Every finding on record at Little Sisters of the Poor

Based on interview, observation, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 of 8 residents. Additionally, the facility failed to maintain sanitary practices during food service, which had the potential to affect all 29 residents in the facility. The findings include:Review of the facility's policy titled, Hand Hygiene revised 08/29/2019, revealed under Purpose, hand hygiene was a simple and effective method for preventing the spread of pathogens, such as bacteria and viruses, which caused infections. Per review, pathogens could contaminate the hands of a staff person during direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity of the resident. Continued review revealed failure to clean contaminated hands could result in the spread of those pathogens to residents, staff (including the person whose hands were contaminated), and environmental surfaces. Further review revealed handwashing (washing with soap and water) must be used but was not limited to the following situations: after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident; and before and after the removal of gloves. Review of facility's training policy titled, Infection Prevention and Control dated 06/12/2026 stated, Glove Protocol, gloves equal barrier, not a substitute for hand washing. Change gloves: After touching contaminated surfaces. Always wash hands before and after glove use. Preventing Cross Contamination, never touch clean items with dirty gloves. Glove Safety: Do Not Touch multiple surfaces with the same gloves.1(a). Review of the admission Record for R22 revealed the facility admitted the resident on 04/08/2024, with diagnoses of abnormal posture and age-related physical debility. Review of R22's Care Plan revealed the facility identified the resident needed a Broda (special positioning chair) chair for safe positioning, pressure relief, and fall prevention related to decreased mobility, weakness, and/or poor trunk control with intervention to ensure proper positioning (head, trunk, hips aligned; feet supported). Observation on 04/28/2026 at 11:57 AM, revealed Certified Nursing Assistant, (CNA) 4 in the dining room with gloves on readjusting a resident (R22) in his wheelchair, touching the resident, his personal blanket, and his wheelchair. Further observation revealed CNA 4 did not perform hand hygiene or change gloves prior to proceeding to assist another resident (R21). Then staff member, CNA 4 turned around and went to assist another resident, R21, eat his lunch meal, touching his silverware, drinkware and dinnerware, never changing gloves or performing hand hygiene.1(b). Review of the admission Record for R21 revealed the facility admitted the resident on 12/19/2023, with diagnoses of Alzheimer's disease with late onset, dementia and feeding difficulties. Review of R21's Care Plan revealed the facility identified the resident was at nutritional risk related to dementia and had an intervention of assistance with meals as needed. Observation on 04/28/2026 at 11:57 AM, revealed CNA 4, with gloves on, assisted R22 and touched the resident's person, blanket, and wheelchair. Continued observation revealed CNA 4 then went to assist R21, with eating his lunch meal. Further observation revealed CNA 4 touched R21's silverware, drinkware and dinnerware, all without changing gloves or performing hand hygiene. Interview was attempted on 04/30/2026 at 2:47 PM, with CNA 4; however, the CNA did not show up to her scheduled work shift, as she had called out. A telephone (phone) interview was attempted on 04/30/2026 at 2:47 PM, with no answer was received and a voicemail message requesting a return call was left; however, no return call was received. 1(c). Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Isolation, revealed under Required equipment an isolation cart was to be outside the room, and the isolation cart was to have disposable gowns, gloves and red bags. Per review, when initiating isolation the Director of Nursing (DON), Infection Control (IC) Nurse, Assistant DON (ADON) or Physician reviewed the Center for Disease Control and Prevention (CDC) guidelines to determine the precautionary measures required. Further review revealed they were to prepare and post the Disease Specific Isolation Precautions sign. Review of the CDC guidelines the facility policy referred to for implementing EBP (www.cdc,gov/hicpac/workgroup/EnhancedBarrierPrecautions.html) revealed EBP were for all residents with any of the following: infections or colonization with a multidrug resistant organism (MDRO) when Contact Precautions did not apply, and/or wounds, and/or indwelling medical devices regardless of MDRO colonization status. Review of the admission Record for R19 revealed the facility admitted the resident on 09/04/2024, with diagnoses of peripheral vascular disease, venous insufficiency, and was noted on 04/20/2026 as having a diagnosis of cellulitis of right lower limb. Review of R19's record and physician orders dated 04/22/2026, revealed the resident had right lower extremity wound care ordered once a day and as needed for cellulitis of the right lower extremity/sepsis. Per review, the order was to cleanse R19's right lower extremity, pat dry, apply calcium alginate, apply gauze, foam and ABD pad then wrap with kerlix. Continued review of R19's orders revealed an order dated 04/04/2026, for Doxycycline Hyclate (an antibiotic) Oral Tablet 100 milligram (mg) to be given by mouth two times a day for right leg cellulitis infection for seven days. Review revealed the order start date was 04/04/2026, and the stop date was 04/11/2026. Further review revealed an additional order given for Doxycycline 100 mg twice daily for the right lower extremity for 10 days, with a start date 04/30/2026 and stop date of 05/10/2026. Review of R19's Care Plan revealed the facility identified the resident was at risk for impairment to skin integrity related to cellulitis of right lower extremity, having been hospitalized [DATE], antibiotic for right lower extremity 04/27/2026, and treatment in place. Further review of the care plan revealed interventions included medications and treatments as ordered and follow the facility's protocols for treatment of injury/breakdown. Observation on 04/28/2026 at approximately 3:00 PM, revealed R19 in her room, with her lower right leg wrapped with kerlix dressing. In interview, at the time of observation, R19 stated her right lower leg had an infection. Further observation revealed no appropriate precaution signage posted outside R19's door or posted on the isolation cart outside the resident's room. In interview with the Medical Director on 04/29/2026 at 3:55 PM, she stated she expected residents who had wounds, colostomies, and cellulitis to be on enhanced barrier precautions. She further stated her expectation was for the facility's infection control staff to inform her of who needed to be in isolation precautions. In interview with the facility's Infection Preventionist (IP) on 04/30/2026 at 5:38 PM, she stated to determine if a resident was to be placed on a precaution would depend on the pathogen involved. The IP said she would call the Medical Director and discuss the resident and pathogen, and the Medical Director made the decision on what type of precautions to use. She reported the types of conditions a resident would qualify for EBP would be a MDRO diagnosis; and wounds that were at risk for increased infection or spread. The IP explained it did not surprise her that the Medical Director expected residents who had wounds, colostomies, or cellulitis to be on EBP because they were on standard precautions. She said Standard Precautions versus (vs) EBP was during wound treatments to wear a gown and gloves for the EBP. The IP stated Standard Precautions was to perform hand hygiene and use gloves. She reported there were no signs for what type of precautions a resident was on posted outside their rooms in order to honor their dignity. The IP stated the facility placed the precaution sign on top of the isolation cart located inside the resident's room. She said she currently had three residents on EBP that she had received the EBP orders for from the Medical Director. The IP reported R19 was not on EBP, as she had been provided education on proper wound care and how to clean it. She stated she assessed R19's risk often and felt it had not increased. The IP stated she had not seen any reason for precautions and had educated and reeducated staff on how to care for R19. She further stated nursing staff knew which residents were on precautions because they had to acknowledge that by clicking inside the electronic medical record. The IP additionally stated the CNA's also knew who was on precaution as they were informed during their morning huddle. In further interview the IP stated staff should change their gloves and perform hand hygiene in between all tasks. In interview with the Director of Nursing (DON) (who was the facility's back up IP) on 04/30/2026 at 6:02 PM, she stated she determined who was placed on precautions according to if the resident was diagnosed with a multidrug resistant organism, wounds, weeping wounds, anything that could potentially splash. She stated it would surprise her to know the Medical Director expected residents who had wounds, colostomies or cellulitis to be on precautions, as they (She and the Medical Director) had regular communication. The DON/back-up IP said the Medical Director visited R19 recently and had not mentioned placing the resident on precautions or any other expectations. She explained there were no precaution signs posted outside of residents' rooms because of the residents' and families' response to that and therefore, the signs had been removed. The DON/back-up IP stated, We educate and if communication lacks, we place the precaution sign inside the resident's room on top of the isolation cart (located there). She further stated staff found out and knew who was on isolation precautions during the facility's morning huddle meeting. The DON/back-up IP additionally said if staff must wear gloves in the dining room, they should change them after touching anything on the table or after touching a resident. In interview with the Administrator on 04/30/2026 at 6:55 PM, she stated staff received infection control training almost weekly. She said in the QAPI meetings they discussed the audits the IP had performed, focusing on staff redemonstrating to ensure their understanding of the concepts taught. The Administrator reported her expectation, if residents were not on a precaution specific to their condition, was for staff to follow the facility's policy and place those residents on precautions that protected the residents and employees. The Administrator explained a risk of not placing residents on isolation precautions was the spread of infection to other residents and employees, and that risk for the facility's age group could be fatal to them. She stated her expectation of staff implementing an effective infection prevention control program was for the IP to put in place and promote a program that protected the residents. The Administrator said if a resident was on precautions, she expected staff to know there should be a sign on that resident's room. She stated she expected staff to know the precautions based off what the residents' electronic record stated. The Administrator further stated she expected one shift to communicate with another shift on what precautions residents were on. She additionally said if an isolation cart was there (inside the resident's room) and staff did not know why, she expected them to ask a nurse or a Sister or look in the resident's electronic chart for that information.

Based on observation, interview, and policy review, the facility failed to maintain sanitary food handling practices during meal service affecting all residents who consumed food in the dining room. Observations during survey revealed staff failed to prevent potential cross-contamination during meal service through improper glove use, hand hygiene practices, and storage of serving utensils. The findings include:Review of the facility policy titled, Food Safety, dated 03/2017 and reviewed 09/2024, revealed it was the facility's policy to provide safe and sanitary storage, handling, and consumption of all food. Per review, the policy noted food handling processes included the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety.Review of the facility's document Infection Prevention & Control F880 & CFR 483.80 Compliance Dietary Staff Training, dated 06/12/2025, revealed the facility trained dietary staff on hand hygiene, glove use, cross-contamination prevention, and safe food handling. Continued review of the training revealed gloves were a barrier and not a substitute for handwashing. Per review of the training, staff were to perform hand hygiene after touching their face, hair, or personal items; after removing gloves; and after handling dirty dishes or trash. Further review of the training revealed staff were to change gloves after touching contaminated surfaces and were not to touch clean items with dirty gloves. In addition, review of the training revealed instructions to staff not to touch their face, hair, or clothing while gloved; and not to reuse gloves after contamination.During meal service observation on 04/29/2026, at 11:32 AM, Dietary Aide (DA) 1 was observed walking through the dining room with a cart containing a large bowl of tossed salad and offering salad to residents while wearing blue gloves. At 11:45 AM, DA 1 was observed to adjust her right earring while wearing the blue gloves, then proceeded to use tongs to serve salad to a resident. Per observation, DA 1 returned the tongs to the salad bowl, where the tongs laid directly on top of the salad, and used the same tongs to serve salad to the next resident. Continued observation revealed the DA again laid the tongs directly on top of the salad. Observation at 11:48 AM, revealed DA 1 remained wearing the same blue gloves, and was observed to adjust her eyeglasses. DA 1 was then observed to retrieve the tongs from the salad bowl, and begin serving salad to another resident, and to return the tongs to lie directly on top of the salad, before serving salad to the next resident. Observation at 11:52 AM, revealed DA 1 cleared used plates from a resident table, then returned to serving salad to residents without performing hand hygiene or changing gloves. Per observation, at 11:53 AM, DA1 performed hand hygiene and donned new gloves; but, was observed at 11:57 AM scratching her face with her right gloved hand before retrieving a plate from the tray line and delivering it to a resident without performing hand hygiene or changing gloves. Observation at 12:00 PM, DA 1 was observed removing her gloves, performing hand hygiene, and donning new gloves. Observation at 12:06 PM, revealed however, DA 1 was observed to use her gloved hands to adjust her hair net and eyeglasses without again performing hand hygiene or changing her gloves before returning to serving food. Further observation at 12:09 PM, revealed DA 1 returned to the tray line, picked up a plate, and delivered it to a resident.Observation on 04/29/2026 at 11:32 AM, during the same meal observation, revealed DA 2 was observed in the dining room wearing blue gloves and filling residents' cups with ice from an ice bucket located on a rolling cart, using an ice scoop. Observation at 11:51 AM, revealed DA 2 touched the handles of the rolling cart while wearing the blue gloves. Per observation, DA 2 then picked up the ice scoop with the same gloves, filled a resident's cup with ice, and then placed the ice scoop directly in the ice where the handle made contact with the ice. Continued observation revealed DA 2 delivered the drink to a resident, returned to the cart, picked up the same scoop from the ice, filled another resident's cup with ice, and delivered the drink to the resident. Observation at 12:00 PM, revealed DA 2 removed the gloves, performed hand hygiene, donned new gloves, and began delivering plates from the tray line to residents seated in the dining room. Observation at 12:10 PM, revealed DA 2 left the dining area, entered the kitchen, and handled a basket of individually wrapped butter, and returned to the tray line to pick up a plate and deliver it to a resident without performing hand hygiene or changing gloves.During interview on 04/30/2026 at 4:12 PM, the Head [NAME] (HC) stated staff were expected to wash their hands before putting on gloves, changing gloves. The HC said staff were to perform hand hygiene if they touched something dirty, and were not permitted to wear the same gloves across multiple tasks, such as clearing used dishes and then serving food. The HC reported staff were to also change gloves and perform hand hygiene after touching their face, glasses, earrings, hair net, or hair, and after clearing used plates before returning to food service. The HC stated salad tongs were to be stored with the handle not touching the salad or placed to rest on a clean plate, and the ice scoop should be stored in a container and not directly on the ice served to residents. The HC further stated the purpose of hand hygiene during meal service was to prevent disease transmission and cross-contamination.During interview on 04/30/2026 at 6:02 PM, the Director of Nursing (DON) stated gloves were not a substitute for performing hand hygiene. The DON stated staff were expected to wash their hands after touching their face, glasses, hair net, jewelry, resident items, or used dishes during meal service, and before returning to clean food service tasks. The DON said staff should not leave the hot cart during meal service and should delegate the task to another staff member if needed. The DON stated if staff touched potentially contaminated surfaces and then continued serving food without performing hand hygiene or glove changes, the staff member should be removed from the dining room because it was a safety risk for residents. The DON further stated the hand-contact portion of serving utensils should never touch the salad, and the ice scoop handle should not touch the ice. The DON additionally said the purpose of proper hand hygiene during meal service was to prevent contamination and risk of infection.During interview on 04/30/2026 at 6:38 PM, the Administrator stated the facility provided hand hygiene and food safety training at hire and annually, performed audits, and reported audit results through the facility's Quality Assurance Performance Improvement (QAPI). The Administrator explained if staff touched potentially contaminated surfaces and then continued serving food without hand hygiene or glove changes, staff should be retrained immediately because it was a violation of infection control. The Administrator said an ice scoop should be kept separately with the handle up and not stored inside on the ice. The Administrator further stated the purpose of hand hygiene during meal service was to remove bacteria transmitted from one surface to another and prevent contamination.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for 1 of 2 Medication Rooms observed. Addtionally, the facility failed to ensure drugs and biologicals were disposed of by the expiration date for 3 of 6 medication and treatment carts. Observation of a medication room refrigerator revealed an insulin pen with no resident label and another pen that was expired. Observation of medication carts revealed multiple medications stored beyond the labeled expiration date. The findings include: Review of the facility policy entitled, Medication Storage, last reviewed 02/2025, revealed the Home (facility) must store all drugs and biologicals in a safe, secure and orderly manner. Per review, the facility was to ensure no expired or discontinued medications were stored within stock, house, routine or PRN (as necessary) medications that were readily available for administration. Continued review revealed the facility must not use discontinued, outdated or deteriorated drugs or biologicals, and ensure all such drugs were returned to the dispensing pharmacy or destroyed. Further review revealed all expired medications were to removed immediately upon discovery and placed in the appropriate holding receptacle for pick up and destruction by the Director of Nursing (DON) or Designee. Observation of medication storage of the facility's Jeanne Jugan Unit (JJU) medication room on 05/14/25 at 3:20 PM revealed the following: 1 Humalog Kwikpen, with an opened date of 05/04/2025, with no resident's name; 1 Insulin Glargine pen for R19, noted as opened 03/23/2025, with a notation stating the pen would expire in 28 days after opening. Review of R19's Medication Administration Record (MAR) for March 2025 and April 2025 revealed R19's Insulin Glargine had been discontinued on 04/07/2025. Observation of the 8 hour cart on the JJU on 5/14/2025 at 3:40 PM, revealed the following: For R13- Latanoprost 125 microgram(mcg)/2.5 milliliter (ml) eye drops, with no documented opened date or expiration date; Dorzalomide Hcl 2% (eye) drops, with no opened date or expiration date. For R27- Zofran (antinausea medication) 4 milligram (mg) oral medication (po) as needed (prn), with an expiration date of 03/30/2025. For R18- Zofran 4 mg po prn, with an expiration date of 03/31/2025. For R19- Metolazone (diuretic medication) 5 mg po, with an expiration date of 03/31/2025; Loperamide (antidiarrheal medication) 2 mg po, expiration date of 03/14/2025; Clopidogrel (a platelet inhibitor medication) 75 mg po, expiration date of 01/31/2025; Vitamin C (dietary supplement) 500 mg po, with an expiration date of 6/21/2024. Observation of the JJU treatment cart on 05/15/2025 at 9:03 AM revealed the following: Normal Saline (NS) solution, 5 ml vials, 28, expired 01/2024; Allevyn Lite Sacrum dressing, expired 08/01/2024; Cathtrip securement device (universal securement system for catheter tubing), expired 07/31/2024; Curad Petrolatum dressing, 3inch x9 inch x3 inch dressings, expired 3/15/2024. Observation of the Holy Family Unit (HFU) treatment cart on 05/15/25 at 9:57 AM revealed the following: NS solution, 5 ml vials, 1 box with 19 vials, expired 01/2024; Normal Saline solution, 5 ml vials, 1 box with 42 vials, expired 06/2022; Aspercreme 4% with Lidocaine cream for R10, expired 11/2024; and SurePrep skin protection wipes: 1 box with 48 wipes, expired 10/2023; 2 boxes with a total of 79 wipes, expired 11/2023; and 1 box with a total of 49 wipes, expired 12/01/2024. During interview with Licensed Practical Nurse (LPN) 3 on 05/15/2025 at 10:25 AM, she stated the reason medications had expiration dates was because they lost their effectiveness over time. During interview with LPN 4 on 05/16/2025 at 9:52 AM, she stated it was important to discard medications by their expiration dates, so they did not give medications that might not be effective. During interview with Registered Nurse (RN) 1 on 05/15/2025 at 11:10 AM, she stated medications were to be discarded before their expiration dates. She stated it was important to do that so residents did not receive medicine that were no longer effective or might hurt them. During interview with the Director of Nursing (DON) on 05/15/2025 at 11:34 AM, she stated it was the facility's policy for the nurses to be checking expiration dates while they were giving medications. She stated the Staff Development Coordinator (SDC) was to audit medications and supplies once per week and pharmacy audited once per month. The DON further stated her expectation was for staff to follow the facility's policy and said expired drugs might be harmful to the resident, so it was all about safety. During interview with the Administrator on 05/16/2025 at 11:48 AM, she stated her expectation was for the certified medication aide (CMA) or nurse to check for expiration dates before administration of medications. She stated the pharmacist reported in the facility's Quality Assurance Performance Improvement (QAPI) meetings on the audits he performed of the medication carts. The Administrator reported if an agency nurse found out-of-date medications, she expected those nurses to report that information to facility staff. She said she expected the SDC and ADON to audit medication and treatment carts at least monthly. The Administrator further stated it was important to discard medications before the expiration date because we would not know if the medicine was effective or if it could be harmful for to the resident.

