on those occasions, she had removed the urine-soaked dressings and informed the nurse. Further interview revealed there had been one (1) occasion when the dressings had not been reapplied the next day, though CNA #40 did not recall who the nurse was or when this had occurred. Interview with the MDS Coordinator on 01/27/2023 at 3:03 PM, revealed her practice was to update residents' care plans based on new orders put in their EMR by the wound care nurse. Further interview revealed the importance of following the care plan was so the residents received the care they needed through the interventions care planned. 4. Review of Resident #71's EMR revealed the facility admitted the resident on 11/25/2019, with diagnoses including Hemiparesis of Right Dominant Side, Aphasia (inability to speak), Dysphagia (difficulty swallowing), and Gastrostomy (a feeding tube directly in the stomach). Review of Resident #71's Quarterly MDS Assessment, dated 01/13/2023, revealed the resident was not assigned a score under the BIMS assessment due to communication barriers and not being interviewable. Further review revealed the facility assessed the resident to have a gastrostomy feeding tube in place and to receive twenty-five percent (25%) or less of his/her total calories from tube feedings. Review of Resident #71's Care Plan dated 11/19/2022, revealed the facility care planned the resident for his/her tube feedings with interventions for gastrostomy care including site care and dressing changes to be performed each shift as per the Physician's Order. Observation, on 01/23/2023 at 9:26 AM, of Resident #71 revealed there was no dressing in place to the resident's gastrostomy site when LPN #5 pulled the resident's clothing back to begin gastrostomy site care. Continued observation revealed LPN #5 cleansed a moderate amount of dried brown drainage from around the gastrostomy tube insertion site. Further observation revealed LPN #5 removed the tube feeding and flush tubing from the previous shift that had not been dated. Interview with LPN #5 on 01/23/2023 at 9:32 AM, revealed the night shift nurse should have performed the gastrostomy site care, to include cleansing the drainage from around the gastrostomy site and re-applying a dressing to the site according to the Physician's Order. LPN #5 stated following the care plan and orders for gastrostomy site care was important to protect the resident from complications including skin breakdown. 5. Review of Resident #255's EMR revealed the facility admitted the resident on 08/26/2022, with diagnoses including Sepsis, Pneumonitis due to Inhalation of Food and Vomit, Dysphagia, Seizures, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #255's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Review of the Discharge MDS assessment dated [DATE], for Resident #255 revealed the facility discharged the resident assessed needs of: requiring extensive assistance to transfer between surfaces; utilizing a wheelchair; and requiring a mechanically altered diet. Review of Resident #255's Care Plan revealed the facility failed to develop care plans for the resident's need for aspiration prevention and fall prevention. Interview with Resident #255's RR on 01/04/2023 at 3:00 PM, revealed staff did not keep the resident's bed in the lowest position, and the height of the bed at times was concerning. The RR stated there had been nothing in place for Resident #255 regarding fall prevention such as, a fall mat, bed rails, or anything else. Further interview revealed there had been multiple occasions when the RR observed staff members, including CNA #13 and LPN #20 giving Resident #255 thin liquids, even after the RR told them the resident had aspirated on thin liquids in the past. Interview with CNA #13 on 01/06/2022 at 2:25 PM, revealed he recalled Resident #255 and remembered the resident had been a high fall risk and was unable to transfer from the bed to the chair without assistance. CNA #13 stated when he worked he ensured Resident #255 wore non-skid footwear and had his/her bed kept in the lowest position. He stated he offered the resident toileting every two (2) hours to reduce his/her risk of falling. In addition, CNA #13 stated he relied on shift report to know what Resident #255's needs were due to inconsistent documentation including the resident's care plan interventions. CNA #13 further stated the inconsistent documentation was due to the frequent management changes at the facility. 6. Review of Resident #348's EMR revealed the facility admitted the resident on 01/05/2023, with diagnoses including Hemiplegia of the Left Side, Dysphagia, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #348's Admission MDS assessment dated [DATE], revealed the facility's assessed the resident with a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed Resident #348 as requiring a mechanically altered diet and extensive assistance with eating. Review of Resident #348's Care Plan dated 01/24/2023, revealed the facility failed to develop a care plan for the resident's need for aspiration prevention and extensive assistance with meals. Observation on 01/05/2023 at 3:13 PM, revealed LPN #5 was at Resident #348's bedside, encouraging him/her to take deep breaths and instructing the resident not to drink soda out of the can because he/she would get choked. Interview with LPN #5 at 3:16 PM, revealed Resident #348 became choked easily when his/her family provided soda that had not been thickened. LPN #5 stated she educated the resident's family, and they had taken the remaining cans of soda home with them. Further interview revealed LPN #5 stated Resident #348 required assistance with eating to prevent aspiration. Interview with the niece of Resident #348 on 01/18/2023 at 1:54 PM, revealed she did not understand why Resident #348 could not have soda to drink. She stated the facility would only provide thickened water for the resident to drink. Interview, with the MDS Coordinator on 01/27/2023 at 3:03 PM, revealed she was responsible for developing care plans based on residents' assessed conditions which were discussed in clinical meetings with the interdisciplinary care team (IDT). Per the MDS Coordinator, she also developed care plans according to new orders entered by the Physician. Further interview revealed she believed a resident's need for thickened liquids was adequately conveyed in the care plan under the weight loss section with the intervention of Diet per MD orders. Interview, with the Director of Nursing (DON) on 01/27/2023 at 3:34 PM, revealed her expectations were for care plans to be developed and followed according to policy. Interview with the Administrator on 01/28/2023 at 1:27 PM, revealed her expectations were for care plans to be individualized in development and interventions followed so residents could achieve their highest quality of life. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/18/2023, alleging removal of the IJ on 12/20/2022. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 11/22/2022, Resident #1 was placed on one-on-one (1:1) supervision immediately upon being brought back into the facility. 1:1 was provided by CNAs. Resident #1 received a head-to-toe assessment by LPN #3, with no new concerns noted. Wander Guard was initiated, and Physician and family were notified. 2. On 11/22/2022 Therapy Director (TD) and LPN #3 were re-educated on the elopement policy, the Wander Guard system, and the red box alarms by the DON. 3. On 11/22/2022 the Administrator and DON completed Ad Hoc Quality Assurance (QA) with the Chief Nursing Officer (CNO) and the Clinical Consultant (CC) to discuss the interviews collected at the time of the event and the investigation preliminary to deter [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policies and investigations, it was determined the facility failed to have an effective system in place to ensure residents who exhibited wandering behaviors or were assessed at risk for elopement received adequate supervision and monitoring for one (1) of sixty-four (64) sampled residents (Resident #1). The facility admitted Resident #1 on 11/12/2022 with diagnoses of Dementia with Agitation and assessed not to be an elopement risk on admission. The facility assessed the resident to have wandering behaviors on one (1) to three (3) days during the seven (7) day look back period. Resident #1 was documented to have been wandering the hallways and attempting to go into other residents' rooms on 11/18/2022; however, there was no documented evidence the facility reassessed the resident for elopement risk. Interview revealed Licensed Practical Nurse (LPN) #3 was administering medication on 11/22/2022 at approximately 10:00 AM, when an alarm sounded, and the LPN observed Resident #1 at the emergency exit. LPN #3 stated even though Resident #1 often talked about having things to do outside of the facility, she did not feel the resident was at risk for elopement, and did not inform the Charge Nurse or Director of Nursing (DON) of that information. On 11/22/2022 at approximately 1:15 PM, Resident #1 eloped from the facility without staff's knowledge and without the alarm on the door sounding. The facility was notified by a passerby at 1:18 PM of a resident walking down the sidewalk next to a major road with no shoes on. Staff responded and located and returned Resident #1 to the facility at 1:26 PM. Staff determined the Resident #1 had exited the unsecured Southwest door on the rehab unit, which was the same door the resident had triggered the alarm on at 10:00 AM that same day. The facility was unable to determine if the red box alarm on the door had been turned off by a staff person, and why the magnetic (mag) lock keypad alarm had not been sounding. Resident #1 was placed on one to one (1:1) supervision until sent out to a psychiatric hospital on 11/29/2022; and readmitted to the facility from the hospital on 12/13/2022, with no report of exit seeking behaviors. Resident #1's comprehensive care plan had been revised on 11/22/2022, to include interventions of a Wander Guard (a device placed on a resident's ankle that caused a door also equipped with the Wander Guard to alarm when the resident exited the door), room change, and increased supervision by staff; however, the resident's one-to-one (1:1) supervision was not resumed. On 12/14/2022 at approximately 6:35 PM, the facility again allowed Resident #1 to elope from the facility without staff's knowledge, through an emergency exit door not equipped with a Wander Guard alarming system. Staff coming to work observed Resident #1 at the edge of the parking lot at 6:40 PM, and returned him/her to the facility. Per interview, alarms had sounded in the dining room which was in use at the time and with the doors closed the alarms could not be heard by staff at the nearest nursing station. The facility's failure to have an effective system in place to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/07/2023, and determined to exist on 11/22/2022 in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F689 at a S/S of a J, along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on 01/07/2023. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/18/2023, alleging removal of the IJ on 12/20/2022. The State Survey Agency (SSA) validated removal of the IJ on 01/25/2023, prior to exit on 01/28/2023, and determined the facility had removed the immediacy of the Jeopardy on 12/20/2022, as alleged, before the initiation of the survey. However, additional deficient practice was identified at F689 at the scope and severity of G. The facility failed to protect residents from accidents for two (2) of the sixty-four (64) sampled residents, Resident #23 and Resident #255. On 12/26/2021, Resident #23 fell in his/her room, sustaining a fracture to his/her right arm, which required hospitalization . Resident #23 fell in the room again on four (4) additional occasions: on 04/08/2022, 07/10/2022, 09/14/2022, and 10/23/2022. On 08/28/2022, a staff member found Resident #255 lying on the floor, bleeding from a laceration on his/her forehead. The findings include: 1. Review of the facility's policy titled, Elopement/Exit Seeking, revised 09/02/2019, revealed cognitively impaired residents with the physical ability to leave the facility without assistance, and who had demonstrated or vocalized a desire to leave the facility were to be placed on a unit with an electronic monitoring system or similarly secured unit. Continued review revealed the resident's elopement risk would be care planned to reduce the potential for elopement and/or redirect the resident if an elopement attempt was made. Further review revealed staff were to promptly report any resident who tried to leave the premises to the Charge Nurse or Director of Nursing (DON). Review of Resident #1's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/12/2022, with diagnoses that included Dementia with Agitation, Anxiety Disorder Unspecified, and Insomnia Unspecified. Per review, of the Admission Minimum Data Set (MDS) Assessment, dated 11/16/2022, for Resident #1 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15), indicating severe cognitive impairment. Continued MDS review revealed the facility assessed Resident #1 with wandering behaviors exhibited one (1) to three (3) days during the seven (7) day look-back period. Continued review of Resident #'1 EMR revealed a Progress Note, dated 11/18/2022 at 1:00 PM, signed by Registered Nurse (RN) #1, the Rehabilitation (Rehab) Unit Manager which documented the resident had been wandering in hallways and attempting to go into other residents' rooms, demonstrating agitation or aggressiveness with redirection or assistance. Review of the Progress Note, dated 11/18/2022, revealed RN #1 contacted the Nurse Practitioner (NP) and received an order for Ativan (a narcotic medication used to treat anxiety and insomnia) prn (as necessary). Review of Resident #1's Comprehensive Care Plan revealed no documented evidence of a care plan addressing elopement or wandering behaviors for the resident prior to his/her elopement from the facility on 11/22/2022. 1. A. Review of the facility's incident report, dated 11/25/2022, revealed Receptionist #1 received a call on 11/22/2022 at 1:18 PM, of a potential missing resident walking on the sidewalk by a busy road next to the facility and was not wearing shoes. Per review of the report, Receptionist #1 notified the Director of Nursing (DON) and the Administrator, and the facility initiated an elopement drill at 1:20 PM. Continued review revealed Resident #1 was located by staff ambulating on the sidewalk next to a busy road at 1:23 PM, and was returned to the facility by staff at 1:26 PM. Review of the incident report further revealed Resident #1 had last been seen in his/her room by staff at approximately 1:15 PM, and had exited the facility's southwest door on the rehab unit without alarms sounding and without staff's knowledge. Review of the report revealed Resident #1 was assessed, placed on 1:1 observation, and moved to a different room. Per the report, the Physician and family were notified, Resident #1's medications (meds) were reviewed, and his/her care plan was reviewed and updated. Further review of the facility's incident report revealed staff education and elopement drills were initiated, doors were checked by an outside contractor and deemed to be functioning properly, and door checks for security were ongoing. Observation, on 01/04/2023 at 3:00 PM, of the path taken by Resident #1 on 11/22/2022, from the facility's emergency exit to the sidewalk by the road, revealed it was approximately one hundred and sixty (160) feet from where Resident #1 was located. Review of Resident #1's care plan revealed on 11/22/2022, the care plan was updated to include a care area noted for elopement/wandering with interventions which included: distracting the resident by offering pleasant diversions, structured activities, food , conversation, television, and books. Continued review revealed the area on the care plan related to Resident #1's preferences was left blank. Further review revealed additional interventions included: monitoring Resident #1 throughout each shift, documenting his/her wandering behaviors and attempted diversions; providing structured activities to include walking inside and outside, reorientation strategies including signs, pictures and memory boxes and toileting; placement of a wander guard to him/her related to elopement; and 1:1 supervision related to elopement. Review of the facility's 1:1 Monitoring documentation revealed the facility kept Resident #1 on 1:1 staff observation from 11/22/2022 at 1:30 PM through 11/29/2022 when the resident was transferred to the psychiatric facility. Continued review of the 1:1 Monitoring documentation revealed a break in the 1:1 documentation from 11/26/2022 at 11:45 AM through 11/27/2022 at 1:30 AM. Review of Resident #1's EMR revealed a skin assessment was completed by LPN #3 on 11/22/2022 at 1:40 PM with no concerns identified. Per EMR review, an elopement risk assessment was completed on 11/22/2022 by LPN #11 with Resident #1 noted as at high risk for elopement with a score of fourteen (14), with anything over a ten (10) indicating a risk for elopement. Further review of the elopement risk assessment revealed Resident #1's room had been changed and a wander guard placed, with orders for the wander guard at that time. Review of pharmacy documentation revealed the Consultant Pharmacist reviewed Resident #1's medications on 11/25/2022 and determined the resident was not on any medication that would cause or increase agitation. Resident #1 was started on Seroquel 25 mg at hour of sleep (hs) following the 11/22/2022 elopement. Review of a Time and Materials Ticket from an outside contractor revealed all facility doors had been checked on 11/22/2022, with all doors determined to be functioning properly. Interview, with Receptionist #1 on 01/20/2023 at 2:11 PM, revealed she received a call after lunchtime on 11/22/2022 from a lady who said she saw an older person on a nearby busy highway with no shoes on. Receptionist #1 stated as soon as she got off phone she went to the DON's (Director of Nursing) office, where the DON, Administrator, and all unit coordinators were at that time. She stated she announced a code green, and everybody went to search. Interview ,on 01/04/2022 at 2:26 PM, with Certified Nursing Assistant (CNA) #2, who worked the rehab unit where Resident #1 was initially admitted , revealed she described Resident #1 as very confused when he/she first arrived, constantly talking about wanting to go home, needing to go to the bank, or wanting to pick up vehicles from the mechanic. She stated Resident #1 had been unsteady upon arrival and staff had to walk with him/her. CNA #2 stated Resident #1 would wander around the unit, and although the resident would go to the doors, he/she would stop at the doors. Continued interview revealed CNA #2 had been working on 11/22/2022, assisting CNA #3 with a resident who required a Hoyer (brand of mechanical lift) lift to go to bed, at the far hallway with the resident's door closed. She stated when she and CNA #3 came out of that room, they heard the code green paged overhead. Per CNA #2, she and CNA #3 started checking resident rooms and noted Resident #1 was not in his/her room. According to CNA #2, she had observed Resident #1 in his/her room maybe five (5) minutes prior to assisting CNA #3 with the Hoyer lift. She stated she stayed on the unit while RN #1 and LPN #3 went other places to search. Further interview revealed when staff returned with Resident #1, they stated he/she was just outside the fence standing next to the road. CNA #2 further stated she sat with Resident #1 until the end of her shift at 3:00 PM, and it was her understanding other staff sat with Resident #1 until he/she was moved that evening to another unit. Interview on 01/04/2022 at 2:45 PM, with CNA #3 revealed Resident #1 was pleasant with wild moments, which she described as the resident would start yelling and nothing you could do would calm him/her down, you would just have to walk away. She stated Resident #1 would sometimes pack all his/her stuff, come to the door, and state he/she was going to catch the bus. Per CNA #3, just about everyday Resident #1 would yell about catching the bus and would talk about leaving the facility often. The CNA stated Resident #1 made comments in front of nursing staff about leaving. She stated she was working on 11/22/2022 with CNA #2 putting a resident to bed in that resident's room with the door closed. Continued interview revealed they heard the code green called overhead when they came out of the room. She stated they did a head count of all residents on the unit and could not locate Resident #1. According to CNA #3, she and a nurse ran down the road to catch Resident #1, who had been standing on the sidewalk right next to the road heading towards an intersection, with a jacket on and non-skid socks on his/her feet. Further interview revealed Resident #1 asked if we were taking him/her back to jail, and when staff told the resident they were taking him/her back to the building, he/she was okay with that. CNA #3 further stated when brought back in, Resident #1 laid down on the bed in his/her room. Interview with LPN #3 on 01/05/2022 at 9:01 AM, and again on 01/06/2022 at 1:20 PM, revealed Resident #1's baseline had been confusion. She stated Resident #1 would often talk about being in the market for a car, having a job interview later, or a meeting scheduled with an attorney, or would be waiting for a train. Continued interview revealed she described Resident #1's behavior as confused, rambling and stated if she had believed the resident to be an elopement risk, she would have stayed glued to him/her. LPN #3 stated she was working the morning of 11/22/2022, and Resident #1 had been up at the nurse's station that morning, looking for a train. Per LPN #3, around 10:00 AM, Resident #1 had set the alarm off on the Southwest emergency exit door of the unit, and when she observed the resident, he/she was holding his/her arms up as though startled and being arrested. Interview revealed LPN #3 had not observed Resident #1 attempting to exit, and it appeared he/she had accidentally set the alarms off by leaning on the door. LPN #3 stated as she did not have a key to the red box alarm on the door that was sounding, she asked the Therapy Director (TD) to turn off the alarm. The LPN stated she observed the TD turn the alarm off, then turned it back to the on position once it stopped alarming. Additionally, LPN #3 stated her intent had been to alert the Unit Manager, RN #1, about the incident of Resident #1 setting off the alarm when she returned to the unit from staff meetings; however, she had not considered it a priority as she did not believe Resident #1 to be exit seeking. Continued interview with Licensed Practical Nurse (LPN) #3 on 01/05/2022 at 9:01 AM, and again on 01/06/2022 at 1:20 PM, revealed when she left for her lunch break, Resident #1 had been standing at the nurse's station talking to CNA #12 (also a medication aide). She stated when she returned from her lunch break, Resident #1 was in his/her room, after having eloped from the facility. She stated she did a head-to-toe assessment of him/her and took vitals. Per LPN #3, Resident #1 had no injuries and was at his/her baseline confusion. Further interview revealed she had been told the alarms had not sounded. Interview further revealed it was believed one (1) of the housekeepers had disabled the alarms, as they had been in and out earlier in the day to go to a storage room; however, she was not there and did not know for certain. Interview with CNA #12, on 01/06/2022 at 10:20 AM, and again on 01/10/2022 at 5:00 PM, revealed she had worked with Resident #1 once or twice prior to his/her elopement. CNA #12 stated Resident #1 had been on one-on-one (1:1) at those times due to his/her behaviors, as the resident had aggressive behaviors and tried to strike a staff member. Per CNA #12, Resident #1 walked around the unit, and often talked about going home. Continued interview revealed CNA #12 had been working on 11/22/2022, when Resident #1 set off the door alarm that morning, and later on was at the nurse's station talking about going home. According to CNA #12, that afternoon she was on the medication (med) cart (as she was a medication aide) and noted Resident #1 was really confused and was again talking about going home. CNA #12 stated she encouraged Resident #1 to sit down, at which point the resident went back towards his/her room. Further interview revealed CNA #12 went back to passing medications (meds) and did not hear any alarms going off. She further stated if the alarm had gone off, it was quite loud and she would have heard it sounding. In addition, she stated she did not see Resident #1 again until staff brought him/her back inside after the resident eloped, at which point he/she had been placed on 1:1 supervision. Interview with RN #1, the Rehab Unit Manager on 01/05/2022 at 1:09 PM; on 01/06/2022 at 2:18 PM; and again on 01/23/2023 at 2:48 PM, revealed Resident #1 was kind of everywhere, and when asked to clarify that statement, she stated the resident had not appeared as focused on one (1) specific thing and walked around a lot. She stated Resident #1 would talk about wanting to play poker, and did other things not available at the facility, but never said anything specific about leaving the facility. According to RN #1, when asked about the progress note she made on 11/18/2022, Resident #1 had been wandering and attempting to enter other residents' rooms. She stated she did not consider Resident #1 as an elopement risk. RN #1 stated she was working on 11/22/2022; however, she had not heard about Resident #1 setting the alarm off earlier that morning, because she was probably in a meeting when that occurred. Continued interview revealed had she been aware of Resident #1 setting off the alarm that morning, it would have prompted her to put interventions in place to address that behavior. She stated interventions would probably have included moving Resident #1 to a more secure unit and 1:1 supervision, which were the common interventions for exit seeking residents. Per RN #1, when Resident #1 eloped, she was in her office on the far hallway of the unit and might not have been able to hear the alarm, even if it had been functioning correctly. Further interview revealed alarms had not been sounding when she received the phone call alerting her to a potential elopement. RN #1 further stated she had never known the red box or keypad alarms to not function unless the red box was turned off with a key and someone had punched in the code for the keypad alarm. In addition, RN #1 stated Resident #1 was moved to the South Unit on 11/22/2022, for increased supervision, as they had a Wander Guard system over there. Interview on 01/05/2023 at 9:45 AM, with the Housekeeping Supervisor (HS) and Housekeeping #2, revealed carpet cleaning machines used to be stored in a storage area on the rehab unit which was through the Southwest emergency exit. However, the machines had been moved to the nursing side as it was more convenient. The HS stated she used to have a key to the red box alarms on the doors, but after the incident of Resident #1 eloping, she now had to get nursing staff to turn off the alarms. Continued interview revealed the Housekeeping staff members had no idea who might have turned the red box alarm off on 11/22/2022, the day Resident #1 eloped. Interview on 01/05/2023 at 10:08 AM, with the Director of Therapy (DT), whose department was just outside the rehab unit, revealed she was working on 11/22/2022, and had Resident #1 on her caseload. She stated she had already been to the rehab unit that day, and last observed Resident #1 lying on his/her bed. Per the DT, she had been at her 9:00 AM morning meeting, when she heard a loud alarm on the rehab unit. Continued interview revealed LPN #3 asked her if she could come reset the door alarm, as Resident #1 had leaned up against the door causing it to go off. The DT stated she turned the red box alarm off, then back to the on position. According to the DT, she then went and provided Resident #1's thirty (30) minute occupational therapy session. Interview revealed later that day when the code green was called overhead, the alarms were not sounding on the rehab unit. She stated they had received several in-services since that day, on what to do when the alarm was sounding. Further interview revealed she had not been aware staff should have done a head count and ensured all residents were present when the alarm went off that morning. Interview with the Administrator on 01/05/2023 at 10:24 AM, revealed the red box alarm was not sounding when Resident #1 eloped from the rehab unit on 11/22/2022. She stated the alarms were working, but the red box alarm had been turned off, and she had not been able to determine who had turned it off. Per the Administrator, at the time Resident #1 eloped, various department heads had a key to the door alarms, which included therapy and housekeeping, as well as maintenance. She stated the keypad alarm was found to be working as well, although someone had punched in the code so it was not alarming. Continued interview revealed she had not been able to determine who had done that. She stated Resident #1 got out the exit door, traveled just outside facility property, and was located by staff. The Administrator stated the red box alarm keys were now kept on the two (2) nurse's stations with the narcotic room keys, and with maintenance to ensure proper oversight of alarms. Further interview revealed staff had been educated on the facility's alarm system and how to respond to alarms. The Administrator further stated Resident #1 was moved to a different unit which was considered more secure and was placed on 1:1 supervision until transfer to a psychiatric facility on 11/29/2022. Interview, on 01/05/2023 at 9:28 AM, with Maintenance revealed he had not been present for either of Resident #1's elopements on 11/22/2022. He stated prior to Resident #1's elopement on 11/22/2022 he had been checking all exits doors weekly for functioning, and since the elopement he had been checking the doors daily. He stated he checked to ensure the red boxes were on and functioning, and that the mag locks were locked. Interview, on 01/24/2023 at 8:08 AM, with the Medical Director revealed he had been contacted on 11/22/2022 by the DON of Resident #1's elopement. Per interview, he was reassured by the DON that the facility was proactively ensuring elopements would not happen again. Further interview revealed the DON further assured him Resident #1 had been relocated to a more secure unit and staff were sitting with him/her 1:1 supervision pending psychiatric hospitalization . Interview, on 01/23/2023 at 9:08 AM, with Resident #1's daughter (Daughter #1) revealed the facility had contacted her following Resident #1's elopement. She stated she had visited the evening of 11/22/2022 and knew they had changed Resident #1's room to a more secure unit and placed an alarm bracelet on him/her. Further interview revealed Resident #1 was doing well when she saw him/her the evening of 11/22/2022. Interview on 01/25/2023 at 3:15 PM, with the Consulting Pharmacist revealed she completed a pharmacy review on Resident #1 medications on 11/25/2022. She stated a review was requested as Resident #1 had been found outside of the facility. Continued interview revealed she reviewed Resident #1's medications looking for anything that would cause or contribute to Resident #1's agitation and the resident was not on any medication which would make him/her agitated. She stated Resident #1 was on Trazadone for anxiety, and prn Lorazepam for severe agitation, and was started on Quetiapine (med used to treat some mood/mental conditions) following the elopement. Interview on 01/23/2023 at 2:13 PM with the MDS Coordinator (RN #3), revealed she updated Resident #1's care plan to include the 1:1 observation and Wander Guard placement the evening of 11/22/2022. Review of Resident #1's EMR revealed a Progress Note from 11/29/2022 noting Resident #1 had been transferred to an inpatient psychiatric facility at 6:30 PM by ambulance. Continued review revealed a nursing readmission assessment completed by LPN #5 upon Resident #1's return on 12/13/2022 revealed the resident to be at risk for elopement. Review of the documentation from the psychiatric facility noted Resident #1 had been treated for a urinary tract infection (UTI) with Macrobid 100 mg bid (an antibiotic) while there. Per review, Seroquel 75 mg hours of sleep (hs) changed to Seroquel 50 mg hs and Seroquel 25 mg at 9:00 AM. In addition, Divalproex 125 mg twice a day (bid) for anxiety was increased to Divalproex 125 mg tid. 1. B. Review of Resident #1's EMR revealed the the resident was readmitted from the psychiatric facility on 12/13/2022, and reassessed as at risk for elopement. Resident #1 again eloped from the facility 12/14/2022 (the day after being readmitted ) as per review of the facility's incident report dated 12/19/2022. Review of the incident report revealed RN #4 arrived at the facility at 6:42 PM on 12/14/2022, and saw Resident #1 standing at the entrance to the parking lot as she pulled in. Per review, RN #4 observed Resident #1 with his/her thumb out (as if hitchhiking), and rolled her window down to ask the resident if he/she needed a ride. Continued review revealed Resident #1 told RN #4, he/she did need a ride to get to the bus stop. Review revealed RN #4 invited Resident #1 into her vehicle to get warm, and Resident #1 agreed and got into the car. The incident report review revealed RN #4 turned on her seat warmers and parked the vehicle, observing Resident #1's clothing to be barely wet (it was raining outside). Per the incident report, RN #4 called the Administrator and chatted with Resident #1 until the Administrator arrived at approximately 6:57 PM, and the resident was escorted back into the facility at 7:02 PM, with the wander guard intact on his/her right ankle. Review revealed during the investigation, Resident #1's wheelchair was observed in the doorway of the dining room, and it was determined the resident had exited the facility through the dining room emergency exit, with the alarms sounding. According to review of the incident report, the alarms were not able to be heard at the nearby nurses station with the dining room doors closed. Further review revealed Resident #1 was assessed, the Physician and family were notified, the care plan was reviewed and updated, and the resident was placed on 1:1 observation ongoing. Review of Resident #1's Comprehensive Care Plan revealed an elopement/wandering care plan with an intervention for 1:1 supervision was added on 12/14/2022, the day he/she eloped from the facility (the resident's care plan had also been revised with 1:1 supervision on 11/22/2022). Review revealed the elopement/wandering care plan interventions also included checking the resident's wander guard daily to ensure proper functioning which was added on 12/15/2022. Review of the facility's 1:1 Monitoring documentation revealed Resident #1 was placed on the monitoring upon return to the facility following the 12/14/2022 elopement. Review of an Invoice from a contract company, dated 12/29/2022 revealed on 12/22/2022 the company wired the dining room door to sound at the nurse's station when the emergency exit was opened. Interview with RN #4 on 01/24/2023 at 8:03 AM, revealed she had cared for Resident #1 when the resident was placed on the rehab unit. She stated she came in to work a little early on the evening of 12/14/2022, and saw Resident #1 standing in the parking lot in the rain, with his/her thumb out like he/she was hitchhiking. Per RN #4, she rolled down her window and asked Resident #1 if he/she needed a ride somewhere, and the resident replied yes, he/she needed a ride to the bus stop. RN #4 stated she encouraged the resident to get in and turned on the seat warmer and heat. Further interview revealed Resident #1 did not appear very wet, and she believed the resident hadn't been outside for very long. RN #4 stated she called the Administrator, who arrived quickly and the resident was returned to the facility with the Administrator. Interview with RN #3, the MDS Coordinator, on 01/23/2023 at 2:13 PM, revealed she updated Resident #1's care plan to include 1:1 supervision on 12/14/2022, after his/her elopement. In addition, she stated she also updated the resident's care plan for checking the functioning of his/her wander guard daily on 12/15/2022. Interview with CNA #6 (also a medication aide) on 01/05/2023 at 3:01 PM, revealed Resident #1 was very confused, hard to redirect, and combative at times. She stated on 12/14/2022 staff were up front waiting on meal trays, and she was passing meds. Per CNA #6, she remembered Resident #1 coming out into the hallway, flailing his/her arms and yelling something she could not understand. CNS #6 stated she continued passing meds, and within thirty (30) minutes she heard Resident #1 had gotten out. She stated Resident #1 had a wander guard on when brought back into facility; however, she had not heard any alarms going off. CNA #6 stated after Resident #1 came back in, staff were assigned to 1:1 supervision of the resident to keep an eye on him/her, twenty-four hours (24) a day seven (7) days a week. Continued interview revealed she had not observed Resident #1 around any of the doors, although he/she would walk up and down the hallway, and was always talking about leaving. CNA #6 further stated since Resident #1's elopement, the alarm now sounded at the nurse's station. Interview on 01/05/2023 at 3:27 PM, with CNA #8 who had been assigned as Resident #1's aide at times after his/her elopement to sit with him/her to provide 1:1 supervision. CNA #8 revealed she had been working on 12/14/2022, when Resident #1 eloped; however, she had been giving showers and had not heard the alarm or the code green announced. She stated when Resident #1 was returned to the facility, he/she had been a little wet, tired, and stated he/she was going to lay down. She stated she sat near Resident #1's bedside when he/she did so. Interview on 01/18/2023 at 8:47 AM, with CNA #29 revealed when they called the code green on 12/14/2022, she ran outside the facility looking for the resident. Interview with the Administrator on 01/05/2023 at 10:24 AM, revealed Resident #1 exited through the dining room emergency exit and had still been in the parking lot when a staff member pulled in for work and noticed the resident. She stated the doors worked and the alarms were supposed to and were sounding; however, during the investigation it was determined the alarm had not been audible at the nurse's station. Further interview revealed following the elopement, Resident #1 was placed on 1:1 supervision, and the doors to the dining room had been locked until the alarm was rewired by the contract company in order for it to be audible at the nurse's station. Int [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide food prepared in a form designated to meet individual needs for one (1) out of sixty-four (64) sampled residents (Resident #255). Resident #255's was admitted to the facility on [DATE] from an acute care hospital where the resident had been treated for Pneumonitis due to Inhalation of Food and Vomit. During the resident's stay in the facility, staff provided the resident with thin liquids when the prescribed diet was for honey thickened liquids. The resident was sent back to the hospital, after a two (2) day stay in the facility, with a diagnosis of Aspiration Pneumonia. The findings include: Review of the facility's policy titled, Thickened Liquids, not dated, revealed the facility was expected to ensure residents with Dysphagia (swallowing difficulty) received appropriately thickened liquids to minimize aspiration (liquid going into the lungs which could cause pneumonia) risk. Further review revealed residents who were admitted to the facility with an order for thickened liquids were referred to Speech Therapy for evaluation, and Nurses obtained Physician diet orders for the thickened liquids and communicated these orders to the Dietary Department. Further review revealed water pitchers containing thin water were not to be kept at the bedside for residents who were at risk for aspiration. Review of Resident #255's electronic medical record (EMR) revealed the facility admitted the resident, on 08/26/2022, a Friday, after transfer from an acute care hospital, with diagnoses including Sepsis, Pneumonitis due to Inhalation of Food and Vomit, Dysphagia, Seizures, and Chronic Obstructive Pulmonary Disease (COPD). Further review revealed Resident #255 only stayed in the facility for approximately forty (40) hours and was discharged back to the hospital on 08/28/2022. Review of Resident #255's Admission Minimum Data Set (MDS) Assessment, dated 08/28/2022, revealed the facility assessed Resident #255 as requiring a mechanically altered diet while a resident of the facility. Review of Resident #255's Care Plan, dated 08/28/2022, revealed no information about dietary needs. Review of Resident #255's Discharge Summary from the acute care hospital, dated 08/26/2022 at 10:11 AM, listed the resident as requiring honey thickened liquids. Review of the facility's document Order Summary Report revealed the diet order for Resident #255 was dated 08/29/2022, the day after the resident had been sent back to the hospital. Review of the details of this order revealed the Director of Nursing (DON) had entered it on 08/29/2022 at 3:29 PM. Review of the facility's document Dining Services Communication Form, not dated, revealed Licensed Practical Nurse (LPN) #20 checked the box indicating honey thickened liquids for Resident #255. Review of Resident #255's dietary record, not dated, revealed an unknown staff member selected thin liquids from a drop-down box in the system used by the dietary department to generate meal tickets for residents. Review of Resident #255's History and Physical from the acute care hospital, dated 08/29/2022, revealed the resident was diagnosed with Aspiration Pneumonia and treated with antibiotics for his/her 08/28/2022 hospital admission. Review of the Progress Note, from the acute care hospital, dated 09/01/2022, revealed the hospital performed a barium swallow study to check for swallowing difficulty and aspiration and found Resident #255 experienced probable aspiration with thin liquids, but there were no identified issues with thickened liquids. Interview with Resident #255's Resident Representative (RR), on 01/04/2023 at 3:00 PM, revealed the RR witnessed multiple staff members, including Certified Nursing Assistant (CNA) #13 and LPN #20, give Resident #255 thin liquids, even after the RR informed staff the resident required honey thickened liquids to prevent choking. The RR reported CNA #13 stated he gave Resident #255 thin water because that was what previous shifts had done, and no one had told him that Resident #255 needed thickened liquids. Interview with CNA #13, on 01/06/2023 at 2:25 PM, revealed he recalled Resident #255 required thickened liquids and reported witnessing the resident cough after drinking thin water. CNA #13 further stated he recalled seeing cups of thin liquids in the resident's room when he would begin his shift and went to the kitchen to get thickened liquids for Resident #255. CNA #13 stated he primarily relied on shift report to know what a resident's specific dietary needs were because documentation at the facility was inconsistent. Interview with CNA #2, on 01/05/2023 at 2:20 PM, revealed she asked the previous shift about a resident's dietary needs because if a resident was given thin liquids when they needed thickened liquids, he/she could choke. CNA #2 stated she did not work at the facility when Resident #255 was there. Interview with CNA #28, on 01/16/2023 at 7:21 PM, revealed he did not recall Resident #255 specifically. CNA #28 stated he was unsure if special dietary needs were documented in the point-of-care charting system the CNA's used at the facility. He stated he relied upon report from the nurse responsible for the resident and meal tickets on the resident's tray to know if a resident needed thickened liquids. Interview with LPN #20, the nurse who completed Resident #255's admission assessment, was attempted via telephone on 01/06/2023 at 2:12 PM, 01/08/2023 at 2:41 PM, and 01/11/2023 at 10:35 AM, with messages left for a return call. However, LPN #20 made no contact with the State Survey Agency (SSA) Surveyor. Interview with LPN #2, on 01/05/2023 at 2:04 PM, revealed she asked the nurse giving report from the acute care hospital about the dietary needs for a resident being admitted to the facility when she was the receiving nurse. LPN #2 further stated dietary needs were entered in the orders because receiving the correct diet was important to the resident's safety related to aspiration. Further interview revealed LPN #2 was not familiar with Resident #255. Interview with LPN #16, on 01/14/2023 at 5:05 PM, revealed LPN #16 did not recall Resident #255 specifically, but it was her practice to fill out the Dietary Communication Form for a new resident and make sure to pass this information along in report. LPN #16 further stated that because ancillary services such as Speech Therapy were not available on the weekends, it was the responsibility of nursing to make sure safety measures were in place for the residents. Interview with the Certified Dietary Manager (CDM), on 01/12/2023 at 10:20 AM, revealed the CDM did not work in the facility when Resident #255 was admitted , so he could not speak to the process used by previous staff, and the computer system did not log who entered information into the resident's profile. He stated it was currently the CDM's role to enter information from the Dietary Communication Form submitted by nursing into the computer system that generated meal tickets with information including a resident's need for thickened liquids. He stated he reviewed Resident #255's Dietary Communication Form and compared it to the computer print-out. He stated the person who entered the information into Resident #255's dietary profile had made an error, but he did not wish to speculate on how that had occurred. Interview with the Administrator, on 01/17/2023 at 10:30 AM, revealed the previous owner took many of the personnel records, and the facility had limited information on prior employees. Interview with the Speech Language Pathologist (SLP), on 01/05/2023 at 12:52 PM, revealed the facility had no therapy records for Resident #255, indicating the resident had not been evaluated by anyone in the therapy department. The SLP stated the facility did not have coverage for Speech Therapy on the weekend, so if a resident was admitted on a Friday evening, that resident would not be evaluated by Speech Therapy until the following Monday. She stated she expected the resident's diet, prior to her evaluation, to be what the resident received at the previous facility. The SLP stated it was her role to communicate her swallowing evaluation findings to frontline care staff and to the kitchen to ensure the residents received the correct diet on their trays. She also stated she tried to ensure staff did not bring the resident thin liquids if that was inappropriate for that resident. The SLP further stated if a resident needed thickened liquids and received thin liquids instead, the resident would be at high risk for aspiration pneumonia and a resulting overall decline in health status due to the pneumonia. Interview with the Director of Therapy, on 01/05/2023 at 1:45 PM, revealed it was her expectation that everyone from the Therapy Department evaluate a resident as soon as possible on Monday following a weekend admission. She further stated residents came from the hospital with dietary orders that nursing and dietary followed until Speech Therapy could evaluate the resident. She stated if a nurse had concerns about a resident aspirating, this should be communicated with the Physician on-call for the weekend. Interview with LPN #11/South Unit Manager, on 01/10/2023 at 2:43 PM, revealed it was her expectation that if a resident required thickened liquids, the Admitting Nurse would enter the order for thickened liquids in the EMR, fill out the Dietary Communication form, send the form to the kitchen, and notify aides assigned to that resident of the need for thickened liquids. LPN #11 stated the facility stocked thickened liquids in the nourishment rooms, and staff could request thickened liquids from the kitchen if the resident asked for something not premixed. She stated it was her expectation for staff to follow the orders for specialized diets whether or not the resident had been evaluated by Speech Therapy. Interview with the Medical Director, on 01/09/2023 at 3:17 PM, revealed it was his expectation for residents to receive thickened liquids as ordered and for these orders to be communicated in the EMR, the care plan, and in shift report. Further interview revealed it was the facility's process for the Admitting Nurse to enter initial orders based on the discharge summary from the hospital, and the Physician would go behind and cosign the orders. Interview with the Director of Nursing (DON), on 01/13/2023 at 8:44 AM, revealed it was her expectation that the Admitting Nurse enter the initial order set, including if the resident needed thickened liquids and for the Unit Managers to look over the orders and correct them as needed. The DON further stated she did not specifically remember entering Resident #255's diet order, but the date on it suggested she had seen the order had been missed, or entered incorrectly, and she corrected it following the clinical meeting, when she returned to work that Monday, 08/29/2022. The DON could not answer why the order had been entered incorrectly into the dietary system. She stated her oversight was for nursing, who filled out the Dietary Communication Form correctly. Further interview revealed the DON stated this process was important to ensure the residents received appropriate diets to prevent aspiration. Interview with the Administrator, on 01/28/2023 at 1:27 PM, revealed it was her expectation for diet orders to be followed according to the resident's needs. She further stated the orders were checked in the clinical meeting, which occurred each day, Monday through Friday. She stated Unit Managers were expected to check over admission orders for each admission, including admissions that occurred on the weekend.

