Every finding on record at Lyndon Crossing, LLC

Based on observation, interview, and review of facility policy, the facility failed to ensure a comfortable, sanitary environment free from odors. The Men's Unit of the facility had ongoing, unpleasant odors of stale urine on all four days of the survey. In additions, feces and/or blood was observed to be smeared on different surfaces on one of the four days of the survey. The failure to maintain a comfortable, sanitary environment which was free from odors, had the potential to affect any of the 23 residents living on this locked unit, as well as staff and the public/visitors in the area.The findings include:Review of the facility policy titled, Safe and Homelike Environment, reviewed/revised 02/16/2024, revealed The facility will provide a safe, clean, comfortable and homelike environment. Per the policy, Environment refers to any environment in the facility that is frequented by residents including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas .and activity areas. The policy noted that orderly is defined as an uncluttered physical environment that is neat and well-kept. 'Sanitary' includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean .Resident care equipment includes, but is not limited to equipment used in the completion of the activity of daily living. The policy also noted that Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department.1. Observations including, but not limited to, on 01/06/2026 at 9:35 AM, 01/07/2026 at 9:43 AM, 01/08/2026 at 9:04 AM, 9:25 AM, 11:30 AM, 4:30 PM, and 01/09/2026 at 7:00 AM, 7:45 AM, 9:00 AM. 9:05 AM, 9:09 AM, 9:13 AM, 9:28 AM, 10:25 AM, 11:44 AM, 12:25 PM, 1:45 PM, 3:29 PM, 3:38 PM, 3:55 PM, and 4:40 PM revealed a strong odor, indicative of stale urine, was present and pervasive on the Men's locked dementia unit. The odor was present and immediately noticeable when entering through the locked doors that led into the unit. In each observation, the odor was strongest in and around the common day room area where residents were sitting on chairs and/or a couch. The odor lessened in intensity, but was still present, as one left the common area and moved down the adjacent halls. Routine housekeeping services and/or resident toileting/incontinence care was noted throughout the day on 01/09/2026. Although fresh odors were noted to lessen after these services, the underlying odor indicative of stale urine remained present and was noted during each observation.Interview on 01/09/2026 at 9:00 AM with Housekeeper 1 revealed she was aware of the odor on the unit and identified it as urine. Housekeeper 1, who spoke limited English, showed the products on her cleaning cart and indicated that she used Bioenzymatic Odor Eliminator spray and disinfectant when cleaning.Interview on 01/09/2026 at 9:05 AM with the Housekeeping Manager confirmed the strong odor of urine was present, adding, It's all day long over here .We all smell it. She offered several possible reasons for the ongoing odor, noting that there were multiple male residents on the dementia unit who were incontinent, and/or had behaviors, including refusals of showers. The Housekeeping Manager also stated that the furniture could be contributing to the odors and added that staff used the Bioenzymatic product once a week to kill bacteria on the chairs used by the residents in the common area. Further interview with the Housekeeping Manager revealed that although she did not know the root cause, she also thought the ventilation system could be contributing to the problem. The Housekeeping Manager stated the Administrator was aware of the odors and would tell her when there were complaints, and they needed to clean.During interview with the Director of Nursing (DON) on 01/09/2026 at 11:48 AM, she stated that the odors were occurring after care and housekeeping staff was constantly on it. She acknowledged that there were men on the dementia unit who refused to bathe, as well as men on the unit who urinated in inappropriate locations, such as on the floor. The DON was unaware that, per the Housekeeping Manager's statement, the chairs on the unit were only being sprayed once per week. She stated that the chairs should be sprayed/disinfected each time immediately after a chair was contaminated due to urine.Interview on 01/09/2026 at 12:25 PM with Social Services (SS) 1, whose office was on the locked unit, revealed he was aware of issues with the urine odor. He stated there were multiple residents on the unit who were frequent wetters. He stated that he had identified that part of the issue was that the material on some of the chairs in the day room was fabric and could not be easily cleaned/disinfected. SS1 added that he himself, routinely cleaned soiled chairs with the Bioenzymatic spray, and had thrown aware at least three fabric chairs that were too