Based on observation, interview, and review of the facility's policies, the facility failed to ensure staff maintained infection control during plating of food for meal service. Observation revealed dietary staff failed to change gloves and/or perform hand hygiene as required. The findings include: Review of the facility's policy, Infection Control, revised 09/20/2024, revealed in order to provide maximum protection for residents, and personnel from pathogenic microorganisms and infectious diseases, methods of prevention and control should be implemented. Further review revealed the primary objectives should be: prevention, referring to eliminating the occurrence of a disease or infection; and controlling which pertained to restricting the spread of existing diseases and infections. Observation on 05/13/2025 at 11:37 AM, of the lunch meal service revealed [NAME] (C) 1 plated food, which included opening a bun using her gloved hand, and opening the door to the serving cart without changing her gloves or performing hand hygiene in between touching the service cart and touching the bun. Per observation, C 1 was also observed touching a tape dispenser and trays and then touching residents' food with her gloved hands, without changing her gloves or performing hand hygiene between touching the tape dispenser, the tray, and touching food items. Further observation revealed C 1 touched her apron with her gloved hands; however, did not change gloves or perform hand hygiene after touching her clothing before proceeding to touch food she was serving to residents. Observation on 05/13/2025 at 11:55 AM, revealed Dietary Aide (DA) 2 placed her gloved hands onto the surface of the counter in the dining room, picked up a tray, served it to a resident and assisted the resident with meal setup. Further observation revealed DA 2 touched her face and then touched the resident's silverware during the meal setup. Observation on 05/13/2025 at 12:05 PM, revealed C 1 dropped a meal ticket onto the floor and DA 3 picked up the meal ticket from off the floor and placed it on a resident's meal tray without changing her gloves or using hand sanitizer prior to passing and setting up the tray for Resident (R)32. In interview with C 1 on 05/13/2025 at 11:50 AM, she stated she plated all the trays for residents who did not dine in the dining room. She said she then changed her gloves and performed hand hygiene after the food cart had been loaded. C 1 further stated the food service cart was wiped down prior to being filled with residents' meal trays. In interview with DA 1, DA 2, and DA 3 on 05/13/2025 at 12:15 PM, they all stated they changed their gloves and performed hand hygiene between meal tray setup and serving of each resident's meal trays in the dining room. In interview with the Dietary Manager (DM) on 05/16/2025 at 9:45 AM, she stated her expectation was for staff serving food in the dining room, to sanitize their hands and don gloves at start of the food service. She said staff were to sanitize and don new gloves when breaking a task. The DM further stated staff should hand sanitize and don new gloves after touching surfaces not sanitized, or their hair, clothing, or other skin surface. In interview on 05/16/2025 at 11:24 AM, the Assistant Director of Nursing (ADON), who was also the interim Director of Nursing (DON) and the back up Infection Prevention (IP) Nurse (the IP nurse was out sick), stated it was her expectation for dietary staff to perform hand hygiene before and after any task that needed gloves. She said staff should change their gloves if they touched anything dirty such as a used plate or bowl. The ADON reported she expected gloves to be changed and hand hygiene performed each time C1 touched the food transport cart. She further stated dietary tickets should not be taped to the plate covers, eliminating the need to touch the tape dispenser. The ADON additionally said anything dietary staff touched that was not clean (such as their clothing or surfaces) would require them to change gloves and perform hand hygiene before touching food. In interview with the facility's Administrator on 05/15/2025 at 11:33 AM, she stated it was her expectation dietary staff change their gloves and perform hand hygiene between serving each resident. She said staff should also change their gloves and perform hand hygiene if they touched their clothing or face, after picking anything up off the floor, or touching any soiled/unclean surface such as a counter top or a food service cart.

Based on interview, record review, and review of the facility's documents and policy, the facility failed to 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 as soon as practicable for 1 of 1 residents sampled for transfer/discharge out of the total sample of 14, (Resident (R)18). Additionally, the facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. The findings include: Review of the facility's Bed Hold and Return policy, reviewed on 02/2025, revealed it was the policy of the facility to provide residents who were transferred to the hospital or go on a therapeutic leave with written information about the State's bed hold duration and payment amount before the transfer. Additionally, review revealed the facility permitted residents to return to the facility after hospitalization or therapeutic leave if their needs could be met by the facility and they were eligible for Medicare, Medicaid or services covered by another payor. Review of R18's Face Sheet revealed the facility admitted the resident on 04/15/2021, with diagnoses of type II diabetes mellitus with hyperglycemia, hyperlipidemia, mild cognitive impairment of unknown etiology, and hypertension. Review of R18's Discharge Summary, dated 05/05/2025 revealed she had been hospitalized on [DATE] for abdominal pain and sepsis due to kidney stones. Review of R18's Physician Progress Note, dated 05/05/2025 revealed R18 returned to the facility after hospitalization from 05/01/2025 through 05/04/2025, for sepsis related to an obstructive stone in her left ureter (tube that carries urine from the kidney to the bladder). Review of R18's Bed Hold Policy Notification, dated 05/01/2025 revealed that it was the facility's form for notifying R18 and her Responsible Party (RP) she had a bed hold for the facility for 14 days while she was hospitalized or on therapeutic leave. In interview on 05/13/2025 at 2:38 PM, R18's RP/Family (F)4 stated the facility called him and told him R18 had been experiencing abdominal pains and asked if it was okay to send her to the hospital for treatment. He said he agreed to that, and R18 was transferred to a nearby hospital. RP/F4 further stated the facility verbally told him of the transfer; however, he had not received written documentation of her bed hold. In interview with the Assistant Director of Nursing (ADON) and interim Director of Nursing (DON) on 05/16/2025 at 9:04 AM, the ADON stated the facility did not mail letters regarding resident transfers and bed holds to residents' RP's. The ADON further stated nor did they email a letter to the Ombudsman. In interview with the Social Services Director (SSD) on 05/16/2025 at 9:05 AM, she stated the facility did not send letters to residents' RPs or the Ombudsman when a resident was transferred to the hospital. She further stated it was part of the admission paperwork given upon admission and they discussed the bed hold policy in that context. In interview with the Administrator (ADM) on 05/16/2025 at 9:07 AM, she stated the facility was different than other nursing facilities. She reported when a resident left for a hospitalization, the facility held the bed regardless of how long the resident might be out of the facility. The ADM further stated for that reason they did not send letters to the resident's RP or the Ombudsman alerting them of the discharge/transfer or the bed hold.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a quality assurance performance improvement (QAPI) plan and program. This had the potential to affect all residents. The findings include: Review of facility policy, Quality Assurance and Performance Improvement Program (QAPI), dated 08/2017, revealed, the facility Medical Director and the Administrator were responsible for implementing the QAPI Program and organizing facility and medical staff functions to accomplish this program. Additionally, a Quality Assurance (QA)Committee coordinated a comprehensive QAPI Program involving medical, nursing, and other ancillary support services. Furthermore, the QA Program was reviewed annually by the QAPI Committee to ensure the program was comprehensive, effective in improving Resident care, and was cost effective. During an interview, on 06/23/2022 at 9:37 AM, the surveyor informed the Administrator the survey team requested the facility QAPI plan since survey initiation on 06/21/2022. The Administrator stated, I do not have a QAPI Plan. The interview continued at 10:13 AM when the Administrator stated the previous Director of Nursing (DON) was expected to complete the QAPI plan but did not get it done. Interview with the Administrator, on 06/24/2022 at 3:11 PM, revealed she had not had training in the area of QAPI and did not understand how it flowed.

Based on interview, document review, and facility policy review, the facility failed to develop and implement a facility assessment. This had the potential to affect all residents. The findings include: A review of the policy titled, Developing Your Facility Assessment: Essential Components, dated 04/2017, indicated, Facility Assessment states a home must conduct and document a facility-wide assessment to define what resources are necessary to care for its Resident competently during day-to-day operations and emergencies. This facility assessment must be completed annually, or when significant changes to the resident population occur. During an interview on 06/23/2022 at 8:13 AM, the Administrator stated, I know we had a facility assessment that was done in 2019, but I do not know where to find one for 2020 or 2021 and yes, the one that was provided to the survey team was completed the day the team arrived. A review of the quality assurance performance improvement (QAPI) meeting minutes from 11/24/2021 indicated the performance improvement project (PIP) for the quarter was for the Administrator to complete the facility assessment with the team's assistance. The minutes indicated it was part of the annual survey compliance and needed to be reviewed by the end of 2021 and then updated, if indicated, in the following thirty (30) days after the review. During a follow up interview on 06/23/2022 at 10:13 AM, the Administrator stated that she knew there was a PIP from 2021 for the Administrator to complete the facility assessment and she stated, I just didn't do it. I'm aware that it needed to be done. During an interview on 06/24/2022 at 2:27 PM, the Director of Nursing (DON) indicated upon her arrival to the facility in April of 2022, she requested the facility assessment because she did not find one to review. The DON was putting together the survey binder and asked the Administrator for the facility assessment, but never received the document from the Administrator. The DON stated there was no discussion as to why it was never received for the survey binder. During an interview on 06/24/2022 at 2:50 PM, the Administrator indicated that during a QA (quality assurance) meeting the attendees brought up that the facility assessment needed completed and she though it was in the Assistant Director of Nursing's office. The Administrator indicated that she thought there was going to be help with getting the facility assessment completed. The Administrator stated her progress was going to be tracked during the QA meetings. The Administrator stated it was her responsibility to get it completed.

Based on interview and record review, the facility failed to ensure residents and/or resident representatives received quarterly trust account statements for thirty-two (32) of thirty-two (32) residents. The findings include: A review of the facility policy, Residents' Personal Funds, revised 02/2022, revealed the facility provided statements upon request by the Resident or Resident Guarantor and mailed the statements at least quarterly with a Statement of Receipt. Additionally, the facility's Resident Services was responsible for reviewing the statements with the Residents who were capable of understanding the information. During an interview on 06/21/2022 at 10:45 AM, Resident #25 (who the facility assessed as cognitively intact with a Brief Interview for Mental Status [BIMS] score of 14) revealed the facility managed their money. Resident #25 indicated he/she wanted to know how much money was in their account and they were unaware of receiving any statements from the facility. Interview with Family Member #14, on 06/24/2022 at 10:44 AM, revealed stated they had not received a statement since moving in February, 2022. Interview, on 06/24/2022 at 1:00 PM, with Resident #17 (who was cognitively intact with a BIMS score of 15) revealed the facility had not informed them of their resident account balance since the second week in February. The facility assessed Resident #17 as cognitively intact with a BIMS score of 15. Resident #17 stated they ordered some clothes in January or February, 2022, and the order came in, but the facility did not provide a new account statement to update the resident. Resident #17 indicated they could get money, but they did not know how much they had. Interview with Business Office Employee #13, on 06/23/2022 at 3:14 PM, revealed she did not manage the resident funds; the position was vacant, and the Administrator was managing the trust fund. Interview with the Administrator, on 06/23/2022 at 4:13 PM, revealed facility staffing included a person who was responsible for resident money, but the position was vacant since February. The Administrator indicated she was the person in charge of sending out resident trust statements due to the vacant position and the facility should send the statements quarterly. She stated Resident #25 would be the person to receive his/her statements, but he/she had not gotten the last statement. During an interview, on 06/24/2022 at 8:03 AM, the Administrator revealed the resident trust statements for the first quarter were not available since the facility had not yet closed out the accounts. The Administrator revealed they had not been done due to the vacant position in the business office.