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 staff provided immediate basic life support, including Cardiopulmonary Resuscitation (CPR) prior to the arrival of emergency medical personnel, as per physician's orders [REDACTED].#5). On [DATE], Resident #5 was readmitted to the facility after hospitalization , and upon re-admission the resident's spouse signed a Rehabilitation Skilled Nursing Center Advance Directive Statement, which stated, in the event the resident experienced a cardiopulmonary arrest, the resident wanted Cardiopulmonary Resuscitation (CPR) performed. On [DATE], per staff interviews and record review, between 11:15 PM and 11:52 PM, staff observed Resident #5 to be unresponsive with absence of respirations and heartbeat. Interview with House Supervisor (HS)/ Licensed Practical Nurse (LPN) #1, revealed upon hearing the resident was unresponsive, she went the nurse's station to check the Advance Directives; however, was unable to locate the resident's chart and went ahead and called 911. While on the phone with 911 dispatch, HS/LPN #1 saw the hospital discharge paperwork for Resident #5 on the nurse's station which had a sticky note on it that said DNR (Do Not Resuscitate), and she canceled the 911 request. There was conflicting staff interviews as to whether CPR had been initiated and stopped during the timeframe of the resident being found unresponsive and HS/LPN #1 finding the sticky note with DNR. Staff interview and record review revealed approximately twelve (12) to twenty (20) minutes later after canceling 911, HS/LPN #1 found Resident #5's chart, turned to the Advance Directives section, saw the resident was Full Code status, and called the 911 dispatcher back to request Emergency Medical Services (EMS). Staff initiated CPR on [DATE] at approximately 12:04 AM. Per record review, Resident #5 was transported to the hospital per EMS where the resident was pronounced dead on [DATE] at 12:36 AM. The facility's failure to have an effective system in place to ensure staff provide immediate basic life support, including Cardiopulmonary Resuscitation (CPR) prior to the arrival of emergency medical personnel, as per physician's orders [REDACTED]. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Advance Directive Policy, revised (MONTH) (YEAR), revealed on admission, the admissions department or designee would notify and provide information to each resident or resident representative, regarding his/her right to make an Advance Directive. Advance Directives were a written method through which a resident or resident's legal representative may provide directions or wishes as to their medical care and were used when a resident was unable to make or communicate his/her decisions about medical treatment. Per Policy, Advance Directives were prepared before any condition or circumstance occurred which might cause the resident to be unable to actively participate in decisions about his/her medical care. Continued review revealed on admission, the resident and/or legal representative should be provided with a copy of the resident's right under state law to accept or refuse treatment and to formulate an Advance Directive. Each resident or resident representative should be asked at the time of admission if he/she has executed an Advance Directive. If the resident or resident representative answers yes, a copy of the Advance Directive should be obtained and placed in the resident's medical record. The resident's physician should be informed of the Advance Directive so that appropriate orders can be obtained in the resident's medical plan of care. Review of the facility's Cardiopulmonary Resuscitation (CPR) and Automatic External Defibrillator (AED) Policy, revised (MONTH) (YEAR), revealed the purpose of the policy was to provide direction for the initiation of CPR Basic Life Support (BLS) and for the use of the AED to treat individuals who experience sudden [MEDICAL CONDITION]. Per Policy, if a resident were to go into cardiac or [MEDICAL CONDITION] arrest, it was the facility's policy to verify code status, call 911, initiate CPR, and follow the instructions of the 911 operator if a resident was determined to be a full code. Further review of the Policy, revealed a licensed and CPR certified associate would perform CPR if a resident did not have known DNR status or physician's orders [REDACTED]. Additional review of the Policy, revealed if an individual (resident, visitor, or associate) were found unresponsive, check breathing briefly to determine if no breathing or no normal breathing as part of a check for [MEDICAL CONDITION] before activating the emergency response system (911) and retrieving the AED. Further review revealed, verify code status of a resident, CPR certified associate would initiate CPR for all residents with a full code, call 911, retrieve AED and emergency cart. Review of Resident #5's medical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Rehabilitation Skilled Nursing Center Advance Directive Statement, signed by the resident's spouse on [DATE], revealed in the event the resident experienced a cardiopulmonary arrest, the resident wanted Cardiopulmonary Resuscitation (CPR) performed. Review of the Progress Note, dated [DATE] at 11:42 PM, signed by Registered Nurse (RN) #2, revealed Resident #5 was found unresponsive by the nurse aide. Per the Note, the nurse could not palpate a pulse and CPR was started and 911 was called. Further review of the Note, revealed the resident was transported to the Hospital and the resident's spouse, Physician, and Administrator were notified. Review of the Situation, Background, Assessment, Recommendation (SBAR), dated [DATE] at 12:38 AM, and not signed by a nurse, revealed Resident #5 was found unresponsive, CPR was started, 911 was called and the resident was transported to the hospital. Interview with RN #2, on [DATE] at 3:19 PM, revealed the SBAR was written by her. Review of the facility's Incident Investigation, completed by the Acting Director of Clinical Services (D[NAME]S), undated, revealed Supporting Documents: Physician/Nurse's Notes were completed; and SBAR/Change of condition was completed. Immediate Action Taken: 911 called and resident transported to the Hospital; Administrator, District Regional Nurse, Responsible Party, Physician, and Coroner were notified. Post Investigation Actions Taken: in-services and associate training provided. Continued review of the Incident Investigation, revealed an interview was conducted with RN #2, which revealed the following sequence of events: Resident #5 was found by State Registered Nurse Aide (SRNA) #1 at approximately 11:25 PM. SRNA #1 came into the hall and called for RN #2, who ran down the hallway and found the resident from the waist down on the bed with his/her upper body toward the ground. LPN #3 called out the resident's name and checked for signs of life. Resident #5 was assisted to the floor for CPR to be performed, when HS/LPN #1 stated the resident was a DNR. CPR was called off and 911 was canceled, then HS/LPN #1 stated the resident was a full code and CPR was initiated. Further review of the Incident Investigation, revealed an interview was conducted with HS/LPN #1, which revealed the following sequence of events: SRNA #1 reported Resident #5 fell . HS/LPN #1 went to check on the resident and the bottom half of his/her body was on the bed. HS/LPN #1 called 911, and then canceled the call when she noticed a document that said DNR. HS/LPN #1 looked in the chart for DNR paperwork and LPN #3 grabbed the crash cart while LPN #1 called 911. EMS came in initially after the call. Additional review of the Incident Investigation, revealed there was no documented evidence of interviews with other staff involved during the incident including LPN #3 and State Registered Nurse Aide (SRNA) #1. Review of the Incident Investigation Timeline, revealed the resident was found unresponsive in his/her room lying with top of body leaning over the left side of the bed at approximately 11:30 PM. CPR was initially stopped due to DNR status on transfer paperwork. Advance Directive Form was found with full code checked, so CPR was initiated and 911 was called. The Timeline did not indicate any other specific times for the events which occurred after the resident was found unresponsive on [DATE]. Review of the 911 audiotape call, revealed HS/LPN #1 called 911 on [DATE] at 11:52 PM to request EMS for a resident who was found unresponsive. While the 911 dispatcher was interviewing HS/LPN #1, she advised the 911 dispatcher the resident had expired and was a DNR and canceled the 911 call. Review of a subsequent 911 audiotape call, revealed HS/LPN #1 called back on [DATE] at 12:04 AM, and stated the resident had no pulse, no respirations, had fallen on his/her head, and was unconscious and bleeding. Further review of this 911 audiotape call, revealed the 911 dispatcher asked HS/LPN #1 if this was the same resident and HS/LPN #1 replied, yes, we need EMS the resident is a full code. Review of Resident #5's Hospital emergency room Note, dated [DATE], revealed the nursing home called medics for a report of a resident found down, then called back and said no code, then called back and said the resident was a full code. Per the Note, the squad went out and found him/her unresponsive, not breathing and asystole (without a heartbeat). Full Advanced Cardiac Life Support (ACLS) was initiated with CPR, intubation, and two (2) rounds of medications with no response. On arrival to the hospital, the resident was noted to have marked cyanosis of the face/head, fixed and dilated pupils, no respiratory efforts, no heart tones or pulse, no response to stimuli, no capillary refill to the digits, and lividity was noted. Per the Note, the Code Blue was called off on [DATE] at 12:36 AM, and Resident #5 was pronounced dead on arrival (DOA). Interview on [DATE] at 3:19 PM, with RN #2, who had been at the facility for three (3) months and was assigned to Resident #5 on the 3:00 PM-11:00 PM shift on [DATE], revealed Resident #5 was admitted on [DATE] and had arrived to the facility sometime just before she came on duty on [DATE] at 3:00 PM. Per interview, the resident's chart was at the desk, and some of it was put together. RN #2 stated she saw Resident #5 around 4:30 PM when she made her first round on the North Hall, and he/she was lying in bed with family present in the room. RN #2 further stated she saw the resident again around 6:45 PM when the resident was up in a wheelchair in the hall around dinner time. Per interview, she saw the resident again around 8:00 PM, and he/she was lying in the bed hollering, and SRNA #1 went in to help the resident put on his/her pajamas. RN #2 stated SRNA #1 taped the resident's call bell to his/her shirt so he/she could reach it when he/she needed assistance. Continued interview with RN #2, revealed she didn't see the resident again until around 11:15 PM, when SRNA #1 came out of the resident's room yelling she needed help. Per interview, RN #2 ran to the resident's room and saw the resident's head, neck and arms were on the floor and the resident's waist and legs were tangled in the oxygen tubing and catheter tubing which was holding the resident's lower body on the bed. RN #2 stated she walked around the bed and saw the resident was blue and she could not palpate a pulse. Per interview, she told SRNA #1 to go get LPN #3. RN #2 stated LPN #3 came into the room and they (RN #2 and LPN #3) started CPR on the resident because they were not sure if the resident was a DNR. RN #2 further stated she wasn't sure of the resident's code status, but she thought she saw a piece of paper on the desk at the beginning of her shift that said the resident was a DNR. RN #2 stated LPN #3 informed her that since she (RN #2) wasn't sure of the resident's code status, they needed to perform CPR on the resident. Further interview with RN #2, revealed HS/LPN #1 called EMS while RN #2 and LPN #3 were performing CPR. RN #2 stated while HS/LPN #1 was on the phone with EMS, HS/LPN #1 saw a piece of paper on the desk that said the resident was a DNR, so CPR was stopped. RN #2 was unsure how long CPR had been performed before it was stopped, and was unaware of the time CPR was stopped. RN #2 further stated she stayed in the room with the resident and HS/LPN #1 went back to the desk to finish getting the chart together and that was when HS/LPN #1 saw the full code papers the resident's spouse had signed when the resident was readmitted . Continued interview revealed HS/LPN #1 then came back to the resident's room, and stated the resident was a full code so she and LPN #3 started CPR again. Per interview, RN #2, did not know how long Resident #5 had been without CPR, before CPR was initiated a second time and EMS was notified the second time. Additional interview revealed Resident #5 never regained a pulse and she was not sure if the resident had a pulse when EMS hooked the resident up to the monitor. Ongoing interview with RN #2, revealed when she reported to work the next day, the Administrator had her document what happened on an SBAR. RN #2 stated she or one of the other nurses should have looked in the resident's chart for the code status before they told the 911 dispatcher the resident was a DNR code status. Interview on [DATE] at 5:40 PM, with SRNA #1, who was assigned to Resident #5, on the 3:00 PM to 11:00 PM shift on [DATE], revealed she saw Resident #5 in his/her room around 3:00 PM after she arrived on duty and went in to help the nurse obtain a weight and vital signs because the resident was a new admission. SRNA #1 stated, around supper time the resident's call light was on and she went in to transfer the resident to the wheelchair so the resident could go to the dining room for dinner. Continued interview with SRNA #1, revealed she saw the resident again around 6:45 PM after dinner because the resident spilled coffee on his/her clothes and she had to take the resident back to his/her room and change his/her clothes. SRNA #1 stated she put pajamas on the resident and made sure the resident had his/her call bell before leaving the resident's room. SRNA #1 further stated around 8:30 PM, the resident's spouse let her know he/she was leaving for the night. Per interview, after the resident's spouse left, she began making her rounds and peeped in on the resident and he/she was sleeping. SRNA #1 stated she saw the resident again around 10:30 PM. Per interview, she did not see the resident again until about 11:15 PM when she peeped in on the resident and saw the resident slumped over the left side of the bed facing away from the door. SRNA #1 stated she walked around the bed and saw the resident's face was on the floor and there was blood on the floor. SRNA #1 further stated the resident was blue and he/she was still connected to the call bell, catheter tubing and the oxygen tubing. Per interview, she hollered for a nurse and told RN #2 to come quick. SRNA #1 stated RN #2 ran down the hall and tried to pick the resident up, but the resident was too heavy. SRNA #1 further stated LPN #3 arrived shortly afterward, came in and stated he/she was probably dead. Per interview, CPR was not initiated at that time. Additional interview with SRNA #1, revealed RN #2 asked what Resident #5's code status was and while HS/LPN #1 was at the desk calling 911, HS/LPN #1 saw a paper on the desk with sticky notes on it that said DNR. Per interview, HS/LPN #1 hollered down the hall to RN #2, that Resident #5 was a DNR, and HS/LPN #1 canceled the 911 call while still on the phone. According to SRNA #1, CPR had never been initiated during the timeframe of the resident being found unresponsive and HS/LPN #1 letting them know the resident was a DNR code status. Continued interview with SRNA #1 revealed after HS/LPN #1 informed RN #2 and LPN #3 the resident was a DNR code status, all the nurse's left the room, and left the resident lying on the floor. Per interview, she was instructed by RN #2 to clean the resident. SRNA #1 further stated, about fifteen (15) or twenty (20) minutes had passed, when HS/LPN #1 got back from her smoke break, went through Resident #5's chart, and identified the resident was a full code. Per interview, HS/LPN #1 told LPN #3 to get the Crash Cart, and HS/LPN #1 called 911 back while LPN #3 and RN #2 entered the resident's room and started CPR. SRNA #1 stated EMS arrived, and Resident #5 was transported to the hospital. SRNA #1 further stated she wrote a statement about the event she had witnessed and put it under the Administrator's door in a sealed envelope before leaving her shift. Further interview with SRNA #1, revealed the nurses should have looked in the resident's chart for the code status and should not have canceled the CPR until they knew for sure the resident's code status. The State Survey Representative attempted to call LPN #3 on [DATE] at 3:45 PM; on [DATE] at 11:12 AM; on [DATE] at 10:00 AM; and on [DATE] at 9:00 AM. However, LPN #3's phone was not set up for messages. The Administrator was informed the State Survey Representative needed to interview LPN #3 on [DATE] at 11:15 AM; however, the nurse did not contact the Surveyor for interview prior to exiting the facility. The State Survey Representative again tried to contact LPN #3 on [DATE] at 9:45 AM, for a post exit interview, and was unable to leave a message for LPN #3. Interview was conducted on [DATE] at 7:20 AM, with HS/LPN #1, who worked the 7:00 PM-7:00 AM shift as the House Supervisor on [DATE]. She stated she had her coat on and was getting ready to leave around 11:50 PM on [DATE], when she heard SRNA #1 yell out for a nurse. HS/LPN #1 further stated when she heard RN #2 yell for LPN #3, she took her coat off to see what was going on. Per interview, when she looked in the door of Resident #5's room she saw the resident with the top half of his/her body on the floor and the bottom half of his/her lower body on the bed. HS/LPN #1 stated she asked if the resident was still breathing and RN #2 said, yes. HS/LPN #1 further stated she went to the nurse's station and while dialing 911, LPN #3 came to the desk and told her the resident was not breathing and had not been breathing for a minute. Per interview, she was looking for the resident's chart to see if the resident was a full code or DNR code status because the resident was a new admission, but could not locate the chart, and did not think to check the computer system for the resident's code status. HS/LPN #1 stated she found Resident #5's admission paperwork with a sticky post it note stating code status DNR so she told the 911 dispatcher the resident was a DNR and was deceased and canceled the 911 call. Further interview with HS/LPN #1, revealed after she hung up the phone, she continued to look for the resident's chart and located it on the desk under another resident's chart. HS/LPN #1 stated when she looked in Resident #5's chart under the Advance Directives Tab she saw the full code papers signed by the spouse on [DATE]. Per interview, she told LPN #3, who was at the desk, the resident was a full code. HS/LPN #1 stated LPN #3 grabbed the Crash cart and HS/LPN #1 grabbed the defibrillator and they ran to the resident's room where RN #2 was still with the resident. HS/LPN #1 further stated she ran back to the nurse's station and called 911 again, then ran back to the resident's room, and she and RN #2 did CPR until EMS arrived. Per interview, Resident #5 was placed on the AED before starting CPR, and the resident never had a heartbeat. HS/LPN #1 stated when EMS arrived and hooked the resident up to the monitor, the resident did not have a heartbeat and the resident was purple. Per interview, she did not complete a Nurse's Notes on [DATE] related to Resident #5. Continued interview with HS/LPN #1, revealed she called and left a message for the Administrator to let her know the events that occurred with Resident #5 that night, but she did not write a statement. She stated she was interviewed by the Acting D[NAME]S the next day related to the incident. When asked to clarify if CPR was initially started when the resident was first found unresponsive, she stated it was not started until she found the full code papers signed by the spouse. She further stated just a few minutes had lapsed from the time the resident was found unresponsive without a heartbeat and respirations, until CPR was started. However, review of the 911 audiotape call, revealed the first call was made at 11:52 PM on [DATE] to request EMS, and then the 911 dispatcher was told the resident had expired, was a DNR, and the 911 call was cancelled. The next 911 call was made at 12:04 AM on [DATE] stating the resident was a full code; a time lapse of approximately twelve (12) minutes. Additional interview with HS/LPN #1, revealed the new Quality Improvement Nurse (QI) started putting Resident #5's admission chart together when the resident arrived at the facility on [DATE], and then handed the chart to her (HS/LPN #1) to finish. Per interview, HS/LPN #1 got busy with another resident which had to be transferred to the hospital, and she did not get a chance to look at Resident #5's chart or finish putting the chart together. She stated, when Resident #5 was found unresponsive on [DATE], she should have moved all the charts on the desk until she found Resident #5's chart because the correct process for verifying code status was to look at the chart under the Advance Directive tab. HS/LPN #1 further stated the chart should have been put together timely and there should not have been discharge hospital paperwork lying out at the nurse's station. Interview on [DATE] at 10:07 AM, with the QI nurse, revealed she had only been at the facility two (2) weeks and was in orientation on the Rehab hall on [DATE], when she was asked if she would assist with putting together Resident #5's admission chart. The QI nurse stated she helped put some of the resident's physician's orders [REDACTED]. Per interview, Resident #5 arrived at the facility around 3:00 PM or 3:30 PM, and she gave report to RN #2 on what she had put into the PCC. The QI Nurse further stated she had put a couple of sticky post it notes on the hospital discharge paperwork about orders that needed to be clarified and things she had dissected out of the history and physical, which she had not inputted into the PCC. Per interview, she put a sticky post it note on the hospital discharge paperwork which stated the DNR needed clarification, and she reported to both RN #2 and HS/LPN #1 that the resident's code status needed to be verified. The QI Nurse stated her last conversation with both nurses was they needed to check the resident's code status. Continued interview revealed she was notified on [DATE] in the morning stand up meeting, Resident #5 was sent out to the hospital and expired, and the Director of Clinical Services (D[NAME]S) and the Administrator were going to start an investigation. Interview on [DATE] at 2:40 PM with the Admission's Assistant (AA), revealed she was responsible for completing the admissions packet paperwork and logging documents into medical records and the business office. The AA stated she went over the admission's packet with the responsible parties/families; completed the initial Face Sheet; obtained the hospital paperwork and verified it with the families; and reviewed the DNR paperwork with the responsible parties/families and had them sign this paperwork. The AA stated after she completed all the paper work she entered the information into PCC and logged it into the Medical Record (MR) at the nurse's station and gave a copy of the information to the Medical Records office and Business office. The AA stated the code status was entered into PCC and finalized by her. The AA further stated when she was done with the paperwork, she reported to the nurse that she was entering the code status into PCC. Further interview with the AA, revealed about a month ago, the process changed and the Admissions staff was told to place the code status paperwork into the resident's hard chart at the nurse's station and report the code status directly to the nurse. Continued interview with the AA, revealed she had completed the admission paperwork for Resident #5 and had discussed the resident's code status with the resident and the resident's spouse and it was the resident's desire to be a full code. Per interview, Resident #5 was alert and oriented and able to verbalize his/her wants and needs. The AA stated she took Resident #5's hospital discharge paperwork and code status paperwork to her office, logged it into PCC, and took the hard copies to the nurse's station, placing the code status paperwork in the plastic sleeve in the Advance Directive section in the hard chart. Further interview revealed she reported Resident #5's code status to the nurse on duty; however, she could not remember which nurse. Interview on [DATE] at 3:00 PM, with the Admission's Coordinator (AC), revealed when Admissions received a referral, Admissions staff verified the resident's insurance, checked the sex offender list, checked demographics and entered the information into the PCC. Per interview, admissions completed the admission packet with the resident and responsible party/family after the resident arrived at the facility and entered it into PCC, uploading all the signed documents. The AC stated they then would give the nursing staff the completed paperwork. The AC further stated they either placed the Face Sheet and code status in the hard chart or would give it directly to the nurse. Per interview, the AC was on vacation on [DATE] and was not aware of everything that happened with Resident #5 until the administrative staff started conducting in-services. Per interview, the admissions department was ultimately responsible for making sure the Advance Directive was in the chart and the nurse was responsible for making sure the chart was complete after admission. Interview was conducted on [DATE] at 3:25 PM, with the Acting Director of Clinical Services (D[NAME]S), who was working at the facility while the new Director of Clinical Services (D[NAME]S) was in training, the week Resident #5 expired. She stated it was her role to help lead the clinical team at the facility; help lead clinical stand-up in the morning; ensure adequate staffing; and, handle anything that came up on a daily basis. Per interview, the nurses involved when Resident #5 was found unresponsive should have looked at the chart to find the resident's code status, as it was located under the Advance Directives Tab of the chart. Additional interview with the Acting D[NAME]S, revealed when she arrived at the facility on [DATE], she helped the Administrator with the investigation. Per interview, she was told SRNA #1 found Resident #5 unresponsive and called for RN #2 who came to the resident's room, while HS/LPN #1 called 911. She further stated it was her understanding, while HS/LPN #1 was on the phone with 911, she saw a note on the desk stating no code so she told 911 not to come. Further interview revealed HS/LPN #1 and RN #2 told her they were not one hundred percent (100%) sure how much time had gone by from the time they said not to code the resident to the time they started CPR, but HS/LPN #1, and RN #2 thought it was only about two (2) minutes. Ongoing interview revealed the nurse's involved should not have looked at the hospital discharge paperwork, but should have looked inside the resident's chart for the code status under the Advance Directive Tab. Per interview, the Acting D[NAME]S stated her only role in the investigation was to interview the nurses, and the Administrator did most of the investigation. Per interview, she only interviewed RN #2 and HS/LPN #1, and did not interview LPN #3 or SRNA #1. Interview on [DATE] at 2:34 PM, with the Director of Clinical Services (D[NAME]S), revealed she was in training in Ohio during the week Resident #5 expired and was made aware of the incident after she returned to the facility. The D[NAME]S stated she did not assist with the investigation and the investigation was completed by the Administrator. Per interview, her role was to educate staff on the proper procedure to verify code status. Continued interview revealed for new admissions or re-admissions nursing staff was to complete the admission paperwork as soon as possible after the resident arrived to the facility, enter the information into PCC and file the code status paperwork into the resident's chart under the Advance Directives tab. Further interview revealed the nurse's should have looked in Resident #5's chart to verify the resident's Advance Directive when the resident was first found unresponsive, before calling 911 the first time. Interview, on [DATE] at 4:50 PM, with Resident #5's Attending Physician (AP), revealed he spoke with HS/LPN #1 after Resident #5 died and was informed she had interpreted the resident's chart as saying the resident was a DNR when the resident was actually a full code. Continued interview with the AP, revealed in the event a nurse found a resident unresponsive, he expected the nurse to get the code status information from the resident's chart before initiating CPR or before making a decision not to perform CPR due to the resident having a DNR order in place. Further interview revealed he expected CPR to be initiated in timely manner because the longer the delay the less likely CPR would be successful. Per interview, he expected the resident's choices to be honored in regards to code status. Interview on [DATE] at 3:00 PM, with the Administrator, revealed she was notified on [DATE], Resident #5 was found unresponsive and HS/LPN #1 called 911. Per interview HS/LPN #1 then looked at a note on the desk that said the resident was a DNR code status, so 911 was canceled. Per interview, HS/LPN #1 later found the resident's chart with the full code paperwork in it, so HS/LPN #1 called 911 back. She stated it was her understanding CPR was only delayed for about two (2) minutes during this incident, and she was unaware of the time lapse between calls to the 911 dispatch. She stated she did not remember receiving a Statement from SRNA #1. Per interview, the nurses failed to verify the resident's code status by looking for the signed Advanced Directive paperwork in Resident #5's chart and that failure lead to the resident not having CPR initiated in a timely manner. She stated it was her expectation that staff follow facility's policy related to Advance Directives and CPR. The Administrator further stated Resident #5 had an Advance Directive on admission, and the resident's wishes should have been honored by the facility and the staff. The facility provided an accept (TRUNCATED)

Based on interview, record review, and review of the facility's policy and the Employee Handbook, it was determined the facility failed to have an effective system to ensure the personal privacy and confidentiality for two (2) of twenty-eight (28) sampled residents (Resident #1 and #11). On 08/16/16, between 8:00 PM and 11:00 PM, three (3) Certified Nursing Assistance (CNAs) were providing care to Resident #1 in the resident's room. During this care, the resident was videotaped by CNA #6. The CNA posted the video of the resident's exposed upper body and recognizable face on the Internet through a social media website. (Refer to F223) In addition, observation of a skin assessment for Resident #11 on 09/14/16, revealed the nurse failed to close the window blinds before initiating the skin assessment. Also, observations on the Rehabilitation Unit, on 09/13/16 and 09/14/16, revealed confidential and clinical information was displayed on a computer screen on top of the medication cart located on the resident hall. The information was accessible to read, as the cart was left unattended. The facility's failure to have an effective system in place to ensure privacy and confidentiality was protected for each resident, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/08/16 and determined to exist on 08/16/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/14/16 with the facility alleging removal of the Immediate Jeopardy on 09/14/16. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/14/16, prior to exit on 09/23/16, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Interview with the Regional Director of Care Services, on 09/09/16 at 9:57 PM, revealed the facility did not have a specific written policy related to residents' personal privacy and confidentiality. He stated the facility provided guidance to staff regarding expected conduct, including restrictions to behaviors which compromised resident privacy and confidentiality. Review of the section of the Employee Handbook, titled More Than A Company - A Calling, dated May 2013, provided to staff upon hire, revealed the use of cell phones or cameras to produce electronic images, and the use of tape recording/listening devices, was strictly prohibited, in order to ensure the privacy of the residents, visitors and associates. Review of the facility's Long Term Care Facility Self-Reported Incident Form, signed by the Administrator on 08/23/16, revealed a former employee (FE) came to the facility on [DATE] at 9:00 AM and reported she had seen inappropriate photos of Resident #1 on a social media website. Continued review of the facility's investigative findings revealed although the resident's face was visible in the images, the staff's faces were not shown; however, the facility was able to identify CNAs #1, #2 and #6 as being present in the resident's room at the time of the incident. The facility was able to confirm CNA #6 recorded care of Resident #1 while CNAs #1 and #2 were present. Review of three (3) photocopied pictures of Resident #1 revealed the first picture showed the side of Resident #1, who was facing a staff member in front of him/her, away from the camera. The resident's bare chest, leg, and face were apparent. Across the lower portion of the photo was a typed caption, What we deal with every [***] ing day. In the upper left corner of the picture a name (later determined to be CNA #6), and 9h ago appeared, indicating the post occurred nine (9) hours earlier. The second photo showed the hand of a staff member placing a gown or shirt on the resident, and the resident appeared to be moving away or perhaps resistant to the act. In the third photo, the resident was dressed in a gown. No staff were identifiable in the pictures. All three (3) photos included CNA #6's name, 9h ago, and the caption, What we deal with every [***] ing day. Interview with Resident #1's spouse, on 09/08/16 at 3:24 PM, revealed knowing the resident was exposed and videotaped during care was very upsetting. Continued interview revealed Resident #1, even in his/her present cognitive state, would have found the incident disturbing, and would be upset if aware of the incident. Review of Resident #'1 medical record revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of three (3), which was indicative of severe cognitive impairment. Interview with CNA #1, on 09/07/16, at 10:30 AM, revealed she was in Resident #1's room with CNAs #2 and #6. She stated CNA #2 was assisting her with dressing the resident. She further stated they had gotten the resident's clothes off without difficulty, but when they attempted to redress the resident in a gown, the resident kept pulling the gown up over his/her head. Continued interview revealed CNA #1 heard CNA #2 say to CNA #6, are you recording? what are you doing?, but CNA #6 did not respond. CNA #1 stated it was a violation of the resident's privacy and dignity because the resident was exposed and was not aware that a video was made. Interview with CNA #2, on 09/07/16 at 11:10 AM, revealed Resident #1 was in the wheelchair while she and CNA #1 attempted to change the resident's clothes and the resident kept pulling the gown over his/her head, exposing the upper body. Continued interview revealed CNA #2 did not know CNA #6 was recording the incident. Further interview revealed videotaping the resident was a violation of the resident's privacy and dignity. CNA #2 added she was informed, during the facility's investigation of the incident, the resident was naked in the photos, which were posted on the social media site for approximately twenty-four (24) hours. She further added it was degrading to the resident. Interview with CNA #6, on 09/07/16 at 4:59 PM, revealed while CNAs #1 and #2 were dressing Resident #1, she videotaped the resident with her cell phone. CNA #6 stated she made a video of the whole resident, and acknowledged the resident was not dressed during portions of the video. Further interview with CNA #6 she was aware of the facility's policy which prohibited the use of cell phones in resident care areas, and did sign that she knew and understood the policy. Continued interview with CNA #6 revealed she should not have sent the video through social media, adding, the fact I took a video of the resident invaded her privacy. Review of Associate Handbook Receipt and Acknowledgement forms revealed CNAs #1, #2 and #6 signed the acknowledgement in January 2016, indicating they would abide by the policies outlined in the handbook. Interview with the Director of Nursing (DON), on 09/08/16 at 9:12 PM, revealed she had seen the three (3) pictures of Resident #1. She stated it was clear the resident was not wearing any clothing in one of the pictures. Continued interview revealed it was a violation of the resident's privacy because the resident was not clothed, there was no consent from the Power of Attorney, and it was posted on a social media site. Interview with the Regional Director of Care Services, on 09/08/16 at 9:57 PM, revealed he viewed the three (3) pictures of Resident #1. He acknowledged the incident was a violation of the resident's dignity and privacy. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed that in viewing the pictures, she saw the resident in different stages of being undressed. She stated CNAs #1, #2 and #6 violated Resident #1's privacy and did not treat the resident with dignity, but believed the resident was not aware of the concern because of his/her cognitive status. 2. Review of the facility Kentucky Resident Rights issued June 2013, revealed each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and care of his personal needs. Review of Resident #11's medical record revealed the facility admitted to the North Unit on 08/24/16 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) score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Observation of a skin assessment on 09/14/16 at 3:25 PM, revealed Licensed Practical Nurse (LPN) #15 failed to close the blinds to the window facing the courtyard which was right beside the resident ' s bed prior to initiating a skin assessment. Interview with LPN #15 on 09/14/16 at 4:25 PM, revealed she realized after the skin assessment she had forgotten to close the blinds and this would have been important for the resident ' s privacy and dignity. Interview on 09/23/16 at 9:24 AM with the Director of Nursing, revealed blinds should be closed before patient care for privacy and dignity reasons. Interview on 09/23/16 at 4:00 PM with the Administrator, revealed blinds should be closed for privacy before beginning a skin assessment. 3. Review of the facility's policy titled Safeguarding of Protected Health Information (PHI), dated 02/25/10, revealed when in use, active resident records, including medication and treatment administration records, report sheets and other documents containing PHI should not be left unsecured or unattended, or left in areas where residents, visitors, or unauthorized individuals could easily view the records. Observation, on 09/08/16 at 7:39 PM, revealed a computer displaying clinical information was located on top of the medication cart on the Rehab Unit and had been left unsecured and unattended by authorized personnel. PHI was visible to others in the area. Further observation revealed the computer was left unattended for eleven (11) minutes before the nurse returned and noticed she had left it unsecured and visible. Interview with Licensed Practical Nurse (LPN) # 9, on 09/08/16 at 7:50 PM, revealed she had left the computer unattended to assist a resident in a nearby room. Continued interview revealed she was responsible for the medication cart and the computer, and should have logged out of the computer prior to assisting the resident. LPN #9 further stated leaving the computer open, unattended, and visible was a breach of confidentiality issue. Observation, on 09/14/16 at 8:30 AM, revealed the computer located on top of the medication cart on the Rehab Unit had been left open and was unattended by authorized personnel. Further observation revealed the computer had been left unattended for six (6) minutes before the Minimum Data Set (MDS) Coordinator walked over and closed the top of the computer. Interview with the MDS Coordinator, on 09/14/16 at 8:36 AM, revealed the computer should not have been left open and unattended, and the nurse responsible for passing medications should have logged out of the screen before walking away. Interview with LPN# 10, on 09/14/16 at 8:40 AM, revealed she was responsible for the computer located on top of the medication cart and should have logged out of the computer before leaving it unattended. Interview with the Director of Nursing (DON), on 09/08/16 at 8:34 PM, revealed computers located on top of the medication carts should be locked when unattended by nursing staff. Further interview revealed it was her expectation that all authorized staff follow the facility's policy regarding confidentiality and PHI. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed it was her expectation the nursing staff follow the facility's policy and keep PHI confidential and secure at all times. The facility provided an acceptable credible allegation of compliance (AOC) on 09/14/16 that alleged removal of the Immediate Jeopardy (IJ) effective 09/14/16. Review of the AOC revealed the facility implemented the following: 1. On 08/08/16, the facility identified three (3) associates who participated in the event regarding Resident #1. They were immediately suspended, not to return to work pending investigation by the Administrator and Director of Clinical Services (DCS). 2. On 08/18/16, a Success Plan was initiated by the Interdisciplinary Team. The plan outlined actions taken by the facility to protect the residents, with all measures noted on the Success Plan to be completed on or before 08/24/16. 3. On 08/18/16 and 08/19/16, the SSC provided counseling to Resident #1 with weekly follow-up to be provided as needed for the next three (3) weeks. 4. On 08/23/16, a training session was provided by the QI nurse to the following: Administrator, DON, ADON, Unit Managers, Admission Assistant; Minimum Data Set (MDS) nurses, Dining Service Manager (DSM), Rehabilitation Manager (RM), SSCs, Staff Development Coordinator (SDC), evening and night shift supervisors, Activity Assistant, Housekeeping (HK) Supervisor, Certified Dietary Manager (CDM), Admission Coordinator (AC), and Resident Program Manager (RPM). The training by the QI nurse to the managers was to ensure no cell phones were in use in resident care areas, and included education on daily rounds to be completed each day by the managers on duty. 5. On 08/23/16, SSC #1 and SSC #2 interviewed fifty (50) residents with a BIMS score of eight (8) or above regarding being treated with dignity and respect. (A BIMS score of 8 or above indicates the resident is considered no more than mild to moderately cognitively impaired, and therefore interviewable.) 6. All staff were re-educated on or before 08/24/16. The QI nurse and SSCs #1, and #2 provided the re-education for all staff regarding the Health Insurance Portability and Accountability Act (HIPAA), abuse, dignity, and privacy. In addition, the education emphasized a prohibition of cell phone use by staff in resident/work areas, with violation to result in corrective action up to and including termination of employment. 7. On 08/25/16, six (6) skin assessments were reviewed for residents with BIMS score of seven (7) or below, who lived on the same hall as Resident #1. The Unit Manager and/or the DON reviewed the skin assessments in order to identify any suspicious areas of concern. 8. On 09/09/16, a training session was provided in the facility by the Regional Director of Care Services to educate the QA nurse, DON, Unit Managers, ADON, Medical Records Director (MRD), Central Supply Clerk (CSC), Health Care Liaison (HCL), and MDS Nurses. The Administrator was not present in the facility; however, was present by speaker phone. The training topics included the facility's Immediate Jeopardy (IJ), corrective actions, signing of acknowledgement of the facility's cell phone practice, QI rounds, abuse and dignity. 9. On 09/9/16 through 09/13/16 employees received training to reiterate the prohibiting of cells phones in resident care areas. 10. The facility documented 210 of 214 employees were educated on cell phone use, dignity, abuse and HIPAA as of 09/13/16. 11. Beginning on 08/23/16, the QA nurse and/or Administrator will review the daily audits five (5) days a week for two (2) weeks, then bi-weekly for four (4) weeks. In addition, the Administrator will review ongoing education and sign-in sheets to ensure education is completed for each employee, including agency staff and new hires, prior to them working in resident areas. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's final investigative report, dated 08/23/16, revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present during the recording. Continued review of the report revealed the three (3) CNAs were terminated from employment. Interviews with the QA Nurse, the DON, and the Administrator on 09/15/16 revealed the CNAs were suspended at the beginning of the investigation, and ultimately terminated from employment by the facility. Review of the Corrective Action form dated 08/23/16, signed by the Administrator and witnessed by the Human Resources Director, revealed the Administrator spoke with CNA #1, CNA #2 and CNA #6 by phone, and informed them due to their knowing participation in a violation of the facility's policy related to social media, the decision had been made to terminate their employment, effective immediately. 2. Review of the Community Success Plan, dated 08/18/16, revealed the facility's Plan of Action/Correction included re-education by Department Managers of all staff related to HIPAA, abuse, dignity, privacy, and cell phone use beginning on 08/18/16, to be completed by 08/24/16. Continued review of the Success Plan revealed SSCs were assigned to provide patient counseling for Resident #1 on 08/18/16 and 08/19/16. In addition, they were to interview all alert and oriented residents in the building regarding being treated with dignity and respect on 08/23/16. Further review of the Success Plan revealed skin assessments to identify any suspicious areas were to be completed by the Unit Managers (LPN #3, LPN #7 and RN #5) for all confused residents on 08/19/16. Additionally, the QI nurse would re-educate all Department Managers regarding daily rounds to be performed during their shifts, throughout the buildings, for six (6) weeks beginning 08/23/16. 3. Review of the SSC Progress Notes, dated 08/18/16, revealed SSC #2 spoke with Resident #1 to discuss the events of 08/16/16 and identify any resident concerns. Continued review of the note revealed Resident #1 did not recall the incident and expressed no concerns. Additional review of SSC Progress Notes revealed follow-up interviews dated 08/19/16, 08/25/16, 08/30/16, and 09/02/16 continued to reveal no resident concerns. Additionally, on 09/06/16, SSC #2 discussed discharge plains with Resident #1's spouse, who made the decision to take Resident #1 home. Interview with SSC #2, on 09/15/16 at 4:27 PM, validated Resident #1 did not recall the incident and was discharged to home. Review of the Training Session Attendance form dated 08/23/16, titled Supervisor Daily Rounds , revealed the following attendee signatures: Administrator, DON, ADON, Unit Managers (LPN #3, LPN#7, and RN #5), Admissions Assistant, MDS nurses, DSM, RM, SSC, SDC, evening and night shift supervisor, Activity Assistant, HK Supervisor, CDM, AC, and RPM. Interviews on 09/15/16 with Activity Assistant #1 at 1:46 PM; Activity Assistant #2 at 2:01 PM, RM at 3:40 PM, SSC #2 at 4:27 PM, and SSC #1 at 6:16 PM, revealed they received training regarding abuse, cell phone use, and treating residents with dignity and respect. Each manager was able to discuss the training topics and explain the daily QI rounds they were responsible for. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated she was responsible for documenting the QI rounds conducted by the managers. She provided the QI audit sheet titled QI Team Rounds . Review of the audit revealed the daily rounds included environmental observation to ensure all resident areas were free of cell phones, residents ' state of dress and grooming, and the following questions: How are you today?; Are associates taking good care of you?; and Do you have any questions regarding your care? 4. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated the Success Plan was created to ensure all employees were held responsible for following the cell phone policy and to continue to monitor resident care areas. Continued interview revealed the Department Managers were re-educated on conducting daily rounds to ensure the staff was compliant with the facility ' s policy on cell phones, and providing dignity and privacy to all residents. She stated the facility's expectation was there would be no tolerance for failure to comply with the cell phone policy. Continued interview revealed a first offense would earn a written warning, and a second offense termination. 5. Review of the report sheets provided by the facility validated fifty (50) residents were interviewed regarding concerns related to dignity and respect. According to the reports, none of the residents expressed concerns. Interview with SSCs #1 on 09/15/16 at 5:16 PM, and SSC #2 on 09/15/16 at 4:27 PM, validated they conducted the interviews. They stated none of the residents expressed concerns related to dignity and respect. Observations on 09/13/16 beginning at 10:45 AM, revealed no concerns related to staff interactions with residents on the 200 hall. No failure to treat residents with dignity and respect was identified, and privacy was maintained during the provision of care. In addition, no staff was observed to be using cell phones in the resident care areas. Interviews with Resident #14 on 09/13/16 at 11:45 AM, and Resident #6 on 09/13/16 at 1:25 PM, revealed they denied any mistreatment by staff, and felt they were treated with respect. Continued interview revealed neither resident recalled seeing staff use cell phones in their rooms during care. 6. Review of the training packet which included information on cameras and tape recording, media inquiries, confidentiality of information, telephone use, HIPAA, abuse, dignity, and phones revealed the training was completed for all staff on 08/22/16, 08/23/16 and 08/24/16. Completed questionnaires related to the training, signed and dated by staff, were included in the packet. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the training and completed the questionnaire. In addition, the interviewed staff was able to discuss the training topics and exhibited an understanding of related facility policy. 7. Review of the Weekly Skin Integrity Review forms confirmed six (6) residents received skin assessments on 08/25/16, conducted by the DON, and Unit Managers (LPN# 3, LPN# 7 and RN #5). Continued review revealed no new skin issues were identified. Interview with the DON, on 09/15/16 at 6:25 PM, revealed the skin assessments were completed as documented, and no new skin concerns were identified. Continued interview with the DON revealed she assisted the unit managers with skin assessments on residents with a BIMS score of seven (7) and below, which indicated they were not interviewable. 8. Review of the training session attendance sheet dated 09/09/16 and titled Education Procedure on IJ, Corrective Action, Acknowledgement, QA Rounds, Abuse and Dignity, revealed training was provided by the Regional Director of Operations. Attendees included the QI Nurse, DON, Unit Managers, ADON, MRD, MDS Nurse, and the Administrator on speaker phone. Interviews on 09/15/16 with the QI Nurse at 5:51 PM, the DON at 6:25 PM, and the Administrator at 6:28 PM, revealed they were present for the training by the Regional Director of Care Services, and topics included the IJ, the facility's prohibition of staff having cell phones in the resident care areas, and signing an acknowledgment of understanding of facility policy. 9. Review of training sheets provided by the QI nurse on 09/15/16 revealed all staff received additional training on the prohibited use of cell phones in the resident care areas between 09/09/16 and 09/13/16. This training including the requirement for staff to sign their acknowledgement and understanding of the facility ' s policies related to cell phone use. Review of the signed acknowledgement forms revealed staff from all departments received the training and understood the facility ' s prohibition of using cell phones in resident care areas. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the additional education regarding no cell phone use in the facility, and were able to discuss the intent of the training and the consequences of failure to adhere to facility guidelines, up to and including termination of employment. 10. Review of the Employee Roster, dated 09/09/16, revealed 210 of 214 facility employees received mandatory training as part of the facility's corrective action prior to 09/14/16. Continued review of the roster revealed four (4) employees had not received the training provided by the facility. Review of sign-in sheets, completed questionnaires, and signed acknowledgement forms revealed they were consistent with the Employee Roster tracking form. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, revealed she had ensured 210 employees received the mandatory training prior to 09/14/16, and the remaining four (4) employees would not be able to work until the education was completed. She stated one (1) of the four (4) was in Africa, one (1) was on medical leave, one (1) was a new employee and had not yet started, and one (1) only worked PRN (as needed). Continued interview with the QI Nurse revealed all new employees received a handbook upon hire that addressed cell phone use in the facility. Additional interview with the QI nurse revealed it was her responsibility to ensure all employees received the training regarding cell phones, abuse, dignity, and HIPAA and would not be able to return to the facility until training is completed. 11. Review of the Administration Review of Daily QI Rounds revealed the QI Nurse audits were completed on 08/23/16, 08/24/16, 08/25/16, 08/26/16, 08/29/16, 08/30/16, 08/31/16, 09/01/16, 09/02/16, 09/06/16, 09/07/16, 09/08/16, 09/09/16, 09/10/16, 09/11/16, 09/12/16, 09/13/16, 09/14/16, and 09/15/16. Interview with the QI nurse, on 09/15/16 at 5:51 PM, revealed she signed off on the audits along with the Administrator, and was responsible for ensuring the audits continued to be completed. Interview with the Administrator, on 09/15/16 at 6:28 PM, revealed it was her responsibility to monitor all audits and see they were forwarded to the QI community, to ensure continued monitoring of cell phone use only outside of resident care areas, and for dignity and privacy to be upheld in the facility.

Based on interview, record review, and review of the facility's policy and the Employee Handbook, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse, for one (1) of twenty-eight (28) sampled residents (Resident #1). On 08/16/16, between 8:00 PM and 11:00 PM, three (3) Certified Nursing Assistance (CNAs) were providing care to Resident #1 in his/her room. During the provision of care, CNA #6 videotaped Resident #1's naked body, and posted the video on a social media Internet site. The facility was notified of the incident on 08/18/16, when a former employee (FE) reported seeing the images of Resident #1 to the facility. Interview with CNA #6 revealed she videotaped Resident #1 during Activities of Daily Living (ADL) care, and sent the video to FE #2 through the social media site. She acknowledged the video of Resident #1 included footage of the resident raising his/her gown during the ADL care, which exposed the resident's entire body. CNA #6 revealed she knew it was wrong and abusive towards the resident. She stated she wanted to capture the goofy side of the resident during care. Interview with FE #2 revealed the video was not sent to her but was posted on CNA #6's social media account for all of her friends to view for a twenty-four (24) hour period and FE #1 reported the incident to the facility. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/08/16, and determined to exist on 08/16/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/14/16 with the facility alleging removal of the Immediate Jeopardy on 09/14/16. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/14/16, prior to exit on 09/23/16, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation Policy, revised 08/2016, revealed instances or allegations of abuse, neglect or exploitation would be treated seriously and were to be reported to the Administrator or the supervisor on duty for investigation and appropriate follow-up. Continued review of the policy revealed mental abuse was defined, but not limited to humiliation, harassment, threats of punishment, withholding of treatment or services, or taking or using photographs or recordings in any manner that would demean or humiliate a resident. This would include using any type of equipment (e.g. cameras, smart phones, and other electronic devices) to take, keep, or distribute such photographs and recordings on social media. Review of the Employee Handbook titled More Than A Company - A Calling, dated May 2013, revealed associates were not to take or place personal telephone calls while working, unless they had management's approval or it was an emergency. The use of personal cellular phones (including text messaging), pagers or other electronic devices during working time and in work areas was prohibited, except in emergency circumstances. Continued review revealed the use of cell phones or cameras to produce electronic images (photographs) and the use of tape recording/listening devices was strictly prohibited to ensure the privacy of residents, visitors and associates. Further review of the policy revealed abuse of the guidelines would result in corrective action, up to and including termination of employment. Review of the facility's Long Term Care Facility-Self Reported Incident Form, signed and dated by the Administrator on 08/23/16, revealed the incident was reported to the facility on [DATE], by FE #1, who came to the facility at 9:00 AM to report inappropriate photos she had seen on social media. Continued review revealed no faces were visible other than the resident's; however, based upon clues in the photo, the facility identified three (3) possible suspects, CNAs #1, #2, and #6. Further review revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present. The facility provided three (3) photocopied pictures of Resident #1 that were presented in black and white. Review revealed the first picture showed the side of Resident #1, who was facing a staff member in front of him/her, away from the camera. The resident's bare chest, leg, and face were apparent. The doors within the room in which the photo was taken were closed. Across the lower portion of the photo was a typed caption, What we deal with every [***] ing day. In the upper left corner of the picture a name (later determined to be CNA #6), and 9h ago appeared, indicating the post occurred nine (9) hours earlier. The second photo showed the hand of a staff member placing a gown or shirt on the resident, and the resident appeared to be moving away to the act. In the third photo, the resident was dressed in a gown. No staff were identifiable in the pictures. All three (3) photos included CNA #6's name, 9h ago, and the caption, What we deal with every [***] ing day. Review of CNA #1's statement, dated 08/18/16 at 4:30 PM, revealed she and CNA #6 were in Resident #1's room providing care. She stated CNA #6 really wasn't helping, so she asked CNA #2 to help. Per the statement, CNA #1 and CNA #2 put a gown on Resident #1, who ripped it off. CNA #1 stated they were able to get the gown on the resident on the second attempt. Furthermore, CNA #1 reported CNA #6 was sitting in the chair during the care of Resident #1. She stated she heard CNA #2 say recording, but did not know what she meant. Continued review of CNA #1's statement revealed she felt stuck between saying something, and her friends. Interview with CNA #1, on 09/07/16 at 10:30 AM, revealed the incident occurred on 08/16/16 sometime near the end of her shift which ended at 11:00 PM. She stated she was in Resident #1's room with CNA #2 and CNA #6. CNA #1 stated CNA #2 was assisting her with dressing Resident #1. CNA #1 revealed she and CNA #2 had gotten the resident's clothes off okay, but when they attempted to put on the resident's gown, the resident kept taking the gown off over his/her head. CNA #1 stated CNA #2 assisted her with putting the resident's gown back on and they transferred the resident from the wheelchair into the recliner chair. CNA #1 stated CNA #6 did not help, and she was not aware of what CNA #6 was doing behind her. She added CNA #6 was standing behind her and CNA #2 was facing CNA #6; therefore, CNA #2 was able to view what CNA #6 was doing. Additionally, she reported she heard CNA #2 state, Are you recording, what were you doing? CNA #1 revealed CNA #6 did not say what she was doing. Continued interview revealed CNA #1 would have reported the incident had she known what CNA #6 was doing. She further stated it was a violation of the resident's privacy and dignity because the resident was not aware he/she was being videoed. CNA #1 stated the incident was a form of abuse, and should not have been posted on social media. Review of CNA #2's statement, dated 08/18/16, revealed CNA #1 and CNA #6 asked CNA #2 to help transfer the resident into his/her chair. CNA #2 revealed the resident fought and cussed at them and ripped his/her gown off. She stated they laughed and she got the resident's gown on. CNA #2, per her statement, revealed CNA #6 took a video and it shocked her. She stated she did not take it seriously and asked, are you on Snapchat (Snapchat is an image messaging mobile phone application which allows users to share images using their smart cell phones.) or what?, and CNA #6 responded, yeah. Continued review of the statement revealed CNA #2 was mainly interested in helping Resident #1. She stated she was notified about the video being on social media by CNA #1, who called her to tell her the facility wanted to discuss the incident related to Resident #1. CNA #2 stated she had not seen the video. Interview with CNA #2, on 09/07/16 at 11:10 AM, revealed her normal shift was from 11:00 AM to 7:00 PM, but she was filling in on the 3:00 PM to 11:00 PM schedule the evening of Monday or Tuesday, but could not be sure of the exact day. (Review of the facility's staffing schedule revealed CNA #2 worked the 3:00 PM to 11:00 PM shift on Tuesday, 08/16/16.) Continued interview with CNA #2 revealed the incident involving Resident #1 occurred between 10:00 PM and 10:30 PM. She reported CNA #1 asked her to assist with Resident #1 because the resident was being combative. CNA #2 further reported when she entered the resident's room, the resident was seated in the wheelchair, CNA #1 was standing to the left of the resident and CNA #6 was standing to the right. Continued interview with CNA #2 revealed she and CNA #1 got the resident's clothes off and attempted to dress the resident in a gown, but the resident took the gown off. She further stated she would not have expected CNA #6 would post a video of a resident on the Internet. She further stated she would have reported the incident if she had known CNA #6 posted the video, but when she asked CNA #6 what she was doing, she did not state exactly what she was doing on her phone. However, per CNA #2's written statement she was aware CNA #6 was on Snapchat. Continued interview with CNA #2 revealed she was later told by CNA #6 that FE #2 took three (3) screen shots from the video and sent them to the facility's Administrator. CNA #2 stated the incident violated Resident #1's privacy and dignity. She further stated she had not seen the video, but was told the resident was naked, and the video was posted on social media for approximately twenty-four (24) hours for the whole world to see. CNA #2 revealed it was abuse, adding it was sexual abuse because the image of him/her should not have been posted on social media, and it would be mental abuse if the resident was aware of it. CNA #2 revealed she felt bad about it and should have reported that CNA #6 had her phone out during resident care. Review of CNA #6's written statement, dated 08/18/16, revealed she, along with CNAs #1 and #2, had taken a picture of Resident #1. She stated it was like a selfie. She further stated all four (4) of them, including the resident, took a picture and she sent it to FE #2 privately. CNA #6 stated the resident's face was cute and she wanted FE #2 to see it. CNA #6 revealed, per her statement, that CNAs #1 and #2 were aware she took the pictures. Further review revealed the resident pulled off his/her gown, but was covered. She added she did not type anything in the picture and did not think it was wrong until she was called in. Interview with CNA #6, on 09/07/16 at 4:59 PM, revealed the incident occurred on 08/16/16 between 8:00 PM and 9:00 PM. She stated CNA #1 and CNA #2 were in Resident #1's room and were attempting to put the resident to bed. She stated CNA #1 and CNA #2 were dressing the resident, and she (CNA #6) videotaped the resident while the CNAs were providing care. She further stated she took a video of the whole resident, acknowledging the resident did not have on his/her gown during portions of the video. CNA #6 stated she took the video because the resident was being goofy, and was poking CNA #1 in the stomach as the resident continued to remove the gown over his/her head. Further interview revealed CNA #6 sent the video to FE #2 through social media, adding that since the former employee was also an aide, she did not feel that bad about sending the video to her. Continued interview revealed CNA #6, after looking back over the incident, now felt bad. She stated, I don't always make the best choices. CNA #6 revealed FE #2 later sent a screen shot of the video to the facility. She further stated she did not see it as abuse before she made the video and posted it on social media, but in reference to the caption typed on the photo, she now recognized it as mental/emotional abuse of Resident #1. Additionally she stated, she did not treat the resident with dignity, and the fact she took the video invaded the resident's privacy. Interview with FE #2, on 09/10/16 at 5:30 PM, revealed she saw the video of Resident #1 approximately three (3) weeks ago, the week of 08/16/16, sometime in the morning about 3:00 AM. She stated the video was not sent to her, but she and FE #1 saw the video posted on CNA #6's social media site for all the world to see. She further stated the video showed the resident's face and upper body. She reported, it was clear the resident was naked. Continued interview revealed the staff in the background was laughing at the resident and the resident was cussing out the staff. FE #2 stated she took a screen shot from the video as evidence and FE #1 reported the incident to the facility. Further interview revealed the video tape was mean because the resident had dementia. Additionally, FE #2 felt the incident was mental abuse because of staff mocking the resident, and the whole thing was a violation of the resident's rights and privacy. Review of FE #1's statement sent to the facility via social media, undated, revealed she was not sure if the facility remembered her from previously working at the facility, but wanted to bring some pictures she saw on social media to the facility's attention. She stated the pictures included a resident with partial nudity. She revealed, per her statement, she knew as a CNA she was required to report abuse and that was why she brought the photos to the facility's attention. Interview with FE #1, on 09/08/16 at 7:13 PM, revealed she saw the photos of Resident #1 when scrolling through her timeline on social media, on 08/18/16 at approximately 12:30 or 1:00 AM. She stated she thought it was one of the ladies she cared for when she previously worked at the facility and she sent the pictures to Social Worker #2. Continued interview revealed when her shift ended, she drove to the facility to bring the pictures to the facility's attention. Further interview revealed it was apparent from the still pictures, two (2) aides were attempting to put on Resident #1's gown, and one (1) person was taking the picture. Additionally, she stated that in one of the pictures, the resident's chest was exposed. She stated the picture was very inappropriate and the face of the resident could be seen. Subsequent interview with FE #1, on 09/11/16 at 8:30 PM, revealed she never saw the video of Resident #1, only the screen shots taken from the video. She stated FE #2 told her about the video, and stated she had pictures of the video but did not know what to do with them. Further interview revealed she knew the incident had to be reported but FE #2 was afraid, so FE #1 told FE #2 to send her the pictures through a private site and she would ensure the facility was notified of the incident. Interview with Licensed Practical Nurse (LPN) #17, on 09/22/16 at 6:39 AM, revealed she was informed about the alleged incident on 08/18/16, sometime in the morning. She stated someone called from outside the facility and stated they wanted to speak with the Social Worker, and she informed the caller the Social Worker was not in. LPN #17 stated she was told by the caller that inappropriate pictures were taken of Resident #1 and posted on social media and the caller had sent a private message to the Social Worker to report the pictures. LPN #17 stated she thought it was abuse and an invasion of the resident's privacy, so she texted the information to the Assistant Director of Nursing (ADON). Interview with the ADON, on 09/22/16 at approximately 8:00 AM, revealed she was not aware of a text message that came to her phone, stating she never received it. She stated she would have expected to receive a call from LPN #17 if there was a concern of abuse. Interview with Social Services Coordinator (SSC) #2, on 09/08/16 at 5:33 PM, revealed she viewed the three (3) images of the resident that were brought into the facility by FE #1. SSC #2 stated she was not aware of the pictures in her message box through social media before it was reported in person. She further stated in the photo, she saw the resident seated in a wheelchair, and one of the photos displayed the resident's gown up and over his/her head. Continued interview revealed the resident's face was clearly visible, and the pictures constituted abuse. Further interview revealed it was a dignity issue and a violation of the resident's right to privacy and confidentiality. Additionally, SSC #2 expressed there was a potential for harm if staff continued to use their cell phones while caring for the residents. Interview with LPN #7/Unit Manager, on 09/08/16 at approximately 5:45 PM, revealed she was notified of the incident by the Director of Nursing (DON) on 08/18/16, who asked her if she could identify the resident by looking at the pictures. She stated it was clear the resident was Resident #1. Further interview with LPN #7 revealed Resident #1 was sitting in a wheelchair and it was clear the resident did not have a shirt on. She stated she looked at the schedule for those who may have cared for Resident #1 on the evening of 08/16/16 and was able to name CNAs #1, #2, and #6. Interview with the DON, on 09/08/16 at 9:12 PM, revealed she was notified of the incident on the morning of 08/18/16 at 7:45 AM. The DON stated LPN #17 reported she had received a weird phone call from a caller, known as FE #1, who stated she saw pictures of a resident posted on social media. Continued interview with the DON revealed FE #1 later came into the facility to report the incident, and explained she came across pictures of one of the facility's residents that she thought she recognized from her previous employment at the facility. Further interview revealed the DON saw three (3) pictures of Resident #1 and it was clear the resident was not wearing any clothing in one (1) of the pictures. The DON stated it was a violation of the resident's privacy because the resident was not clothed, there was no consent from the Power of Attorney (POA), and it was posted on social media. She further stated it was sexual and emotional/mental abuse, regardless of the resident's cognitive abilities, and was a dignity issue for the resident. Interview with the Regional Director of Care Services, on 09/08/16 at 9:57 PM, revealed he viewed the three (3) pictures of Resident #1. He stated he saw two (2) staff members, but could not make them out. He reported one of the pictures showed the resident was uncovered, and the caption was there in the picture, which read, What we deal with every [***] ing day. Continued interview with the Regional Director of Care Services revealed he was not certain the incident was abuse because the resident was cognitively impaired, so it was difficult to determine how the resident felt. Further interview revealed it was a violation of the resident's dignity. Additionally, the Regional Director of Care Services acknowledged there was a potential for continued abuse, privacy, and dignity issues if staff used their phones while providing care. He stressed it was important to use this situation as a case scenario to educate staff. A follow-up interview with the Regional Director of Care Services was attempted on 09/19/16. According to the DON, the Regional Director of Care Services was no longer affilliated with the facility and would not be returning. A post-survey interview with the corporate Operations Specialist, on 10/26/16 at 4:26 PM, revealed she confirmed via e-mail the Regional Director of Care Services's last day at the facility was 09/16/16, and his employment with the corporation ended on 09/20/16. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed when she came to work the morning of 08/18/16, FE #1 was talking to the DON. She stated FE #1 saw pictures of Resident #1 on a social media site and came to the facility to report it. The Administrator further stated upon viewing the pictures, she saw the resident in different stages of being undressed. She reported the resident was clothed from the waist down, but revealed the resident's shirt was off and a banner (caption within the photo) was covering the resident's breast. Further interview with the Administrator revealed the CNAs violated the resident's privacy and dignity and stated it was abuse, but believed the resident was not aware of the concern because of his/her cognitive status. Initial interview with Resident #1's spouse, on 09/08/16 at 10:00 AM, revealed the facility notified him/her about the pictures taken of Resident #1. The spouse stated the facility reported Resident #1 was only in the background of the pictures that were taken. Further interview with the spouse, on 09/08/16 at 3:24 PM, revealed he/she did not know the details of the video pictures, including the fact Resident #1 was undressed and exposed in the photos, until the interview with the State Agency. Continued interview revealed learning the resident was exposed and videotaped was upsetting, and Resident #1, even in his/her cognitive state, would have found the incident disturbing and would have been upset. Furthermore, the spouse was bothered by the fact the facility Administrator did not tell him/her the whole story. Record review revealed the facility admitted Resident #1 on 07/21/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 07/28/16, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of three (3), which was indicative of severe cognitive impairment. The facility provided an acceptable credible allegation of compliance (AOC) on 09/14/16 that alleged removal of the Immediate Jeopardy (IJ) effective 09/14/16. Review of the AOC revealed the facility implemented the following: 1. On 08/08/16, the facility identified three (3) associates who participated in the event regarding Resident #1. They were immediately suspended, not to return to work pending investigation by the Administrator and Director of Clinical Services (DCS). 2. On 08/18/16, a Success Plan was initiated by the Interdisciplinary Team. The plan outlined actions taken by the facility to protect the residents, with all measures noted on the Success Plan to be completed on or before 08/24/16. 3. On 08/18/16 and 08/19/16, the SSC provided counseling to Resident #1 with weekly follow-up to be provided as needed for the next three (3) weeks. 4. On 08/23/16, a training session was provided by the QI nurse to the following: Administrator, DON, ADON, Unit Managers, Admission Assistant; Minimum Data Set (MDS) nurses, Dining Service Manager (DSM), Rehabilitation Manager (RM), SSCs, Staff Development Coordinator (SDC), evening and night shift supervisors, Activity Assistant, Housekeeping (HK) Supervisor, Certified Dietary Manager (CDM), Admission Coordinator (AC), and Resident Program Manager (RPM). The training by the QI nurse to the managers was to ensure no cell phones were in use in resident care areas, and included education on daily rounds to be completed each day by the managers on duty. 5. On 08/23/16, SSC #1 and SSC #2 interviewed fifty (50) residents with a BIMS score of eight (8) or above regarding being treated with dignity and respect. (A BIMS score of 8 or above indicates the resident is considered no more than mild to moderately cognitively impaired, and therefore interviewable.) 6. All staff were re-educated on or before 08/24/16. The QI nurse and SSCs #1, and #2 provided the re-education for all staff regarding the Health Insurance Portability and Accountability Act (HIPAA), abuse, dignity, and privacy. In addition, the education emphasized a prohibition of cell phone use by staff in resident/work areas, with violation to result in corrective action up to and including termination of employment. 7. On 08/25/16, six (6) skin assessments were reviewed for residents with BIMS score of seven (7) or below, who lived on the same hall as Resident #1. The Unit Manager and/or the DON reviewed the skin assessments in order to identify any suspicious areas of concern. 8. On 09/09/16, a training session was provided in the facility by the Regional Director of Care Services to educate the QA nurse, DON, Unit Managers, ADON, Medical Records Director (MRD), Central Supply Clerk (CSC), Health Care Liaison (HCL), and MDS Nurses. The Administrator was not present in the facility; however, was present by speaker phone. The training topics included the facility's Immediate Jeopardy (IJ), corrective actions, signing of acknowledgement of the facility's cell phone practice, QI rounds, abuse and dignity. 9. On 09/9/16 through 09/13/16 employees received training to reiterate the prohibiting of cells phones in resident care areas. 10. The facility documented 210 of 214 employees were educated on cell phone use, dignity, abuse and HIPAA as of 09/13/16. 11. Beginning on 08/23/16, the QA nurse and/or Administrator will review the daily audits five (5) days a week for two (2) weeks, then bi-weekly for four (4) weeks. In addition, the Administrator will review ongoing education and sign-in sheets to ensure education is completed for each employee, including agency staff and new hires, prior to them working in resident areas. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's final investigative report, dated 08/23/16, revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present during the recording. Continued review of the report revealed the three (3) CNAs were terminated from employment. Interviews with the QA Nurse, the DON, and the Administrator on 09/15/16 revealed the CNAs were suspended at the beginning of the investigation, and ultimately terminated from employment by the facility. Review of the Corrective Action form dated 08/23/16, signed by the Administrator and witnessed by the Human Resources Director, revealed the Administrator spoke with CNA #1, CNA #2 and CNA #6 by phone, and informed them due to their knowing participation in a violation of the facility's policy related to social media, the decision had been made to terminate their employment, effective immediately. 2. Review of the Community Success Plan, dated 08/18/16, revealed the facility's Plan of Action/Correction included re-education by Department Managers of all staff related to HIPAA, abuse, dignity, privacy, and cell phone use beginning on 08/18/16, to be completed by 08/24/16. Continued review of the Success Plan revealed SSCs were assigned to provide patient counseling for Resident #1 on 08/18/16 and 08/19/16. In addition, they were to interview all alert and oriented residents in the building regarding being treated with dignity and respect on 08/23/16. Further review of the Success Plan revealed skin assessments to identify any suspicious areas were to be completed by the Unit Managers (LPN #3, LPN #7 and RN #5) for all confused residents on 08/19/16. Additionally, the QI nurse would re-educate all Department Managers regarding daily rounds to be performed during their shifts, throughout the buildings, for six (6) weeks beginning 08/23/16. 3. Review of the SSC Progress Notes, dated 08/18/16, revealed SSC #2 spoke with Resident #1 to discuss the events of 08/16/16 and identify any resident concerns. Continued review of the note revealed Resident #1 did not recall the incident and expressed no concerns. Additional review of SSC Progress Notes revealed follow-up interviews dated 08/19/16, 08/25/16, 08/30/16, and 09/02/16 continued to reveal no resident concerns. Additionally, on 09/06/16, SSC #2 discussed discharge plains with Resident #1's spouse, who made the decision to take Resident #1 home. Interview with SSC #2, on 09/15/16 at 4:27 PM, validated Resident #1 did not recall the incident and was discharged to home. Review of the Training Session Attendance form dated 08/23/16, titled Supervisor Daily Rounds , revealed the following attendee signatures: Administrator, DON, ADON, Unit Managers (LPN #3, LPN#7, and RN #5), Admissions Assistant, MDS nurses, DSM, RM, SSC, SDC, evening and night shift supervisor, Activity Assistant, HK Supervisor, CDM, AC, and RPM. Interviews on 09/15/16 with Activity Assistant #1 at 1:46 PM; Activity Assistant #2 at 2:01 PM, RM at 3:40 PM, SSC #2 at 4:27 PM, and SSC #1 at 6:16 PM, revealed they received training regarding abuse, cell phone use, and treating residents with dignity and respect. Each manager was able to discuss the training topics and explain the daily QI rounds they were responsible for. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated she was responsible for documenting the QI rounds conducted by the managers. She provided the QI audit sheet titled QI Team Rounds . Review of the audit revealed the daily rounds included environmental observation to ensure all resident areas were free of cell phones, residents ' state of dress and grooming, and the following questions: How are you today?; Are associates taking good care of you?; and Do you have any questions regarding your care? 4. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated the Success Plan was created to ensure all employees were held responsible for following the cell phone policy and to continue to monitor resident care areas. Continued interview revealed the Department Managers were re-educated on conducting daily rounds to ensure the staff was compliant with the facility ' s policy on cell phones, and providing dignity and privacy to all residents. She stated the facility's expectation was there would be no tolerance for failure to comply with the cell phone policy. Continued interview revealed a first offense would earn a written warning, and a second offense termination. 5. Review of the report sheets provided by the facility validated fifty (50) residents were interviewed regarding concerns related to dignity and respect. According to the reports, none of the residents expressed concerns. Interview with SSCs #1 on 09/15/16 at 5:16 PM, and SSC #2 on 09/15/16 at 4:27 PM, validated they conducted the interviews. They stated none of the residents expressed concerns related to dignity and respect. Observations on 09/13/16 beginning at 10:45 AM, revealed no concerns related to staff interactions with residents on the 200 hall. No failure to treat residents with dignity and respect was identified, and privacy was maintained during the provision of care. In addition, no staff was observed to be using cell phones in the resident care areas. Interviews with Resident #14 on 09/13/16 at 11:45 AM, and Resident #6 on 09/13/16 at 1:25 PM, revealed they denied any mistreatment by staff, and felt they were treated with respect. Continued interview revealed neither resident recalled seeing staff use cell phones in their rooms during care. 6. Review of the training packet which included information on cameras and tape recording, media inquiries, confidentiality of information, telephone use, HIPAA, abuse, dignity, and phones revealed the training was completed for all staff on 08/22/16, 08/23/16 and 08/24/16. Completed questionnaires related to the training, signed and dated by staff, were included in the packet. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM,

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure the facility's abuse policy was fully implemented for two (2) of twenty-eight (28) sampled residents (Residents #1 and #11). On 08/16/16, between 8:00 PM and 11:00 PM, Certified Nursing Assistant (CNA) #6 videotaped Resident #1 while care was being provided by two (2) other CNAs. The resident was unclothed during portions of the video, and his/her face was visible and recognizable. CNA #6 posted the video to a social media site. On 08/18/16, a former employee (FE) came to the facility and reported seeing the images on social media. State Agency interviews identified multiple residents and staff who reported excessive and inappropriate cell phone usage; however, the facility failed to interview residents regarding cell phone usage during the facility's investigation. In addition, staff present at the time CNA #6 videotaped Resident #1 failed to report the incident. (Refer to F223) Furthermore, during a skin assessment conducted by the facility for Resident #11, the State Survey Agency observed a large bruise on the resident's lower back. Interviews revealed a CNA observed the bruise on 08/25/16, but did not report it per the facility's policy. The facility's failure to have an effective system in place to ensure the abuse policy was fully implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/08/16 and determined to exist on 08/16/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/14/16 with the facility alleging removal of the Immediate Jeopardy on 09/14/16. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/14/16, prior to exit on 09/23/16, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Abuse, Neglect and Exploitation Policy, revised 08/2016, revealed instances or allegations of abuse would be treated seriously and must be reported to the Administrator or the supervisor on duty for investigation and appropriate follow-up. The definition of mental abuse included humiliation, harassment, or taking or using photographs or recordings in any manner that would demean or humiliate a resident and distributing such images or recordings on social media. Continued review revealed any associate who witnessed or suspected abuse had occurred would immediately report the incident. Further review revealed to prevent abuse, the facility would identify, correct and intervene in situations where abuse was more likely occur. Additionally, abuse prevention efforts would include supervision of employees to identify inappropriate behaviors. Review of the Employee Handbook titled, More Than A Company - A Calling, dated May 2013, revealed the use of cell phones or cameras to produce electronic images and the use of tape recording/listening devices were strictly prohibited to ensure the privacy of the residents, visitors and associates. Abuse of these guidelines would result in corrective action, up to and including termination of employment. Review of the facility's Long Term Care Facility Self-Reported Incident Form, signed by the Administrator on 08/23/16, revealed on 08/18/16, a FE reported having seen inappropriate photos of Resident #1 on social media. There were no faces visible in the images other than the resident's; however, the facility was able to confirm CNA #6 videotaped Resident #1 while CNAs #1 and #2 provided care. Review of three (3) photocopied pictures of Resident #1, taken from the original video, revealed one (1) picture showed Resident #1's bare chest, leg, and face were apparent. Across the lower portion of the photo was a typed caption, What we deal with every [***] ing day. Interview with Certified Nursing Assistant (CNA) #6, on 09/07/16 at 4:59 PM, revealed she acknowledged she posted the video of Resident #1 on social media. Further interview with CNA #6 revealed the policy related to cell phones was in the Employee Handbook, and she knew staff was not supposed to use their phones in resident care areas. She stated everyone in the facility had their phones on them, even though they weren't supposed to. Review of CNA #1's written statement, dated 08/18/16 at 4:30 PM, revealed she heard CNA #2 say recording, but did not know what she meant. Continued review of the statement revealed CNA #1 felt stuck between saying something, and her friends. Interview with CNA #1, on 09/07/16 at 10:30 AM, revealed she could not see what CNA #6 was doing, but she heard CNA #2 ask, Are you recording, what are you doing? CNA #1 stated CNA #6 did not respond to the question; therefore, CNA #1 denied knowing what was happening. Review of CNA #2's written statement, dated 08/18/16, revealed she knew CNA #6 had her phone and asked her, are you on Snapchat or what?, and CNA #6 responded yeah. (Snapchat is an image messaging mobile phone application which allows users to share images using their smart cell phones.) Continued review of the statement revealed CNA #2 did not take it seriously. Interview with CNA #2, on 09/07/16 at 11:10 AM, revealed the incident was sexual abuse because the image of an unclothed Resident #1 should not have been posted on social media, and it would also be mental abuse if the resident was aware of it. Continued interview revealed she should have reported CNA #6 had her phone out during resident care. Interview with the Director of Nursing (DON), on 09/08/16 at 9:12 PM, revealed she interviewed CNA #1 and CNA #2 at the same time. She stated CNA #2 admitted in the interview with the DON that she knew CNA #6 was on Snapchat in Resident #1's room. She reported CNA #2 stated in her written statement that she should have reported CNA #6. The DON further stated CNA #1 denied knowing CNA #6 was on her phone. Continued interview with the DON revealed all of them should have reported the incident immediately. Interview with the Regional Director of Care Services, on 09/08/16 at 9:57 PM, revealed he questioned the CNAs involved of circumstances surrounding the event. He stated he could not recall their names, but felt one (1) of the aides knew it was a violation as it was happening. Continued interview revealed the incident should have been reported immediately. Review of the facility's investigation of the incident revealed interviewable residents (resident with a BIMS score of 8 or above) were questioned regarding any concerns they may have related to dignity and respect. There was no documented evidence the residents were questioned about staff use of cell phones, for making/receiving calls or for taking photos or video recordings, in the resident care areas. Furthermore, review of the facility's list of interviewable residents revealed Resident #22 and Residents C, D, F, G and H were not interviewed at all. Interviews with each resident, on 09/08/16, revealed all reported having frequently observed staff using their cell phones, making and receiving calls, in their rooms or other common areas. Residents #22, C, D, F, G and H revealed no facility staff had interviewed them regarding a concern related to the practice. Interview with Social Service Coordinator (SSC) #1 and SSC #2, on 09/08/16 at 5:33 PM, revealed during their investigation, they interviewed all alert and oriented residents and asked the residents if staff treated them with dignity and respect. They stated they did not ask the residents if staff had used their cell phones while caring for them, but probably should have included that question in their interviews. Interview with the Director of Nursing (DON), on 09/23/16 at 1:02 PM, revealed it would have been important to include questions that related to staff using their telephone in resident care areas as part of the investigation to determine if the policy was being followed. Staff interviews also revealed staff used their cell phones in resident care areas. Interview with CNA #4, on 09/07/16 at 2:12 PM, revealed the facility had not been strict with staff about the use of cell phones in the building and it they had, the incident related to Resident #1 could have been prevented. Interview with Licensed Practical Nurse (LPN) #2, on 09/08/16 at 9:48 AM, revealed she saw CNA #6 on the phone a lot. She stated she thought it was a problem because there was a lot of cell phone usage in the common area by staff. She stated it had been necessary to tell CNAs to put their phones away and take care of the residents. Further interview revealed LPN #2 addressed her concern with the night shift manager, who informed her it was okay for staff to have phones out. Further interview with LPN #2 revealed that allowing staff to have their cell phones set them up for failure. Continued interview revealed she had not been directed to perform any monitoring of staff related to cell phone use. Interview with the night shift supervisor, on 09/22/16 at 6:30 AM, revealed she was aware some staff used their cell phones, and she often had to tell them to put them away. Continued interview revealed she had never stated it was okay for them to be on their phones. Interview with LPN #7/Unit Manager, on 09/08/16 at 5:45 PM, revealed staff could have cell phones on their person, but could not use the phone while in resident care areas. She stated it would be difficult to monitor staff for cell phone use when they were providing care behind closed doors, but she relied on the integrity of the staff. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed she discussed with the Ombudsman about staff using their phones during dining service. She stated she asked staff to monitor staff more closely during dining services for staff that were on their phones. However, the facility had no documented evidence of any monitoring of the use of cell phones, and no evidence of re-education of staff related to the prohibited practice, prior to the incident on 08/16/16. Further interview with SSCs #1 and #2, on 09/08/16 at 5:33 PM, revealed they were aware staff was using their phones in the common area, adding, We all had phones that we carried. The SSCs reported the issue had never come up in a staff meeting. Additionally, they stated it was difficult to monitor and ensure staff was not using their phones while providing care to the residents, thus the facility could not ensure a similar incident would not happen again if staff continued to carried their phones while caring for residents. Further interview with the DON, on 09/08/16 at 9:12 PM, revealed she had noticed staff with their phones out in resident care areas and she had often told them to put the phones away. She stated she was not sure the Administrator knew about staff using their phones in the care area, but added the Administrator should have been made aware. Continued interview with the DON revealed management had allowed staff to carry their phones on their person, but they were not supposed to use them in resident care areas. The DON further stated it would be difficult to monitor and ensure staff was not using their phones inappropriately, according to facility policy. Further interview with the DON revealed that the only way to prevent this from happening again would be to have the staff members store their phones in lockers in the break rooms. Further interview with the Regional Director of Care Services, on 09/08/16 at 9:57 PM, revealed he was not aware staff were using their phones in the resident care areas and acknowledged he had not stayed in the facility late enough to observe the 3:00 PM to 11:00 PM shift. He stated it would have been a good idea to interview residents about the usage of cell phones in resident care areas during the facility's investigation. He further stated facility policy prohibited the use of cell phones with video/camera capability, but staff could keep their phones on their person. Continued interview with the Regional Director of Care Services revealed it was his expectation that staff would not answer their phones in resident care areas, especially while caring for the resident. Further interview with the Regional Director of Care Services revealed the use of cell phones in resident care areas was not acceptable practice. A follow-up interview with the Regional Director of Care Services was attempted on 09/19/16. According to the DON, the Regional Director of Care Services was no longer affilliated with the facility and would not be returning. A post-survey interview with the corporate Operations Specialist, on 10/26/16 at 4:26 PM, revealed she confirmed via e-mail the Regional Director of Care Services's last day at the facility was 09/16/16, and his employment with the corporation ended on 09/20/16. Further interview with the Administrator, on 09/23/16 at 5:30 PM, revealed she was not aware of any other instances of where staff were using their phones in the resident care areas, but should have been made aware. The Administrator reported her understanding of the facility's policy was a prohibition against using phones that had the ability to produce electronic images, adding the phone could be on the body, but not out in the work area. Continued interview revealed it would be difficult to ensure staff did not use their phones while in resident care areas, to prevent abuse of resident's confidentially, if they were carrying their phones. Additionally, the Administrator stated it would have been helpful to be more specific in their investigation of the incident involving Resident #1 on 08/16/16, as per their policy, by asking the residents if they observed staff using their phones in resident care areas. 2. Review of the facility's Abuse, Neglect & Exploitation Policy, revised 08/2016, revealed an injury of unknown source met both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: the extent of the injury; the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); the number of injuries observed at one particular point in time; or the incidence of injuries over time. Continued review of the policy revealed if abuse was suspected or confirmed, it must be immediately reported to the management team. Review of the facility's Investigation Report, dated 09/15/16, revealed LPN # 15 noticed the bruise to Resident #11's back while conducting a skin assessment for the State Survey Agency. Continued review revealed Certified Nurse Aide (CNA) # 29 revealed she first saw the bruise on 08/25/16 after the resident had been admitted to the facility and did not report it. Ongoing review revealed CNA #13 noted the large bruise at the shift change on 09/14/16 when CNA # 22 reported it to him. According to the investigation, CNA #13 stated it was reported to him that the resident was actively dying and the night shift nurse had been notified when the bruise was first noticed. However, CNA #13 did not know who the night shift nurse was. Additional review of the Investigation report revealed CNA #28 had seen the bruise on 09/03/16 or 09/04/16 and did not report it. Ongoing review of the Investigation Report revealed all staff who had noticed the bruise failed to report the bruise immediately per facility policy. Interview on 09/14/16 at 3:35 PM, with LPN #15, revealed she was not aware Resident #11 had a bruise to the right lower back until it was pointed out by the surveyor at the time of the skin assessment. Further interview revealed the CNAs had not reported the bruise to her. However, interview on 09/14/16 at 5:13 PM with CNA #13, revealed the family of Resident #11 showed him the bruise to the resident's lower back on 09/14/16, and he reported it to LPN# 15 on 09/14/16. Additional interview revealed the CNA was to report any suspected injuries to the nurse on duty, or to the supervisor. Interview on 09/14/16 at 3:38 PM, with CNA #29, revealed she noticed the bruise to the resident's right lower back the day after the resident was admitted to the facility and thought the facility was aware but did not report the bruise because she assumed the nurse who had done the admission skin assessment had seen it. Further interview revealed the CNA had been trained in abuse by her supervisors and she stated she was to report an injury of unknown origin to the nurse immediately. However, per interview she failed to report the bruise. Interview on 09/15/16 at 3:00 PM with CNA #22, revealed she had noticed the bruise to the residents back on 09/12/16 and reported it to Registered Nurse (RN) #2, who stated she was already aware of it. Further interview revealed CNA #22 had been trained on abuse, was able to recall the types of abuse, and stated she always reported any skin issues to the nurse on duty. Interview on 09/16/16 at 8:35 AM with RN #2, revealed she noticed a bruise to Resident #11's right lower back one (1) to two (2) weeks ago while changing the dressing to the residents coccyx. Further interview revealed she reported the bruise to LPN #12 during the oncoming morning report. Continued interview revealed she did not fill out an Incident Report after identifying the bruise, did not document the bruise in the Progress Notes, and did not notify the Director of Nursing (DON) or the Physician. Ongoing interview with RN #2 revealed she had been trained on abuse and she should have documented the bruise in the Progress Notes, completed an Incident Report, and should have reported the bruise to the DON and Physician immediately. Interview on 09/21/16 at 4:30 PM, with the DON, revealed it was the DON's expectation that all staff follow the facility's Abuse policy and report injuries of unknown origin. Interview on 09/23/16 at 5:30 PM with the Administrator, revealed the staff member who had first noticed the bruising should have initiated an Incident Report, and should have reported it to the DON/Administrator and Physician so that an investigation could have been started immediately and the State Agencies could have been notified. Additional interview with the Administrators revealed it was her expectation that staff follow the facility's Abuse Policy. The facility provided an acceptable credible allegation of compliance (AOC) on 09/14/16 that alleged removal of the Immediate Jeopardy (IJ) effective 09/14/16. Review of the AOC revealed the facility implemented the following: 1. On 08/08/16, the facility identified three (3) associates who participated in the event regarding Resident #1. They were immediately suspended, not to return to work pending investigation by the Administrator and Director of Clinical Services (DCS). 2. On 08/18/16, a Success Plan was initiated by the Interdisciplinary Team. The plan outlined actions taken by the facility to protect the residents, with all measures noted on the Success Plan to be completed on or before 08/24/16. 3. On 08/18/16 and 08/19/16, the SSC provided counseling to Resident #1 with weekly follow-up to be provided as needed for the next three (3) weeks. 4. On 08/23/16, a training session was provided by the QI nurse to the following: Administrator, DON, ADON, Unit Managers, Admission Assistant; Minimum Data Set (MDS) nurses, Dining Service Manager (DSM), Rehabilitation Manager (RM), SSCs, Staff Development Coordinator (SDC), evening and night shift supervisors, Activity Assistant, Housekeeping (HK) Supervisor, Certified Dietary Manager (CDM), Admission Coordinator (AC), and Resident Program Manager (RPM). The training by the QI nurse to the managers was to ensure no cell phones were in use in resident care areas, and included education on daily rounds to be completed each day by the managers on duty. 5. On 08/23/16, SSC #1 and SSC #2 interviewed fifty (50) residents with a BIMS score of eight (8) or above regarding being treated with dignity and respect. (A BIMS score of 8 or above indicates the resident is considered no more than mild to moderately cognitively impaired, and therefore interviewable.) 6. All staff were re-educated on or before 08/24/16. The QI nurse and SSCs #1, and #2 provided the re-education for all staff regarding the Health Insurance Portability and Accountability Act (HIPAA), abuse, dignity, and privacy. In addition, the education emphasized a prohibition of cell phone use by staff in resident/work areas, with violation to result in corrective action up to and including termination of employment. 7. On 08/25/16, six (6) skin assessments were reviewed for residents with BIMS score of seven (7) or below, who lived on the same hall as Resident #1. The Unit Manager and/or the DON reviewed the skin assessments in order to identify any suspicious areas of concern. 8. On 09/09/16, a training session was provided in the facility by the Regional Director of Care Services to educate the QA nurse, DON, Unit Managers, ADON, Medical Records Director (MRD), Central Supply Clerk (CSC), Health Care Liaison (HCL), and MDS Nurses. The Administrator was not present in the facility; however, was present by speaker phone. The training topics included the facility's Immediate Jeopardy (IJ), corrective actions, signing of acknowledgement of the facility's cell phone practice, QI rounds, abuse and dignity. 9. On 09/9/16 through 09/13/16 employees received training to reiterate the prohibiting of cells phones in resident care areas. 10. The facility documented 210 of 214 employees were educated on cell phone use, dignity, abuse and HIPAA as of 09/13/16. 11. Beginning on 08/23/16, the QA nurse and/or Administrator will review the daily audits five (5) days a week for two (2) weeks, then bi-weekly for four (4) weeks. In addition, the Administrator will review ongoing education and sign-in sheets to ensure education is completed for each employee, including agency staff and new hires, prior to them working in resident areas. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's final investigative report, dated 08/23/16, revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present during the recording. Continued review of the report revealed the three (3) CNAs were terminated from employment. Interviews with the QA Nurse, the DON, and the Administrator on 09/15/16 revealed the CNAs were suspended at the beginning of the investigation, and ultimately terminated from employment by the facility. Review of the Corrective Action form dated 08/23/16, signed by the Administrator and witnessed by the Human Resources Director, revealed the Administrator spoke with CNA #1, CNA #2 and CNA #6 by phone, and informed them due to their knowing participation in a violation of the facility's policy related to social media, the decision had been made to terminate their employment, effective immediately. 2. Review of the Community Success Plan, dated 08/18/16, revealed the facility's Plan of Action/Correction included re-education by Department Managers of all staff related to HIPAA, abuse, dignity, privacy, and cell phone use beginning on 08/18/16, to be completed by 08/24/16. Continued review of the Success Plan revealed SSCs were assigned to provide patient counseling for Resident #1 on 08/18/16 and 08/19/16. In addition, they were to interview all alert and oriented residents in the building regarding being treated with dignity and respect on 08/23/16. Further review of the Success Plan revealed skin assessments to identify any suspicious areas were to be completed by the Unit Managers (LPN #3, LPN #7 and RN #5) for all confused residents on 08/19/16. Additionally, the QI nurse would re-educate all Department Managers regarding daily rounds to be performed during their shifts, throughout the buildings, for six (6) weeks beginning 08/23/16. 3. Review of the SSC Progress Notes, dated 08/18/16, revealed SSC #2 spoke with Resident #1 to discuss the events of 08/16/16 and identify any resident concerns. Continued review of the note revealed Resident #1 did not recall the incident and expressed no concerns. Additional review of SSC Progress Notes revealed follow-up interviews dated 08/19/16, 08/25/16, 08/30/16, and 09/02/16 continued to reveal no resident concerns. Additionally, on 09/06/16, SSC #2 discussed discharge plains with Resident #1's spouse, who made the decision to take Resident #1 home. Interview with SSC #2, on 09/15/16 at 4:27 PM, validated Resident #1 did not recall the incident and was discharged to home. Review of the Training Session Attendance form dated 08/23/16, titled Supervisor Daily Rounds , revealed the following attendee signatures: Administrator, DON, ADON, Unit Managers (LPN #3, LPN#7, and RN #5), Admissions Assistant, MDS nurses, DSM, RM, SSC, SDC, evening and night shift supervisor, Activity Assistant, HK Supervisor, CDM, AC, and RPM. Interviews on 09/15/16 with Activity Assistant #1 at 1:46 PM; Activity Assistant #2 at 2:01 PM, RM at 3:40 PM, SSC #2 at 4:27 PM, and SSC #1 at 6:16 PM, revealed they received training regarding abuse, cell phone use, and treating residents with dignity and respect. Each manager was able to discuss the training topics and explain the daily QI rounds they were responsible for. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated she was responsible for documenting the QI rounds conducted by the managers. She provided the QI audit sheet titled QI Team Rounds . Review of the audit revealed the daily rounds included environmental observation to ensure all resident areas were free of cell phones, residents ' state of dress and grooming, and the following questions: How are you today?; Are associates taking good care of you?; and Do you have any questions regarding your care? 4. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated the Success Plan was created to ensure all employees were held responsible for following the cell phone policy and to continue to monitor resident care areas. Continued interview revealed the Department Managers were re-educated on conducting daily rounds to ensure the staff was compliant with the facility ' s policy on cell phones, and providing dignity and privacy to all residents. She stated the facility's expectation was there would be no tolerance for failure to comply with the cell phone policy. Continued interview revealed a first offense would earn a written warning, and a second offense termination. 5. Review of the report sheets provided by the facility validated fifty (50) residents were interviewed regarding concerns related to dignity and respect. According to the reports, none of the residents expressed concerns. Interview with SSCs #1 on 09/15/16 at 5:16 PM, and SSC #2 on 09/15/16 at 4:27 PM, validated they conducted the interviews. They stated none of the residents expressed concerns related to dignity and respect. Observations on 09/13/16 beginning at 10:45 AM, revealed no concerns related to staff interactions with residents on the 200 hall. No failure to treat residents with dignity and respect was identified, and privacy was maintained during the provision of care. In addition, no staff was observed to be using cell phones in the resident care areas. Interviews with Resident #14 on 09/13/16 at 11:45 AM, and Resident #6 on 09/13/16 at 1:25 PM, revealed they denied any mistreatment by staff, and felt they were treated with respect. Continued interview revealed neither resident recalled seeing staff use cell phones in their rooms during care. 6. Review of the training packet which included information on cameras and tape recording, media inquiries, confidentiality of information, telephone use, HIPAA, abuse, dignity, and phones revealed the training was completed for all staff on 08/22/16, 08/23/16 and 08/24/16. Completed questionnaires related to the training, signed and dated by staff, were included in the packet. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the training and completed the questionnaire. In addition, the interviewed staff was able to discuss the training topics and exhibited an understanding of related facility policy. 7. Review of the Weekly Skin Integrity Review forms confirmed six (6) residents received skin assessments on 08/25/16, conducted by the DON, and Unit Managers (LPN# 3, LPN# 7 and RN #5). Continued review revealed no new skin issues were identified. Interview with the DON, on 09/15/16 at 6:25 PM, revealed the skin assessments were completed as documented, and no new skin concerns were identified. Continued interview with the DON revealed she assisted the unit managers with skin assessments on residents with a BIMS score of seven (7) and below, which indicated they were not interviewable. 8. Review of the training session attendance sheet dated 09/09/16 and titled Education Procedure on IJ, Corrective Action, Acknowledgement, QA Rounds, Abuse and Dignity, revealed training was provided by the Regional Director of Operations. Attendees included the QI Nurse, DON, Unit Managers, ADON, MRD, MDS Nurse, and the Administrator on speaker phone. Interviews on 09/15/16 with the QI Nurse at 5:51 PM, the DON at 6:25 PM, and the Administrator at 6:28 PM, revealed they were present for the training by the Regional Director of Care Services, and topics included the IJ, the facility's prohibition of staff having cell phones in the resident care areas, and signing an acknowledgment of understanding of facility policy. 9. Review of training sheets provided by the QI nurse on 09/15/16 revealed all staff received additional training on the prohibited use of cell phones in the resident care areas between 09/09/16 and 09/13/16. This training including the requirement for staff to sign their acknowledgement and understanding of the facility ' s policies related to cell phone use. Review of the signed acknowledgement forms revealed staff from all departments received the training and understood the facility ' s prohibition of using cell phones in resident care areas. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the additional education regarding no cell phone use in the facility, and were able to discuss the intent of the training and the consequences of failure to adhere to facility guidelines, up to and including termination of employment. 10. Review of the Employee Roster, dated 09/09/16, revealed 210 of 214 facility employees received mandatory training as part of the facility's corrective action prior to 09/14/16. Continued review of the roster revealed four (4) employees had not received the training provided by the facility. Review of sign-in sheets,