urine-soaked to be cleaned/disinfected. He noted that he had discussed the issue with the Administrator, who was talking with corporate staff about replacing them with chairs covered in a vinyl-type (rather than cloth) material which could be cleaned/disinfected. However, the replacement of all chairs had not yet occurred. Observation of the common day room on 01/09/2025 at 1:45 PM confirmed SS1's statement that not all seating in the area had a surface material that could be readily cleaned/disinfected, with a resident sitting in a cloth-covered chair.A second interview with the Housekeeping Manager on 01/09/2026 at 12:35PM revealed she wished to clarify her initial statement. She explained that in addition to the weekly use of the Bioenzymatic product, staff will also clean a chair when it is soiled. However, she continued, this did not always happen as some of the residents stayed in the chairs all day long, so they could not immediately be cleaned/disinfected at the time it was needed. An additional interview with the Housekeeping Manager on 01/09/2026 at 4:40 PM confirmed SS1's statement that the cloth-covered chairs could not be thoroughly cleaned/disinfected, pointing out a cloth recliner in the day room.During an interview with the Minimum Data Set (MDS) Coordinator on 01/09/2026 at 2:30 PM, she described the bathroom on the locked unit as having a foul odor. The MDS Coordinator noted a lot of residents on the unit refused care or showers. She added that housekeeping staff only works during the day, and the aides are responsible for clean-up at night. Observation on 01/09/2026 at 3:30 PM revealed the MDS Coordinator's office was in the portion of the facility where the Men's locked unit was located and access to her office was past the bathroom which was located off of the common day area. During interview with the Administrator on 01/09/2026 at 4:50 PM, he stated, There are occasions when there are odors, but it is not pervasive. He added that if there were odors in the facility, they were on the Men's dementia unit, adding that there were residents on this unit who urinated and defecated in inappropriate places, such as the floor or flowerpots. He confirmed that there were no housekeeping staff working in the evening, adding that if cleaning was needed at that time, the aides working on the unit were responsible and had access to housekeeping supplies. The Administrator initially stated that no one on staff had talked to him about any ideas to reduce/relieve odors. However, when asked about SS1's statement that he had spoken to him, the Administrator confirmed that SS1 had told him about the problem related to cleaning/disinfecting cloth-covered chairs. He stated that a request for replacing the chairs was in the quarterly budget; however, corporate approval had not yet been granted. Further interview with the Administrator revealed that he thought that all cloth chairs were removed from the unit and was unaware that this had not yet occurred.2. a. In addition to the urine odor, observation also revealed a strong odor of feces was present on the Men's locked dementia unit on 01/09/2026 at 7:45 AM, 9:00 AM, 9:05 AM, and 9:09 AM. Observation at 9:09 AM revealed that the odor of feces was strongest around Shower room [ROOM NUMBER]. Observation of Shower room [ROOM NUMBER] at this time with the Housekeeping Manager revealed that there was feces smeared down the left outer side of the toilet bowl. Soiled resident clothing was also noted on the floor at this time. The Housekeeping Manager revealed she was unaware of the condition of the room prior to surveyor intervention, adding That's what's causing the smell in here. It needs to be cleaned up. Additional observation of Shower room [ROOM NUMBER] on 01/09/2026 at 9:28 AM revealed that staff had just finished helping a resident with toileting. Although the soiled clothing was gone from the floor, observation revealed the outside of the toilet remained smeared with feces. In addition, blood was noted on the lip of the sink in the room. b. Observation on 01/09/2026 at 9:13 AM, prior to entering Shower room [ROOM NUMBER], (which was on a different wing of the locked unit), also revealed a strong odor of feces. Upon entry to this room with the Housekeeping Manager, observation revealed multiple streaks of feces on the floor in front of the toilet, the sink, and on the floor of the shower area. At this point, the Housekeeping Manager noted that she was also unaware of the condition of the shower room prior to surveyor intervention, adding, This one needs to be cleaned, too. Further interview with the Housekeeping Supervisor revealed that there was no set schedule as to when the Shower rooms (which were also used for toileting residents) were to be cleaned, as housekeeping staff were also responsible for cleaning administrative offices and resident rooms.