Based on observation, interview, record review, and policy review, the facility failed to administer oxygen as ordered by the physician for one (1) of two (2) residents (Resident #20) reviewed for oxygen. The findings include: A review of the facility policy, Oxygen Therapy, Nasal Cannula, revised 03/2021, revealed the facility attached a pre-filled humidifier bottle to flow meter and attached nasal cannula tubing to humidifier bottle. Review of facility records revealed the facility admitted Resident #20 on 09/15/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #20 with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), and determined the resident with severe cognitive impairment. Additionally, the MDS indicated the resident received oxygen while a resident. A review of the Comprehensive Care Plan, initiated 09/15/2021, revealed the resident received oxygen therapy related to COPD. Interventions included to administer oxygen as ordered. A review of physician orders for Resident #20 revealed an order, dated 09/15/2021, for humidified oxygen via nasal cannula at two (2) L (liters)/min. Observation of Resident #20's oxygen concentrator, on 06/21/2022 at 9:55 AM, indicated oxygen was being administered at two and a half (2.5) liters via nasal cannula. Observation of Resident #20's oxygen concentrator, on 06/21/2022 at 1:33 PM, indicated oxygen was administered at two and a half (2.5) liters and no humidifier bottle was identified on the concentrator. Resident #20 was observed on 06/22/2022 at 8:28 AM lying in bed, and oxygen via nasal cannula was being administered. The oxygen concentrator indicated oxygen was being administered at two and a half (2.5) liters. Observation of Resident #20 on 06/22/2022 at 11:13 AM revealed the oxygen concentrator did not have a humidifier bottle on the concentrator as ordered and oxygen was set at a rate of two and a half (2.5) liters. Observation of Resident #20, on 06/22/2022 at 2:44 PM, revealed the oxygen concentrator to be missing the humidifier bottle. Oxygen was being administered at a rate of two and a half (2.5) liters. Interview with Certified Medication Technician (CMT) #8, on 06/22/2022 at 3:23 PM, CMT #8 revealed there were orders in the medication administration record (MAR) directing staff how many liters of oxygen should be administered. CMT #8 indicated she checked to make sure oxygen was at the correct level each day. CMT #8 indicated there were no residents receiving humified oxygen. Interview, on 06/22/2022 at 3:33 PM, with Registered Nurse (RN) #1 revealed oxygen was administered according to the physician orders in the chart. When asked what setting for the oxygen, RN #1 stated the setting was above two (2) liters. RN #1 also stated Resident #20 was not receiving humidified oxygen. During an interview, on 06/22/2022 at 3:54 PM, with the Director of Nursing (DON), the DON was asked to observe Resident #20's oxygen concentrator. The DON revealed the oxygen was being administered to Resident #20 above two (2) liters. The DON stated the oxygen concentrator did not have the humidifier bottle with water attached to administer humidified oxygen to Resident #20. The DON reviewed the physician's orders for oxygen and indicated that Resident #20 should be receiving humidified oxygen at two (2) liters. On 06/24/2022 at 12:46 PM, during an interview with the DON, the DON stated that the expectations of the staff were to follow the physician's orders when administering oxygen. Interview with the Administrator, on 06/24/2022 at 1:04 PM, the Administrator indicated the physician orders were expected to be followed at all times.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure discontinued controlled medication was disposed in a timely manner. Observation revealed the cabinet in the Lab Room, which held controlled medication awaiting destruction, contained one thousand and twenty-five and one half (1025.5) pills of controlled medication. In addition, forty point five (40.5) milliliters (ml) of liquid [MEDICATION NAME], and zero point five (0.5) ml of injectable Testosterone were stored in the same location. The findings include: Review of the facility's policy, Narcotics-Disposal, revised (MONTH) (YEAR), revealed all discontinued or expired narcotics were to be removed from the unit inventory locked medication cart, stored in a locked box in the lab room, and double locked. The stored narcotics were to be reconciled monthly and placed in an empty sharp container with an added solidifier. Furthermore, the consultant pharmacist monitored the narcotic records to ensure the controlled drugs were destroyed on a routine basis. Review of the Drug Enforcement Administration (DEA), 21 Code of Federal Regulation 1317.80, dated [DATE], revealed a long-term care facility could dispose of controlled substances (medication), Schedules II, III, IV, and V, on behalf of an ultimate user who resided, or had resided, at such long-term care facility by transferring those controlled substances into an authorized collection receptacle located at the long-term care facility. When disposing of such controlled substances by transferring those substances into a collection receptacle, such disposal would occur immediately, but no longer than three (3) business days after the discontinuation of use by the ultimate user. Discontinuation of use included a permanent discontinuation as directed by the physician as the result of the resident's transfer from the long-term care facility, or as a result of death. Observation, on [DATE] 10:35 AM, of the cabinet in the Lab Room, with the Director of Nursing (DON), revealed it contained three (3) shelves of scheduled medication, awaiting destruction, filled to capacity. The DON and the Assistant Director of Nursing (ADON) counted the contents of the cabinet, which determined there were 1025.5 controlled medication pills; 25.5 ml of 20 milligram (mg) per 5 ml of liquid [MEDICATION NAME]; 15 ml of 5 mg per 1 ml of liquid [MEDICATION NAME]; and 0.5 ml of 200 mg per 1 ml of injectable Testosterone. During the count, the ADON identified the last count occurred (MONTH) (YEAR), which the DON also confirmed. Interview with the ADON, on [DATE] at 11:17 AM, revealed controlled medications were to be destroyed once a month but the months seemed to get away from her and the DON, as they did not realize it had been so long since the last destruction. She stated she and the DON were responsible for counting and destroying controlled medications monthly to ensure the medications were not stolen, and it was facility policy. She stated she could not remember if pharmacy staff had ever asked to check the cabinet. Interview with the DON, on [DATE] at 11:17 AM, revealed discontinued controlled medications were to be destroyed monthly and she did not realize it was (MONTH) (YEAR) since the last count and destruction was completed. She stated it was her responsibility to ensure the medications were disposed of properly. She stated could not remember pharmacy staff asking her to review the controlled medications awaiting destruction. Interview with the Administrator, on [DATE] at 12:17 PM, revealed she was not aware of issues with controlled medication destruction. The Administrator voiced surprise with the amount of controlled medications awaiting disposal.

Based on observation and interview, it was determined the facility failed to ensure scheduled medications were stored securely in one (1) of one (1) medication rooms. Observation of the medication room refrigerator revealed the locked boxed for scheduled medications was not permanently affixed to the refrigerator, nor double locked. In addition, the key to the cabinet that held scheduled medications awaiting destruction was in the Director of Nursing's (DON) top desk drawer, which was unlocked. The findings include: The facility did not provide a policy for securement of medications. 1. Observation, on 06/05/19 at 10:16 AM, revealed the unit medication refrigerator was not locked. The refrigerator contained a black locked medication box; however, it was not affixed to the inside of the refrigerator. Registered Nurse (RN) #1 removed the black box from the refrigerator and placed it on the counter. The box contained the following scheduled medications: [REDACTED]. Interview with RN #1, on 06/05/19 at 10:16 AM, revealed multiple people were able to unlock the unit medication door, which included the unit nurse, Assistant Director of Nursing (ADON), and Director of Nursing (DON). She stated the scheduled medications were not under a double lock system and scheduled medications were supposed to be under a double lock system at all times for the safety of everyone, and to prevent theft. She further stated someone could take the scheduled medications from the medication room since the box was not affixed to the refrigerator and the room was accessible to multiple staff. RN #1 stated the facility was to ensure scheduled medications were safe and secured at all times. Interview with the ADON, on 06/05/19 at 11:29 AM, revealed refrigerated scheduled medications were to be under a double lock system. She stated she, the DON, the Charge Nurse, as well as the Medication Technician, had a key to access the medication room. She stated the refrigerator was not locked and the scheduled medication box was not chained to the refrigerator. She further stated it was the facility's responsibility to ensure scheduled medications were safe and secured at all times. The ADON revealed because the refrigerated scheduled medication box was not affixed to the refrigerator, it could be removed and end up in the wrong hands. Interview with the DON, on 06/05/19 at 11:29 AM, revealed she was able to access the unit medication room and the medication refrigerator was not locked on the outside. She stated the scheduled medication box was not chained to the refrigerator and therefore could be removed from the unit. She stated the facility was responsible to ensure all medications were secured at all times. 2. Observation, on 06/05/19 at 10:35 AM, revealed the DON went to her office, opened the unlocked top drawer of her desk, and pull out a ring of keys from the left side of the top drawer. The key ring contained the key to the cabinet that held scheduled medication awaiting destruction. The door that connected the DON's office to the Medical Records office was open. The DON walked across the hallway, opened the Lab Room door, and opened the locked cabinet with the key she obtained from her desk drawer, which revealed three (3) shelves of scheduled medication filled to capacity. Interview with the DON, on 06/05/19 at 10:35 AM and 11:29 AM, revealed she always kept the key to the cabinet that held the scheduled medications awaiting destruction in the top drawer of her desk. She stated the drawer was not locked and the door to the adjacent room, Medical Records, was usually open. The DON stated the key was left there at night and on the weekends. She did not carry the key ring because it was too heavy and she did not use it often. According to the DON, she left her door unlocked on occasion, and the key could have been taken and the scheduled medication removed. Interview with the Administrator, on 06/05/19 at 12:17 PM, revealed the facility was responsible to ensure all scheduled medications were secured appropriately. The Administrator stated the key to the cabinet that held scheduled medications awaiting destruction should never be left unattended because it could fall into the wrongs hands and the medications could be taken.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure staff maintained infection control during medication administration for one (1) of twenty (20) residents, Resident #9. Observation revealed staff failed to sanitize hands before and after medication administration. In addition, staff handled medication with bare hands and placed a medication tablet on the surface of a table. The findings include: Review of the facility's policy, Infection Control Standard Practice, revised (MONTH) (YEAR), revealed hands were to be washed before and after contact with a resident. Review of the facility's policy, Medication Administration, dated (MONTH) (YEAR), revealed staff was to wash hands before and after administration of medications. Waterless hand sanitizer was on each medication cart to be used between administration of medication to each resident. Review of the facility's policy, Handwashing, dated (MONTH) (YEAR), revealed hands were to be washed before and after direct contact with residents, residents' equipment, and before and after any procedure. The policy stated handwashing was for the prevention of cross-infection between staff and residents. Observation of medication administration, on 06/03/19 at 8:10 AM, revealed Certified Medication Technician (CMT) #1 handled medication cards and the medication cart, and placed Resident #9's medications in a medication cup, without sanitizing her hands. CMT #1 picked up a medication tablet with her bare hands when the tablet bounced out of the medication cup onto the surface of the medication cart. The CMT placed the tablet back into the medication cup, proceeded into Resident #9's room, and assisted the resident with the consumption of the medications without sanitizing hands prior to entering the room. Further observation revealed CMT #1 removed the resident's chocolate calcium chew from the protective wrapper, placed the chocolate chew tablet, using her bare hands, on the over the bed table, and instructed Resident #9 to eat the chew tablet, which Resident #9 complied. CMT #1 proceeded to the medication cart, documented the administration of Resident #9's medications, and took the cart to the next resident's door and proceeded to acquire medications from the cart. CMT #1 did not sanitize her hands after Resident #9's medication administration was completed or before she acquired the next resident's medications out of the medication cart. Interview with CMT #1, on 06/03/19 at 10:06 AM, revealed staff was to sanitize or wash their hands before and after medications were obtained from the medication cart, as well as before and after contact with a resident. She stated everyone was to have good hand hygiene to prevent the spread of infection. The CMT stated she was told the medication cart surface was a clean surface and medications could be returned in the cup. However, she stated medications were not to be handled by bare hands because a resident could potentially become ill, as germs from bare hands could be transferred to the medication and spread to the resident when they ingested the medication. She stated the facility educated her on infection control during medication administration, but she was not audited during medication administration for infection control techniques. Interview with CMT #2, on 06/03/19 at 10:06 AM, revealed staff was to wash or sanitize hands before and after medications were obtained from the cart. CMT #2 stated hands were to be sanitized before staff entered a resident's room, when staff completed medication administration, and when staff left a resident's room. She stated hand hygiene was essential to prevent the spread of germs to the residents. Staff was not to touch medications with bare hands, and if medications fell out of a medication cup, it was to be discarded because of potential contamination with germs. She further stated staff was not to handle medication with bare hands because the germs on staffs' hands transferred onto the medication and into the resident's mouth. The CMT further stated she received annual infection control education and was checked off in a skills lab, but she was not audited during medication administration. Interview with Licensed Practical Nurse (LPN) #1, on 06/03/19 at 10:10 AM, revealed all staff was to wash hands before and after resident care as well as before and after medication administration. She stated staff was not to handle medications with bare hands, and medication cart surfaces were not clean and medications were to be discarded if contact with the surface was made. LPN #1 revealed everyone was responsible for infection control concerning proper hand hygiene, as unwashed hands handling medications could cause residents to become ill. According to the LPN, staff was educated on hand hygiene and infection control three (3) months ago and checked off in a skills lab, but she was not audited during medication administration. Interview with the Assistant Director of Nursing (ADON), on 06/05/19 at 11:29 AM, revealed staff was educated during annual in-services and monthly in-services on infection control practices in all areas. She further revealed staff was educated a couple months ago by the Staff Educator on infection control practices, which included hand hygiene during medication administration. She stated staff was to wash their hands before and after resident contact, before and after medication administration, when visibly soiled, and anytime contact was made with surfaces or equipment. The ADON revealed staff was not to handle medications with bare hands due to possible cross contamination. She stated she did not complete an audit for medication administration; however, she stated during rounds she visualized staffs' practices when they administered medication, which did not reveal any issues that needed addressed. The Staff Educator was not available for interview. Interview with the Director of Nursing (DON), on 06/05/19 at 11:29 AM, revealed she did not identify issues with infection control practices during rounds. She stated staff was to perform hand hygiene practices at all times to prevent the spread of infection. According to the DON, staff was not to handle medications with bare hands, and cart counter tops were not clean surfaces. Interview with the Administrator, on 06/05/19 at 12:17 PM, revealed the facility had not identified issues with infection control practices concerning medication administration and hand hygiene. She further stated she relied on the nursing administration to identify issues and re-educate staff.