Based on interview, record review, review of the Administrator's Job Description and the facility's policy and procedures, it was determined the facility's Administration failed to have an effective system in place to ensure that it was administered in a manner that protected residents from abuse. On 08/16/16, three (3) Certified Nursing Assistants (CNAs) were caring for Resident #1. CNA #6 videotaped the resident with her cell phone. Still pictures taken from the video showed the resident with the upper body exposed. The resident's face was clearly visible and recognizable, and a caption typed over the pictures read, what we deal with every [***] ing day. The facility was notified of the incident on 08/18/16, when a former employee reported seeing the images of Resident #1 on a social media site. Additionally, interviews with staff and residents revealed staff was frequently observed to be on their phones while in resident care areas. The Administrator acknowledged having been notified about excess phone usage, and asked staff to monitor it; however, Social Service Coordinators (SSCs) #1 and #2 revealed the discussion never came up in their staff meetings and Licensed Practical Nurse (LPN) #2 stated she was not aware she was supposed to monitor staff on their phones. The facility's failure to have an effective Administration to ensure the facility's policies were implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/08/16 and determined to exist on 08/16/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/14/16 with the facility alleging removal of the Immediate Jeopardy on 09/14/16. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/14/16, prior to exit on 09/23/16, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F-164, F-223, and F-226 ) The findings include: Review of the facility's job description for Health Care Administrator, dated August 2010, revealed it was the Administrators job to direct the day-to-day health care functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. Additionally, the Administrator would review community policies and procedures periodically, and make routine inspections of the community to ensure established policies and procedures were being implemented and followed. Review of the Center for Clinical Standards and Quality/Survey and Certification Group, Reference : S&C: 16-33-NH, published by the Centers for Medicare and Medicaid Services (CMS) and dated 08/05/16, revealed each resident had the right to be free from all types of abuse, including mental abuse. Mental abuse included abuse that was facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Additionally, the CMS directive included each nursing home would review and/or revise their written abuse prevention policies and procedures to include and ensure nursing home staff were prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident, including the use of any type of equipment to take, keep, or distribute photographs and recordings on social media. Review of the facility's Abuse, Neglect and Exploitation Policy, revised 08/2016, revealed instances or allegations of abuse, neglect or exploitation would be treated seriously and must be reported to the Administrator or the supervisor on duty for investigation and appropriate follow-up. Continued review revealed mental abuse was defined to include humiliation, harassment, or taking or using photographs or recordings in any manner that would demean or humiliate a resident. This would include using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute such photographs and recordings on social media. Further review revealed abuse prevention efforts would include identification, correction, and intervention in situations where abuse and neglect were more likely to occur. In addition, prevention efforts included supervision of associates to identify inappropriate behaviors. Review of the facility's Long Term Care Facility Self-Reported Incident Form, signed by the Administrator on 08/23/16, revealed a former employee (FE) came to the facility on [DATE] at 9:00 AM and reported she had seen inappropriate photos of Resident #1 on a social media website. Continued review of the facility's investigative findings revealed although the resident's face was visible in the images, staff faces were not shown; however, the facility was able to identify CNAs #1, #2 and #6 as being present in the resident's room at the time of the incident. The facility was able to confirm CNA #6 recorded care of Resident #1 while CNAs #1 and #2 were present. Interview with the Administrator, on 09/23/16 at 4:00 and 5:30 PM, revealed the Ombudsman had informed her about staff using their phones during dining service. The Administrator stated her resolution was to have staff monitored more closely during dining services for the use of cell phones. The Administrator could not provide specific details on the monitor, evidence of education about cell phone usage, or documentation of a monitor. The Administrator further stated she was not aware of any other instances of staff using their phones in the resident care areas, but she should have been made aware if that was the case. Interview with the Ombudsman, on 09/13/16 at 3:00 PM, revealed she had observed staff on their phones during dining service. The Ombudsman stated it had gotten so bad she sometimes had to tell staff when a resident needed their attention. She stated she had discussed her concerns with the Administrator, whose only reply was that staff knew they were not supposed to be on their phones. Interview with CNA #2, CNA #6 and CNA #4 revealed they had received education upon hire that cell phones should not be used in resident care areas; however, per interview this was never enforced. Interview with Licensed Practical Nurse (LPN) #2 and LPN #17 revealed there was a lot of cell phone usage in the facility. Per interview, they had not been directed to monitor the practice. Interview with Social Service Coordinator (SSC) #1 and SSC #2, on 09/08/16 at 5:33 PM, revealed they were aware staff used their phones in the common areas, and stated we all had phones we carried. Continued interview revealed a concern related to cell phone usage had never been discussed in a staff meeting. Interview with the Director of Nursing (DON), on 09/08/16 at 9:12 PM, revealed she had noticed staff with their phones out in resident care areas and she had often told them to put the phones away. The DON stated she did not inform the Administrator of staff having their phones out, but should have made her aware. Further interview with the DON revealed the only way to prevent this from happening again would be to have the staff members store their phones in lockers in the break rooms. Interview with the Regional Director of Care Services, on 09/08/16 at 9:57 PM, revealed he was not aware of, and had not observed, staff using their phones in the resident care areas. The Regional Director stated he could not speak on behalf of the Administrator because he was not certain if the Administrator was aware that staff was using their phones inappropriately prior to the incident with Resident #1 on 08/16/16. Continued interview with the Regional Director of Care Services revealed it would have been his expectation the Administrator be informed if staff were using their phones in resident care areas, adding it was not an acceptable practice according to the facility's policy. A follow-up interview with the Regional Director of Care Services was attempted on 09/19/16. According to the DON, the Regional Director of Care Services was no longer affilliated with the facility and would not be returning. A post-survey interview with the corporate Operations Specialist, on 10/26/16 at 4:26 PM, revealed she confirmed via e-mail the Regional Director of Care Services's last day at the facility was 09/16/16, and his employment with the corporation ended on 09/20/16. Further interview with the Administrator, on 09/23/16 at 4:00 PM and 5:30 PM, revealed she acknowledged the Medical Directors role and function was to provide input on any areas of concern, and to assist in developing, reviewing and implementing policies and procedures regarding clinical care of residents to ensure the facility followed current standards of care. She stated they reached out to him for input when needed; however, she was not aware she was to notify the Medical Director immediately of an Immediate Jeopardy situation. She stated she had not contacted the Medical Director related to the allegation of abuse for Resident #1 because she was in the process of changing contracts for Medical Directors, and did not see the need to contact the current Medical Director. Interview with the Medical Director, on 09/20/16 at 8:07 AM and 12:55 PM, and on 09/23/16 at 12:30 PM, revealed he desired to be notified by the facility of any concerns so that he could be involved in decision making and plan of correction. Further interview revealed he was not informed by the Administrator about the Immediate Jeopardy related to abuse. He stated he found out about the information from his Nurse Practitioner who heard the information on the news. Continued interview with the Medical Director revealed he should have been notified about the incident so that he could have assisted the facility with a plan of correction. Subsequent interview with the Administrator, on 09/15/16 at 6:28 PM, revealed she was aware of the CMS Standards and Quality/Survey & Certification group memo that was sent to all facilities on 08/05/16, and showed her copy of the memo to the State Survey Agency surveyor. Continued interview revealed she felt she followed the guidelines expressed by CMS in the memo. The facility provided an acceptable credible allegation of compliance (AOC) on 09/14/16 that alleged removal of the Immediate Jeopardy (IJ) effective 09/14/16. Review of the AOC revealed the facility implemented the following: 1. On 08/08/16, the facility identified three (3) associates who participated in the event regarding Resident #1. They were immediately suspended, not to return to work pending investigation by the Administrator and Director of Clinical Services (DCS). 2. On 08/18/16, a Success Plan was initiated by the Interdisciplinary Team. The plan outlined actions taken by the facility to protect the residents, with all measures noted on the Success Plan to be completed on or before 08/24/16. 3. On 08/18/16 and 08/19/16, the SSC provided counseling to Resident #1 with weekly follow-up to be provided as needed for the next three (3) weeks. 4. On 08/23/16, a training session was provided by the QI nurse to the following: Administrator, DON, ADON, Unit Managers, Admission Assistant; Minimum Data Set (MDS) nurses, Dining Service Manager (DSM), Rehabilitation Manager (RM), SSCs, Staff Development Coordinator (SDC), evening and night shift supervisors, Activity Assistant, Housekeeping (HK) Supervisor, Certified Dietary Manager (CDM), Admission Coordinator (AC), and Resident Program Manager (RPM). The training by the QI nurse to the managers was to ensure no cell phones were in use in resident care areas, and included education on daily rounds to be completed each day by the managers on duty. 5. On 08/23/16, SSC #1 and SSC #2 interviewed fifty (50) residents with a BIMS score of eight (8) or above regarding being treated with dignity and respect. (A BIMS score of 8 or above indicates the resident is considered no more than mild to moderately cognitively impaired, and therefore interviewable.) 6. All staff were re-educated on or before 08/24/16. The QI nurse and SSCs #1, and #2 provided the re-education for all staff regarding the Health Insurance Portability and Accountability Act (HIPAA), abuse, dignity, and privacy. In addition, the education emphasized a prohibition of cell phone use by staff in resident/work areas, with violation to result in corrective action up to and including termination of employment. 7. On 08/25/16, six (6) skin assessments were reviewed for residents with BIMS score of seven (7) or below, who lived on the same hall as Resident #1. The Unit Manager and/or the DON reviewed the skin assessments in order to identify any suspicious areas of concern. 8. On 09/09/16, a training session was provided in the facility by the Regional Director of Care Services to educate the QA nurse, DON, Unit Managers, ADON, Medical Records Director (MRD), Central Supply Clerk (CSC), Health Care Liaison (HCL), and MDS Nurses. The Administrator was not present in the facility; however, was present by speaker phone. The training topics included the facility's Immediate Jeopardy (IJ), corrective actions, signing of acknowledgement of the facility's cell phone practice, QI rounds, abuse and dignity. 9. On 09/9/16 through 09/13/16 employees received training to reiterate the prohibiting of cells phones in resident care areas. 10. The facility documented 210 of 214 employees were educated on cell phone use, dignity, abuse and HIPAA as of 09/13/16. 11. Beginning on 08/23/16, the QA nurse and/or Administrator will review the daily audits five (5) days a week for two (2) weeks, then bi-weekly for four (4) weeks. In addition, the Administrator will review ongoing education and sign-in sheets to ensure education is completed for each employee, including agency staff and new hires, prior to them working in resident areas. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's final investigative report, dated 08/23/16, revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present during the recording. Continued review of the report revealed the three (3) CNAs were terminated from employment. Interviews with the QA Nurse, the DON, and the Administrator on 09/15/16 revealed the CNAs were suspended at the beginning of the investigation, and ultimately terminated from employment by the facility. Review of the Corrective Action form dated 08/23/16, signed by the Administrator and witnessed by the Human Resources Director, revealed the Administrator spoke with CNA #1, CNA #2 and CNA #6 by phone, and informed them due to their knowing participation in a violation of the facility's policy related to social media, the decision had been made to terminate their employment, effective immediately. 2. Review of the Community Success Plan, dated 08/18/16, revealed the facility's Plan of Action/Correction included re-education by Department Managers of all staff related to HIPAA, abuse, dignity, privacy, and cell phone use beginning on 08/18/16, to be completed by 08/24/16. Continued review of the Success Plan revealed SSCs were assigned to provide patient counseling for Resident #1 on 08/18/16 and 08/19/16. In addition, they were to interview all alert and oriented residents in the building regarding being treated with dignity and respect on 08/23/16. Further review of the Success Plan revealed skin assessments to identify any suspicious areas were to be completed by the Unit Managers (LPN #3, LPN #7 and RN #5) for all confused residents on 08/19/16. Additionally, the QI nurse would re-educate all Department Managers regarding daily rounds to be performed during their shifts, throughout the buildings, for six (6) weeks beginning 08/23/16. 3. Review of the SSC Progress Notes, dated 08/18/16, revealed SSC #2 spoke with Resident #1 to discuss the events of 08/16/16 and identify any resident concerns. Continued review of the note revealed Resident #1 did not recall the incident and expressed no concerns. Additional review of SSC Progress Notes revealed follow-up interviews dated 08/19/16, 08/25/16, 08/30/16, and 09/02/16 continued to reveal no resident concerns. Additionally, on 09/06/16, SSC #2 discussed discharge plains with Resident #1's spouse, who made the decision to take Resident #1 home. Interview with SSC #2, on 09/15/16 at 4:27 PM, validated Resident #1 did not recall the incident and was discharged to home. Review of the Training Session Attendance form dated 08/23/16, titled Supervisor Daily Rounds , revealed the following attendee signatures: Administrator, DON, ADON, Unit Managers (LPN #3, LPN#7, and RN #5), Admissions Assistant, MDS nurses, DSM, RM, SSC, SDC, evening and night shift supervisor, Activity Assistant, HK Supervisor, CDM, AC, and RPM. Interviews on 09/15/16 with Activity Assistant #1 at 1:46 PM; Activity Assistant #2 at 2:01 PM, RM at 3:40 PM, SSC #2 at 4:27 PM, and SSC #1 at 6:16 PM, revealed they received training regarding abuse, cell phone use, and treating residents with dignity and respect. Each manager was able to discuss the training topics and explain the daily QI rounds they were responsible for. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated she was responsible for documenting the QI rounds conducted by the managers. She provided the QI audit sheet titled QI Team Rounds . Review of the audit revealed the daily rounds included environmental observation to ensure all resident areas were free of cell phones, residents ' state of dress and grooming, and the following questions: How are you today?; Are associates taking good care of you?; and Do you have any questions regarding your care? 4. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated the Success Plan was created to ensure all employees were held responsible for following the cell phone policy and to continue to monitor resident care areas. Continued interview revealed the Department Managers were re-educated on conducting daily rounds to ensure the staff was compliant with the facility ' s policy on cell phones, and providing dignity and privacy to all residents. She stated the facility's expectation was there would be no tolerance for failure to comply with the cell phone policy. Continued interview revealed a first offense would earn a written warning, and a second offense termination. 5. Review of the report sheets provided by the facility validated fifty (50) residents were interviewed regarding concerns related to dignity and respect. According to the reports, none of the residents expressed concerns. Interview with SSCs #1 on 09/15/16 at 5:16 PM, and SSC #2 on 09/15/16 at 4:27 PM, validated they conducted the interviews. They stated none of the residents expressed concerns related to dignity and respect. Observations on 09/13/16 beginning at 10:45 AM, revealed no concerns related to staff interactions with residents on the 200 hall. No failure to treat residents with dignity and respect was identified, and privacy was maintained during the provision of care. In addition, no staff was observed to be using cell phones in the resident care areas. Interviews with Resident #14 on 09/13/16 at 11:45 AM, and Resident #6 on 09/13/16 at 1:25 PM, revealed they denied any mistreatment by staff, and felt they were treated with respect. Continued interview revealed neither resident recalled seeing staff use cell phones in their rooms during care. 6. Review of the training packet which included information on cameras and tape recording, media inquiries, confidentiality of information, telephone use, HIPAA, abuse, dignity, and phones revealed the training was completed for all staff on 08/22/16, 08/23/16 and 08/24/16. Completed questionnaires related to the training, signed and dated by staff, were included in the packet. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the training and completed the questionnaire. In addition, the interviewed staff was able to discuss the training topics and exhibited an understanding of related facility policy. 7. Review of the Weekly Skin Integrity Review forms confirmed six (6) residents received skin assessments on 08/25/16, conducted by the DON, and Unit Managers (LPN# 3, LPN# 7 and RN #5). Continued review revealed no new skin issues were identified. Interview with the DON, on 09/15/16 at 6:25 PM, revealed the skin assessments were completed as documented, and no new skin concerns were identified. Continued interview with the DON revealed she assisted the unit managers with skin assessments on residents with a BIMS score of seven (7) and below, which indicated they were not interviewable. 8. Review of the training session attendance sheet dated 09/09/16 and titled Education Procedure on IJ, Corrective Action, Acknowledgement, QA Rounds, Abuse and Dignity, revealed training was provided by the Regional Director of Operations. Attendees included the QI Nurse, DON, Unit Managers, ADON, MRD, MDS Nurse, and the Administrator on speaker phone. Interviews on 09/15/16 with the QI Nurse at 5:51 PM, the DON at 6:25 PM, and the Administrator at 6:28 PM, revealed they were present for the training by the Regional Director of Care Services, and topics included the IJ, the facility's prohibition of staff having cell phones in the resident care areas, and signing an acknowledgment of understanding of facility policy. 9. Review of training sheets provided by the QI nurse on 09/15/16 revealed all staff received additional training on the prohibited use of cell phones in the resident care areas between 09/09/16 and 09/13/16. This training including the requirement for staff to sign their acknowledgement and understanding of the facility ' s policies related to cell phone use. Review of the signed acknowledgement forms revealed staff from all departments received the training and understood the facility ' s prohibition of using cell phones in resident care areas. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the additional education regarding no cell phone use in the facility, and were able to discuss the intent of the training and the consequences of failure to adhere to facility guidelines, up to and including termination of employment. 10. Review of the Employee Roster, dated 09/09/16, revealed 210 of 214 facility employees received mandatory training as part of the facility's corrective action prior to 09/14/16. Continued review of the roster revealed four (4) employees had not received the training provided by the facility. Review of sign-in sheets, completed questionnaires, and signed acknowledgement forms revealed they were consistent with the Employee Roster tracking form. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, revealed she had ensured 210 employees received the mandatory training prior to 09/14/16, and the remaining four (4) employees would not be able to work until the education was completed. She stated one (1) of the four (4) was in Africa, one (1) was on medical leave, one (1) was a new employee and had not yet started, and one (1) only worked PRN (as needed). Continued interview with the QI Nurse revealed all new employees received a handbook upon hire that addressed cell phone use in the facility. Additional interview with the QI nurse revealed it was her responsibility to ensure all employees received the training regarding cell phones, abuse, dignity, and HIPAA and would not be able to return to the facility until training is completed. 11. Review of the Administration Review of Daily QI Rounds revealed the QI Nurse audits were completed on 08/23/16, 08/24/16, 08/25/16, 08/26/16, 08/29/16, 08/30/16, 08/31/16, 09/01/16, 09/02/16, 09/06/16, 09/07/16, 09/08/16, 09/09/16, 09/10/16, 09/11/16, 09/12/16, 09/13/16, 09/14/16, and 09/15/16. Interview with the QI nurse, on 09/15/16 at 5:51 PM, revealed she signed off on the audits along with the Administrator, and was responsible for ensuring the audits continued to be completed. Interview with the Administrator, on 09/15/16 at 6:28 PM, revealed it was her responsibility to monitor all audits and see they were forwarded to the QI community, to ensure continued monitoring of cell phone use only outside of resident care areas, and for dignity and privacy to be upheld in the facility.

Based on interview, record review, and review of the facility's policy and Plan of Correction for 06/09/16 survey, it was determined the facility failed to maintain an effective Quality Assurance (QA) Program that was structured to identify quality issues with the potential for negatively affecting residents, and failed to develop and implement appropriate plans to correct identified deficient practices. This failure effected six (6) of twenty-eight (28) sampled residents (Resident #1, #11, #15, #16, #19, and #20). The facility failed to develop an effective plan of action when Administrative staff was made aware staff were using cell phones in resident care areas. State Survey Agency interviews identified multiple residents and staff who reported excessive and inappropriate cell phone usage; however, the facility failed to interview residents regarding cell phone usage. In addition, the facility failed to educate staff related to not using cell phones in resident care areas prior to 08/16/16. On 08/16/16, between 8:00 PM and 11:00 PM, Certified Nursing Assistant (CNA) #6 videotaped Resident #1 while care was being provided by two (2) other CNAs. The resident was unclothed during portions of the video, and his/her face was visible and recognizable. CNA #6 posted the video to a social media site. On 08/18/16, a former employee (FE) reported seeing the images on social media to the facility. (Refer to F-164, F-223, and F-226 ) In addition, the facility QA Program failed to develop an effective plan of action when a problem was identified in August 2016, with skin assessments and wound assessment documentation not being completed on admission, re-admission, and weekly. Interview and record review revealed the QA action plan failed to implement a skin sweep of all residents to ensure all wounds were identified and documented; failed to ensure skin assessments were completed weekly and were accurately; failed to ensure appropriate descriptions/documentation of wound assessments were completed; and failed to ensure all residents with wounds were being tracked weekly. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. This affected (5) of twenty-eight (28) sampled residents (Resident #11, #15, #16, #19, and #20). (Refer to F-314, and F-309) Also, the facility failed to develop an effective plan of action to ensure there was an effective infection control program related to proper hand hygiene during skin assessments and dressing changes. This was a repeat deficiency from an Abbreviated Survey with an exit date of 03/02/16. (Refer to F-441) The facility's failure to have an effective system in place to maintain an effective Quality Assurance (QA) Program that was structured to identify quality issues with the potential for negatively affecting residents, and to develop and implement appropriate plans to correct identified deficient practices has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/08/16 and determined to exist on 08/16/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/14/16 with the facility alleging removal of the Immediate Jeopardy on 09/14/16. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/14/16, prior to exit on 09/23/16, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Facility's policy, titled Quality Assurance Overview, dated October 2006, revealed the primary goals of the Quality Assurance Committee were to monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assurance Program and to provide a means whereby opportunities for improvement relative to resident care were identified and resolved through an interdisciplinary approach and positive outcomes were reinforced through education and monitoring. Suggested Committee Members included the Medical Director. 1. Review of the Center for Clinical Standards and Quality/Survey and Certification Group, Reference : S&C: 16-33-NH, published by the Centers for Medicare and Medicaid Services (CMS) and dated 08/05/16, revealed each resident had the right to be free from all types of abuse, including mental abuse. Mental abuse included, but was not limited to, abuse that was facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Further review revealed a nursing home resident had the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care. Continued review revealed taking photographs or recordings of a resident and/or his/her private space without the resident's or designated representative's written consent was a violation of the resident's right to privacy and confidentiality. Additionally, the CMS directive included each nursing home would review and/or revise their written abuse prevention policies and procedures to include and ensure that nursing home staff were prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a residents, including the use of any type of equipment (cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media. Review of the facility's Long Term Care Facility Self-Reported Incident Form, signed by the Administrator on 08/23/16, revealed a former employee (FE) came to the facility on [DATE] at 9:00 AM and reported inappropriate photos of Resident #1 were on a social media website. Further review of the facility's investigative findings revealed although the resident's face was visible in the images, staff faces were not shown; however, the facility identified Certified Nursing Assistants (CNAs) #1, #2 and #6 as being present in the resident's room at the time of the incident. The facility was confirmed CNA #6 recorded care of Resident #1 while CNAs #1 and #2 were present. Review of the facility's investigation of the incident revealed interviewable residents (resident with a Brief Interview for Mental Status of of eight (8) or above per the Minimum Data Set Assessment) were questioned regarding any concerns they may have related to dignity and respect. However, there was no documented evidence the residents were questioned about staff use of cell phones, for making or receiving calls; or for taking photos or video recordings, in the resident care areas. Additionally, review of the facility's list of interviewable residents revealed Resident #22 and Residents C, D, F, G and H were not interviewed at all. Interviews with each resident by the State Survey Agency, on 09/08/16, revealed all each resident reported having frequently observed staff using their cell phones, making and receiving calls, in their rooms or other common areas. However, Residents #22, C, D, F, G and H revealed no facility staff had interviewed them regarding a concern related to this practice. Staff interviews conducted by the State Survey Agency further revealed staff knew they could not use their cell phones in resident care areas, but this was not enforced by the facility and everyone was on their phones, from direct care staff, to nurses, to administration. Interview with the Director of Nursing (DON), on 09/08/16 at 9:12 PM, revealed she had noticed staff with their phones out in resident care areas and she had instructed them to put the phones away. She stated she was not sure the Administrator knew about staff using their phones in the care area; however, stated the Administrator should have been made aware. Interview with the Administrator, on 09/15/16 at 6:28 PM, and on 09/23/16 at 5:30 PM, revealed the Ombudsman had informed her about staff using their phones during dining service prior to the incident with Resident #1 on 08/16/16, and her resolution was to have staff monitor more closely during dining services for the use of cell phones. However, the Administrator was unable to provide specific details of re-education about cell phone usage, or evidence that monitoring for cell phone usage was documented prior to the incident on 08/16/16. Continued interview revealed she had not contacted the Medical Director related to the incident with Resident #1, because she was in the process of changing contracts for Medical Directors and did not see the need to contact the current Medical Director. Per interview, she was aware of the Standards and Quality/Survey & Certification group memo that was sent to all facilities on 08/05/16, and followed guidelines that were expressed by the Center for Medicare and Medicaid Services (CMS). Interview with the Medical Director, on 09/20/16 at 8:07 AM and 12:55 PM, revealed he was the facility's Medical Director and had attended a few QA meetings. He revealed he was not informed by the Administrator about Resident #1. He stated he found out about the information from his Nurse Practitioner who heard the information on the news. The Medical Director stated he would have expected to be notified about the incident so that he could have assisted the facility with a plan of correction. 