Based on interview and record review, the facility failed to ensure that one (Resident (R) 3) of 26 sampled residents had an admission Minimum Data Set (MDS) assessment completed within 14 days of admission. R3 was admitted on [DATE], and the MDS V200B date, signifying completion of the assessment, was not completed until 11/05/2025.The findings include:Review of R3's Census tab in the electronic medical record (EMR) revealed the resident was admitted on [DATE]. The review of the admission MDS, with an Assessment Reference Date (ARD) of 10/21/2025, revealed that V200B date, signifying completion of the Care Area Assessment (CAA) Process, was not signed by the MDS Coordinator until 11/05/2025, the 22nd day of admission.Interview with the MDS Coordinator on 01/09/2026 at 3:30 PM revealed that she was the Registered Nurse (RN) responsible for signing R3's admission MDS as complete. She confirmed that R3's admission MDS was due to be completed no later than 10/28/2025, the 14th day of admission to the facility. She stated that the delay in completing the resident's admission MDS occurred because she was waiting for Social Services (SS) staff to complete various portions of the assessment. Review of assessment documentation with the MDS Coordinator confirmed that data for which SS staff was responsible was not locked in the computer system until 11/03/2025, and she, herself, did not sign V200B, signifying completion of the CAA process portion of the MDS until 11/05/2025. Further interview with the MDS Coordinator revealed that sometimes SS falls behind and there had been other assessments which were late, due to untimely completion of the sections assigned to SS staff. Interview with SS1 on 01/09/2026 at 3:55PM revealed that SS2, who was not present, was the SS staff responsible for R3's admission MDS. He reviewed the EMR and stated that SS2's portion of the MDS assessment was opened on 10/27/2025 and signed on 11/03/2025. SS1 explained that the total MDS could not be completed and locked until all portions were done, confirming that the MDS Coordinator did not sign the MDS as complete until 11/06/2025, three days after SS2 completed his portion. Further interview with SS1 revealed that it was possible that SS2 had actually completed the assessment on time but then failed to lock the work timely so that the information in the assigned sections could populate and MDS Coordinator could sign the total MDS document as complete. SS1 stated he was aware of times when this occurred, adding, I have had to go on and lock behind him.Interview with the Director of Nursing (DON), on 01/09/2026 at 4:09 PM, revealed that she was unaware of any issues with late MDS assessments or issues with SS staff not completing and/or locking their portions of the assessment process in a timely manner. Additional interview with the DON on 01/09/2025 at 5:21 PM revealed that the facility did not have a specific policy regarding time frames for MDS assessments, and instead, followed the requirements of the Resident Assessment Instrument (RAI) manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 October 2025, revealed that for admission assessments, the CAA(s) Completion Date (Item V0200B2) must be no later than review of the 14th calendar day of the resident's admission (admission date + 13 calendar days).Interview with the Administrator on 01/09/2026 at 4:50 PM revealed that his expectation was that MDS assessments were submitted timely for a multitude of reasons and he was unaware of any late assessments prior to surveyor intervention.

Based on interview, record, review, and review of facility policy, the facility failed to ensure that one (Resident (R) 38) of 26 sampled residents had a thorough, complete medical record which reflected the care that was provided. R38 had no documentation of medication administration or multiple contacts with the physician in accordance with physician orders.The findings include:Review of the facility policy, titled, Timely Administration of Insulin, reviewed/revised 02/14/2024, revealed the procedures included, Document on the medication administration record the time and location of the insulin injection. Review of the facility policy, titled, Medication [sic] Administration, reviewed/revised 02/14/2024, revealed staff are to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Sign MAR [Medication Administration Record] after administered. For those medications requiring vital signs, record the vital signs on the MAR.Review of the facility policy, titled, Notification of Change, reviewed/revised 03/20/2025, revealed the facility must consult with the resident's physician when there are circumstances that require a need to alter treatment, including, but not limited to, exacerbation of a chronic condition. Review of these policies revealed they did not address the need for accurate, complete documentation (including documentation of physician notification, documentation of orders given, and documentation of medication administration in response) when physician notification was required due to vital signs outside established parametersReview of R38's Census tab in the electronic medical record (EMR) revealed the facility admitted the resident on 12/22/2025. Per the Medical Diagnosis tab, R38's diagnoses included diabetes mellitus Type 2. Review of R38's care plan, initiated 12/23/2025, revealed the Resident has Diabetes Mellitus. Per the care plan, interventions to minimize the risk of complications for diabetes included, Administer medications as ordered, and Obtain blood sugars as ordered, notify MD [physician] of abnormal results as indicated.Review of the resident's physician orders, dated 12/23/2025, revealed they included insulin Lispro, 16 units (U) three times a day, insulin Glargine 30U once per day, and dapagliflozin 10 milligrams each day. In addition, physician orders included sliding scale insulin twice a day, based on blood sugar (BS) readings. Review of the sliding scale order revealed that the order only went as high as 351- 400, which would require 20U of insulin. Per the order, staff were to contact the physician for blood sugar readings over 400, with no specific sliding scale dose established.Review of R38's 12/2025 Medication Administration Record (MAR) revealed that on five instances in 12/2025, R38's blood sugar reading was greater than 400.a. 12/26/2025 Bedtime (HS) - BS = 525. Review of the MAR revealed the nurse coded 9, which per the legend, meant Other/See Nurse