Based on observation, interview, and record review, it was determined the facility failed to implement the care plan for one (1) of three (3) sampled residents, Resident #1. The facility determined Resident #1 was at risk for falls; however, the resident left the facility unsupervised. The findings include: Review of Resident #1's clinical record revealed the facility admitted the resident on 09/12/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident was not steady with transitions and walking, but stabilized without staff assistance and ambulated with a rolling walker. Review of Resident #1's Care Plan, initiated 09/21/18, revealed the resident had the potential to fall related to being unsteady during position transitioning and during ambulation. Interventions included keeping walkways clear and free of clutter, and prompt response to requests for assistance. Review of a facility investigation, dated 10/04/18, revealed staff first observed Resident #1 outside in the parking lot of the facility, walked up the driveway to the entrance of the facility, and sat in a chair on the facility's front porch. Staff asked the resident where he/she had been and the resident stated he/she had walked over to the store to get a soft drink. Review of the facility's video revealed the resident exited the facility's front door on 10/04/18 at 9:43 AM, ambulating with a rolling walker, and returned to the facility at 10:08 AM. Observation of Resident #1, on 10/09/18 at 11:15 AM, revealed the resident in a recliner chair with a wanderguard bracelet on his/her right arm. Interview with Resident #1, on 10/09/18 at 11:15 AM, revealed he/she walked over to the store but when he/she got there, it was closed. The resident stated a friend was supposed to meet and walk with him/her; however, the friend never showed so he/she went alone. The resident stated in hindsight, he/she probably should not have left the facility without telling someone because if he/she had an accident, no one would know where he/she was. The resident revealed he/she fell in the past, when he/she lived at a Personal Care Home, and hurt his/her shoulder. Observation of the pathway taken by Resident #1 revealed a concrete, winding pathway that was shaded and smooth with an occasional rough spot in the concrete. Interview with the Maintenance Director, on 10/10/18 at 8:15 AM, revealed it was seven-hundred and fifty-two (752) feet from the facility porch to the store's parking lot, which was one quarter (0.25) of a mile. Interview with Front Lobby Receptionist #1, on 10/09/18 at 10:40 AM, revealed she monitored the reception area in the front lobby and residents and visitors were required to sign in and out on a log. She stated she was not clear on what happened on 10/04/18 when Resident #1 exited the front door, as at that time, around 9:00 AM, several volunteers were signing into the building and it seemed several people were around the reception area desk. She revealed if she had observed the resident leaving the building, she would have stopped the resident and asked him/her where they were going. She stated it was very important to know which residents left the building and which residents were in the building, as a safety measure. Interview with the MDS Nurse, on 10/10/18 at 10:30 AM, revealed Resident #1 was recently assessed for a decline when living on a Personal Care Unit. She stated the resident was admitted to the skilled nursing unit after a decline had been noted in judgement and had become forgetful. The nurse stated the resident was care planned as a risk for falls because he/she had experienced a fall when he/she lived on the Personal Care Unit. She stated she did not feel it was a good idea for Resident #1 to go off the facility grounds without supervision due to the risk of a fall. Interview with Licensed Practical Nurse #1, on 10/09/18 at 1:52 PM, revealed Resident #1 had a decline in the recent past and needed more assistance with activities of daily care. She revealed many mornings the resident's leg were [MEDICAL CONDITION] and he/she had been care planned a fall risk, and staff needed to anticipate his/her needs and keep his/her area free of clutter. Interview with the Certified Medication Technician, on 10/10/18 at 10:00 AM, revealed Resident #1 was not mentally or physically able to ambulate that far without staff supervision. Interview with the Director of Nursing, on 10/10/18 at 8:30 AM, revealed Resident #1 recently transferred from the personal care to the skilled nursing level of care due to behaviors, and an overall medical decline. She stated the receptionist was responsible to safeguard the entrance and exit doors because anytime a resident left the building without adequate supervision, there was a risk of an accident. She stated Resident #1 was care planned for potential falls and had a history of [REDACTED]. Interview with the Administrator, on 10/10/18 at 8:50 AM, revealed the facility had a responsibility to all residents to safeguard them from possible harm. She stated the reception area was one of the lines of monitoring the facility had put into place and residents were required to sign in and out of the facility. She continued to state anytime a resident was observed leaving the facility, staff should politely acknowledge the resident and find out what they were doing or were going. She stated one of the safeguards Resident #1 had in place was the care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (1) of three (3) sampled residents, Resident #1. Resident #1 left the facility, unsupervised. The findings include: Review of the facility's policy, Signing Out, Residents, revised (MONTH) (YEAR), revealed each resident leaving the premises must be signed out to ensure the safety and health of the resident. Staff who observed a resident leaving the premises, and unsure if the resident had signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. Review of the facility's Resident Guidelines, not dated, provided to the family and resident upon admission, revealed residents were requested to sign in and out at the front desk upon departure from the facility, and arrival to the facility. Review of the facility's policy, Elopement, dated (YEAR), revealed it was the policy of the facility to protect confused residents from wandering away from safe areas unsupervised and unnoticed. Record review revealed the facility admitted Resident #1 on 09/12/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident was not steady with transitions and walking, but stabilized without staff assistance and ambulated with a rolling walker. Review of Resident #1's Care Plan, initiated 09/21/18, revealed the resident had the potential to fall related to being unsteady during position transitioning and during ambulation with interventions to keep walkways clear and free of clutter, and prompt response to requests for assistance. Review of a facility investigation, dated 10/04/18, revealed Resident #1 was first observed by staff outside in the parking lot of the facility. Staff stated they saw the resident walk up the driveway to the entrance of the facility and sat in a chair on the facility's front porch. Staff asked the resident where he/she had been and the resident stated he/she walked over to store to get a soft drink. Review of the facility's video revealed the resident exited the facility's front door on 10/04/18 at 9:43 AM. The resident ambulated with a rolling walker and returned to the facility at 10:08 AM. Observation of Resident #1, on 10/09/18 at 11:15 AM, revealed the resident in a recliner chair with a wanderguard bracelet on his/her right arm. Interview with Resident #1, on 10/09/18 at 11:15 AM, revealed he/she walked over to the store but when he/she got there, it was closed. The resident stated a friend was supposed to meet and walk with him/her; however, the friend never showed so he/she went alone. The resident stated in hindsight, he/she probably should not have left the facility without telling someone because if he/she had an accident, no one would know where he/she was. The resident revealed he/she did have a fall in the past when he/she lived at a Personal Care Home, and hurt his/her shoulder. Interview with the Maintenance Director, on 10/09/18 at 10:45 AM, revealed the facility had twenty (20) alarmed exit doors and three (3) doors with wanderguard alarms. He stated a receptionist or a security guard monitored the facility entrance door twenty-four (24) hours a day and the facility used security cameras. He stated the facility required residents, or their families, to sign them in and out of the facility. Observation of the pathway taken by Resident #1 revealed a concrete, winding pathway. The pathway was shaded and smooth with an occasional rough spot in the concrete. Continued interview with the Maintenance Director, on 10/10/18 at 8:15 AM, revealed it was seven hundred an fifty-two (752) feet from the facility porch to the store's parking lot, which was one quarter (0.25) of a mile. Review of the National Weather Service Report for 10/04/18, revealed the weather was sunny and the temperature in the lower eighties (80's) Fahrenheit. Interview with Front Lobby Receptionist #1, on 10/09/18 at 10:40 AM, revealed she monitored the reception area in the front lobby and residents and visitors were required to sign in and out on a log. She stated when Resident #1 exited through the front door on 10/04/18, around 9:00 AM, several volunteers were signing into the facility and it seemed several people were around the reception area desk. However, review of the Visitors Register revealed on 10/04/18, one visitor signed in at 9:15 AM and exited the facility at 10:20 AM, and one visitor signed in at 9:50 AM and exited at 10:10 AM. Continued interview with the Receptionist revealed if she had seen the resident leaving the building, she would have stopped the resident and asked him/her where he/she was going. She stated it was very important to know which residents left the building and which residents were in the building, as a safety measure. Interview with Certified Nursing Assistant (CNA) #1, on 10/09/18 at 1:25 PM, revealed she was taking her break in the lower parking lot on 10/04/18, and saw Resident #1 walking back onto the facility property. The CNA stated she asked Resident #1 where he/she had gone and if he/she was all right, and the resident stated he/she was fine and had walked over to store but it was closed. Interview with the Certified Medication Technician, on 10/10/18 at 10:00 AM, revealed all residents were required to sign in and out at the front desk. She stated the facility required that in order to safeguard and keep track of residents who left the facility. She stated Resident #1 was not mentally or physically able to ambulate that far without staff supervision. Interview with Licensed Practical Nurse #1, on 10/09/18 at 1:52 PM, revealed she was familiar with Resident #1 and often cared for him/her. She stated she saw Resident #1 on 10/04/18 around 9:30 AM, when he/she walked back to his/her room after breakfast. She revealed the resident was independent for the most part. She stated the resident had a decline in the recent past and needed more assistance with activities of daily care. She revealed many mornings the resident's leg were [MEDICAL CONDITION], and he/she had been care planned a fall risk and staff needed to anticipate his/her needs, and keep his/her area free of clutter. Interview with the MDS Nurse, on 10/10/18 at 10:30 AM, revealed Resident #1 had been recently assessed for a decline and was noted to have a decline in judgement and had become forgetful. The nurse stated the resident had been care planned as a risk for falls because he/she had experience a fall when he/she lived on the personal care unit. She stated she did not feel it was a good idea for Resident #1 to go off the facility grounds without supervision due to the risk of falls. Interview with the Director of Nursing, on 10/10/18 at 8:30 AM, revealed Resident #1 was recently transferred from personal care to the skilled nursing level of care due to behaviors, and an overall medical decline. She stated the receptionist was responsible to safeguard the entrance and exit doors because anytime a resident left the building without adequate supervision, there was a risk of an accident. Interview with the Administrator, on 10/10/18 at 8:50 AM, revealed the facility had a responsibility to all residents to safeguard them from possible harm. She stated the reception area was one of the lines of monitoring the facility had put into place. The Administrator stated residents were required to sign in and out of the facility and all residents, identified as elopement risks, had their pictures posted behind the receptionist's desk. She continued to state anytime a resident was seen leaving the facility, staff should politely acknowledge the resident and find out what they were doing or where they were going.

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 one (1) of eighteen (18) sampled residents, Resident #8, received adequate supervision to prevent elopement from the facility. Resident #8 was assessed by the facility on 10/21/16 as high risk for elopement and a Wander Guard Bracelet was applied on 10/26/16. On 11/04/16, Resident #8 was found outside the building, unsupervised, in the back employee parking lot, by an employee returning from a meal break. Staff interviews revealed they heard no alarms sound when the resident left the facility. In addition, observations and staff interviews revealed the facility failed to ensure all exit ways, doors and elevators, were effectively monitored and/or secured to prevent the elopement of Resident #8 and potentially other residents at risk for elopement. The facility had assessed and identified a total of six (6) residents at high risk for wandering and/or elopement. The facility's failure to have an effective system in place to ensure staff provided adequate supervision of residents has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 02/17/17, and determined to exist on 11/04/16. The facility was notified of the Immediate Jeopardy on 02/17/17. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 02/22/17, which alleged removal of the Immediate Jeopardy on 02/22/17. However, during the validation of the A[NAME] the State Survey Agency (SSA) determined the facility had only reassessed thirteen (13) residents for elopement risk; not all residents per the A[NAME]. After surveyor intervention, the remaining twenty (20) residents were reassessed on 02/23/17. Therefore, the Immediate Jeopardy was determined to be removed on 02/24/17. The findings include: Review of the facility's policy titled Elopement, not dated, revealed confused residents were protected from wandering away from safe areas unsupervised and unnoticed. An Elopement risk assessment was completed on admission and with each Minimum Data Set (MDS) assessment for those residents with a [DIAGNOSES REDACTED]. A current photo of the resident would be placed at the front desk with a notice of elopement risk. A door/bracelet alarm may be initiated. In addition, upon recognition that a resident had gone missing, an incident report would be filled out along with an investigation of possible systems failure and new interventions. The internal investigation would be initiated within twenty-four (24) hours. The Director of Nursing and/or the Administrator would initiate the investigation. Review of a document provided by the Director of Nursing (DON), titled #482 Elopement, dated 11/04/16, and time stamped 20:55, revealed Registered Nurse (RN) #1 completed the incident description/report. The description narrative revealed at 5:05 PM a Certified Nursing Assistant (CNA) reported Resident #8 was walking outside in the employee parking lot. This report also revealed two (2) staff (unidentified in the report), had reported the resident attempted to go out of the Holy Family back door and that they redirected the resident both times. The incident report revealed no injuries were observed. The report identified predisposing situation factors to Resident #8's elopement as confusion, active exit seeker, wandering behavior, and able to ambulate without assistance. Per interview with the DON, on 02/16/17 at 2:00 PM, no further investigation of the incident was conducted. Review of the nurse's notes, dated 11/04/16, Resident #8 said he/she went out the back door. This door was described in the nurse's note as The Holy Family exit door. The resident also told RN #1 that he/she went out for a walk around the building. Interview, on 02/23/17 at 10:30 AM with the Activities Staff, revealed she observed Resident #8 at the Holy Family Unit's exit door sometime during the afternoon of 11/04/16. She went towards Resident #8 to redirect him/her away from the exit. Per interview, she did not hear the Wander Guard Sensor alarm sounding and Resident #8 was standing about two (2) feet from the exit. The Activities Staff stated she walked the resident toward his/her room but she could not remember if Resident# 8 entered his/her room. The Activities Staff thought she reported finding the Resident #8 near the exit to RN #1 but she could not remember how RN #1 responded to that information. Interview, on 02/17/17 at 10:40 AM with CNA #7, revealed she observed Resident #8 outside the building on 11/04/16, somewhere within the hour of 4:00 PM to 5:00 PM. CNA #7 stated she had just completed her personal meal break (which lasted about 15-20 minutes) and she had not seen Resident #8 in the parking lot area when she first went to her car for her break. CNA #7 stated when she got out of her car, which was facing a wooded area, she walked toward the employee's entrance at the rear side of the building and saw Resident #8 walking on the driveway that led from the front of the facility toward the rear of the building and delivery entrance. CNA #7 stated she walked toward Resident #8 and the resident said he/she could not remember how to get back inside the building. The resident was wearing daytime clothing that seemed appropriate for the weather, and the attire included a sweater; the resident did not show signs of injury. CNA #7 stated the resident was also wearing a Wander Guard Bracelet. Per interview, she took Resident #8 back inside to his/her living unit. She stated she could not remember exactly which nurse was on duty, but she reported to a nurse where she found Resident #8. CNA #7 stated she wondered if someone had allowed the resident to go out, without knowledge that he/she was not to be outside, alone. Interview, on 02/17/17 at 1:32 PM with RN #1, revealed she was on duty the evening Resident #8 left the building. RN #1 stated she did not receive any reports from staff that Resident #8 had shown exit-seeking behavior earlier that day before CNA #7 brought the resident back inside the facility. She stated she did not do a full body assessment of Resident #8, but the resident did not show any signs of pain or injury. Per interview, the resident said that he/she got mixed up while walking outside. RN #1 stated she checked for placement and function of Resident #8's Wander Guard Bracelet and she walked Resident #8 to each of the Wander Guard alarmed exits to ensure the resident's bracelet was working. She stated the Wander Guard Alarms were functioning, but the alarm at the(NAME)Jugan Exit made a very quiet sound, and she reported this to the maintenance department staff. RN #1 stated the alarm was not loud enough during the test on 11/04/16, and that staff should be able to hear the alarm sounding on any of the nursing unit's hallways. RN #1 stated she thought