2. Review of the facility's Skin Observation and Wound Prevention Protocol, revised July 2015, revealed upon admission the Charge Nurse would complete physical observation documenting findings within the Admission Data Collection form and if a wound was present on admission the Charge Nurse would initiate and describe the wound on the Weekly Wound Data Collection Sheet (WWDCS), complete the Braden Scale, notify the Dining Service Manager, initiate treatment intervention, and initiate a Plan of Care. Further review revealed weekly the Charge Nurse would complete the Skin Integrity Review form for all residents; document any integumentary findings including appearance of the wound and treatment applied/initiated per health care provider order in the progress notes; initiate treatment interventions per health care provider order for new or newly identified wounds; initiate or continue to describe the wound on the WWDCS; and update plan of care with each intervention. Continued review of the Protocol, revealed the Director of Clinical Services (Director of Nursing) or designee should weekly review the WWDCS providing direction and oversight; review the Weekly Pressure Ulcer and Weekly Skin Reports; notify health care provider within Twenty-Four (24) hours of all new in-house acquired pressure ulcers, and update the care plan at the time of new in house pressure ulcer or skin integrity issues, when identified and /or change of condition identified. Interview on 09/22/16 at 1:00 PM, with the Assistant Director of Nursing (ADON)/Wound Nurse, revealed Licensed Practical Nurses (LPN's) could not stage pressure ulcers per the facility's policy, and the staging would have to wait until a Registered Nurse (RN) could assess the wound. She further stated the previous DON completed the Weekly Wound Data Collection Sheet (WWDCS) which was the form where the wounds were staged, described, and measured weekly, up until she left the facility in the middle of July 2016, and then it was the Unit Managers responsibility to ensure these forms were completed every week. Continued interview, revealed she was the Acting DON after the previous DON left and this was verbally communicated by her to the Unit Managers during a morning meeting and she assumed the Unit Managers informed the floor nurses they were to complete the WWDCS by checking the computer each shift to see which residents were due to have the WWDCS completed. However, she stated she had not ensured there was education with the licensed staff related to this process change, related to the WWDCS Form, or related to how to stage, describe and measure wounds. In addition, there was no documented evidence she had informed the Unit Managers of this process change. Additional interview with the ADON/Wound Nurse, revealed the Unit Managers were to audit the wound documentation weekly in the Collaborative Care Review (CCR) Meeting where wounds were to be discussed. However, she stated she did not always attend these CCR Meetings and at the time the previous DON left, she did ensure there was a tracking system to ensure the WWDCS were being completed weekly for each resident who was identified to have a wound. She further stated she was unaware the WWDCS was not being completed weekly until a Corporate Nurse came to the facility in August 2016 to review documentation and identified this concern. She stated at that time the Corporate Nurse told her she would be responsible for completing the WWDCS for each wound which was to start 08/24/16, and she had been completing the WWDCS weekly herself since that date. Per interview once it was revealed there was a concern with the WWDCS not being completed weekly for each wound, there was no skin sweep to evaluate the current condition of the wounds, and again no education with licensed nurses related to the facility's wound protocol related to assessing and documenting wounds on admission, re-admission, or weekly. Per her interview, the resolution was to find out from each Unit Manager which residents had wounds and start doing the WWDCS herself. Interview on 09/23/16 at 2:00 PM with the Quality Assurance Nurse, revealed when it was identified in August 2016, by the Corporate Nurse that the wound assessments were not being completed weekly with tracking of the wounds it was discussed in the QA Meeting which took place on 08/24/16. She stated the Plan was to have the ADON to take over completing the Weekly Wound Data Collection Flowsheets. She further stated during the meeting there was no discussion of concerns with the nurses not completing the Weekly Wound Data Collection Flowsheets on admit or re-admit, no discussion of the need for licensed nurses to be educated related to describing, staging, and measuring wounds, and no discussion of the need for nurses to know which forms they were to complete and how to complete the forms in the electronic system. Continued interview revealed she was not aware of a skin sweep being done or discussed in the meeting. She further stated the Medical Director did not attend this meeting. Review of the QA Meeting signature sheet for 08/24/16, revealed there was no signature for the Medical Director. Interview with the DON on 09/23/16 at 9:24 AM, revealed she had been the Unit Manager on the Rehab Unit before taking the position as DON three (3) weeks ago. She stated at the time she took her position as DON, the ADON was already completing the WWDCS. Continued interview revealed she had done a skills fair in July 2016 related to documentation of wounds and she went through the computer program point click care with licensed nurses; however, had not ensured all nurses received this education. Interview with the Medical Director, on 09/23/16 at 12:30 PM, revealed he he was not notified until this morning that Corporate had identified a concern back in August related to pressure ulcers and Vascular ulcers not being documented as per the wound protocol and this morning he also learned the concern was ongoing. He revealed pressure ulcers were avoidable in most cases and wounds had to be consistently and accurately assessed, and monitored to ensure they were healing and not deteriorating. He further stated he desired to be notified of facility concerns, but had missed the Quality Assurance Meeting in August and was not notified related to the wounds not being consistently assessed. Interview with the Administrator, on 09/23/16 at 4:00 PM, revealed up until the middle of July 2016, the previous DON was completing the weekly WWDCS. The Administrator acknowledged after the previous DON, left it was unclear who was completing the WWDCS, but it was her expectation the Unit Managers ensured they were being completed during the transition time. However, per interview there was no formal meeting to inform the Unit Managers of their responsibility in the process change and she was unsure if there was any tracking of the wounds during this transition time. She stated during August 2016, the Corporate Nurse stayed at the facility for about three (3) weeks to assist after the previous DON left and on 08/24/16 the corporate nurse met with the ADON, the new DON, and the Quality Assurance (QA) Nurse and reviewed their duties. She further revealed during the meeting the corporate nurse revealed there needed to be someone in the leadership role related to wounds because concerns were identified related to clinical records and documentation and the wound protocol not being followed. The Administrator further revealed, during this meeting the Corporate Nurse discussed the success plan going forward which included placing the ADON in charge of completing the WWDCS herself, and ensuring wounds were tracked. Continued interview with the Administrator, verified she was unaware there was a concern with the WWDCS not being completed until after the Corporate Nurse identified the problem in August. She further stated, after the concern was recognized in August related to the WWDCS not being consistently completed, there was no housewide skin sweep to visualize wounds and compare with documentation and treatment orders or to look for unidentified wounds. In addition, she stated there was no inservice housewide for all licensed staff to ensure they understood their roles related to pressure ulcers and the facility wound protocol. 3. Based on observation, interview, and record review, it was determined the facility failed to maintain an effective infection control program in order to prevent the development and transmission of disease and infection within the facility. This was a repeat deficiency for the facility which was cited 06/09/16 for deficiencies related to staff failing to perform hand hygiene when appropriate during a dressing change. Review of the facility's Plan of Correction, with a compliance date of 07/22/16, revealed re-education was completed for all licensed nurses and CNA's regarding hand washing techniques and replacing gloves per handwashing/hand hygiene policy. Further review revealed a dressing change would be observed weekly for six (6) weeks by Administrative Nurses for proper hand washing techniques and replacing gloves as appropriate. Continued review revealed the result of the audit would be forwarded to the the QA committee monthly. Observation during this survey on 09/14/16, revealed a nurse to failed to perform hand hygiene after moving a trash can with her hands and prior to conducting the skin assessment for Resident #11. In addition, the same nurse failed to use proper hand hygiene prior to checking Resident #11's peri -area during the skin assessment. In addition, observation during this survey of a skin assessment and dressing changes for Resident #15 on 09/15/16, revealed the nurse failed to perform hand hygiene and change gloves at appropriate times during the skin assessment and before and after treatment and dressing changes to the resident's multiple wounds. Interview on 09/23/16 at 2:00 PM with the QA Nurse, revealed staff were re-educated related to hand hygiene and proper glove use on 07/01/16 by the QA Nurse and other administrative nurses for CNA's and licensed nurses. She further stated observations of nurses completing dressing changes were done weekly for six (6) weeks; however, the audits did not continue after that as there were no more concerns with hand hygiene not being performed with the audits. Interview on 09/23/16 at 9:24 AM with the DON, (DON) revealed it was her expectation that hand hygiene and change of gloves be be performed at appropriate times prior to, during, and after skin assessments and dressing changes. She revealed until this survey, she was unaware there was a continued concern with hand hygiene. Interview with the administrator on 09/23/16 at 4:00 PM, revealed she was unaware there were continued concerns with hand hygiene and glove use. The facility provided an acceptable credible allegation of compliance (AOC) on 09/14/16 that alleged removal of the Immediate Jeopardy (IJ) effective 09/14/16. Review of the AOC revealed the facility implemented the following: 1. On 08/08/16, the facility identified three (3) associates who participated in the event regarding Resident #1. They were immediately suspended, not to return to work pending investigation by the Administrator and Director of Clinical Services (DCS). 2. On 08/18/16, a Success Plan was initiated by the Interdisciplinary Team. The plan outlined actions taken by the facility to protect the residents, with all measures noted on the Success Plan to be completed on or before 08/24/16. 3. On 08/18/16 and 08/19/16, the SSC provided counseling to Resident #1 with weekly follow-up to be provided as needed for the next three (3) weeks. 4. On 08/23/16, a training session was provided by the QI nurse to the following: Administrator, DON, ADON, Unit Managers, Admission Assistant; Minimum Data Set (MDS) nurses, Dining Service Manager (DSM), Rehabilitation Manager (RM), SSCs, Staff Development Coordinator (SDC), evening and night shift supervisors, Activity Assistant, Housekeeping (HK) Supervisor, Certified Dietary Manager (CDM), Admission Coordinator (AC), and Resident Program Manager (RPM). The training by the QI nurse to the managers was to ensure no cell phones were in use in resident care areas, and included education on daily rounds to be completed each day by the managers on duty. 5. On 08/23/16, SSC #1 and SSC #2 interviewed fifty (50) residents with a BIMS score of eight (8) or above regarding being treated with dignity and respect. (A BIMS score of 8 or above indicates the resident is considered no more than mild to moderately cognitively impaired, and therefore interviewable.) 6. All staff were re-educated on or before 08/24/16. The QI nurse and SSCs #1, and #2 provided the re-education for all staff regarding the Health Insurance Portability and Accountability Act (HIPAA), abuse, dignity, and privacy. In addition, the education emphasized a prohibition of cell phone use by staff in resident/work areas, with violation to result in corrective action up to and including termination of employment. 7. On 08/25/16, six (6) skin assessments were reviewed for residents with BIMS score of seven (7) or below, who lived on the same hall as Resident #1. The Unit Manager and/or the DON reviewed the skin assessments in order to identify any suspicious areas of concern. 8. On 09/09/16, a training session was provided in the facility by the Regional Director of Care Services to educate the QA nurse, DON, Unit Managers, ADON, Medical Records Director (MRD), Central Supply Clerk (CSC), Health Care Liaison (HCL), and MDS Nurses. The Administrator was not present in the facility; however, was present by speaker phone. The training topics included the facility's Immediate Jeopardy (IJ), corrective actions, signing of acknowledgement of the facility's cell phone practice, QI rounds, abuse and dignity. 9. On 09/9/16 through 09/13/16 employees received training to reiterate the prohibiting of cells phones in resident care areas. 10. The facility documented 210 of 214 employees were educated on cell phone use, dignity, abuse and HIPAA as of 09/13/16. 11. Beginning on 08/23/16, the QA nurse and/or Administrator will review the daily audits five (5) days a week for two (2) weeks, then bi-weekly for four (4) weeks. In addition, the Administrator will review ongoing education and sign-in sheets to ensure education is completed for each employee, including agency staff and new hires, prior to them working in resident areas. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's final investigative report, dated 08/23/16, revealed the facility confirmed CNA #6 recorded Resident #1 during care, and CNAs #1 and #2 were present during the recording. Continued review of the report revealed the three (3) CNAs were terminated from employment. Interviews with the QA Nurse, the DON, and the Administrator on 09/15/16 revealed the CNAs were suspended at the beginning of the investigation, and ultimately terminated from employment by the facility. Review of the Corrective Action form dated 08/23/16, signed by the Administrator and witnessed by the Human Resources Director, revealed the Administrator spoke with CNA #1, CNA #2 and CNA #6 by phone, and informed them due to their knowing participation in a violation of the facility's policy related to social media, the decision had been made to terminate their employment, effective immediately. 2. Review of the Community Success Plan, dated 08/18/16, revealed the facility's Plan of Action/Correction included re-education by Department Managers of all staff related to HIPAA, abuse, dignity, privacy, and cell phone use beginning on 08/18/16, to be completed by 08/24/16. Continued review of the Success Plan revealed SSCs were assigned to provide patient counseling for Resident #1 on 08/18/16 and 08/19/16. In addition, they were to interview all alert and oriented residents in the building regarding being treated with dignity and respect on 08/23/16. Further review of the Success Plan revealed skin assessments to identify any suspicious areas were to be completed by the Unit Managers (LPN #3, LPN #7 and RN #5) for all confused residents on 08/19/16. Additionally, the QI nurse would re-educate all Department Managers regarding daily rounds to be performed during their shifts, throughout the buildings, for six (6) weeks beginning 08/23/16. 3. Review of the SSC Progress Notes, dated 08/18/16, revealed SSC #2 spoke with Resident #1 to discuss the events of 08/16/16 and identify any resident concerns. Continued review of the note revealed Resident #1 did not recall the incident and expressed no concerns. Additional review of SSC Progress Notes revealed follow-up interviews dated 08/19/16, 08/25/16, 08/30/16, and 09/02/16 continued to reveal no resident concerns. Additionally, on 09/06/16, SSC #2 discussed discharge plains with Resident #1's spouse, who made the decision to take Resident #1 home. Interview with SSC #2, on 09/15/16 at 4:27 PM, validated Resident #1 did not recall the incident and was discharged to home. Review of the Training Session Attendance form dated 08/23/16, titled Supervisor Daily Rounds , revealed the following attendee signatures: Administrator, DON, ADON, Unit Managers (LPN #3, LPN#7, and RN #5), Admissions Assistant, MDS nurses, DSM, RM, SSC, SDC, evening and night shift supervisor, Activity Assistant, HK Supervisor, CDM, AC, and RPM. Interviews on 09/15/16 with Activity Assistant #1 at 1:46 PM; Activity Assistant #2 at 2:01 PM, RM at 3:40 PM, SSC #2 at 4:27 PM, and SSC #1 at 6:16 PM, revealed they received training regarding abuse, cell phone use, and treating residents with dignity and respect. Each manager was able to discuss the training topics and explain the daily QI rounds they were responsible for. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated she was responsible for documenting the QI rounds conducted by the managers. She provided the QI audit sheet titled QI Team Rounds . Review of the audit revealed the daily rounds included environmental observation to ensure all resident areas were free of cell phones, residents ' state of dress and grooming, and the following questions: How are you today?; Are associates taking good care of you?; and Do you have any questions regarding your care? 4. Interview with the QI Nurse, on 09/15/16 at 5:51 PM, validated the Success Plan was created to ensure all employees were held responsible for following the cell phone policy and to continue to monitor resident care areas. Continued interview revealed the Department Managers were re-educated on conducting daily rounds to ensure the staff was compliant with the facility ' s policy on cell phones, and providing dignity and privacy to all residents. She stated the facility's expectation was there would be no tolerance for failure to comply with the cell phone policy. Continued interview revealed a first offense would earn a written warning, and a second offense termination. 5. Review of the report sheets provided by the facility validated fifty (50) residents were interviewed regarding concerns related to dignity and respect. According to the reports, none of the residents expressed concerns. Interview with SSCs #1 on 09/15/16 at 5:16 PM, and SSC #2 on 09/15/16 at 4:27 PM, validated they conducted the interviews. They stated none of the residents expressed concerns related to dignity and respect. Observations on 09/13/16 beginning at 10:45 AM, revealed no concerns related to staff interactions with residents on the 200 hall. No failure to treat residents with dignity and respect was identified, and privacy was maintained during the provision of care. In addition, no staff was observed to be using cell phones in the resident care areas. Interviews with Resident #14 on 09/13/16 at 11:45 AM, and Resident #6 on 09/13/16 at 1:25 PM, revealed they denied any mistreatment by staff, and felt they were treated with respect. Continued interview revealed neither resident recalled seeing staff use cell phones in their rooms during care. 6. Review of the training packet which included information on cameras and tape recording, media inquiries, confidentiality of information, telephone use, HIPAA, abuse, dignity, and phones revealed the training was completed for all staff on 08/22/16, 08/23/16 and 08/24/16. Completed questionnaires related to the training, signed and dated by staff, were included in the packet. Interviews on 09/15/16 with CNA #8 at 11:27 AM, CNA #10 at 11:37 AM, CNA #11 at 11:47 AM, CNA #9 at 11:54 AM, Activity Assistant #1 at 1:46 PM, Housekeeping (HK) staff #1 at 1:57 PM, Activity Assistant #2 at 2:01 PM, HK #2 at 2:14 PM, CNA #12 at 2:25 PM, Dietary Server #1 at 2:30 PM, DM at 2:36 PM, HK #3 at 2:44 PM, Cook #2 at 2:53 PM, HK #4 at 2:59 PM, CNA #14 at 3:05 PM, Dietary Server #2 at 3:11 PM, CNA #15 at 3:17 PM, CNA #13 at 3:27 PM, LPN #5 at 4:16 PM, CNA #16 at 4:36 PM, and LPN #8 at 5:10 PM revealed all had received the training and completed the questionnaire. In addition, the interviewed staff was able to discuss the training topics and exhibited an understanding of related facility policy. 7. Review of the Weekly Skin Integrity Review forms confirmed six (6) residents received skin assessments on 08/25/16, conducted by the DON, and Unit Managers (LPN# 3, LPN# 7 and RN #5). Continued review revealed no new skin issues were identified. Interview with the DON, on 09/15/16 at 6:25 PM, revealed the skin assessments were completed as documented, and no new skin concerns were identified. Continued interview with the DON revealed she assisted the unit managers with skin assessments on residents with a BIMS score of seven (7) and below, which indicated they were not interviewable. 8. Review of the training session attendance sheet dated 09/09/16 and titled Education Procedure on IJ, Corrective Action, Acknowledgement, QA Rounds, Abuse and Dignity, revealed training was provided by the Regional Director of Operations. Attendees included the QI Nurse, DON, Unit Managers, ADON, MRD, MDS Nurse, and the Administrator on speaker phone. Interviews on 09/15/16 with the QI Nurse at 5:51 PM, the DON at 6:25 PM, and the Administrator at 6:28 PM, revealed they were present for the training by the Regional Director of Care Services, and topics included the IJ, the facility's prohibition of staff having cell phones in the resident care areas, and signing an acknowledgme

Based on observation, interview, record review, and review of facility's policy, it was determined the facility failed to ensure the facility's protocol was implemented related to pressure ulcers to ensure a resident at risk for pressure ulcers or a resident with pressure ulcers, received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for five (5) of twenty-eight (28) sampled residents (Resident #11, #15, #16, #19, and #20). Review of the facility Skin Observation and Wound Prevention Protocol, revealed on admission the Charge Nurse was to complete a physical observation and document findings with the Admission Data Collection Form and if a wound was present on admission, the Charge Nurse would initiate and describe the wound on the Weekly Wound Data Collection Sheet (WWDCS). Further review revealed the Charge Nurse was to complete the Skin Integrity Review Form for all residents weekly, and if a wound was present, the Charge Nurse would initiate or continue to describe the wound on the WWDCS. Staff interview and record review for the timeframe investigated February 2016 through September 2016, revealed pressure ulcers were not measured, described, staged, nor treatments obtained timely for new admissions or re-admissions with pressure ulcers, and also for residents with newly identified pressure ulcers. In addition, the Weekly Wound Data Sheets (WWDCS's) were not completed timely, or were not completed at all for wounds, and there was no documented evidence of consistent monitoring of the progress of the residents' wounds. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. The findings include: Review of the facility's Skin Observation and Wound Prevention Protocol, revised July 2015, revealed upon admission the Charge Nurse would complete physical observation documenting findings within the Admission Data Collection form and if a wound was present on admission the Charge Nurse would initiate and describe the wound on the Weekly Wound Data Collection Sheet (WWDCS), complete the Braden Scale, notify the Dining Service Manager, initiate treatment intervention, and initiate a Plan of Care. Further review revealed weekly the Charge Nurse would complete the Skin Integrity Review form for all residents; document any integumentary findings including appearance of the wound and treatment applied/initiated per health care provider order in the progress notes; initiate treatment interventions per health care provider order for new or newly identified wounds; initiate or continue to describe the wound on the WWDCS; and update plan of care with each intervention. Continued review of the Protocol, revealed the Director of Clinical Services (Director of Nursing) or designee should weekly review the WWDCS providing direction and oversight; review the Weekly Pressure Ulcer and Weekly Skin Reports; notify health care provider within Twenty-Four (24) hours of all new in-house acquired pressure ulcers, and update the care plan at the time of new in house pressure ulcer or skin integrity issues, when identified and /or change of condition identified. Interview on 09/22/16 at 1:00 PM, with the Assistant Director of Nursing (ADON)/Wound Nurse, revealed the nurse who conducts the Admission Assessment was responsible for entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet as part of the development of the Initial Care Plan by checking the intervention check skin on a daily and weekly basis, in order for the Weekly Skin Integrity Review and the Weekly Wound Data Collection to appear on the Physician's Orders and on the Treatment Administration Record in the electronic system. She stated this process would allow the electronic system to alert the nurses that the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheets were due to be completed. She further stated the floor staff nurses were to complete the Admission Data Collection Form related to pressure ulcers on admission, and re-admission to measure and describe pressure ulcers, but not necessarily stage the pressure ulcers because Licensed Practical Nurses (LPN's) could not stage pressure ulcers according to the facility's policy. She stated the staging would have to wait until a Registered Nurse (RN) could assess the wound. Further interview revealed the floor nurses were to complete the Weekly Skin Integrity Reviews (WSIR) on a weekly basis and on this form they did not have to list the staging or measurements of wounds. She further stated the previous DON completed the Weekly Wound Data Collection Sheet (WWDCS) which was the form where the wounds were staged, described, and measured weekly, up until she left the facility in the middle of July 2016, and then it was the Unit Managers responsibility to ensure these forms were completed weekly. She stated she was the Acting DON after the previous DON left and this was verbally communicated by her to the Unit Managers during a morning meeting and she assumed the Unit Managers informed the floor nurses they were to complete the WWDCS weekly by checking the computer each shift to see which residents were due to have the WWDCS completed. She further revealed she had not ensured there was education with the licensed staff related to this process change, related to the WWDCS Form, or related to how to stage, describe and measure wounds. In addition, she had no documented evidence she had informed the Unit Managers of this process change. Further interview with the ADON/Wound Nurse, revealed the Unit Managers were to audit the wound documentation weekly in the Collaborative Care Review (CCR) Meeting where wounds were to be discussed. However, she stated she did not always attend these CCR Meetings and at the time the previous DON left, she did not have a tracking system to ensure the WWDCS was being done weekly for each resident who was identified to have a wound. She stated she was unaware the WWDCS was not being completed weekly until a Corporate Nurse came to the facility in August 2016 to review documentation and identified the concern. She stated at that time the Corporate Nurse told her she would be responsible for completing the WWDCS for each wound which was to start 08/24/16, and she had been completing the WWDCS weekly since that date. Continued interview revealed once it was revealed there was a concern with the WWDCS not being completed weekly for each wound, there was no skin sweep to evaluate the current condition of the wounds, and again no education with licensed nurses related to the facility's wound protocol related to assessing and documenting wounds on admission, re-admission, or weekly. She stated she just went to each Unit Manager to find out which residents had wounds and started doing the WWDCS on 08/23/16 herself. 1. Review of Resident #20's medical record revealed the facility admitted the resident on 08/04/16 with [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection Form dated 08/04/16 under the section titled Skin Integrity revealed Resident #20 was assessed as having a Stage II Pressure Ulcer to the sacrum region measuring Length (L) 4.4 centimeters (cm) x Width (W) 9.2 cm x Depth (D) 0.1 cm. The documented Braden Scale Score as part of the Nursing Admission Collection Form was fourteen (14) and per the scale if the total score was sixteen (16) or less initiate skin integrity interventions and document on the Interim Care Plan. Review of the Admission MDS assessment dated [DATE] revealed the facility assessed Resident # 20 as having a single Stage II Pressure Ulcer at the time of admission to the facility. Review of Resident #20's Care Plan, initiated on 08/04/16 and revised 09/02/16, revealed the resident had impaired skin integrity related to a Stage II Pressure Ulcer. The goal stated the resident would not have worsening of skin alteration through the next review date. Documented interventions to achieve the stated goal included applying a moisture barrier to protect the skin surrounding the wound, providing wound treatment per Physician's orders, encouraging good nutrition and hydration and evaluating the resident's skin condition on a daily and weekly basis. Review of Physician's Orders dated 08/04/16, revealed orders for Venelex Ointment (topical debridement chemical agent) to be applied to the coccyx wound topically every day and night shift related to pressure ulcers of the sacral region. Further review revealed no orders for a Weekly Skin Integrity Review nor orders to document any wounds on the Weekly Wound Data Collection Sheet, as per protocol in order for the electronic record to alert the nurses the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet were due to be completed. Review of Resident #20's August 2016 Treatment Administration Record (TAR) revealed wound care was documented as being provided as ordered by the resident's physician starting 08/04/16. Further review of Resident # 20's August 2016 TAR revealed no intervention for a Weekly Skin Integrity Review or a Weekly Wound Data Collection. Further review of Resident #20's medical record revealed there was no documented evidence of a Weekly Wound Data Collection Sheet and no documented evidence the resident's wound was assessed after the wound assessment on admission, 08/04/16. Interview conducted on 09/21/16 at 1:59 PM, with Licensed Practical Nurse (LPN) #3, revealed on 08/04/16 he had been pulled to Resident # 20's assigned unit to help with the admission process and had conducted Resident # 20's initial assessment. While reviewing the 08/04/16 initial assessment documentation, LPN #3 acknowledged the resident's wound staging and measurements were accurate at the time the assessment was conducted. During the interview LPN # 3 stated I assessed the wound as a Stage 2 Pressure Ulcer. When asked if staging a pressure ulcer was allowed by an LPN under facility policy, LPN # 3 stated, As an LPN, I am trained to recognize tissue types but I'm not sure what the facility's policy is. LPN # 3 acknowledged he also initiated wound care interventions on the resident's Care Plan per the electronic record. Upon review of the Care Plan LPN #3 acknowledged he missed entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet on the Care Plan; therefore, this data did not get carried over to the Physician's orders or the TAR for August 2016. LPN #3 revealed the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet wound have to be initiated on the resident's electronic Care Plan, in order to alert the facility nurses that a wound assessment was due to be conducted. Review of Resident #20's Physician's orders dated 08/16/16, revealed the resident's pressure ulcer treatment orders were changed from applying Venelex to the wound twice a day to applying Santyl (topical debridement chemical agent) to the wound twice a day and then covering the wound with an Alleyn dressing. Telephone interview was attempted with the resident's Physician's Assistant (PA) on 08/23/16 at 11:03 AM; however, the PA did not return the call. Post Survey interview conducted by telephone on 09/27/16 at 5:02 PM, with the resident's PA, revealed she was unsure if she had ever assessed Resident # 20's wound. The PA stated she was unable to recall any details of Resident # 20's pressure ulcer without reviewing the medical record. When asked about the Physician's order written on 08/16/16 for the topical chemical [MEDICATION NAME] agent Santyl, the PA stated a facility nurse must have called her and made the request for the topical agent. The PA stated, she probably did describe the wound to me but I don't recall. I see a lot of residents with a lot of wounds and for me to remember anything about this particular wound is impossible. When asked if she believed facility staff should have notified her if Resident # 20's wound status began to deteriorate, the PA stated obviously, I would expect staff to call me and let me know if a resident's wound was getting worse. Review of RN #1's Nurse's Note entry dated 08/24/16 at 1:41 PM, revealed the resident was transferred to an Acute Care Hospital (ACH) for unresponsiveness. Review of Resident #20's ACH Discharge Summary dated 08/30/16, revealed the resident's admitting [DIAGNOSES REDACTED]. Further review revealed the resident underwent [REDACTED]. Per the ACH Discharge Summary, Resident # 20's pressure ulcer wound was most likely not a cause of infection to the resident. Observation on 9/20/16 at 11:09 AM, of Resident #20's wound care performed by Registered Nurse (RN) #5 and Licensed Practical Nurse (LPN) #12, revealed the presence of a Stage IV pressure ulcer to the resident's coccyx area. The wound was observed to have a beefy pink wound bed with edges well approximated and scant blood tinged drainage. The wound measured by RN # 5 revealed the wounds was 4.0 cm W x 3.3 cm L x 1.5 cm D and staged at a Stage IV pressure ulcer. RN # 5 treated and assessed the wound with the assistance of LPN # 12. During Resident # 20's wound care, RN #5 revealed the resident's wound had been recently surgically debrided at an outside facility. Interview with RN #5 immediately following Resident # 20's dressing change, revealed the resident had been transferred to an Acute Care Hospital (ACH) on 08/24/16 following a change in mental status. RN #5 further stated while recovering at the ACH Resident # 20 underwent the unscheduled surgical procedure to debride the wound. Interview conducted 09/21/16 at 3:24 PM, with LPN #24, revealed she conducted Resident # 20's dressing changes a total of seven (7) times from the time of the residents admission on 08/04/16 through the residents transfer to the ACH on 08/24/16. LPN #24 acknowledged performing the resident's dressing changes on the following dates: 08/08/16, 08/12/16, 08/13/16, 08/14/16, 08/18/16, 08/19/16 and 08/22/16. During the interview LPN # 24 was able to provide limited details of her recollection of the resident's wound. The LPN stated I recall very little about this wound. The top layer of skin was off and it had slough tissue. The day before he/she was sent out to the hospital, it seemed it was getting larger but not deeper. LPN #24 verified she signed-off when she performed the resident's dressing changes and verified the resident had a wound to the coccyx as per her Nurse's Progress Notes. She stated, I did not measure or document a description of the wound, but if there had been a wound assessment that was due on my shift I would have done it. She stated the wound assessment did not show up on the electronic TAR to be done while she was assigned to the resident. Continued interview revealed when she recognized a wound needed to be measured, she would alert the ADON. LPN #24 stated the previous DON was measuring, staging and describing wounds when she first started working at the facility a few months ago. She stated after the previous DON left, the ADON was then responsible for measuring the wounds. Interview conducted on 09/21/16 at at 4:09 PM, with RN # 1, revealed the RN conducted Resident # 20's dressing changes a total of three (3) times from the time of the residents admission on 08/04/16 through the residents transfer to the ACH on 08/24/16. RN #1 acknowledged performing the resident's dressing changes on the following dates: 08/10/16, 08/17/16 and 08/24/16. During the interview RN #1 stated, she did not remember much about the wound and she did not remember ever documenting an assessment of the resident's coccyx wound. When asked how she would be alerted if a resident was due to have a wound assessment performed, RN # 1 stated If a resident is due to have a wound assessment, it will appear on the electronic Treatment Record. That's what guides us to conduct an ordered wound assessment. Interview on 09/21/16 at 2:37 PM, with the North Unit Manager (UM), revealed weekly skin assessments were ordered for every new resident. During the interview, the UM revealed she was on vacation and not at the facility on the day the facility admitted Resident #20. The UM further revealed she was unaware of who was designated to enter the weekly wound assessment order in her absence. The UM acknowledged there was no Physician's order for weekly wound assessments for the resident on the day of admission to the facility, and since the resident was admitted with a Stage II pressure ulcer, an order for [REDACTED]. Interview, on 09/22/16 at 12:59 PM, with the ADON/Wound Nurse revealed the nurse who conducted Resident #20's Admission Assessment was responsible for entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet as part of the development of the initial care plan, in order for it to appear on the resident's TAR. The ADON stated, Since no Weekly Wound Data Review appears on Resident #20's Treatment Record, it goes to reason that it was not entered by LPN #3 when he did the initial assessment. During the interview, the ADON acknowledged Resident #20's coccyx pressure ulcer was not measured and staged following the admission assessment and prior to transfer and admission to the ACH on 08/24/16. Further interview with the ADON/Wound Nurse, revealed as Acting DON, at the end of July, she informed the Unit Managers they were ultimately responsible for ensuring the Weekly Wound Data Collection Sheets were completed for those residents assigned to their individual units. She verified during the time of 08/04/16 through 08/24/16, the Unit Managers should have ensured the Weekly Wound Data Collection Sheets were completed. Interview on 09/23/16 at 2:22 PM, with the DON revealed she assumed her responsibilities as DON at the facility on 09/06/16, and prior to assuming the DON responsibilities she was the UM on the facility's Rehab Unit. She stated prior to 09/06/16, she had no involvement with Resident # 20's pressure ulcer wound. The DON revealed it was her understanding Resident # 20 was admitted with a Stage II pressure ulcer on 08/04/16, was transferred to an ACH on 08/24/16, underwent a surgical debridement and came back with a Stage IV pressure ulcer. The DON acknowledged it was the admitting nurse's responsibility to enter a weekly wound monitoring assessment as part of the admission orders [REDACTED]. The DON stated wounds were discussed every morning, Monday through Friday, during clinical meetings; however, she could not recall if Resident # 20's wound was discussed during any of the morning clinical meetings prior to the resident being transferred to the ACH on 8/24/16. Per interview, staff nurses who conducted the twice a day dressing changes for the resident would not have been responsible for conducting the weekly wound assessments. Interview on 09/23/16 at 4:03 PM, with the facility's Administrator, revealed she was unaware the admission wound assessment was the only wound assessment done for Resident #20 prior to the resident's transfer to the ACH. She stated she was unaware of the lack of documentation related to skin assessments for Resident #20 until after Surveyor intervention. She further stated it was her expectation that wounds be properly staged, described, and measured on admission and weekly thereafter. The Administrator stated it was a concern if a resident's wound was not assessed for a couple of weeks and potential skin issues could arise or worsening wounds could occur if not assessed. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 07/15/16 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary, dated 07/15/16, from the transferring facility revealed Resident #19 had an active problem of Decubitus Ulcer of the Heel as of 07/11/16. Continued review of the paperwork from the Hospital revealed a Wound Progress Note, dated 07/11/16, describing Stage II areas of partial thickness skin loss of 0.5 cm L X 0.5 cm W on either side of the sacrum. Further review of the Wound Progress Note revealed a Suspected Deep Tissue Injury (SDTI) to the left heel which measured 2.0 cm X 2.0 cm and was non-blanchable. Review of the Admission/Readmission Report Sheet completed by Registered Nurse (RN) #4, dated 07/15/16, revealed it was reported by the Hospital, Resident #19 had a reddened area to the coccyx/buttocks and a left heel Deep Tissue Injury (DTI). Review of the Admission Data Collection Form, dated 07/15/16, completed by Licensed Practical Nurse (LPN) #16, revealed under Section 2 - Skin Conditions, Resident #19 was admitted with a history of venous skin issues to the coccyx, buttocks. Further review revealed the resident had an abrasion which was described as a scalded-type area to the bilateral buttocks with measurements of 5 cm L X 5 cm W. Continued review revealed no documented evidence of a SDTI on the Admission Data Collection form for Resident #19. The Skin Conditions section was signed as being completed by RN #3. Review of the facility's Admission Data Collection Section 5, Braden Scale, dated 07/15/16, revealed Resident #19 scored a seventeen (17) and per the scale if the total score was sixteen (16) or less initiate skin integrity interventions and document on the Interim Care Plan. Review of the Weekly Skin Integrity Review, completed by RN #4 on 07/22/16, revealed Resident #19 had a non-blanchable Stage II pressure ulcer on the Coccyx measuring 8.0 cm X 7.5 cm. Continued review revealed the resident had a STDI to the left heel measuring 2.5 cm X 3 cm. Further review of the Weekly Skin Integrity Review revealed these skin issues were not new skin issues. However, review of the Admission MDS Assessment, dated 07/22/16, revealed under Section M, Skin Conditions, the facility assessed Resident #19 as being at risk for developing pressure ulcers and having no pressure ulcers on admission. Review of the Order Summary Report for Resident #19, with an Order Date Range of 07/01/16 to 07/31/16 and the July 2016 Treatment Administration Record (TAR) revealed no treatments for the coccyx and heel pressure ulcers were initiated until 07/24/16, nine (9) days after admission. Review of Physician's Orders dated 07/24/16 revealed orders for [MEDICATION NAME] Extra Protective Cream and Allevyn (An Adhesive dressing for wound healing) to the Coccyx, to be changed every three (3) days and as needed, on 07/24/16. Continued review of Physician's Orders dated 07/24/16 revealed an order for [REDACTED]. Phone interview with LPN #16, on 09/23/16 at 11:15 AM, revealed he did not remember admitting Resident #19 and did not remember performing the resident's skin assessment. LPN #16 stated he usually didn't perform the skin assessments on new admissions since the new admissions would be admitted to the facility during the day shift. LPN #16 stated when a resident was admitted , the nurse should review the paperwork from the transferring facility and perform a head to toe full assessment and document their findings on the Admission Data Collection form. LPN #16 further stated the nurse should follow-up with the Medical Provider with any concerns noted during the assessment and to obtain treatment orders as needed. Phone interview with RN #3, on 09/23/16 at 9:55 AM, revealed she no longer worked at the facility and did not remember admitting Resident #19 or anything regarding the resident's pressure ulcers. RN #3 stated the procedure with any new admission was to review the transferring paperwork as well as performing a full head to toe skin assessment to document any findings. RN #3 further stated she would only document her own findings on the Admission Data Collection form since the information in the transferring paperwork could be inaccurate. Continued interview revealed she would contact the Medical Provider if any concerns were noted during the assessment and obtain any treatment orders needed. Phone interview with RN #4, on 09/27/16 at 9:05 AM, revealed she remembered taking the report from the transferring facility regarding Resident #19 but she did not admit the resident or do the initial skin assessment because although he/she was supposed to be admitted to the unit she was working, he/she was admitted to anther unit in the facility. RN #4 stated she was unsure if the admitting nurse had the pre-admission information. She further stated she did remember completing the Weekly Skin Integrity Review on 07/22/16 and notifying the Physician's Assistant regarding the residents pressure ulcers to the coccyx and heel but stated she could not remember why the Physician's Assistant did not order treatments to be put into place upon being notified. RN #4 stated the orders could have been delayed if the medical provider wanted to assess the wounds or wanted the facility's wound care nurse to assess before putting treatments in place, but she stated she couldn't remember the exact details. Further interview revealed she did not think the pressure ulcers were new at the time she completed the Weekly Skin Integrity Review on 07/22/16 because she remembered them from report from the transferring facility. Review of the Weekly Wound Data Collection Flow Sheet dated 07/26/16, completed by DON revealed Resident #19 was admitted with a SDTI as well as the Stage II Pressure Ulcer on 07/15/16. Continued review of the Wound Data Collection Flow Sheet revealed the Medical Provider was notified of these skin issues on 07/22/16 with the family notified on 07/26/16. Further review of the Weekly Wound Data Collection Flow Sheet revealed the Coccyx wound was documented as a Stage II Pressure ulcer measuring 8 cm L x 7.5 cm W x 0 cm D and the left heel wound was assessed as a Suspected Deep Tissue Injury (SDTI) with measurements of 2.5 cm L x 3 cm W x 0 cm D. Review of Resident #19's Comprehensive Care Plans (CCP) revealed the facility did not initiate a CCP for Actual Impaired Skin Integrity until 09/09/16 even though the facility had identified actual impaired skin on admission 07/15/16 and on 07/22/16. The facility identified the Focus of the CCP to be Resident #19 had Impaired Skin Integrity: Actual related to Stage II to coccyx and related to Stage II to the left heel now presented as Stage I. The Goal stated the resident's pressure ulcers would show signs of healing and remain free from infection initiated on 09/09/16. The interventions were all initiated on 09/09/16, and included: administer treatments as ordered and monitor for effectiveness; monitor/document wound healing by measuring length, width, and depth; assess and document status of peri wound tissue, wound bed and healing progress; and report declines to the Medical Doctor initiated on 09/09/16. Resident #19 refused a skin assessment on 09/19/16 at 5:00 PM. Interview with the DON, on 09/21/16 at 3:50 PM, revealed Resident #19 was originally going to be admitted to the Rehab Unit, but after receiving information from the hospital related to the resident's confusion, it was decided the resident would be admitted to the North Unit where the resident could also receive rehabilitation therapy. The DON stated Resident #19 was then transferred to the Rehab Unit after the resident's confusion cleared and and RN #4 performed the Weekly Skin Integrity Review on 07/22/16. The DON stated it was her expectation for the nurses to perform a thorough and accurate skin assessment upon admission to the facility and to contact the Medical Provider to obtain treatment orders when pressure ulcers were identified. Phone interview with the Physician's Assistant on 09/22/16 at 3:10 PM, revealed she could not recall a specific date or time she was notified of Resident #19's pressure ulcers to the heel or to the coccyx nor when she put treatment orders in place without reviewing the medical record. She stated she had seen Resident #19's pressure ulcers and felt the pressure areas were healing. The Physician's Assistant further stated it was her expectation for the facility staff to perform accurate assessments upon admission and to contact her for orders/treatments for any conditions found during the assessments. 3. Review of Resident #16's medical record revealed the facility admitted the resident on 05/10/16 to the North Unit with [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection Form dated 05/10/16, completed by LPN #18, under the section listed Braden Scale revealed Resident #16's score was a fifteen (15) and per the scale if the score was sixteen (16) or less, initiate skin integrity interventions and document on the Interim Care Plan. Further review revealed the resident had an open area measuring 3.5 cm by 2.5 cm to the right outer ankle; however, there was no stage noted for the pressure ulcer. Resident #16's Care Plan dated 05/10/16, stated the resident had a problem of actual impairment to skin integrity related to weakness, incontinence and current pressure area upon admission. However, there was no description or location of the impaired skin noted on this care plan. The goal stated the resident would be free of skin breakdown and would have no worsening of skin alteration through next review. There were several interventions including keep skin clean and dry, provide treatments as ordered, and licensed nurse to evaluate skin on a weekly basis. Review of Resident #16's Physician's orders dated May 2016, revealed orders dated 05/11/16, to document any wounds on the Weekly Wound Data Collection Sheet (WWDCS) every Saturday. Further review revealed there was no documented evidence of Physician's orders related to the right ankle wound until 05/13/16, three (3) days after the resident was admitted with the wound. Review of the Physician's orders dated 05/13/16, revealed orders to cleanse the right outer ankle with Normal Saline, pat dry, and apply Allevyn. Review of the WWDCS dated 05/13/16, also completed by LPN #18, revealed the wound on the right outer ankle was present on admission and was a Stage II measuring 2.5 width, 3.3 length with moderate serous drainage, 95 % (percent) eschar and 5 percent (%) granulation. Review of the Admission MDS assessment dated [DATE], revealed facility assessed the resident as having one (1) unstageable pressure ulcer which was present on admission with eschar. Phone interview on 09/22/16 at 2:44 PM and 09/23/16 at 11:00 AM with LPN # 18, who admitted Resident #16 on 05/10/16, revealed she was not sure if she was educated at the facility related to how to perform skin assessments. She stated if she admitted a resident with a pressure ulcer she would measure the wound and get a Registered Nurse (RN) to assess the wound in order to stage because per facility policy LPN's at the facility were not to stage wounds. Further interview revealed it would be important to stage a wound in order to have a reference point as to what the wound looked like on admission. Continued interview revealed she would notify the Physician for a treatment order if a resident was admitted with a wound; however, she was not sure if she notified the physician and ordered a treatment on admission on 05/10/16 for Resident #16, because she could not remember back that far. Although there was Weekly Skin Integrity Reviews (WSIR) completed on 05/15/16 and 05/21/16, there was no Weekly Wound Data Collection Sheet (WWDCS) as per policy and as per Physician's orders to indicate the measurement and staging of the wound from 05/13/16 until 05/29/16, sixteen (16) days later for Resident #16. Review of the WSIR da

Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to ensure Comprehensive Care Plans were revised for four (4) of twenty-eight sampled residents (Residents #5, #11, #15, and #16). On 06/04/16, Resident #5 fell in his/her room. The Care Plan was not updated to reflect any new interventions to prevent further falls. On 07/21/16, the resident had an unwitnessed fall in the bathroom which resulted in abrasions and a Cervical Spine Fracture. After the fall, the Care Plan was updated with an intervention to encourage the resident to use the call light for assistance. However, interviews with the Unit Manager and the Director of Nursing revealed the intervention was not appropriate for the resident at that time, and did not reflect the root cause of the fall. On 08/24/16, Resident #15 was assessed as having new wounds including an unstageable Pressure Ulcer measuring 1.3 Length (L) x 2.0 Width (W) to the right foot bony prominence, an unstageable pressure ulcer to the right heel measuring 3.0 L x 4.1 W, and an unstageable Pressure Ulcer to the left heel measuring 2.9 L x 3.7 W which were later all identified as Vascular Wounds. Although the bilateral heel ulcers and right foot bony prominence ulcer were identified on 08/24/16, there was no documented evidence the facility evaluated and revised the Care Plan until 09/15/16, more than three (3) weeks later to state the resident had bilateral heel ulcers and a right ankle ulcer and there was no clarification on the Care Plan to state the heel ulcers and right ankle ulcer were Vascular ulcers. In addition, Physician's orders were received for non-weight bearing to the Left Heel on 09/01/16 and staff interview revealed they were transferring the resident with the Hoyer Lift (mechanical lift) ; however, there was no documented evidence of a Care Plan update related to the new intervention for non-weight bearing and use of Hoyer Lift. Also, although Resident #16 was admitted with a pressure ulcer to the right ankle, the Comprehensive Care plan was not revised accurately as the resident's wounds changed and when new wounds were identified. Furthermore, although Resident #11 was admitted on [DATE] with three (3) pressure ulcers, there was no revision on the Comprehensive Care Plan to indicate if the pressure ulcers were healing or deteriorating. The findings include: Review of the facility policy, titled Care Plans-Comprehensive, revised October 2010, revealed Assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition change. The Care Plan was to be reviewed and updated for a significant change, when the desired outcome was not met, when the resident was readmitted to the facility from a hospital stay and quarterly. Review of the facility's policy titled Falls Prevention, revised 07/16, revealed residents would be evaluated for the potential risk of falling so that reasonable and appropriate measures would be taken for each resident to mitigate those risks to coordinate management of acute and recurrent falls, to promote early identification of a risk for falls and reduction of multiple falls, and to enable residents to maintain their highest level of independence in a safe environment without significant risk or injury. Continued review revealed the design and implementation of the Care Plan would include the Interdisciplinary Team (IDT), who would discuss the findings of fall investigations, and where reasonable and appropriate modify the plan of care. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 04/03/09 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/29/16, revealed the facility assessed the resident as having a BIMS score of seven (7), which indicated the resident was severely cognitively impaired. Review of Resident #5's Fall Care Plan, revised on 09/01/16, revealed the resident was at risk of falls related to impaired balance, weakness, and use of [MEDICAL CONDITION] medications. The goal was for the resident to be free of falls and associated injuries daily, with interventions that included obtaining a medication review per the Nurse Practitioner, the Medical Director and the Pharmacy Consultant. Review of the facility's Fall Incident Report, dated 06/04/16 at 2:55 AM, revealed Resident #5 was found on hands and knees at the bedside, and reported to the nurse he/she thought he/she just rolled out of bed. Further review revealed the resident sustained [REDACTED]. Interview with the South Unit Manager (LPN #7), on 09/22/16 at 5:15 PM, revealed the recommended intervention to update the Care Plan after the fall on 06/04/16, was to educate the resident to use his/her call light. However, review of the Care Plan revealed it was not updated with this intervention. Review of the facility's Fall Incident Report, dated 07/21/16 at 1:05 AM, revealed Resident #5 sustained an unwitnessed fall in his/her bathroom. Review of the Hospital Document Review Report dated 07/23/16, revealed Resident #5 was admitted to the hospital on [DATE] after an unwitnessed fall at the facility. Per the Report, the resident was found to have an abrasion on his/her forehead and an abrasion on the left knee. Also, the resident was diagnosed to have a Spinal [MEDICAL CONDITION] cervical (C2) vertebra related to the fall. Further review revealed the resident was discharged back to the facility on [DATE] with a Cervical Collar. Continued interview with the South Unit Manager/LPN #7 revealed the recommended intervention after the fall on 07/21/16 was to encourage the resident to call for assistance. She stated she was not certain this was an appropriate intervention for the resident because he/she did not always use the call light for assistance. Interview with Licensed Practical Nurse (LPN) #1, on 09/22/16 at 5:15 PM, who was frequently assigned to the resident, revealed the resident was declining and was experiencing more falls. She stated it was important to have interventions after each fall to hopefully prevent future falls. Further interview with the South Unit Manager/ LPN #7, on 09/22/16 at 1:55 PM, revealed when a resident sustained [REDACTED]. LPN #7 stated the nurse would fill out the investigation report form and add what interventions they would like to recommend be put in place related to the fall. She further stated the interventions were reviewed by the Unit Manager the next day to see if the intervention was appropriate and the fall and possible interventions were discussed in the Interdisciplinary Team Meetings (IDT) meetings. She further stated the MDS Coordinator was responsible for updating the Care Plan based on what was determined in the IDT meeting. Additionally, South Unit Manager/LPN #7 stated it was important to revise the care plans so that everyone was on the same page regarding the care of the resident, and to prevent future falls from occurring. Interview with the MDS Coordinator, on 09/23/16 at 11:46 AM, revealed she attended the daily morning Interdisciplinary Team (IDT) meetings, and residents who had falls were discussed to ensure appropriate Care Plan interventions were implemented. She stated she was usually the person who actually updated the Care Plans. She acknowledged there was no documented evidence of a care plan revision with a new intervention after Resident #5's fall on 06/04/16, but revealed there should have been a new intervention to address the fall. Additionally, she stated she did not look to determine the root cause of a fall, but relied on the expertise of the Assistant Director of Nursing (ADON), who reviewed the interventions. The MDS Coordinator further stated it was important to revise each resident's care plan, in order to provide a clear picture of the resident. Interview with the ADON, on 09/23/16 at 3:08 PM, revealed she was responsible for reviewing and assessing residents and Care Plans for appropriate interventions after a fall. She stated resident falls were discussed in the morning IDT meetings. She further stated the nurse would complete an investigation of the fall to determine the root cause of the fall, and suggest an intervention. The ADON further stated she looked to see if the proper interventions were put in place, adding we look at the reason for the fall. Further interview revealed the MDS nurse would make sure the interventions were added to the resident's Care Plan. The ADON stated Resident #5 should have had a new intervention put in place to address the fall on 06/04/16, i.e. the Care Plan should have been revised. Regarding the fall on 07/21/16, the ADON stated the appropriate update to the resident's Care Plan was to have the resident call for assistance. Interview with the DON, on 09/23/16 at 1:02 PM, revealed it was her expectation that Resident #5's care plan would have been updated to reflect the facility's new interventions after the fall on 06/04/16. Additionally, she stated she would have expected staff to develop an intervention for Resident #5's fall on 07/21/16 that reflected the root cause of the fall. Continued interview revealed a more appropriate intervention would have been to provide increased monitoring to the resident. She stated the process of reviewing falls and applying appropriate preventive interventions was important to promote the best outcome for the resident. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed it was her expectation that Resident #5's Care Plan was updated with an appropriate intervention after each fall. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 07/15/16 to the South Unit with a [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection dated 07/15/16, revealed the resident had impaired skin integrity with a Gangrene diagnoses. Review of the Weekly Wound Data Collection Flowsheet dated 07/15/16 revealed the resident's whole Left Great Toe was necrotic. Continued review revealed the resident had a left pinky toe scab measuring 0.25 centimeters (cm). Review of Resident #15's Comprehensive Care Plan initiated 07/18/16, and revised 08/25/26, revealed Resident #15 had a problem of impaired skin integrity related to gangrene [DIAGNOSES REDACTED]. The goal stated the resident's impaired areas would show improvement and the resident would remain free of pressure ulcers. The many interventions included prevalon boots to bilateral feet at all times, and pressure relieving device for wheelchair. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #15 as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact, and as having no Venous or Arterial Ulcers. Further review revealed the resident was assessed as extensive assist for transfers with two (2) persons and as non-ambulatory. Review of the Weekly Skin Integrity Review, dated 07/27/16, 08/03/16, and 08/11/16, revealed the resident had a necrotic Left Great Toe, with no other documented evidence of further skin breakdown. Review of the Weekly Wound Data Collection Flow Sheet, dated 08/24/16, completed by Licensed Practical Nurse (LPN) #1, revealed the resident had an unstageable Pressure Ulcer measuring 1.3 Length (L) x 2.0 Width (W) to the right foot bony prominence with 75% Eschar, rolled and macerated wound an unstageable pressure ulcer to the right heel measuring 3.0 L x 4.1 W, with the wound bed 90% eschar, wound edges rolled, macerated and intact and an unstageable Pressure Ulcer to the left heel measuring 2.9 L x 3.7 W. Per record review these areas were not identified until 08/24/16. Review of Physician's orders dated 08/25/16, revealed orders for [MEDICATION NAME] to bilateral heels and right bony prominence of right foot every day and night shift, prevalon boots to bilateral feet as resident allows at all times, and appointment with Vascular Surgeon on 09/01/16 related to the resident's necrotic areas. Review of the Vascular Surgeons consult on 09/01/16, revealed Resident #15 had severe Peripheral Artery disease to the left foot and the left heel was dry gangrene and there was to be no pressure or weight bearing to the left foot; however, the right foot ulcers were not mentioned in the Note. Review of new Physician's orders dated 09/01/16 revealed orders for non-weight bearing to the left lower extremity. Interview with LPN #21 on 09/20/16 at 2:45 PM, revealed the resident was no longer weight bearing due to the ulcers on his/her heels and was transferred per hoyer lift (mechanical lift) since the last Vascular Surgeon Appointment on 09/01/16. Review of the Comprehensive Care Plan revealed a problem which was revised 09/15/16 to state the resident had bilateral heel ulcers and an ulcer to the right outer ankle; however, the Care Plan did not indicate the type of ulcers (pressure ulcers or vascular ulcers). Interventions were added on 09/13/16 for prevalon boots to bilateral feet when in wheelchair to avoid pressure to left heel, and use large leg pad/support to the left side of wheelchair. Further interventions were added on 09/15/16 for heel lift wedge to be used when in bed, heels to float off edge with no pressure to heels, and do not use prevalon boots in bed. In addition, although the resident was to be non-weight bearing to the left heel and interviews revealed staff were using a Hoyer Lift for transfers, there was no documented evidence the Care Plan was revised to state the resident was non-weight bearing and to use a Hoyer lift. Interview on 09/15/16 at 11:00 AM and 09/21/16 at 4:15 PM with Resident Assessment Instrument (RAI) Coordinator/RN #6, who was responsible for developing and revising Resident #15's Care Plan, revealed she received report of changes in residents' condition in the morning meetings Monday through Fridays and also the computer alerted her to changes. She further stated the care plans related to wounds were to indicate the types of wounds, whether pressure ulcers or Vascular ulcers for the development of the care plan, and also were to be revised as the resident's wounds healed or deteriorated. Continued interview revealed per the Care Plan she did a revision on 09/15/16 for Resident #16's new ulcers to the lower extremities; however, should have updated the Care Plan sooner related to the resident's wounds to the lower extremities. She further revealed she was to indicate the type of ulcers on the skin care plans but may not have realized at the time of the update that the new ulcers to the resident's lower extremities were vascular. Further interview revealed she should have ensured the care plan was updated related to non- weight bearing and using a Hoyer Lift. Interview with the Director of Nursing (DON) on 09/23/16 at 9:24 AM, revealed she expected the care plans to be updated accurately as wounds changed in order to track the progression of the wounds, as well as when there was a change in transfer/ambulation status and the Resident Assessment Coordinators were responsible for developing and revising the care plans. 3. Review of Resident #16's medical record revealed the facility admitted the resident on 05/10/16 to the North Unit with [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection Form dated 05/10/16, completed by LPN #18, revealed the resident had an open area measuring 3.5 cm by 2.5 cm to the right outer ankle with no no stage noted for the pressure ulcer. Review of Resident #16's Care Plan initiated on 05/10/16, revealed the resident had actual impairment to skin integrity/current pressure area on admission; however, the Care Plan did not note the location of stage of the pressure ulcer. The Care Plan goal stated the resident would be free of skin breakdown and would have no worsening of skin alteration through next review. The interventions including keep skin clean and dry, provide treatments as ordered, and licensed nurse to evaluate skin on a weekly basis. Review of the Admission MDS assessment dated [DATE], revealed facility assessed the resident as having one (1) unstageable pressure ulcer which was present on admission with eschar. Resident #16 was hospitalized from [DATE] through 06/16/16. Review of the Nurse's Notes dated 06/16/16 at 6:30 PM, completed by LPN #19, revealed the resident arrived back from the hospital with the following skin issues: open areas to the left heel and right outer ankle, two (2) areas to the right outer leg, right heel red/non-blanchable, and open area to the coccyx. Review of the Care Plan revision on 06/16/16, when the resident returned from the hospital revealed the resident had Stage II pressure ulcers on the right ankle, sacrum, and left heel. Review of the WWDCS dated 06/20/16, revealed Resident #16 was assessed to have a right ankle unstageable pressure area measuring 2.5 cm L x 1.5 cm W, a Vascular ulcer to the right lower leg measuring 4.0 cm L x 2.5 cm W x 0.1 cm depth, a Stage II pressure ulcer to the sacrum measuring 2.5 cm L x 1.5 cm W x 0.1 cm depth and a left heel Stage II pressure ulcer measuring 3.8 cm L x 3.8 cm W x 0.2 cm depth. However, the Care Plan was not revised again after the WWDCS on 06/20/16 to indicate the resident had an unstageable pressure ulcer to the right ankle and a right lower leg Vascular ulcer. Review of the next WWDCS dated 07/19/16, revealed Resident #16 was assessed as having a Stage II right ankle pressure ulcer measuring 1.0 cm L x 0.8 cm W x 0.1 cm depth, a Vascular ulcer to the right lower leg measuring 2.4 cm L x 1.0 cm W x 0.1 cm depth, a Stage II pressure ulcer to the sacrum measuring 1.5 cm L x 1.0 cm W x 0.1 cm depth, and a left heel Stage III pressure ulcer measuring 1.5 cm L x 2.0 cm W x 0.1 cm depth. Per the Care Plan as of 07/19/16 when the last revision was made, the resident had a Stage II Pressure Ulcer to the the right ankle, and sacrum and a Stage III pressure ulcer to the left heel. However, per the WWDCS on 07/19/16, the resident had a Vascular ulcer to the right lower leg which was not identified on the Care Plan. Interview with the ADON/Wound Nurse on 09/20/16 at 9:00 AM, revealed the Care Plan should have been revised accurately as Resident 16's wounds changed. Interview with the DON, on 09/23/16 at 9:24 AM, revealed the Care Plan was to be revised accurately with staging and location of wounds, as well as types of wounds. 4. Review of Resident #11's medical record revealed the facility admitted to the North Unit on 08/24/16 with [DIAGNOSES REDACTED]. Review of Physician's orders dated 08/24/16, for Resident #11 revealed orders to clean the ulcer on the coccyx with Normal Saline (NS), apply Santyl and cover with Allevyn and document any wounds on the WWDCS every Saturday. Review of Resident #11's Care Plan initiated 08/25/16, revealed the resident had potential/actual impairment to skin integrity however, there was no description, or location of the skin alteration on the care plan. The goal stated the resident would be free of skin breakdown and would have no worsening of skin alteration. There were several interventions including to turn and reposition as needed, and evaluate skin on a daily and weekly basis. However, review of Resident #11's medical record revealed there was no Weekly Wound Data Collection Sheet (WWDCS) completed on admission for this resident. Review of the Daily Skilled Note dated 08/25/16 at 4:44 AM, completed by LPN #25, revealed the resident had a Stage II pressure ulcer to the left buttock, a Stage II pressure ulcer to the right buttock and a Stage I pressure ulcer to the coccyx; however, there was no measurements of the pressure ulcers for the pressure ulcers. Review of Resident #11's Weekly Skin Integrity Review (WSIR) dated 08/27/16 completed by LPN #20 revealed the resident had a right buttock Stage II pressure ulcer and a left buttock Stage II pressure ulcer, and there was no mention of the coccyx wound. Review of the Admission MDS assessment dated [DATE] revealed the facility assessed the resident as having only one (1) stage II pressure ulcer which was present on admit. Further record review revealed Resident #11's pressure ulcer to the coccyx was measured for the first time on 09/13/16, twenty (20) days after admission, and there was no documented evidence in the clinical record the pressure ulcers to the bilateral buttocks had ever been measured. The first WWDCS's completed for this resident, dated 09/13/16, which included measuring and staging was completed by the ADON/Wound Nurse, and revealed the resident was assessed to have a Stage II pressure ulcer to the coccyx measuring 0.8 cm L x 0.5 cm W and there was no further skin breakdown noted. Further review of the skin Care Plan initiated 08/25/16 revealed there was never a revision to the Care Plan to state the resident had pressure ulcers or the stage of the pressure ulcers. Continued interview with North Unit Manager/RN #5, on 09/21/16 at 2:37 PM, acknowledged treatment orders should have been obtained on admission for Resident #11 for all pressure areas identified and the WWDCS should have been completed on admit and every week thereafter. Further interview revealed it was important to track and follow wounds with measurements and staging and also to update the care plan related to the wounds location, stage or type of ulcer either vascular or pressure ulcer. Interview with the ADON on 09/23/16 at 9:24 AM, revealed she looked at all wounds on 08/24/16 and 08/25/16 when she was assigned to complete all the Weekly Wound Data Collection Sheets and relied on the Unit managers to tell her which residents on the unit had pressure or vascular ulcers. She further stated she missed doing the WWDCS on Resident #11 from the time of admission until 09/13/16 because she was unaware the resident had pressure ulcers and did not ensure a skin sweep was done to identify all pressure ulcers when she was notified she would be doing the WWDCS on 08/23/16 when she was assigned to complete the WWDCS for the residents. She acknowledged Resident #11's Care Plan should have been revised to reflect the resident's current skin condition. Interview with the DON, on 09/23/16 at 9:24 AM, revealed she reviewed the record and was in acknowledgment the WWDCS was not completed for Resident #11's pressure ulcers on admission as per policy or weekly as per policy and there was no documented evidence the Physician was notified of the need for treatment orders for the pressure ulcers to the bilateral buttocks on admission or afterwards. She further acknowledged the care plan should have been revised accurately related to this residents wounds. Further interview on 09/15/16 at 11:00 AM and 09/21/16 at 4:15 PM with Resident Assessment Instrument (RAI) Coordinator/RN #6, revealed the RAI Coordinator who was responsible for revising Resident #11 and #16's Care Plans no longer worked at the facility and had resigned recently. She acknowledged the resident's Care Plans should have been revised to reflect the types of ulcers, stages of ulcers accurately as the residents' skin condition changed.