Resident #8's Wander Guard Bracelet had originally been placed because the resident was very active and he/she had shown an increased amount of confusion. RN #1 stated she contacted the Director of Nursing (DON) who directed her to implement every fifteen (15) minute checks of the Resident for 24 hours. RN #1 stated staff immediately began making the 15 minute observations. RN #1 stated she made sure the resident was under the direct supervision of the staff while she also notified the resident's Physician and Power of Attorney. Review of the service provider's work performed/recommendations stated, replaced Mag Lock (magnetic lock) on first hallway exit (Jeanne Jugan unit) with new(NAME)Mag Lock model number one-seven-zero-three-six ( ); back hall Mag Lock was turned off by key switch. The work was completed on 11/07/16. Interview with the Maintenance Supervisor, on 02/17/17 at 9:15 AM, revealed the DON told him she had found out the Roam Alert door did not work on the(NAME)Jugan skilled nursing unit on the weekend of 11/04/16. He had a message on his voice mail and phoned the service provider on Monday 11/07/16. The Magnetic Lock (Mag Lock) had to be replaced on the(NAME)Jugan Skilled Nursing Unit, because it did not lock. Per interview, he checked the alarm system weekly; however, he did not start documenting these checks until 12/2016. Continued interview with CNA #7 on 02/17/17 at 10:40 AM, revealed she was concerned upon seeing Resident #8 outside without staff in attendance because she knew the resident was no longer allowed to go outside, unsupervised. CNA #7 stated Resident #8 had resided at the facility for about three (3) years, and she noticed the resident had become increasingly confused over the past year, prior to November, and recently, as well. Review of the clinical record for Resident #8, revealed the facility admitted the resident on 04/01/15 with multiple [DIAGNOSES REDACTED]. The facility's most recent annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a score of an eleven (11) out of a possible fifteen (15) on the Brief Interview of Mental Status (BIMS) and to be ambulatory using a walker as an assistive device for walking. The resident was assessed to need oversight, encouragement or cueing for locomotion occurring while off of his/her living unit. Review of the quarterly MDS assessment, completed 10/07/16, revealed the facility assessed the resident was independent for locomotion off the unit with set up help only and the resident was assessed with [REDACTED]. Continued review of Resident #8's clinical record revealed the facility conducted an Elopement Risk Assessment for Resident #8, dated 08/17/16, and the resident was assessed to be at moderate risk for elopement, scoring an eight (8) on the assessment. A range of 4-8 on the assessment tool indicated a resident would be at moderate risk for elopement. A score of ten (10) or above, would place a resident at high risk for elopement. The assessment triggered the need for implementation of a plan of care for elopement/wandering. The notes section of the elopement assessment revealed the resident exhibited short term memory issues, as he/she left the building with two (2) family members to say goodbye to them. The resident did not come back inside, and was found seated on a porch of an apartment building that adjoined the facility. According to this assessment form, an elopement plan was implemented with a picture of the resident placed at the front reception desk, and staff at reception was informed that the resident was not to leave the front porch area of the facility. The facility conducted the next Elopement Risk Assessment for Resident #8 on 10/21/16, and that assessment revealed the resident was at high risk (scoring 12) for wandering/elopement. The score on the assessment tool triggered the implementation of a plan of care for wandering/elopement. Review of the notes section of this assessment revealed the facility would continue with the elopement plan, and that use of a Wander Guard bracelet had been implemented for Resident #8. The resident's picture was to remain at the front desk, and reception desk staff would be aware to supervise the resident when he/she sat on the facility's front porch. However, review of the nurses' notes in Resident #8's clinical record, dated 10/26/16, revealed the Wander Guard was not placed on the resident's right wrist until 10/26/16. The note further read, after the bracelet had been applied, Resident #8 asked what the device was for and was told the resident the Wander Bracelet had been placed to keep him/her safe. Further review of the clinical record revealed the facility failed to revise the resident's comprehensive care plan for wandering/elopement. Interview, on 02/16/17 at 9:20 AM with Certified Medication Technician (CMT) #1, revealed Resident #8 wore a Wander Guard Bracelet because she liked going outside, and had gotten confused, not remembering how to come back in. CMT #1 stated Resident #8 would attempt to leave the building when the weather was nice. Interview, on 02/16/17 at 9:30 AM with the DON, revealed the facility placed a list and pictures at the front reception desk area of those residents who were assessed as at risk for wandering. Review, on 02/16/17 at 4:50 PM, of the pictures for elopement seeking residents, stored at the facility's reception desk, revealed instructions below Resident #8's picture that the resident was not leave the porch without an escort or family member. Even though Resident #8 was assessed at high risk for elopement and had left the facility without staff knowledge, the resident was still allowed to sit on the porch without supervision. Further interview, on 02/16/17 at 2:00 PM with the facility's DON, revealed Resident #8 exited the building on 11/04/16 without the staff's knowledge. She stated the resident was found by CNA #7, in a back parking lot of the facility. She stated employees parked there and delivery trucks utilized that driveway and parking spaces when dropping off supplies. The DON stated RN #1 notified her the elopement had occurred, and the facility implemented every 15 minute observations of Resident #8 for 24 hours. The DON stated she also learned Resident #8 had attempted to leave the facility, twice, earlier in the day before the actual elopement. The DON stated that prior to becoming more confused, Resident #8 would often walk around the grounds of the facility. The DON stated she completed an incident report after learning Resident #8 left the building, unsupervised, but she did not complete an investigation of the incident. The DON stated she informed the Administrator of the incident, but was unsure how long the resident was outside on 11/04/16, before staff brought him/her back inside. Interview, on 02/16/17 at 2:22 PM with the facility's Administrator, revealed the DON informed her of Resident #8's exit from the building on 11/04/16. She stated it was her understanding the resident was found in the parking lot at the main entrance of the facility. The Administrator stated that the parking lot could be used as the employee parking lot in the evenings because most of the parking spaces were empty in the evening. The Administrator stated Resident #8 was a very religious person, and had a history of [REDACTED]. In addition, she stated Resident #8 had previously enjoyed sitting on the facility's front porch. Per interview, staff was not sure which door the resident exited. Observations during the survey revealed multiple exit doors that were not secured and accessible to residents. Observation, on 02/15/17 at 8:25 AM, revealed two (2) sets of double doors, located in the hallway between the facility's lobby/administration area and the resident living units. The doors were accessible to residents, unlocked, and when opened, did not alarm. The double doors on the left side of the hall led out onto a balcony with a four (4) foot high railing, overlooking a grassy area elevated nine (9) feet and eight (8) inches above the ground. The double doors on the right side of the hall led to a small patio-like area with a step off of eight (8) inches above the ground. The small patio adjoined a grassy area leading to a gazebo near the street. Observation, on 02/15/17 at 4:05 PM, revealed a door to the convent (Stairwell B) was unlocked and not equipped with an alarm. It was accessible to residents and at the bottom of the stairwell, was a door that exited the building to a grassy area. The door was unlocked and not equipped with an alarm. Interview, on 02/16/17 at 2:00 PM, with the DON, revealed she had worked at the facility for twenty-five (25) years and was unaware there was an additional exit to outside the building from Stairwell B. Interview with Security Guard (SG) #1 on, 02/16/17 at 4:15 PM, revealed entrance doors were locked when it got dark outside. He could not pin point a time, or a schedule for when all doors, except fire exits, remained secured. His guard duties included rounding the facility, lower level and first floor, checking the areas surrounding the facility, and checking stairs wells. His duty started at 4:00 PM and concluded at 12:00 AM, when the duty was handed off to another guard. Observation, on 02/17/17 at 9:45 AM of the two (2) elevators in the Medical Hall, revealed the elevator doors were not armed with a Roam Alert and were accessible to residents. The elevators led down to the garage where there was a door that exited the building. The door was not locked and not equipped with an alarm. Observation, on 02/17/17 at 9:50 AM, of the elevator in the(NAME)Jugan Unit, revealed the elevator door was not armed with a Roam Alert and accessible to residents. Interview with the Maintenance Supervisor on, 02/17/17 at 9:25 AM, revealed there was nothing preventing a resident from getting onto the elevators. He stated the elevators were not equipped with alarms and were not locked. Review of the Roam Alert (RA) system pamphlet revealed each resident requiring a Wander Guard protection wore a RA radio frequency tag containing a unique Identification (ID) number. The RA was worn on the individual's wrist or ankle and was attached to a tear-proof band that was waterproof. The Door Controller device(s) that generated a field defining the door coverage monitored the RA. A resident entering this field generated a Wander Alarm. The door controller could activate an optional magnetic door lock that generated a loiter alarm if the resident did not move away from the door within 55 seconds. Review of the facility's RA check list revealed the Maintenance Supervisor initiated RA checks on 12/19/16 for three (3) RA armed exit doors weekly on Mondays. There were no issues identified on the check list. Observation, on 02/15/17 at 12:30 PM, revealed the facility had three (3) Wander Guard/Roam Alert armed exits. Staff identified the exits as the Medical Hallway exit,(NAME)Jugan exit, and the Holy Family exit. Observation of the RA function on the Medical Hall exit, on 02/16/17 at 1:15 PM, revealed an alarm with a low volume beep tone. Interview, on 02/16/17 at 1:20 PM, with CNA #2 on the Medical Hall, revealed she did not hear the alarm go off when it was tested at 1:15 PM. Observation of the RA function on the(NAME)Jugan exit, on 02/16/17 at 1:22 PM, revealed an alarm with a low volume beep tone. Observation of the RA function on the Holy Family Exit, on 02/16/17 at 1:25 PM, revealed an alarm with a low volume beep tone. Interview, on 02/16/17 at 1:28 PM with CNA #3 on Holy Family unit, revealed she did not hear the alarm sound at 1:25 PM. Interview, on 02/17/17 at 6:55 PM with CMT #1, revealed if she was in a resident's room she would not be able to hear the alarm if it went off. Interview with the Maintenance Supervisor, on 02/23/17 at 8:35 AM, revealed the alarms probably did not sound loud enough to be heard if direct care staff was in a resident's room. However, he stated he was not concerned about it because the doors would lock automatically if a resident attempted to open the push bar on the door. He then stated any electric and electronic equipment could malfunction. Review of the facility's monthly fire drill reports conducted by the Maintenance Supervisor revealed, function of fire exit doors were checked with fire drills. No other maintenance of exit doors took place unless staff reported a door malfunctioned per the Maintenance Supervisor. Interview with the DON, on 02/17/17 at 2:30 PM, revealed she understood an elopement to mean someone trying to get away from the facility. However, Resident #8 had wanted to come back inside the facility. Further interview with the DON revealed if a resident at risk for elopement was not supervised, there was a potential for harm. She said the resident might not be safe and wonder away, even possibly get out on the street. Interview with the Administrator, on 02/17/17 at 4:10 PM, revealed the facility had a Quality Assurance Performance Improvement (QAPI) meeting in (MONTH) of (YEAR). The DON had concerns about doors and brought these to the attention of the committee. Exit doors of concern were discussed. An extra Roam Alert bracelet was purchased for testing. However, no formal plan was developed to address the elopement of Resident #8, or any other residents at risk for elopement. She considered it to be an elopement if a resident had gone into the woods, or out onto the street. However, the Administrator did not think Resident #8 had eloped because she was still on the facility grounds. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The MDS Coordinator revised Resident #8's care plan to address the elopement risk and wandering on 02/18/17. 2. The Administrator, Mother Superior, Director of Nursing (DON), and Assistant Director of Nursing (ADON) reviewed and revised the facility's policies and procedures on 02/18/17. 3. The DON and ADON reassessed every resident for elopement risk and reviewed each resident's care plan on 02/19/17. All care plans needing revision were updated by 02/21/17. 4. The Service Coordinator provided in-service education to all employees working on 02/19/17 and conducted in-services on 02/20/17 regarding the facility's policy and procedures. Staff not present will be in-serviced when they return to work. 5. All residents at risk for elopement risk were placed on 15-minute checks beginning on 02/20/17 until all exit doors were secured. 6. The ADON contacted the Corporate Offices on 02/20/17 to upgrade the functions of the Electronic Charting System. 7. The names and photos of all residents assessed as elopement risk were placed at the Reception desk on 02/20/17. 8. On 02/20/17, vendors were contacted to provide the following: installation of more cameras, installation of alarms on all doors and elevators, installation of gates to prevent resident from exiting on stairwells, installation of key pads on identified doors within the facility, and placement of lock on door leading to the garage area. All devices were in place on 02/21/17. 9. On 02/21/17, the company providing services for the facility's Wander Guard system checked all alarms and exits with no issues identified. The SSA validated the facility implemented the following actions: 1. Interview, on 02/24/17 at 1:15 PM with the Assistant Director of Nursing (ADON), revealed she reviewed Resident #8's care plan to ensure the resident's elopement risk status was listed, and to ensure the care plan was current. Review of Resident #8's care plan, on 02/27/17 at 10:00 AM, revealed the resident's care plan was revised on 02/17/17 with the goal to safely maneuver to desired locations and interventions for staff to be accompanied by staff/family member to outdoor locations, presence of a Wander Guard checked every shift and the function of the Wander Guard checked twice daily. 2. Interview, on 02/24/17 at 8:45 AM with the Administrator, revealed the Administrator, Mother Superior, the Director of Nurses (DON) and the Assistant Director of Nurses conducted a review of the facility's policies on wandering and elopement. She stated the meeting was held on 02/18/17, and the Medical Director reviewed the policies, was made aware of the changes made, and the Medical Director made no further changes to the policies. The Administrator stated the committee discussed making sure all staff was fully aware of how and to whom they should report a missing resident. The revision to the Elopement policy included the Director of Nursing, the Administrator, and the front desk reception staff would be notified immediately, and the reception staff would page to the department supervisors, Missing and the resident's name. Continue interview with the Administrator, revealed in addition, an investigative report template had been developed for use in conducting the investigation of an elopement. To the policy, titled Monitoring of Residents at Risk for or Potential Risk for Elopement included a change for every 15-minute location checks for residents who eloped and were returned to their unit. Those every 15-minute staff observations would be documented and would remain in effect until the Internal Investigation by the DON or Administrator was completed. The Administrator stated the facility's policy for Wandering was reviewed with no changes made to the policy, and the Wander Guard Policy was reviewed with no changes made to the policy. With the revisions of the policies, the Administrator stated she would expect the DON and/the nurse in charge of the nursing units to notify her, or any other of the Sisters in Supervision, immediately when a resident was discovered missing. She stated she, or another Sister in Supervision, would notify the resident's family member or Power of Attorney, and the facility's Corporate representative. Review, on 02/24/17, of the facility's reviewed/revised policies revealed the changes as stated by the Administrator. 3. Review, on 02/23/17, of the census at the facility, revealed 33 residents currently resided on the LTC living units. Record review revealed the facility had only reassessed the 13 residents, who were previously assessed as an elopement risk. The remaining 20 residents were assessed for elopement risk by 02/23/17 after surveyor intervention, and all of the resident's care plans were updated with the assessment risk value, and interventions for wandering and/or elopement risk, as appropriate to the assessment results. Interview, on 02/24/17 at 1:15 PM with the Assistant Director of Nursing (ADON), revealed she was responsible for ensuring the residents on the LTC units were assessed for elopement risk. She said residents' care plans were reviewed to ensure the care plans included interventions and the resident's elopement risk value, as appropriate. The ADON further stated if through her assessments, a resident was identified as having exit seeking/wandering behaviors, or a desire to leave the facility, the Activities Staff would photograph the resident so the reception staff would have a pictorial record of residents at risk for elopement. She stated, going forward, if there was an actual elopement, the resident would be placed on every 15-minute staff observations, which would be recorded and stored in the resident's clinical record. She stated the Interdisciplinary Team would meet to discuss additional plans of action to keep the resident safe. In addition, the white board, in the nurse's stations would be kept current to ensure staff was aware of those residents who were at risk for wandering and/or elopement. In addition, she was directed to review the care plans of all residents with Alzheimer' Disease, Dementia or memory deficits and to assess and add safety interventions to those residents' care plans. 4. Review, on 02/24/17 of the in-service education and staff attendance records revealed the facility had conducted in-service education on the facility's revised policies for Elopement, Monitoring of Residents at Risk for or Potential Risk for Elopement, Wandering Policy and the Wander Guard System Policy. Interview, on 02/24/17 at 10:53 AM with the Staff Development Registered Nurse (RN), revealed the in-service education began on 02/19/17 (which was a Sunday), and was conducted by the DON on that day. The DON ensured staff signed they had received the training. The Staff Development Nurse stated she provided the in-service training on 02/20/17. She stated all staff in attendance signed to verify their attendance, and the in-service education occurred across all three (3) shifts. She stated after each in-service session, a discussion/question and answer session was provided for the staff, if there were questions or a need to clarify the training provided. The Staff Development Nurse stated, going forward, education on the policies would also be provided to newly hired staff members during the orientation period. She stated the facility had recently hired two (2) new staff and they had received the in-service education on 02/22/17, regarding the revised policies for Elopement, Potential Risk Factors for Elopement, Wandering, and the Wander Guard System. She stated there were six (7) staff remaining to be trained. She said all of them had been contacted, and a date had been set for their in-service education. She stated one staff member had been off work related to illness. She stated the plan was the remaining staff members would be trained on the policies before their next scheduled workday. The Staff Development Nurse also stated she was in the process of developing a presentation on Prevention of Elopement of Residents. She stated her research and content had been acquired from web-based resources for Dementia and Alzheimer's Disease. Review of the list of staff who still needed training on the policy revisions, revealed the names of seven (7) staff, their titles, and the date for their scheduled training. Interview on 02/24/17 at 10:45 AM with CNA #6, revealed the facility had provided in-service education on the Wander Guard Devices, Elopement Policy and Wandering Policies, as well as information on conducting every 15 minute observations and every one hour observations of residents as related to their elopement risk assessments. Interview, on 02/23/17 at 11:27 AM with RN #1, revealed the facility had provided in-service education on Elopement and Wandering Resident Policies, and she had received this education within the week. She also stated she had observed other staff receiving this in-service education. Interview, on 02/24/17 at 10:35 AM with CMT #12 and on 02/24/17 at 10:55 AM with CMT #17, revealed they had received recent in-service education on how residents at high risk for elopement were identified, re-education on policies for elopement and wandering, the new alarms that had been placed at the elevators and exit doors. CMT #17 stated if a resident was missing, she was to report to the nurse in charge and to the DON immediately, and a search would be conducted until the resident was found. 5. Interview with the ADON on 02/ 24/17 at 1:15 PM, revealed any resident with a Wander guard and any residents assessed at high risk for elopement have been monitored every 15 minutes since 02/20/17. The monitoring would continue every 15 minutes until a re-evaluation of the security of all alarms, exits, and the general environment for safety was completed. Interview, on 02/24/17 at 10:35 AM with CMT #12 and on 02/24/17 at 10:55 AM with CMT #17, revealed residents at high risk for elopement were under staff observation every 15 minutes to ensure they were safe. CMT #6 stated the observations were documented, as well. Review of the every 15 minute observations/checklists revealed all residents the facility identified at high risk for wandering had been observed every 15 minutes, and observations were documented beginning on 02/20/17. 6. Interview, on 02/24/17 at 1:15 PM with the ADON, revealed she had contacted Corporate Office and was able to address and correct the matter within the electronic care plan template used by the facility. 7. Observation, on 02/23/17, revealed photos of residents who were identified as at high risk for elopement were stored at the front lobby reception desk for staff who had reception and switchboard duties. Interview, on 02/24/17 at 10:10 AM with Reception Staff #27, revealed she provided relief help for the full time reception staff, and she received recent in-service education about elopement and wandering. She stated the Staff Development RN provided her training. Reception Staff #27 stated she had access to a pictorial list of residents who were at high risk for wandering and/or elop (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system in place to revise the comprehensive plan of care for one (1) of eighteen (18) sampled residents (Resident #8) who was assessed at risk for elopement. (Refer to F323) Resident #8 was assessed by the facility on 10/21/16 as high risk for elopement and a Wander Guard Bracelet was applied on 10/26/16. On 11/04/16, Resident #8 was found outside the building, unsupervised, in the back employee parking lot, by an employee returning from a meal break. Staff interview and record review revealed the resident's comprehensive care plan had never been revised to address the resident's elopement risk, increased wandering, and actual elopement on 11/04/16. The facility's failure to have an effective system in place to ensure the revision of the Interdisciplinary Plan of Care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/17/17, and determined to exist on 11/04/16. The facility was notified of the Immediate Jeopardy on 02/17/17. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 02/22/17, which alleged removal of the Immediate Jeopardy on 02/22/17. However, during the validation of the A[NAME], the State Survey Agency (SSA) determined the facility had only reassessed thirteen (13) residents for elopement risk; not all residents per the A[NAME]. After surveyor intervention, the remaining twenty (20) residents were reassessed on 02/23/17. The State Survey Agency determined the Immediate Jeopardy was removed on 02/24/17. The findings include: Review of the facility's policy titled Care Plan, dated 05/2006, revealed every resident had a comprehensive care plan as part of their medical record. The policy further stated an interdisciplinary team would prepare and update the care plan for each resident at least every ninety (90) days. Review of the facility policy titled Accident/Incident Reports - Residents, dated 05/2006, revealed the resident care plan should be updated as necessary following an accident/incident. Review of the facility policy titled Wandering, not dated, revealed all residents who would be at risk for harm because of wandering behavior would have a resident care plan that addressed that issue. If a resident repeatedly wandered off the unit, the resident care plan should reflect a monitoring schedule to ensure the resident's safety. Review of the facility policy titled Wander Guard System, not dated, revealed following the interdisciplinary team's review, if it was determined there was a need for a Wander Guard bracelet, this would be documented (added to the Care Plan). Further review of the policy revealed the renewal date for battery life of the Wander Guard device would be added to the Care Plan. Review of the facility policy titled Elopement, not dated, revealed elopement risk assessments would be completed on admission for residents with a [DIAGNOSES REDACTED]. For those residents at risk, an individualized care plan which respects the resident's needs and ensures a safe environment would be made. For example, a door/bracelet alarm may be initiated. Assessment of the effectiveness of the care plan would be brought to the Interdisciplinary Team for review and any changes would be made on an as needed basis. Further review of the facility's elopement policy, revealed an incident report would be filled out along with an investigation of a possible system failure with new interventions. The internal investigation would be initiated within twenty-four (24) hours. The Director of Nurses and/or the Administrator would initiate the investigation. Review of a document titled #482 Elopement, dated 11/04/16, and time stamped 20:55, revealed Registered Nurse (RN) #1 completed the incident description/report. The description narrative revealed at 5:05 PM a Certified Nursing Assistant (CNA) reported Resident #8 was walking outside in the employee parking lot. This report also revealed two (2) staff (unidentified in the report) had reported the resident attempted to go out of the Holy Family back door and that they redirected the resident both times. The incident report revealed no injuries were observed. The report identified predisposing situation factors to Resident #8's elopement as confusion, active exit seeker, wandering behavior, and able to ambulate without assistance. Review of the clinical record for Resident #8, revealed the facility admitted the resident on 04/01/15 with multiple [DIAGNOSES REDACTED]. Review of Resident #8's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of an eleven (11) out of a possible fifteen (15). The resident was assessed to be ambulatory using a walker as an assistive device. The resident was assessed to need oversight, encouragement or cueing for locomotion occurring while off of his/her living unit. Review of the quarterly MDS assessment completed 10/07/16, revealed the resident was independent for locomotion off the unit with set-up help only and the facility assessed the resident's BIMS to be a twelve (12) out of a possible fifteen (15). Review, of Resident #8's Comprehensive Plan of Care, originally developed on 04/01/15, revealed a component within the plan of care (initiated on 04/08/16) for the resident's disorientation to time as well as short term memory loss. Interventions included encouraging the resident to participate in socialization, cognitively challenging activities, regular visitation with family and friends, and completion of BIMS assessments every three (3) months. Continued review of Resident #8's clinical record revealed the facility conducted an Elopement Risk Assessment on Resident #8, dated 08/17/16, and the resident was assessed to be at moderate risk for elopement, scoring an eight (8) on the assessment. A range of 4-8 on the assessment tool indicated a resident would be at moderate risk for elopement. A score of ten (10) or above, would place a resident at high risk for elopement. The assessment triggered the need for implementation of a plan of care for elopement/wandering. The notes section of the elopement assessment revealed the resident exhibited short term memory issues, as he/she left the building with two (2) family members to say goodbye to them and did not come back inside. He/she was found seated on a porch of an apartment building that adjoined the facility. According to this assessment form, an elopement plan was implemented with a picture of the resident placed at the front reception desk, and staff at the reception desk was informed that the resident was not to leave the front porch area of the facility. However, review of the resident's comprehensive care plan revealed the care plan had not been revised to include the resident's elopement risk. Further review of Resident #8's clinical record revealed the facility conducted the next Elopement Risk Assessment for Resident #8 on 10/21/16, and the assessment revealed the resident was at high risk (scoring 12) for wandering/elopement risk. The score on the assessment tool triggered the implementation of a plan of care for wandering/elopement. Review of the notes section of this assessment revealed the facility would continue with the elopement plan, and use of a Wander Guard had been implemented. The resident's picture was to remain at the front desk, and reception staff would be aware to supervise the resident when he/she sat on the facility's front porch. Review of the nurses' notes, dated 10/26/16, revealed the Wander Guard was placed on the resident's right wrist on 10/26/16. Per the note, staff told the resident the Wander Bracelet had been placed to keep him/her safe. However, review of the resident's comprehensive care plan revealed the care plan had not been revised to include the resident's elopement risk or the intervention of the Wander Guard bracelet. Continued review of the nurses' notes within Resident #8's clinical record, revealed an entry dated 11/04/16, which gave an account of Resident #8's departure from the building without staff awareness. However, review of the resident's care plan revealed the plan of care had not been revised to address the resident's elopement or exit seeking behaviors. Review of an Elopement Risk Assessment, dated 01/20/17, revealed Resident #8 remained at high risk for elopement scoring a 14 on the assessment. However, review of the resident's comprehensive care plan, with a revision date of 01/19/17, revealed the resident's care plan still had not been revised to address the resident's elopement on 11/04/16 or exit seeking behaviors. Interview, on 02/17/17 at 1:32 PM with RN #1, revealed she was on duty on 11/04/16, second shift, as the RN Supervisor when Resident #8 eloped. She revealed after Resident #8 eloped on 11/04/16, she contacted the Director of Nursing (DON) who directed her to implement every fifteen (15) minute checks of the Resident for 24 hours. RN #1 stated staff immediately began making those 15 minute observations. RN #1 stated she did not make any revisions to Resident #8's care plan after the incident, but that it would have been her responsibility to update the care plan and/or notify the Minimum Data Set (MDS) nurse who could have made revisions to Resident #8's Plan of Care. Interview, on 02/16/17 at 11:11 AM with the Assistant Director of Nursing (ADON), revealed she conducted the Elopement Risk Assessments for residents in conjunction with the quarterly MDS assessments and planned care conferences where a resident's status and care needs were discussed. If a resident's scored at a level on the Risk Assessment tool that placed him/her at moderate to high risk for elopement, the facility would implement the elopement protocol, which meant the resident's picture and name would be available to reception desk staff, and the resident would be identified as one at increased risk for wandering and elopement. The ADON stated the resident's care plan would also be updated to include information about the resident's elopement risk, with appropriate interventions for keeping the resident safe. During the Interdisciplinary Team (IDT) Meetings, the MDS Nurse would be informed of any changes in a resident's elopement risk status, or she would call the MDS Nurse, as needed, and provide information about changes in a resident's risk for wandering/elopement. Interview, on 02/17/17 at 2:09 PM with the MDS Nurse, revealed she oversaw the care planning process that was conducted with the IDT. She stated the DON and ADON also made revisions to residents' care plans, but the DON assigned staff nurses to review residents' care plans, as well. The MDS Nurse stated if a resident was assessed as high risk for elopement, this would be discussed in daily staff meetings. She stated care plans were reviewed weekly on Mondays and Tuesdays. If it was determined a resident was truly at risk for elopement, this information should be found in the resident's care plan. She stated, if it was determined to be a legitimate concern, a resident's tendency to wander should be considered a mood or behavior. The MDS Nurse stated it had previously been considered safe for Resident #8 to go outside, unsupervised, but as his/her cognitive decline progressed, the resident probably needed some help. The MDS Nurse stated she was unsure when Resident #8's Wander Guard was placed, and she said she thought there was a time when the resident was allowed to sit on the facility's front porch with the Wander Guard on, but that she was not absolutely sure about that. The MDS Nurse stated she became aware of Resident #8's elopement, but was not clear on when she learned this information. She stated the resident's care plan should have been updated to reflect the wandering behavior, and any new interventions that were put in place. The MDS nurse stated she could not recall any specific discussions she had with staff about Resident #8 after the elopement, or any actions taken to revise the resident's care plan. The MDS Nurse stated a resident's care plan should be current, as the CNA Kardex (instructions for care of the residents) was prepared/updated to reflect the information recorded in the resident's comprehensive care plan. Upon review of Resident #8's care plan, the MDS Nurse stated there did not appear to be a focus area in the plan for the Wander Guard applied to Resident #8. The MDS Nurse stated it was important to ensure Resident #8's wandering behavior was addressed in the comprehensive care plan because if the resident eloped, he/she could experience injury from a fall or could get hit by a car, if outside and unsupervised by staff. Observation, on 02/17/17 at 9:50 AM, revealed when the ADON logged into the electronic medical record for Resident #8, she could not find a focus area for wandering or for the placement of the resident's Wander Guard Bracelet, within the resident's care plan. Interview, with the ADON on 02/17/17 at 9:50 AM during the aforementioned observation, revealed she stated she could not explain why interventions for wandering were not showing up in Resident #8's care plan. Interview, with the DON, on 02/17/17 at 8:56 AM, revealed if a resident exhibited wandering behavior, this information should be included in the plan of care, and any safety interventions such as the application of a Wander Guard Bracelet, and increased monitoring, etc., should be included in the plan of care. The DON stated she was unsure why Resident # 8's plan of care was not revised after the elopement on 11/04/16. But, the care plan should have been updated to include the every fifteen (15) minute checks that were implemented on 11/04/16 for 24 hours, other more frequent monitoring of the resident's location in the facility, and there should have been an intervention to ensure the Wander Guard armed exits and the resident's Wander Guard Bracelet were both functioning properly. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The MDS Coordinator revised Resident #8's care plan to address the elopement risk and wandering on 02/18/17. 2. The Administrator, Mother Superior, Director of Nursing (DON), and Assistant Director of Nursing (ADON) reviewed and revised the facility's policies and procedures on 02/18/17. 3. The DON and ADON reassessed every resident for elopement risk and reviewed each resident's care plan on 02/19/17. All care plans needing revision were updated by 02/21/17. 4. The Service Coordinator provided in-service education to all employees working on 02/19/17 and conducted in-services on 02/20/17 regarding the facility's policy and procedures. Staff not present will be in-serviced when they return to work. 5. All residents at risk for elopement risk were placed on 15-minute checks beginning on 02/20/17 until all exit doors were secured. 6. The ADON contacted the Corporate Offices on 02/20/17 to upgrade the functions of the Electronic Charting System. 