Based on observation, interview, record review, review of facility's policies, and review of the National Federation of Licensed Practical Nurses publication entitled Nursing Practice Standards for the Licensed Practical/Vocational Nurse, it was determined the facility failed to ensure services provided meet professional standards of quality for one (1) of twenty-eight (28) sampled residents (Resident #20). The facility failed to ensure assessment and care planning sufficient to meet the needs of Resident #20 who was a newly admitted resident on 08/04/16. On 08/04/16, the resident was assessed as having a Stage II Pressure Ulcer to the sacrum region measuring Length (L) 4.4 centimeters (cm) x Width (W) 9.2 cm x Depth (D) 0.1 cm. However, on 08/04/16 during the admission process, the facility failed to indicate on the resident's Skin Initial Care Plan electronic record an intervention to Evaluate skin condition on a daily and weekly basis. There was no documented evidence the resident's wound was assessed after the initial wound assessment on 08/04/16 and prior to the resident being transferred to an Acute Care Hospital (ACH) for unresponsiveness on 08/24/16. Review of Resident #20's ACH Discharge Summary, dated 08/30/16, revealed the resident's admitting [DIAGNOSES REDACTED]. Staff interviews revealed in order for staff to be alerted to conduct the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet on the electronic Treatment Administration Record (TAR), the intervention Evaluate skin condition on a daily and weekly basis would have to be entered on the electronic Initial Care Plan. The findings include: Review of the facility Care Plans-Preliminary Policy, revised August 2006, revealed a Preliminary Plan of Care to meet the resident's needs shall be developed for each resident within twenty-four (24) hours of admission. The Interdisciplinary Team will review the Attending Physician's order and implement a nursing care plan to meet the resident's needs. The Preliminary Care Plan will be used until the staff can conduct the comprehensive assessment and develop the Interdisciplinary Care Plan. Review of the facility's Skin Observation and Wound Prevention Protocol, revised July 2015, revealed upon admission the Charge Nurse would complete physical observation documenting findings within the Admission Data Collection form and if a wound was present on admission the Charge Nurse would initiate and describe the wound on the Weekly Wound Data Collection Sheet (WWDCS), complete the Braden Scale, notify the Dining Service Manager, initiate treatment intervention, and initiate a Plan of Care. Review of the National Federation of Licensed Practical Nurses publication, dated October 2003, entitled Nursing Practice Standards for the Licensed Practical/Vocational Nurse, section Practice, revealed the Licensed Practical/Vocational Nurse shall know and utilize the nursing process in planning, implementing and evaluating health services and nursing care for the individual patient or group. The planning of nursing includes: assessment/data collection of health status of the individual patient, the family and community groups; and reporting information gained from assessment/data collection. Interview on 09/22/16 at 1:00 PM, with the Assistant Director of Nursing (ADON)/Wound Nurse, revealed the nurse who conducts the Admission Assessment was responsible for entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet as part of the development of the Initial Care Plan by checking the intervention check skin on a daily and weekly basis, in order for the Weekly Skin Integrity Review and the Weekly Wound Data Collection to appear on the Physician's Orders and on the Treatment Administration Record in the electronic system. Review of Resident #20's clinical record revealed the facility admitted the resident on 08/04/16 with [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection Form dated 08/04/16, under the section titled Skin Integrity, revealed the facility assessed Resident #20 to have a Stage II Pressure Ulcer to the sacrum region measuring Length (L) 4.4 centimeters (cm) x Width (W) 9.2 cm x Depth (D) 0.1 cm. Review of Resident #20's Initial Care Plan, initiated 08/04/16, revealed the resident had a problem of impaired skin integrity related to a Stage II Pressure Ulcer. However, review of Resident #20's Initial Care Plan revealed the intervention Evaluate skin condition on a daily and weekly basis, was not selected as an intervention. Review of Physician's Orders dated 08/04/16 revealed revealed no Physician's orders for a Weekly Skin Integrity Review nor orders to document wounds on the Weekly Wound Data Collection Sheet. Review of Resident #20's Treatment Administration Record (TAR) dated 08/01/16 -through 08/31/16, revealed no intervention for a Weekly Skin Integrity Review or a Weekly Wound Data Collection. Continued review of Resident # 20's medical record revealed there was no documented evidence the resident's wound was assessed after the initial wound assessment on admission, 08/04/16 prior to the resident being transferred to the Acute Care Hospital (ACH) on 08/24/16 where Resident #20 underwent the unscheduled surgical procedure to debride the wound. Interview on 09/21/16 at 1:59 PM, with LPN # 3, revealed on 08/04/16 he had been pulled from another unit to Resident #20's assigned unit to help with the admission process and had conducted Resident #20's initial assessment on 08/04/16. LPN # 3 revealed he also initiated wound care interventions for Resident #20 on the resident's Initial Care Plan per the electronic record; however, per interview, he missed entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet on the Initial Care Plan. As a result of this error, these interventions were not carried over to the Physician's orders or the TAR for August 2016. LPN # 3 revealed the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet needed to be initiated on the resident's electronic Care Plan, in order to alert the facility nurses that the skin assessment and wound assessment was due to be conducted. Interview on 09/21/16 at 2:37 PM, with the North Unit Manager (UM), revealed weekly skin assessments were to be ordered for every new resident. The UM reviewed the record and acknowledged there was no Physician's order for weekly wound assessments for the resident on the day of admission to the facility. Interview on 09/22/16 at 12:59 PM, with the Assistant Director of Nursing (ADON), revealed the nurse who conducted Resident #20's Admission Assessment was responsible for entering the Weekly Skin Integrity Review and the Weekly Wound Data Collection Sheet as part of the development of the initial care plan, in order for it to appear on the resident's TAR. The ADON acknowledged Resident #20's coccyx pressure ulcer was not measured and staged after the initial admission wound assessment and prior to transfer and admission to the ACH on 08/24/16. Interview on 09/23/16 at 2:22 PM, with the Director of Nursing (DON), revealed Resident #20 was admitted with a Stage II pressure ulcer on 08/04/16, and it was the admitting nurse's responsibility to enter a weekly wound monitoring assessment as part of the admission orders [REDACTED]. Interview on 09/23/16 at 4:03 PM, with the facility's Administrator, revealed she was not aware the Admission wound assessment was the only wound assessment done for Resident #20 prior to the resident's transfer to the ACH unit this survey. She further stated it was her expectation that pressure ulcer interventions be care planned to include weekly wound assessments.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent falls for two (2) of twenty-eight sampled residents, Resident #5 and Resident #16. Resident #5 sustained a fall on 06/04/16; however, there was no documented evidence of further interventions implemented in order to prevent additional falls. On 07/21/16, the resident had an unwitnessed fall in the bathroom which resulted in abrasions and a spinal fracture of the second cervical (C2) vertebra related to the fall. In addition, on 08/11/16, Psychiatric Services recommended Resident #5's Vistaril be decreased from fifty (50) milligrams (mg) three (3) times a day to twenty-five (25) mg three (3) times a day due to increased confusion and falls. However, the facility failed to ensure the Psychiatric Services recommendation was followed, and entered as an order after the Physician's Assistant agreed with the recommendation. As a result, Resident #5 continued to receive Vistaril 50 mg three (3) times a day from 08/11/16 until 09/06/16 when the recommendation was made a second time, after the resident sustained [REDACTED]. Resident #16, after a fall on 05/26/16, had Care Plan interventions initiated for a hi-low bed. However, observations during the State Agency survey revealed the bed was not maintained in a low position. In addition, the facility failed to ensure the resident environment remained as free from accident hazards as possible. Observation on the Rehab Unit on 09/13/16 revealed the housekeeping closet door was not properly closed with potentially hazardous chemicals inside and accessible to the residents. The findings include: The facility's policy titled Falls Prevention, revised 07/16, revealed residents would be evaluated for the potential risk of falling so that reasonable and appropriate measures would be taken for each resident to mitigate those risk: To promote appropriate clinical and multi-disciplinary assessment of falls and fall risk factors. To coordinate management of acute and recurrent falls. Early identification of risk for falls and reduction of multiple falls, enable residents to maintain highest level of independence in a safe environment without significant risk or injury. Continued review revealed (d) the Design and Implementation of the Plan of Care would include the Interdisciplinary Team that would discuss the findings of fall investigations and where reasonable and appropriate, modify the plan of care. Measures included, but not limited to, engaging resident in programs of interest/preference, orienting residents and/or legal representatives regarding fall prevention measures, low bed and fall mats, and making appropriate room reassignments. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 04/03/09 with [DIAGNOSES REDACTED]., and Psychotic Disorder with Hallucinations. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 06/01/16, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderate cognitive impairment. Further review under Section G for Functional Status, revealed the resident was assessed to transfer and able to walk in his/her room and in the corridor with supervision and support of one (1) person physical assist. Review of Resident #5's Fall Care Plan, initiated 07/01/15 and revised 09/01/16, revealed the resident was at risk for falls related to impaired balance, weakness, and use of psychotropic medications. The goal stated the resident would be free of falls and associated injuries daily with interventions that included: encourage the resident to ask for assist when feeling fatigued when ambulating; provide assist with transfers as directed, and an intervention dated 07/01/15 for a medication review per the Nurse Practitioner (NP), Medical Director (MD), and Pharmacy Consultant. Review of the facility's Fall Incident Report, dated 06/04/16 at 2:55 AM, revealed Resident #5 was found on hands and knees at the bedside, and reported to the nurse he/she thought he/she just rolled out of bed. The resident sustained [REDACTED]. Interview with the Unit Manager/Licensed Practical Nurse (LPN) #7 revealed the recommended intervention to update the Care Plan was to educate the resident to use his/her call light. However, review of the Care Plan revealed it was not updated with this intervention. Review of the facility's Fall Incident Report, dated 07/21/16 at 1:05 AM, revealed Resident #5 was found in the bathroom. Further review revealed the resident had an unwitnessed fall and was sent to the hospital. Continued review of the Falls Incident report revealed no documented evidence the facility identified the root cause to the resident's fall. Review of the hospital record revealed Resident #5 was admitted to the hospital on [DATE] after an unwitnessed fall at the facility. Per the Report, the resident was found to have an abrasion on his/her forehead and an abrasion on the left knee. Additionally, the resident was diagnosed to have a spinal fracture of the second cervical (C2) vertebra related to the fall. Further review revealed the resident was discharged back to the facility on [DATE] with a Cervical Collar. Review of the revision to the Comprehensive Care Plan, initiated 07/22/16, revealed the intervention put in place after the resident's fall on 07/21/16 was to encourage the resident to call for assist when needing to transfer. Interview with the Unit Manager /LPN #7, on 09/22/16 at 5:15 PM, revealed the recommended intervention for the fall on 07/21/16 was to encourage the resident to call for assistance. She stated she was not certain this was an appropriate intervention for the resident because he/she did not always use the call light for assistance. Interview with the MDS Coordinator, on 09/23/16 at 11:46 AM, revealed revision of the Care Plans always fell back on the MDS Nurses. She stated, in the morning Interdisciplinary Team Meeting (IDT) new interventions were discussed for resident's with falls, and generally it was up to the MDS Nurse to actually update the Care Plan. She further stated she was unable to locate any documented evidence to confirm an intervention was put in place after Resident #5's fall on 06/04/16, but revealed there should have been a new intervention to address the fall. Additionally, she stated she did not look to determine the root cause of a fall, but relied on the expertise of the Assistant Director of Nursing (ADON), who reviewed the interventions. Continued interview revealed it was important to revise the resident's care plan, in order to provide a clear picture of the resident. Interview with the ADON, on 09/23/16 at 3:08 PM, revealed she was in charge of reviewing and assessing for appropriate interventions for residents who had had falls. She stated the nurse would notify her or the Director of Nursing (DON) when a resident sustained [REDACTED]. Continued interview with the ADON revealed the nurse would complete an investigation to determine the root cause of the fall and would suggest an intervention. The ADON stated she looked to see if the proper interventions were put in place, adding we look at the reason for the fall. Further interview revealed the MDS Nurse would make sure the interventions were added to the resident's Care Plan. The ADON stated the resident should have had a new intervention put in place to address the fall on 06/04/16. Regarding the fall on 07/21/16, the ADON stated the appropriate update to the resident's Care Plan was to have the resident call for assistance. Interview with the DON, on 09/23/16 at 1:02 PM, revealed Care Plans were discussed in morning IDT meetings and the MDS nurse would make any updates or revisions to the Care Plans. Continued interview revealed she would have expected Resident #5's care plan to have been updated to reflect the facility's interventions after the fall on 06/04/16, with a goal of preventing further falls. Additionally, she stated she would have expected staff to develop an intervention for Resident #5's fall on 07/21/16 that would have reflected the root cause of the fall. She further stated a more appropriate intervention would have been to provide increased monitoring to the resident. She stated this was important to promote the best outcome for the resident. Review of Resident #5's physician's orders [REDACTED]. Vistaril is a prescription medication used to control nausea and vomiting, to relieve itching caused by allergic conditions, and to cause sedation before and after general anesthesia and in the treatment of [REDACTED]. Review of Resident #5's Psychiatric Services Follow-Up Evaluation, dated 08/11/16, revealed the Psychiatrist recommended the resident's Vistaril be decreased from fifty (50) mg to twenty-five (25) milligrams (mg) by mouth every eight (8) hours due to increased confusion and falls. Further review revealed the Physician's Assistant signed the Psychiatric Services consult on 08/22/16. However, there was no documented evidence an actual order was written to reflect the recommendation. Review of Nursing Progress Notes, dated 08/15/16 at 11:10 AM, revealed LPN #1 wrote, per psychiatric services, decrease Vistaril to twenty-five (25) mg by mouth every eight (8) hours related to increased confusion. Review of the Medication Administration Record (MAR) revealed no documented evidence the Vistaril dose was decreased as recommended by the Psychiatric consult. Continued review of the MAR revealed Resident #5 received fifty (50) mg of Vistaril three (3) times a day from 08/11/16 (the day the Psychiatric consult recommended the decreased dose) through 09/07/16 at 2:00 PM. Review of the subsequent Fall Incident Report, dated 08/27/16 at 2:45 AM, revealed the resident stated he/she rolled out of bed. Per the Report, Resident #5 insisted on lying in his/her bed with feet hanging out of his/her bed, and refused to be compliant with staff recommendations and verbalized that on several occasions. Further review revealed the resident sustained [REDACTED]. Review of the Fall Incident Report dated 09/03/16 at 5:45 AM revealed the nurse observed Resident #5 sitting up on the side of the bed and leaning forward. The nurse was unable to catch the resident in time, and the resident tumbled out of bed and fell on his/her head. Continued review revealed the resident hit his/her head on the bedside table. Review of the Emergency Department (ED) record revealed Resident #5 was brought into the ED on 09/03/16 at 6:43 AM, per Emergency Medical Services (EMS) after a sustained fall from bed at the facility. Continued review revealed the resident was wearing a C-Collar due to a prior Cervical (C2) fracture. (This C2 fracture was sustained in the resident's fall at the facility on 07/21/16.) Further review of the ED record revealed the resident had minor superficial abrasions over his/her left forehead, and a laceration/skin tear about two point five (2.5) centimeters (cm) in length on the right forearm, which was closed with steri-strips. A list of the resident's medications from the facility included included Vistaril fifty (50) mg three times a day. Resident #5 was discharged and transferred back to the facility on [DATE]. Review of the Psychiatric Services Follow-Up Evaluation, dated 09/06/16, revealed a second recommendation for the resident's Vistaril to be decreased from fifty (50) mg to twenty-five (25) milligrams (mg) by mouth every eight (8) hours, related to increased confusion and falls. Interview with Licensed Practical Nurse (LPN) #1, on 09/22/16 at 5:15 PM, revealed the Psychiatric Services orders come from Social Service Coordinator (SSC) #2, and the Unit Manager was to input the Psychiatric Services orders into the electronic record under the Physician Orders. She stated that by adding a Nurses Progress Note, the physician's orders [REDACTED]. Further interview with LPN #1 revealed she was not certain how the order got missed and the Vistaril dose was not decreased as per the Psychiatric Services recommendations from 08/11/16. Continued interview with LPN #1 revealed the physician's orders [REDACTED].#5 from having more falls. Interview with the Unit Manager/LPN #7, on 09/23/16 at 10:53 AM, revealed Social Service Coordinator (SSC) #2 would send any recommendations from the Psychiatric Services to the unit for the Unit Manager and the Physician's Assistant to review. Continued interview revealed she was not certain if Social Services followed up with the Unit Managers once the recommendation was sent to the units to find out if the recommendations were followed. Additionally, she stated she could not explain LPN #1's documentation and how the order was missed. However, she stated physician's orders [REDACTED]. Further interview revealed the resident's care plan should have been followed related to re-evaluating the resident's medications after the fall on 08/27/16 and if this had been done, it may have been caught that the Psychiatric Services recommendations from 08/11/16 were not followed as far as decreasing the Vistaril. Interview with SSC #2, on 09/23/16 at 2:54 PM, revealed the nurses or the Physician's Assistant (PA) would request Psychiatric Services to review the residents' medications. SSC #2 stated when Psychiatric Services came to consult with the residents, the Psychiatric Nurse Practitioner would give her the recommendations and she would deliver those recommendations to the Unit Manager or the nurse on the floor and that was where the process ended for her. However, SSC #2 further stated she should have followed up with the Unit Manager related to the Psychiatric Services recommendations on 08/11/16 to ensure the physician's orders [REDACTED].#5's Vistaril dose. Interview with the Physician's Assistant (PA), on 09/22/16 at 3:35 PM, revealed it was her expectation that staff follow her orders. She stated she received, and agreed with, the Psychiatric recommendation to decrease Resident #5's Vistaril related to repeated falls. She further stated it was her expectation the recommendation was followed as a physician's orders [REDACTED].>Further interview with the DON, on 09/23/16 at 1:02 PM, revealed it was her expectation that physician's orders [REDACTED]. She stated Resident #5's Vistaril should have been decreased the first time Psychiatric Services made the recommendation, to prevent further falls. The DON further revealed it was her expectation that Resident #5's care plan would have been followed to re-evaluate the resident's medications to prevent further falls after the 08/27/16 fall. Interview with the Administrator, on 09/23/16 at 5:30 PM, revealed it was her expectation that all consultant recommendations were followed up on, and all physician orders [REDACTED]. 2. Review of Resident #16's medical record revealed the facility admitted the resident on 05/10/16 to the North Unit with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the resident was assessed to have had a fall with fracture prior to admission. Review of Resident #16's medical record revealed a Fall assessment dated [DATE] which indicated the resident was at risk for falls related to a history of falls, change in cognitive status, behaviors, vision, decreased mobility and impaired balance. Review of the Comprehensive Care Plan initiated 05/10/16, revealed the resident was at risk for falls related to weakness with a goal stating the resident would not sustain serious injury through next review. There were several interventions including routine room monitoring, bed in lowest position when occupied by resident, and Hi Low Bed. Review of the Current Certified Nursing Assistant (CNA) Care Plan, revealed an intervention for HI Low Bed. Review of the Fall Incident Report, dated 05/26/16 at 5:30 AM, revealed the resident had an unwitnessed fall. Per the Report the resident was found lying on the floor on his/her left side and moved arms and legs without difficulty; however there was an abrasion to the right elbow and bruising to the right upper quadrant. Further review revealed the Physician was notified and and X-Rays were ordered to the right lower ribcage which were negative. Continued review revealed the intervention placed to prevent further falls was to have a low bed which was to be in low position. Observation on 09/19/16 at 1:55 PM, revealed Resident #16 was in bed on his/her back and the low bed was not in low position all the way to the floor. Interview at the time of observation with Certified Nurse Aide (CNA) #10 revealed she used the Kardex as a reference which was the CNA Care Plan from the kiosk, if she had questions about a resident's care. She further stated she also reviewed the kiosk if she was not familiar with the resident. Continued interview revealed she knew the resident's bed was to be in low position, but she failed to put the bed all the way to the floor after providing care. Interview the Licensed Practical Nurse (LPN) #8 on 09/19/16 at 2:00 PM, revealed she was assigned to Resident #16 and it was important for the CNA's to follow the CNA Care Plan in the kiosk. She stated Resident #16's bed should have been in low position. She further stated she completed rounds throughout the shift but had not noted the bed was not to the floor prior to being questioned by the surveyor. Observation on 09/21/16 at 10:00 AM, revealed Resident #16 was in bed on his/her back with his/her eyes closed and the bed was not in low position all the way to the floor. Interview on 09/21/16 at 10:10 AM, with CNA #8, revealed she checked the kardex (Nurse Aide Care Plan) in the kiosk for questions about care but should check it at the beginning of the shift for residents in which she was assigned. She stated she had not looked at the Kardex today for Resident #16 and was not sure if the bed was to be to the floor, but she went ahead and lowered the bed to the floor. Interview with the Unit Manager of the North Hall/Registered Nurse (RN) #5 on 09/21/16 at 10:05 AM, revealed the nurses were to oversee the CNA's to ensure fall interventions were in place. She stated the CNA's received report from other CNA's and also should check the CNA Care Plan during the shift. She further stated she did rounds once a shift to talk to residents, and ensure care was being provided and she also talked to CNA's during rounds to see if there were any concerns. She further acknowledged it was important for Resident #16's bed to be lowered to the floor after care to assist in preventing falls. Interview on 09/23/16 at 9:24 PM, with the DON, revealed it was important for fall interventions to be implemented in order to prevent further falls. Interview with the Administrator on 09/23/16 at 4:00 PM, revealed it was her expectation for staff to implement fall interventions. 3. Review of the facility's Safety for Residents Policy, dated July 2015, revealed storage areas for chemicals should be locked while unattended. Observation on 09/13/16 at 1:35 PM, revealed the housekeeping closet door was not closed shut on the Rehab Unit. Further observation revealed five (5) bottles of Ecolab Hand Sanitizer, two (2) bottles of Laundry Fresh Room Freshener, six (6) boxes of Heavy Duty Alkaline Bathroom Cleaner, six (6) boxes of Ecolab Professional Strength Glass Cleaner, two (2) boxes of Ecolab Disinfecting Acid Bathroom Cleaner, four (4) boxes of Alkaline Bathroom Cleaner, seven (7) boxes of Keystone Multi Quat Sanitizer, six (6) boxes of Revitalize Carpet Cleaner, four (4) cans of Boardwalk Gum Remover, seven (7) bottles of Brown Gone RTU, and one (1) case of SOS Stainless Steel Pads with six (6) boxes per case. Review of the Material Safety Data Sheet for Ecolab Hand Sanitizer, revealed it could cause burns of the respiratory tract, eyes and skin. Review of the Material Safety Data Sheet for Laundry Fresh Room Freshener, revealed it could cause eye and skin irritation. Review of the Material Safety Data Sheet for Heavy Duty Alkaline Bathroom Cleaner, revealed it could cause eye burns and skin irritation. Further review revealed it was harmful if swallowed or inhaled, and could cause severe respiratory tract irritation. Review of the Material Safety Data Sheet for Ecolab Professional Strength Glass Cleaner, revealed it could cause respiratory tract irritation, eye and skin irritation, and may be fatal if swallowed. Review of the Material Safety Data Sheet for Alkaline Bathroom Cleaner, revealed it could cause burns of the eyes, skin, and respiratory tract. Review of the Material Safety Data Sheet for Keystone Multi Quat Sanitizer, revealed it could cause irritation of the eyes, skin, respiratory tract and digestive system. Review of the Material Safety Data Sheet for Ecolab Disinfecting Acid Bathroom Cleaner, revealed it could cause eye irritation. Review of the Material Safety Data Sheet for Revitalize Carpet Cleaner, revealed it could cause eye irritation. Review of the Material Safety Data Sheet for Boardwalk Gum Remover, revealed it could cause eye and skin burns; and if inhaled could cause headache, disorientation, nausea, rapid respiration, and possible unconsciousness. Review of the Material Safety Data Sheet for Brown Gone RTU, revealed it could cause skin, eye and ingestion irritation. Review of the Material Safety Data Sheet for SOS Stainless Steel Pads, revealed it could cause eye and skin irritation; and nausea and vomiting. Interview on 09/13/16 at 1:40 PM with Certified Nurse Aide (CNA) #14 who worked on the Rehab Unit, revealed the housekeeping closet should be locked and only accessible to the housekeeper on the rehab unit. Further interview revealed the chemicals in the closet could be harmful to residents and visitors. Interview on 09/13/16 at 1:48 PM, with Housekeeper #6, revealed the housekeeping closet door should be closed at all times when not in use, and she had exited the closet door without ensuring the door had shut all the way and therefore the door had not locked. Continued interview revealed she should have made sure the door had completely closed prior to leaving the area to prevent potential safety hazard to residents and visitors. Interview on 09/13/16 at 2:30 PM, with the Housekeeping Supervisor, revealed the housekeeping closet door should be completely closed before the housekeeper walks away so that it would lock and to prevent possible harm to residents and visitors. Further interview revealed it was his expectation that the housekeeping staff follow the facility's Safety for Residents Policy. Interview on 09/23/16 at 5:30 PM, with the Administrator, revealed the housekeeping closet door should have been completely closed prior to the housekeeper leaving the area. Further interview revealed it was her expectation that staff make sure they follow the facility's policy and ensure all hazardous materials are secured behind locked doors when unattended.

Based on observation, interview, record review, Evacuation Plan review, and Grading Permit review, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents. The facility failed to ensure the Evacuation Plan was updated to reflect necessary changes to fire exits related to construction. The facility failed to ensure all accessible exits had a safe path to a public way. The facility failed to ensure staff was trained and knowledgeable regarding which fire exits were appropriate for evacuation during construction and required monitoring to prevent accidents. On 12/28/10, the facility began construction by digging a 25 foot retention pond affecting the safe path to public way from the two south exits of the facility. On 05/29/11 a fire was identified in room 117; however, staff interviews revealed they would have evacuated the residents through the south exits as they did not have knowledge of any changes in the evacuation plan nor had they been instructed to monitor the exits to ensure the safety of all residents. The two south fire exits, one located nearest room 117 and near the Physical Therapy (PT) department led to an uneven rocky and dirt surface and the other exit, located near resident rooms 230 and 231, led to a ditch which was approximately twelve (12) feet deep. Both south fire exit doors remained accessible to all staff, residents and visitors with no staff supervising the two (2) exit doors despite the facility's knowledge there was not a safe path to a public way due to construction. These two south fire exits were the nearest exit, per the facility's evacuation plan, for fifty-five (55) of the facility's eight-four (84) residents. Based on the above findings, it was determined the facility's failure to have an effective system in place to supervise two accessible fire exits to ensure residents had a safe path for exit to a public way this failure is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 06/02/11 and was determined to exist on 12/28/10. (Refer to K38 Life Safety Code) The findings include: Review of the facility's Safety and Disaster Preparedness Introduction, Fire Safety and Evacuation Plan in Case of Fire (used for employee in-service), not dated, revealed staff were to remove residents to the nearest fire exit or beyond the nearest fire wall. The plan detailed two south fire exits. One south fire exit was located near the Physical Therapy (PT) department and was designated as the nearest exit for sixteen (16) residents of the facility. The other exit was located near resident rooms 230 and 231 and was designated as the nearest exit for thirty-nine (39) residents. Interview, on 06/02/11 at 10:00 AM with the Construction Superintendent, revealed construction began on 12/28/10 which affected the two (2) south exits of the nursing facility. Review of the Grading Permit revealed the local government granted the grading permit on 12/28/10. Continued interview, on 06/07/11 at 3:30 PM with the Construction Superintendent, revealed a twenty-five (25) foot deep hole was dug outside the south exit door nearest to resident rooms 230 and 231 on 12/28/10. He further indicated he was unaware of exit discharge needing to lead to a public way. Review of the facility's Evacuation plan revealed there was no evidence the facility had changed the evacuation plan related to the construction which began 12/28/10. Per interview with Registered Nurse (RN) #1, on 06/01/11 at 12:10 PM, a fire was identified in room 117 on 05/29/11. The RN stated if evacuation were necessary, staff would have taken residents out the two (2) south exits detailing the exits were near the PT department and rooms 230 and 231. Observation, on 05/31/11 at 2:00 PM, revealed the south fire exit located near the PT department led to an uneven rocky and dirt surface. Further observation revealed the south fire exit located nearest to resident rooms 230 and 231 led to a ditch, which was approximately twelve (12) feet deep within eight (8) feet from the exit door. Observation, on 05/31/11 3:15 PM, revealed both exit doors remained accessible to all staff, residents, and visitors. Observation, on 06/01/11 at 2:00 PM, revealed no staff was supervising the exit door nearest PT or the exit door nearest resident rooms 230 and 231. Continued observations, at 3:00 PM and 4:00 PM, revealed no staff was supervising the two (2) exits. Observations, on 06/02/11 at 9:00 AM, 11:00 AM and 2:00 PM, revealed no staff was supervising the exit door nearest PT or the exit door nearest resident rooms 230 and 231. Interview with SRNA #2, on 06/03/11 at 5:38 PM, revealed she had received no training to monitor doors related to residents accessing and exiting, in case of an emergency. Interview with SRNA #2, on 06/01/11 at 6:36 PM, revealed if the fire on 05/29/11 had become a situation in which evacuation of residents was required, staff would have used the exits nearest the PT department and resident rooms 230 and 231. Interview with Licensed Practical Nurse (LPN) #3, on 06/1/11 at 6:53 PM, revealed if residents from the South unit had to be evacuated they would evacuate through the exit door nearest to the South Nurse's station which is nearest to resident rooms 230 and 231. Interview with the Administrator, on 06/03/11 at 7:00 PM, revealed the precautions taken to ensure the two (2) exits in the back of the facility were not used included the wander guard system, signs which stated it was a construction area do not use and key pads which had a code that no one except maintenance knew the code to operate. However, interview with SRNA #11, on 06/06/11 at 5:35 PM, revealed he had observed two (2) residents, Resident #3 and #6, attempt to exit the building through the front door by pushing down on the panic bar which caused the door to alarm. The facility Social Services Director identified eight (8) residents requiring supervision due to cognitive deficits, lack of safety awareness, risk for elopement and who the facility had applied wander guard bracelets to assist in supervision. Continued interview with the Administrator revealed he acknowledged that despite the wander guard alarming system being installed on these doors, both doors would unlock and open if the doors' panic bars had been engaged for fifteen (15) seconds. The facility was unable to provide documented evidence they had developed and implemented an emergency evacuation plan specific to address the two (2) south exits involved in construction. Furthermore, there was no evidence the facility had trained staff regarding the appropriate, safe use of these two (2) exits or monitoring of the exits due to construction.

Based on interview, record review, and review of the acceptable Allegation of Compliance (AOC) it was determined Immediate Jeopardy (IJ) identified during the Abbreviated Survey (06/06/11) had been removed related to supervision to prevent accidents; however, non-compliance continued to exist, as the facility had not completed staff education, nor developed and implemented a Plan of Correction (POC) related to accidents and supervision. In addition, the facility continued to monitor the newly developed evacuation plan through the Quality Assurance (QA) program to ensure the effectiveness of the plan and new systems implemented to prevent recurrence and maintian compliance. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 06/20/11 revealed the facility sealed the emergency exits leading to the construction site from the outside. After completion of a walkway, one exit was reopened as an evacuation route. In addition, a fence was built to enclose the construction site, preventing public access to the area. The evacuation plan was revised and new signs were posted to direct staff and residents to a safe area in the event of fire or other emergency. Physical monitoring of the exit around the clock was initiated. Further review of the AOC revealed daily rounds for identification of potential hazards were conducted, utilizing the newly-developed Environment Quality Assurance (QA) Form. The Maintenance Director was conducting four (4) safety rounds daily. Staff re-education of new policies and procedures related to the evacuation plan had been conducted. Facility administration was conducting random competency checks on the new procedures six (6) times daily. Fire, Evacuation, Elopement and Hazard Drills had been conducted on all three (3) shifts. All data collection from daily rounds, random competencies, and analysis of drill responses were reported at daily QA meetings and will be taken to the next monthly QA meeting. The above information was verified through staff interviews and record reviews. However, record review and interview with the Administrator revealed not all staff had received the training and assessment of competencies, specifically those staff on leave or staff who were PRN (as needed). Interview with the Administrator on 06/24/11 at 8:00 PM revealed facility staff currently on leave or who work on a PRN (as needed) basis had been mailed training materials which included acknowledgement forms. The Administrator stated all forms had not been received back by the facility and training would not be completed until those staff members reported for their next assigned shift. Continued interview revealed the Environment Quality Assurance forms, data collected from daily rounds, and competencies would be reviewed at the next monthly QA meeting which was scheduled for 07/13/11 and would be attended by the Medical Director.

Based on observation and interview, it was determined the facility failed to be administered in a manner which enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, related to provision of care in accordance with acceptable Standards of Practice. The facility administration failed to ensure compliance with Life Safety Code requirements and failed to ensure the residents' environment remained as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents. On 12/28/10, the facility had construction begin which affected the two south fire exit doors. The facility failed to ensure the south fire exit doors had a safe path to a public way; one exit led to a 12 foot deep retention pond and the other exit had an uneven rocky dirt surface. Both exit doors were accessible to residents, staff, and visitors with no monitoring or supervision of the exit doors. These two south fire exits were the nearest exit, per the facility's evacuation plan, for fifty-five (55) of the facility's eight-four (84) residents. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently had caused was was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care was identified on 06/02/11 and determined to exist on 12/28/10 and is ongoing. The findings include: Review of the facility's Safety and Disaster Preparedness Introduction, Fire Safety and Evacuation Plan in Case of Fire (used for employee in-service), not dated, revealed staff was to remove residents to the nearest fire exit or beyond the nearest fire wall. Observation, on 05/31/11 at 2:00 PM, revealed the south fire exit located nearest to the Physical Therapy (PT) Department led to an uneven rocky and dirt surface and the exit located nearest to resident rooms [ROOM NUMBERS] led to a ditch, which was approximately twelve (12) feet deep. Observations revealed both exit doors remained accessible to all staff, residents and visitors. There were no staff observed supervising the two (2) exit doors despite the facility's knowledge there was not a safe path to a public way due to construction. (Refer to F-323 and F-454 and to LSC K38, CMS 2567L Event ID 1VJJ21) There was no evidence Administration had evaluated and/or revised the evacuation plan related to the south fire exits having no safe path to a public way and no evident the facility trained staff on any necessary changes identified to ensure unsafe exits were not utilized. The Administrator did consult with the Construction Superintendent who told him the exits were okay, even after the State Building Inspector on 04/07/11 had stated the exits needed to be clear and accessible to residents, staff, and visitors. (Refer to F-323 and F-518). Interview with the Administrator, on 06/01/11 at 4:25 PM, revealed the Quality Assurance Committee meeting was held on 05/11/11 in which a new fire education and plan developed by the corporate office had been discussed; however, the facility was unable to provide evidence of action taken to address the south fire exits being unsafe for exit in the event of an emergency requiring evacuation nor to ensure monitoring of the doors as they remained accessible despite the unsafe path due to construction. (Refer to F-520). Interview on 06/02/2011 at 11:30 AM with the facility Administrator revealed when asked why he did not ensure the south exits were accessible to a public way he stated the Construction Superintendent had told him the exits were okay. This was confirmed by the Construction Superintendent on 06/02/2011 at 10:00 AM who also revealed that he was unaware that these exits required a safe path to a public way. Continued interview with the Administrator, on 06/06/11 at 4:25 PM, revealed no problems had previously been identified with the fire safety and evacuation plan; however, the State Building Inspector on 04/07/11 had stated the exits needed to be clear and accessible to residents, staff, and visitors. He further stated he felt the precautions taken by the facility were appropriate to keep individuals from exiting the two (2) back exit doors despite the observations of the exit doors during the survey revealed no staff were monitoring the exits which remained accessible to all staff, residents, and visitors.

Based on interview, record review, and review of the acceptable Allegation of Compliance (AOC) it was determined that Immediate Jeopardy (IJ) identified during the Abbreviated Survey (06/06/11) had been removed related to training of staff on emergency response; however, non-compliance continued to exist as the facility had not completed staff education, nor developed and implemented an acceptable Plan of Correction (POC) related to staff education. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 06/20/11 revealed the facility implemented a revised emergency evacuation plan and began conducting mandatory educational activities for all staff related to fire safety and emergency evacuation procedures. The Director of Nursing and the Staff Development Coordinator and their designees conducted the inservices, which included written tests. In addition, random competency evaluations of staff knowledge of the new procedures were being conducted daily. Fire, elopement and evacuation drills were conducted on all shifts. Interview with the Staff Development Coordinator, on 06/24/11 at 5:15 PM, revealed data collected from written tests, random competency checks and analysis of drills were being reported to daily Quality Assurance (QA) meetings attended by all department heads. Random interviews with staff from all departments revealed ready knowledge of emergency preparedness and new evacuation procedures. Interviews conducted on 06/24/11 with direct care staff, nursing staff, and other facility staff revealed verification the facility had provided training on the new emergency evacuation policy and procedure. The education was also verified through record review. However, record review and interview with the Administrator revealed not all staff had received the training and assessment of competencies, specifically those staff on leave or staff who were PRN (as needed). Interview with the Administrator on 06/24/11 at 8:00 PM revealed the next QA monthly meeting on 07/13/11 would be attended by the Medical Director. He stated all QA activities to that point, including drill response audits and staff competency evaluations, would be reviewed and revisions made as deemed necessary by the QA Committee.

Based on observation, interview, Emergency Plan review, and Grading Permit review, it was determined the facility failed to ensure the quality assessment and assurance committee (QA) was effective in identifying and correcting quality issues with the potential for negatively affecting residents. The facility's quality assurance committee failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident receives adequate supervision to prevent accidents. The facility failed to identify two (2) emergency exit doors (south), which led to construction areas, did not have a safe path to a public way and failed to identify the accessibility for residents to use the exits. These failures prevented the facility from implementing effective measures to ensure appropriate supervision of the two exit doors or to prevent accessibility while having an unsafe path to a public way during construction despite having a committee meeting on 05/11/11 which discussed a new fire education and plan. Furthermore, the facility failed to ensure staff was trained regarding emergency evacuation procedures related to the two south fire exits affected by the construction and failed to train staff related to supervision of the accessible exits. These two south fire exits were the nearest exit, per the facility's evacuation plan, for fifty-five (55) of the facility's eight-four (84) residents. Based on the above findings it was determined the facility failed to have an effective system to identify quality of care issues to ensure residents received quality of care to ensure the resident environment remained as free of accident hazards as is possible; and each resident receives adequate supervision to prevent accidents, which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 06/02/11 and was determined to exist on 12/28/10. The findings include: Review of the facility's emergency evacuation plan revealed staff was to evacuate residents to the nearest exit. On 12/28/10, per interview with the Construction Superintendent and review of the Grading Permit revealed construction began by digging a retention pond varying in size from twenty-five (25) foot hole to a twelve (12) deep foot deep ditch which was eight (8) feet wide. This construction affected the two (2) south fire exit doors. On 05/31/11 at 2:00 PM, observation revealed the fire exit located near the Physical Therapy department led to an uneven rocky and dirt surface. The exit located nearest to resident rooms [ROOM NUMBERS] led to a ditch, which was approximately twelve (12) feet deep. There was no evidence that the facility had implemented a change in the emergency evacuation plan or provided training to staff related to the accessibility, appropriate use of the exits and the need for monitoring the exits after the construction began on 12/28/10. Interview with the Administrator, on 06/01/11 at 4:25 PM, revealed the a Quality Assurance Committee meeting was held on 05/11/11 in which a new fire education and plan developed by the corporate office had been discussed. While the facility's committee met, the facility could provide no evidence of action taken to ensure the safety of residents in having a safe path to a public way for the two south exits, or ensuring monitoring of the south exit doors while the exit doors were accessible to all residents, staff, and visitors. Interview with the Administrator on 06/03/11 at 7:00 PM revealed the precautions taken to ensure the two (2) exits in the back of the facility were not used included the wander guard system, signs which stated it was a construction area do not use and key pads which had a code that no one except maintenance knew the code to operate. The only new addition was the sign after the construction began. Further interview with the Administrator, on 06/07/11 at 4:25 PM, revealed no problems had previously been identified with the fire safety and evacuation plan and he felt the precautions taken were appropriate to keep individuals from exiting the two (2) back exit doors. However, SRNA #11 interview, on 06/06/11 at 5:35 PM, revealed he had observed two (2) residents, Resident #3 and #6, attempt to exit the building through the front door by pushing down on the panic bar which caused the door to alarm. The facility Social Services Director identified eight (8) residents requiring supervision due to cognitive deficits, lack of safety awareness, risk for elopement and who the facility had applied wander guard bracelets to assist in supervision. The Administrator further acknowledged both doors would unlock and open if the doors' panic bars had been engaged for fifteen (15) seconds. Observation, on 06/01/11 at 2:00 PM, at 3:00 PM and 4:00 PM and on 06/02/11 at 9:00 AM, 11:00 AM and 2:00 PM, revealed no staff was supervising the exit door nearest PT or the exit door nearest resident rooms [ROOM NUMBERS]. Interviews with SRNA #2, on 06/01/11 at 6:36 PM, and Licensed Practical Nurse (LPN) #3, on 06/1/11 at 6:53 PM, revealed these staff would have used the south fire exits to evacuate residents should an event have required evacuation. Further interview with SRNA #2 revealed she had received no training to monitor doors related to residents accessing and exiting, in case of an emergency. The facility was unable to provide documented evidence the quality assurance committee identified quality concerns related to the two south fire exits and took action to secure a safe path to a public way and monitoring the fire exits while the exits paths were affected by the construction. Furthermore, the facility quality assurance committee was unable to provide evidence that they had identified the need for training of staff regarding the fire exits to ensure staff was trained regarding the appropriate, safe use of these two (2) exits or monitoring of the exits due to construction.