7. The names and photos of all residents assessed as elopement risk were placed at the Reception desk on 02/20/17. 8. On 02/20/17, vendors were contacted to provide the following: installation of more cameras, installation of alarms on all doors and elevators, installation of gates to prevent resident from exiting on stairwells, installation of key pads on identified doors within the facility, and placement of lock on door leading to the garage area. All devices were in place on 02/21/17. 9. On 02/21/17, the company providing services for the facility's Wander Guard system checked all alarms and exits with no issues identified. The SSA validated the facility implemented the following actions: 1. Interview, on 02/24/17 at 1:15 PM with the Assistant Director of Nursing (ADON), revealed she reviewed Resident #8's care plan to ensure the resident's elopement risk status was listed, and to ensure the care plan was current. Review of Resident #8's care plan, on 02/27/17 at 10:00 AM, revealed the resident's care plan was revised on 02/17/17 with the goal to safely maneuver to desired locations and interventions for staff to be accompanied by staff/family member to outdoor locations, presence of a Wander Guard checked every shift and the function of the Wander Guard checked twice daily. 2. Interview, on 02/24/17 at 8:45 AM with the Administrator, revealed the Administrator, Mother Superior, the Director of Nurses (DON) and the Assistant Director of Nurses conducted a review of the facility's policies on wandering and elopement. She stated the meeting was held on 02/18/17, and the Medical Director reviewed the policies, was made aware of the changes made, and the Medical Director made no further changes to the policies. The Administrator stated the committee discussed making sure all staff was fully aware of how and to whom they should report a missing resident. The revision to the Elopement policy included the Director of Nursing, the Administrator, and the front desk reception staff would be notified immediately, and the reception staff would page to the department supervisors, Missing and the resident's name. Continue interview with the Administrator, revealed in addition, an investigative report template had been developed for use in conducting the investigation of an elopement. To the policy, titled Monitoring of Residents at Risk for or Potential Risk for Elopement included a change for every 15-minute location checks for residents who eloped and were returned to their unit. Those every 15-minute staff observations would be documented and would remain in effect until the Internal Investigation by the DON or Administrator was completed. The Administrator stated the facility's policy for Wandering was reviewed with no changes made to the policy, and the Wander Guard Policy was reviewed with no changes made to the policy. With the revisions of the policies, the Administrator stated she would expect the DON and/the nurse in charge of the nursing units to notify her, or any other of the Sisters in Supervision, immediately when a resident was discovered missing. She stated she, or another Sister in Supervision, would notify the resident's family member or Power of Attorney, and the facility's Corporate representative. Review, on 02/24/17, of the facility's reviewed/revised policies revealed the changes as stated by the Administrator. 3. Review, on 02/23/17, of the census at the facility, revealed 33 residents currently resided on the LTC living units. Record review revealed the facility had only reassessed the 13 residents, who were previously assessed as an elopement risk. The remaining 20 residents were assessed for elopement risk by 02/23/17 after surveyor intervention, and all of the resident's care plans were updated with the assessment risk value, and interventions for wandering and/or elopement risk, as appropriate to the assessment results. Interview, on 02/24/17 at 1:15 PM with the Assistant Director of Nursing (ADON), revealed she was responsible for ensuring the residents on the LTC units were assessed for elopement risk. She said residents' care plans were reviewed to ensure the care plans included interventions and the resident's elopement risk value, as appropriate. The ADON further stated if through her assessments, a resident was identified as having exit seeking/wandering behaviors, or a desire to leave the facility, the Activities Staff would photograph the resident so the reception staff would have a pictorial record of residents at risk for elopement. She stated, going forward, if there was an actual elopement, the resident would be placed on every 15-minute staff observations, which would be recorded and stored in the resident's clinical record. She stated the Interdisciplinary Team would meet to discuss additional plans of action to keep the resident safe. In addition, the white board, in the nurse's stations would be kept current to ensure staff was aware of those residents who were at risk for wandering and/or elopement. In addition, she was directed to review the care plans of all residents with Alzheimer' Disease, Dementia or memory deficits and to assess and add safety interventions to those residents' care plans. 4. Review, on 02/24/17 of the in-service education and staff attendance records revealed the facility had conducted in-service education on the facility's revised policies for Elopement, Monitoring of Residents at Risk for or Potential Risk for Elopement, Wandering Policy and the Wander Guard System Policy. Interview, on 02/24/17 at 10:53 AM with the Staff Development Registered Nurse (RN), revealed the in-service education began on 02/19/17 (which was a Sunday), and was conducted by the DON on that day. The DON ensured staff signed they had received the training. The Staff Development Nurse stated she provided the in-service training on 02/20/17. She stated all staff in attendance signed to verify their attendance, and the in-service education occurred across all three (3) shifts. She stated after each in-service session, a discussion/question and answer session was provided for the staff, if there were questions or a need to clarify the training provided. The Staff Development Nurse stated, going forward, education on the policies would also be provided to newly hired staff members during the orientation period. She stated the facility had recently hired two (2) new staff and they had received the in-service education on 02/22/17, regarding the revised policies for Elopement, Potential Risk Factors for Elopement, Wandering, and the Wander Guard System. She stated there were six (7) staff remaining to be trained. She said all of them had been contacted, and a date had been set for their in-service education. She stated one staff member had been off work related to illness. She stated the plan was the remaining staff members would be trained on the policies before their next scheduled workday. The Staff Development Nurse also stated she was in the process of developing a presentation on Prevention of Elopement of Residents. She stated her research and content had been acquired from web-based resources for Dementia and [MEDICAL CONDITION]. Review of the list of staff who still needed training on the policy revisions, revealed the names of seven (7) staff, their titles, and the date for their scheduled training. Interview on 02/24/17 at 10:45 AM with CNA #6, revealed the facility had provided in-service education on the Wander Guard Devices, Elopement Policy and Wandering Policies, as well as information on conducting every 15 minute observations and every one hour observations of residents as related to their elopement risk assessments. Interview, on 02/23/17 at 11:27 AM with RN #1, revealed the facility had provided in-service education on Elopement and Wandering Resident Policies, and she had received this education within the week. She also stated she had observed other staff receiving this in-service education. Interview, on 02/24/17 at 10:35 AM with CMT #12 and on 02/24/17 at 10:55 AM with CMT #17, revealed they had received recent in-service education on how residents at high risk for elopement were identified, re-education on policies for elopement and wandering, the new alarms that had been placed at the elevators and exit doors. CMT #17 stated if a resident was missing, she was to report to the nurse in charge and to the DON immediately, and a search would be conducted until the resident was found. 5. Interview with the ADON on 02/ 24/17 at 1:15 PM, revealed any resident with a Wander guard and any residents assessed at high risk for elopement have been monitored every 15 minutes since 02/20/17. The monitoring would continue every 15 minutes until a re-evaluation of the security of all alarms, exits, and the general environment for safety was completed. Interview, on 02/24/17 at 10:35 AM with CMT #12 and on 02/24/17 at 10:55 AM with CMT #17, revealed residents at high risk for elopement were under staff observation every 15 minutes to ensure they were safe. CMT #6 stated the observations were documented, as well. Review of the every 15 minute observations/checklists revealed all residents the facility identified at high risk for wandering had been observed every 15 minutes, and observations were documented beginning on 02/20/17. 6. Interview, on 02/24/17 at 1:15 PM with the ADON, revealed she had contacted Corporate Office and was able to address and correct the matter within the electronic care plan template used by the facility. 7. Observation, on 02/23/17, revealed photos of residents who were identified as at high risk for elopement were stored at the front lobby reception desk for staff who had reception and switchboard duties. Interview, on 02/24/17 at 10:10 AM with Reception Staff #27, revealed she provided relief help for the full time reception staff, and she received recent in-service education about elopement and wandering. She stated the Staff Development RN provided her training. Reception Staff #27 stated she had access to a pictorial list of residents who were at high risk for wandering and/or elopement. She also kept a log of residents who went out of the facility for visitation or other out-of-building events. She stated the reception staff gave report when she came to relieve them for breaks, regarding any change in a resident's wandering risk status. 8. Observation, 02/24/17 at 1:05 PM of all elevators in the facility, with Maintenance Staff #26, revealed a chiming alert had been installed to alert front reception of any individual who approached the elevator doors. This was a temporary alert until permanent security installations were completed. Review of formal communication from the Elevator and Alarm Companies, dated 02/23/17, revealed a list of the equipment needed for the permanent security of the facility's elevators, was provided to the facility. Observation on 02/14/17 at 1:09 PM of the exit at stairwell (Stairwell A) near the chapel, and the chapel exit to the Terrace revealed a [MEDICATION NAME] alarm was installed and this was a temporary alarm until permanent security could be installed. Observation on 02/24/17 at 1:16 PM, revealed the door to the convent (Stairwell B), had an audible alarm installed. In addition, a key lock had been installed so that the Sisters would have access via a key to enter stairwell B to proceed to the convent. Interview, on 02/24/17 at 1:25 PM with CNA #6, revealed when Stairwell B door was opened, via a test, she responded to the alarm, and she stated she was responding the alarm to be sure a resident was not leaving the unit, unsupervised. Interview, on 02/24/17 at 8:20 AM with the Maintenance Director, revealed he was in the process of receiving cost quotes for the permanent security that would be installed for all the exits. Review of the itemized receipts for purchase of the temporary audible alarms installed and placed at the elevators, the exits to the facility's terrace, and to Stairwells and A and B, were purchased on 02/21/17. Observation on 02/24/17 at 1:15 PM of the Garage Door exit at the lower level of the building, revealed the door was equipped with a [MEDICATION NAME] alarm, and a key lock was installed, as well. This was the garage where the facility's vans, a car, and small lawn tractor were parked. An additional observation on 02/24/17 at 1:15 PM, revealed the video monitor for this garage and its exit had been moved/modified to allow the reception desk staff to view this garage area and the garage exit. Review of the Job Completion Form from the Security Services Company, for the garage camera modification, revealed the work was completed on 02/23/17. Review of the invoice provided by the Locksmith Company that installed the garage door lock, revealed the work was completed on 02/22/17, with a purchase order number listed on the invoice. Interview, on 02/24/17 at 9:00 AM with Maintenance Director, revealed a local fence company was hired to install a door/gait to the terrace stairwell. There were two (2) flights of stairs leading to the driveway. The door/gait would prevent anyone (who was not authorized to be on the terrace, unsupervised); from falling on or going down the stairs. The door/gait had been ordered, but the Maintenance Director said the company representative told him it would take up to three (3) weeks to complete the work. In the meantime, the doors leading to the terrace were [MEDICATION NAME] alerted, and the doorway to the craft room from the main hall would remain locked when unoccupied by staff. Staff, the security guards, and all Sisters of the Order had been instructed to ensure the Craft Room Door remained locked when no staff were working in the room. Review of the fence company proposal, dated 02/22/17, revealed the gate/doorway for the terrace stairwell, was ordered on [DATE]. A purchase order number was also listed on this document. 9. Continued interview, on 02/24/17 at 9:00 AM with Maintenance Director, revealed on 02/21/17 the Company that provided services for the facility's Roam Alerted/Wander Guard Equipped Exits, inspected all three (3) Roam Alerted Exits on the Long Term Care Nursing Units, and there were no issues identified with the function of the Roam Alert alarms. In addition, the alarm sound for each of those doors was increased to make the alarm more audible. Observation, on 02/24/17 at 1:35 PM, when the Roam Alerted Alarm was tested (Medical Hallway Door), revealed the level of sound from the alarm was easily audible through the hallways and at the nurses' stations.

Based on interviews, record reviews and review of the facility's policy, it was determined the facility failed to implement the facility's Abuse Policy by ensuring a criminal background check, a Nurse Aide Abuse Registry check, and a certification verification for two (2) of six (6) newly hired employees. Certified Nursing Assistant (CNA) #1 and CNA/Certified Medication Aide (CMT) #2. The findings include: Review of the facility's Human Resource Policy regarding Hiring of Direct Care Staff, dated [DATE], revealed the facility would employ individuals to work in direct personal care who have not been found guilty of abusing, neglecting, or mistreating residents by a court of law, or have not had a finding entered into the Kentucky Board of Nursing (KBN) concerning abuse. The facility would obtain verification by telephone or fax prior to hiring any individual to work in direct care. Review of six (6) new hire employee files revealed the facility initally hired CNA #1 on [DATE]. The facility re-hired the CNA on [DATE] without checking the Nurse Aide Abuse Registry, completing a criminal background check or validation of the current certification until [DATE], 75 days after hire. Review of the employee file for CNA/CMT #2 revealed the facility hired CNA/CMT #2 on [DATE]. CNA/CMT #2's certification expired on [DATE], thirteen (13) days after hire. The facility failed to reverify her certification status until [DATE], 96 days after the certification expired. Review of the facility's Human Resources employee checks revealed the KentuckyCourtNet.gov was used for criminal background checks and the Kentucky Board of Nursing (KBN) website was used to validate Nure Aide Abuse Registry checks and employees and volunteers were checked for licensure and certifications. Interview with the Director of Human Resources, on [DATE] at 8:50 AM, revealed he had rehired CNA #1 with out verification of the Nurse Aide Abuse Registry and criminal background check and did not validate the CNA/s certification. He further hired a CNA/CMT whose Certification expired 13 days after hire without re-verification. In addition he stated he was unaware that a re-hired employee had to be verified. Interview with the Director of Nursing, on [DATE] at 2:18 PM, revealed all new staff whether a re-hire or new hire were to have a criminal background check, Nurse Aide Abuse Registry check, and the KBN Licensure/Certification validation prior to the employee's start date. In addition, she stated those verifications were necessary for the protection of residents. Interview with the Administrator, on [DATE] at 3:05 PM, revealed Human Resources was responsible to ensure all staff were verified before a start date was offered to a new or re-hired employee.

Based on interviews and record reviews, it was determined the facility failed to ensure the required background checks were completed for two (2) of six (6) employee files reviewed. Certified Nursing Assistant (CNA) #1 and CNA/Certified Medication Tech (CMT) #2. The Human Resource Department failed to obtain a Criminal Background Check, Nurse Aide Abuse Registry check and validate the current Certification for CNA #1. In addition, the Human Resource Department failed to obtain validation of certification for CNA/CMT #2 before it had expired. The findings include: Review of the facility's policy regarding Hiring Direct Care Staff, effective [DATE], revealed the facility would hire no employee until verification was received from the Kentucky Board of Nursing (KBN) that there are no findings against the individual. Review of six (6) new hire employee files revealed the facility initally hired CNA #1 on [DATE]. The facility re-hired the CNA on [DATE] without checking the Nurse Aide Abuse Registry, completing a criminal background check or validation of the current certification until [DATE], 75 days after hire. Review of the employee file for CNA/CMT #2 revealed the facility hired CNA/CMT #2 on [DATE]. CNA/CMT #2's certification expired on [DATE], thirteen (13) days after hire. The facility failed to reverify her certification status until [DATE], 96 days after the certification expired. Interview, on [DATE] at 8:50 AM, with the Director of Human Resources (HR) revealed he was not aware that when a previous staff member was re-hired, an Nurse Aide Abuse Registry check, a criminal background check, and certification were to be verified no matter how long the staff member was gone. Interview, on [DATE] at 2:18 PM, with the Director of Nursing (DON) revealed the facility obtained verifications from the Nurse Aide Abuse Registry, criminal background check, and a certification validation was to be completed before the new or re-hired staff member's start date. In addition, she stated if the verifications had not been completed before the start date it placed residents at risk for possible abuse. Interview, on [DATE] at 3:05 AM, with the Administrator revealed before a potentially new staff member was offered a job, a criminal background check, a Nurse Aide Abuse Registry check, and certification verification had to be completed. In addition, she stated all rehired employees must be verified.

Based on observation, interview and review of the Dietary Policies and Procedures, it was determined the facility failed to ensure food was stored, prepared and served under sanitary conditions. Food items were retained past expiration dates, held too long in storage and some without labels. Equipment (meat slicer) was stored with dried food particles. There was no evidence of a system to rotate stock. Staff failed to utilize the appropriate size scoop when serving a starch (mashed potatoes). In addition, the facility failed to clean and sanitize dishes to ensure safe use. The findings include: Review of the facility's Dietary policies revealed Safe Operation of the Hobart Dishwasher (not dated or revised) directed staff to wash hands thoroughly before picking up clean dishes from the dishwasher and to let them air dry for several seconds after leaving the machine. Staff were to handle clean dishes by the edges, and to keep their fingers from the mouth of cups and glasses. Review of the Dietary policy Storage of Food Items, dated 07/19/10, revealed rotation of stock using the first in, first out was essential. They were to place newly received products behind old stock. A labeling gun was to be used to stamp the items indicating the date they were received prior to placing the items on the shelf. Dented cans and damaged articles were to be placed in a designated area to be returned to the vendor. Review of the Donated Food Items Policy, dated 02/28/01, revealed all donated foods would be carefully inspected for expiration dates and sell by dates and discarded as necessary. All highly perishable donated foods that could not be frozen would be used within one day of delivery. Foods would be dated and labeled accordingly. Review of the Food Storage policy revealed all foods should be properly stored according to temperatures. Dietary Policy for Cleaning Meat Slicer (not dated), revealed the machine must be cleaned immediately after each use. Review of the Dietary Policy for Health, Grooming and Conduct of Personnel, Infection Control (not dated), revealed staff were to keep hair covered with a hair net or cap and dietary staff were to avoid touching mouth, face, nose, hair or arms while handling food. If parts of the body were touched they were to wash hands before proceeding. No policy was provided regarding appropriate scoop sizes utilized to portion foods. Review of the Daily Menu revealed for lunch the meat/protein portion was 3 ounces, starch serving was 1/2 cup, and vegetable serving was a 1/2 cup. Observation, on 12/10/13 at 7:30 AM, of the kitchen revealed the refrigerator had an extra large stainless steel bowl with a label dated 11/21/13, overfilled with grapefruits cut in half. In the walk-in refrigerator, a large plastic container held a white liquid substance covered with loose plastic wrap, dated December 2005 and another large stainless pot with a white liquid substance covered with loose plastic wrap dated December 2009 (staff identified the white liquid as milk). Four (4) large boxes labeled cheese cake, were opened, filled with pumpkin cheese cakes and plain cheesecakes wrapped in sealed plastic wrap. The containers were not dated. Seven (7) pecan pies dated December 2004 and eight (8) caramel pumpkin pecan pies dated 12/01/13 were labeled as sale by dates. A ten (10) inch pumpkin pie was not dated. A large box of individual sliced pies and cakes were piled together with no identifying information or dates labeled on them and were stacked on top of two (2) large boxes of produce. The refrigerator near the stoves had four (4) divided plates with prepared pureed food and not labeled to identify the food or dated. Interview, on 12/10/13 at 10:45 AM, with the Dietary Manager (DM) revealed everything was to be labeled and dated when opened. She stated they did not keep food over three (3) days. She stated the staff was going to use the milk in the recipes. She stated they would not know the use by or expiration date of the milk when it was removed from the original container. She stated the cheesecakes and pies were all donated to the facility for the festival. She stated they had several festivals since Thanksgiving, but was not sure of the dates. She stated she knew they were to have dates on them to ensure they were safe to serve to the residents. She stated they were going to throw them out today. She indicated she or two of her staff were to examine all donated foods for expiration dates and sell by dates to ensure they were safe. She stated she had inspected them but could not recall when they were delivered to the facility. The cheesecakes had been previously frozen and they could not re-freeze them again. She stated they should have been disposed. She should not have kept the individual slices of pies and cakes without having labels on them. Interview with Dietary Staff #1, on 12/12/13 at 11:20 AM, revealed a lot of the food, cheesecakes, pies, cupcakes, and breads had been donated for the festival held after Thanksgiving. Dietary Staff #1 stated she had asked if they should be used since there were no labels or dates on them. She indicated she had asked the DM if they were to keep them and was told they were to use them. She stated they did not inventory or keep records of the donated food items. She stated they used to date the foods upon arrival; however, the stamp was not working and they just quit labeling and dating when they received the food items. She stated the undated and labeled items should have been discarded. She stated everything placed in the refrigerator should be dated and discarded after three (3) to four (4) days. Observation, on 12/10/13 at 10:45 AM, of the dry storage area revealed two (2) eleven (11) pound boxes of Natural Dates were on the shelf. The label on the box stated to keep in cold storage, recommended temperature of 35 degree Farenheit. Numerous six (6) pound (plus) cans of Tomatoes, Puree, Refried Beans, Lima Beans, Butter Beans, Kale, Asparagus, Chili Beans, Kidney Beans, Wax Beans, Pears, Pineapple, and Applesauce had no dates to identify expiration or when it was placed on the shelves for use. Ten (10) six (6) pound cans of water chestnuts were on the shelf for use and stamped, best if used by Jan. 13, 2013. There was no evidence of a system to determine if the stock was rotated to ensure the oldest was used first. One six (6) pound and twelve (12) ounce can of Butter Beans and one six (6) pound can of Zucchini Tomatoes were dented and on the storage shelf for use. Additional observation, revealed two (2), one gallon containers of Italian Fat Free Dressing had a clear tape wrapped around the lid and the top of the container. There was no date identifying when or if the containers had been opened. Interview, on 12/12/13 at 9:30 AM, with the Dietary Manager (DM) revealed the Dates were brought in for the Sisters. She stated she did not know when they were delivered or how long they had been on the shelf. She stated the directions recommended for the Dates to be refrigerated. She stated dented cans were not to be kept. She stated she could not identify when the can goods had been rotated or if they were within their expiration date since there was no identifying information on the cans. She stated they used to mark the cans, but had stopped. She stated they received many donated food items, that she and two other staff would inspect them. She stated she would make the call to keep or dispose of the food items. She stated staff were supposed to rotate the food supplies; however, she was not able to identify if the can goods and dry goods had been rotated. She stated the Italian Dressing was given to them by a cooking school and she did not know if they had been opened or not. She stated the school may have used the dressing for a test recipe and sent the rest to the facility. She stated it should have been refrigerated and dated after opening, not left in the dry storage room. She stated it was important to ensure the foods were safe for the residents. Continued interview with Dietary Staff #1, on 12/12/13 at 11:20 AM, revealed they rotated the can goods when they received the new ones. She stated they used to stamp a date received on the cans; however, the stamp broke and they stopped marking the can goods. They were not supposed to keep dented cans and they should be discarded. She stated she could not tell when the can goods were delivered or if they were rotated or not. She stated they did not have a system in place to ensure rotation of the food supplies were done. She stated the Dates should have been refrigerated and not placed in the dry storage room. Observation, on 12/11/13 at 8:20 AM, in the small dining room, revealed CNA's #2 and #3 were serving food from the steam table. CNA #2 and #3 had their bangs and sides of their hair hanging loosely outside of the hair covering. Observation, on 12/11/13 at 12:00 PM, revealed CNA #4 was filling plates with food for the residents in the small dining room. Her hair was hanging outside of the head covering. As she prepared an alternate choice for Resident #7, she was observed to use a half cup scoop to dip green beans out of the steam table, she did not fill the scoop to capacity and did not empty all the contents of the scoop onto the resident's plate. CNA #4 used a 1/4 cup scoop to serve mashed potatoes for the resident. She picked up a sliver of turkey approximately 2"x 3" to place on the plate. When asked what the scoop sizes were, she stated she did not know. Review of the lunch menu for 12/11/13, revealed the alternate food was 1/2 cup mashed potatoes and 1/2 cup of green beans. Meat or protein identified 3 ounces as a serving size. No alternate meat or protein was identified on the menu. Interview with Dietary Cook #2, on 12/11/13 at 11:45 AM, revealed she did not know the scoop sizes in the mashed potatoes or in the green beans. She thought it was maybe a size 16, but did not know the portion size. Additional interview at 12:00 PM with Dietary Cook #2 revealed she went to find out the size of the scoop in the mashed potatoes and said it was 1/4 cup and it should have been a 1/2 cup. She stated it was important to know the portion sizes to ensure the residents received the appropriate caloric intake to meet their needs. Interview, on 12/11/13 at 12:05 PM, with CNA #4 revealed she was a CNA and had not been trained in dietary services. She stated she did not know the differences in the size of servings for the scoops. She stated the resident preferred small portions and the dietary card would be circled for small portions. She reviewed the dietary list and stated she did not know what 3 ounces of meat was and did not know the differences of the scoop portions. Observation of the dietary card for Resident #7 revealed no small portion selection had been identified. Observations, on 12/12/13 at 8:29 AM, revealed CNA #3 was in the small dining room kitchen preparing breakfast drinks for residents with her bangs and sides of temple hair unsecured by the head covering. Interview with CNA #3, on 12/12/13 at 8:29 AM, revealed she did not know she had to keep all of her hair covered. She stated she had not been trained to serve food. Interview, on 12/12/13 at 8:45 AM, with Dietary Aide #4, revealed staff were supposed to cover all their hair; however, the covering provided by the facility would slide off. She stated she had not been trained to identify the appropriate scoop and serving sizes. She stated they usually used the scoops put into the food. She stated when giving portions to the resident she would "eye ball it". Interview with the Dietary Manager, on 12/12/13 at 9:30 AM, revealed she did not train the CNA's on the dietary process. She stated she had not directed the staff to train the CNA's. She stated her staff would tell the CNA's about the process of serving foods; however, she could not ensure the CNA's were knowledgeable regarding the dietary process. She stated, she guessed she should do an orientation for the CNA's regarding food service. She stated the CNA's did not have to wear hair covering when delivering the resident's food; however, anyone preparing and serving resident's food from the steam table should have their hair secured by the head covering. Observation, on 12/10/13 at 11:37 AM, during the initial tour of the kitchen revealed the meat slicer had a plastic cover over it and was ready for use. A dried yellowish, crusted substance was observed on the back of the blade and on the base of the machine. Review of the Dietary Equipment Cleaning Schedule revealed no December schedule was available for staff to document cleaning done. Interview with Dietary Cook #1, on 12/11/13 at 11:37 AM, revealed she had used the meat slicer the previous day to slice turkey. She stated it should have been cleaned after each use and it was not done. She stated she would document on the cleaning schedule when she used and washed the meat slicer; however, there was no schedule out for December. Observations, on 12/12/13 at 8:58 AM, during the dietary sanitation tour revealed Dietary Staff #3 had loaded a rack of bowls to be cleaned. After they came through the dishwasher and rinse cycle, she began to remove the bowls and stack them while they had water droplets running into the bowls and on the outside of the bowls. When questioned about stacking the bowls while wet, Dietary Staff #3 reached for one (1) of two (2) dish towels that was on the shelf over the dishwasher system. A large open Rubbermaid container sitting on the floor was half full with white cotton dish towels with a blue stripe were piled in the container. She started to dry the bowls with the dishcloth and stated if they were not dry they had to dry them with the dishcloths provided by the facility. She stated "I know they are supposed to air dry because the cloth towels can flake off onto the dishes", as she continued to stack the bowls. Dietary Staff #3 was observed to have a clear nasal drainage to run down from the nares. Dietary Staff #3 reached for a paper towel and wiped her nose. As she held the soiled paper towel in her right hand she folded the towel and placed it on the "clean" cart then tossed the soiled paper towel in the trash can. She then began to remove the other bowls from the rack holding the bowls in her bare hands placing her thumb inside of the bowl as she observed them. She continued to stack the bowls together with her soiled hands. Surveyor intervened and she stopped, stating she should have washed her hands before touching anything. Interview with Dietary Staff #3, on 12/12/13 at 9:10 AM, revealed she was supposed to wash her hands when going from dirty to clean and did not think. She stated she should have disposed of the paper towel and washed her hands prior to stacking any other dishes. Interview with the Dietary Manager, on 12/12/13 at 9:30 AM, revealed a previous Sister had directed the dietary staff to use the dish cloths to dry dishes. She stated they were supposed to air dried when they came out of the dishwasher and should be allowed to dry while on the table. She stated the towels were originally to be used on the pots and pans. She stated bacteria grows in water and staff should not stack the wet dishes. In addition, she stated the staff were to clean the equipment after each use. She stated they had a dietary equipment cleaning schedule for staff to sign off when they completed the job. She stated she had not printed a schedule for December as of 12/12/13.

Based on observation, interview, record review, and review of the facility "Abuse" policy, it was determined the facility failed to report and complete an investigation regarding an allegation of Misappropriation of Property for one (1) of ten (10) sampled residents (Resident #4). In addition, the facility failed to complete a Nurse Aide Abuse Registry Check on or before hire for one (1) of five (5) employees (Employee #1). The findings include: Review of the facility policy "Resident Abuse/Neglect" revised 03/09/09, revealed under "Investigation"...1. The Administrator shall conduct an investigation and report the results as noted: a. observation and interview of the resident. b. Review of the resident's clinical record..c. staff, resident, family and /or visitor interviews including, in the case of suspected resident abuse, all staff assigned to the resident during the previous 48 hours..d. review of incident reports involving the resident.. e. review of employee schedules and personnel records and f. review of Quality Assurance records......2. The Administrator or Director of Nursing shall notify the resident, physician, family, or responsible party....4. The results of the investigation shall be described in a written report which shall be provided to the State Survey Agency, Adult protective Services, and as appropriate, law enforcement officers. The report shall be provided within five (5) working days of the incident.....5. A copy of the investigation report shall be provided to the QA Committee..... Under the Misappropriation of Resident Property section of the "Abuse Policy"....6. As soon as possible, but within no more than 2 hours of the suspected abuse, neglect or mistreatment, the Administrator shall notify the State Agency, local agencies (public health and local law enforcement (of the suspect abuse, neglect or mistreatment. 1. During the review of the 5G Protocol regarding Abuse investigations, completed by the facility, it was determined Resident #4 had reported $200.00 missing the week of 11/18/13. This had been reported to the Accounts Manager, on 11/25/13. Review of the "Report of Missing Property", completed by the facility, revealed the resident reported a family member had given him/her cash for his/her birthday, and had put the money inside a pocket of a sweater inside the room closet. The report revealed the resident was unsure if the closet had been locked or not, and expressed he/she was not so concerned, but wanted the facility aware. Review of Resident #4's clinical record revealed the resident had been admitted , on 12/07/10, with [DIAGNOSES REDACTED]. The resident was alert and oriented with no behavior concerns, according to the 11/08/13 Annual Comprehensive Assessment. Interview with Resident #4, on 12/12/13 at 4:10 PM, revealed the resident's closet was locked and the key was kept on his/her person. The resident revealed he/she did not know how the key was used to unlock the closet, but stated it could be done. The resident stated there had been no follow-up regarding the incident, and the Social Services Director had spoke with him/her initially after the incident. Interview with the Director of Nursing (DON), on 12/12/13 at 3:55 PM, revealed she may have heard something in passing regarding the incident, but did not know the outcome. The DON stated the Social Services Director always handles any allegations of Misappropriation of Property, and forwards the "Report of Missing Property" to the Administrator for reporting. Interview with the Social Services Director, on 12/12/13 at 3:30 PM, revealed all residents are given locked closets upon admission. The Director stated she was responsible for completing the initial report, which is given to the Administrator for reporting. The Social Service Director stated there were few reports of abuse or misappropriation in the facility; however, stated residents are encouraged to report any grievances upon admission. The Director stated she interviewed Resident #4 after the incident was reported to her, and the resident was not concerned about the money at the time. Interview with the Administrator, on 12/12/13 at 3:50 PM, revealed Resident #4 had not told the administrator of the incident; however, revealed the incident was reported to the Account Manager, who reported to Social Services Director. The Administrator stated that Social Services handles all the interviews with residents, and completes the initial report, which is then given to her. The Administrator stated the resident was not concerned about the $200.00 missing, so she did not report the allegation to any State Agencies, complete a thorough investigation, or complete or send the required 5 day follow up to the state agency. The Administrator stated they don't always report misappropriation allegations, unless they substantiate the allegation. The Administrator also revealed they had no reports of suspected abuse since the last survey, and had only a couple of reports of misappropriation of property. B. Review of the facility policy regarding "Abuse Misappropriation of Resident Property" related to Screening revealed....it is the policy of the Little Sisters of the Poor to conduct personal reference checks and criminal investigation checks on all personnel. In addition, potential employees are screened for a history of abuse, neglect, or mistreating residents by verifying that a potential employee's name is not listed on the State Nurse's Aide Registry and by checking with the appropriate licensing boards and registries. Review of the employee file, on 12/12/13, revealed employee #1 had a hire date of 12/06/13; however, the nurse aide abuse registry check was not completed until 12/09/13, or three (3) days after hire. Interview with the Human Resources Director, on 12/12/13 at 11:30 AM, revealed Nurse Aide Abuse Registry Checks should be completed on or before hire for all new employees. The HR Director stated Employee #1's registry check was completed after hire, because she had been a previous employee here. The HR director stated the Nurse Aide Registry Check should have been completed prior to starting work.