Notes. Review of Nurse's Notes for 12/26/2025 at 10:17 PM revealed R38's ACC [Accu-Chek used to measure blood sugar] was 525. NP [Nurse Practitioner Name] was notified ordered that 20 Unit is [sic] be administered. Further review of the note revealed that although the nurse documented the NP gave an order, there was no evidence that the insulin was actually given.b. 12/27/2025 HS - BS = 537. Per the MAR, the nurse again coded 9, indicating the need to refer to Nurse Notes. Review of the Nurse Notes for 12/27/2025 at 8:11 PM revealed Resident ACC was 537. NP ordered prescribed dose. However, review of the note, as well physician orders revealed that there was no dose prescribed for BS of greater than 400; only the order to call the doctor if the BS were higher than 400. There was no evidence as to the amount that the NP ordered at this time, or what amount (if any), the nurse administered.c. 12/28/2025 Morning - BS = 410. Per the MAR, the nurse coded 13, which, per the legend meant No insulin required. Review of R38's progress notes for the day revealed no evidence that the nurse followed the order and contacted the physician when the resident's blood sugar was over 400.d. 12/29/2025 Morning- BS 401. Per the MAR, the nurse again coded 13, indicating No insulin required. Review of R38's progress notes for the day revealed no documentation that the nurse informed the physician the resident's blood sugar was over 400.e. 12/29/2025 HS - BS = 465. Per the MAR, the nurse coded 9, which per the legend, meant Other/See Nurse Notes. An Administration Note, on 12/29/2025 at 11:31 PM repeated the sliding scale order which had been in place since 12/23/2025. However, there was no evidence that the nurse followed the order and contacted the physician when the resident's blood sugar was over 400.During an interview with a family member of R38 (FM38) on 01/08/2026 at 1:54 PM, he expressed concerns about the resident having elevated blood sugars and delays in insulin administration.Interview on 01/09/2026 at 10:30 AM with the Registered Nurse (RN) East Unit Manager (UM) revealed that neither of the two nurses who were responsible for these five instances were working. The RN East UM reviewed R38's MAR and notes and confirmed the above record review, including that there was no documentation that the dose ordered on 12/26/2025 was, in fact, given. In response to the 12/27/2025 HS reading, she stated, I can't see what was given. The RN East UM stated that there was no order for set sliding scale order for blood sugars over 400, and she could not tell, by reviewing the documentation what order the NP gave or what the nurse, in fact, administered. Further interview with the RN East UM revealed that there was no evidence that the physician/NP was notified of the 12/28/2025 and 12/29/2025 readings greater than 400.During an interview with the Director of Nursing (DON) on 01/09/2026 at 11:48 AM, she reviewed the MAR and notes. The DON stated that at that time she could not confirm what happened, based on the documentation and would do further investigation.A second interview was conducted with the DON on 01/09/2026 at 3:40 PM. The DON stated that, after investigation, it appears it's a documentation error, indicating that the nurses needed training. She stated that she had contacted both nurses, and believed that the care was provided as ordered, but the record did not include documentation of their actions. She stated that for the 12/26/2025 instance, the nurse stated she had given the 20U of insulin; however, she failed to document its administration. The DON continued that the nurse told her than the note on 12/27/2025 that the NP ordered prescribed dose meant that the NP ordered the same 20 U that she had also ordered the previous day. However, the DON confirmed, there was no documentation to verify this. She stated that although there was no documentation for the other three instances, she also contacted the NP, who told her she was notified about each of the elevated BS readings. The DON noted that Clearly, education re documentation is needed.Interview with the NP by telephone on 01/09/2026 at 4:12 PM revealed that she was aware that R38 had elevated BS readings during the last week of 12/2025. She stated that she could not remember being contacted every time it occurred, but knew she had talked to staff and, in response to the elevated BS, had tapered R28's prednisone (a potent synthetic corticosteroid medication which increases blood sugar.)Interview with the Administrator on 01/09/2026 at 4:50 PM revealed that, as an attorney, Documentation is key to me. He stated that both his and the DON's expectation regarding documentation was that it be accurate and complete.

Based on observation, interview, and record review, the facility failed to store medications in a secure manner. Observations revealed medications on top of a medication cart, with no staff in view of the cart. The findings include:Review of the facility policy, Medication Storage, dated 02/01/2024, revealed under the General Guidelines that all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.Review of policy review records revealed the medication storage policy was reviewed and acknowledged by Licensed Practical Nurse 4 and dated 09/24/2025.During observation and interview on12/17/2025 at 8:50 AM, revealed Medication Cart C was unattended, positioned to the right of the nurse's station and locked. On top of the cart was a container of medication labeled with a resident's name. Additionally, a capped syringe was lying on the cart along with a glucometer (device used to measure blood glucose) with a test strip sticking out of the glucometer. Licensed Practical Nurse (LPN) 4 returned to the cart and when asked about the medications on the cart, LPN 4 stated loudly . I need to get the medications passed!Interview with LPN4 on 12/17/2025 at 10:40 AM revealed he was trying to get the medications out on time, and he revealed he was aware that it was against facility policy to leave medications unattended on top of the medication cart. He stated that he could go to the unit manager, if he needed assistance. LPN4 stated it was important to provide quality care to the residents, which included safely storing medication and syringes where the resident cannot access.Interview with Registered Nurse 1 on 12/17/2025 at 10:00 AM revealed medications and syringes or any patient identifiers are not to be stored on top of the carts or left unattended as this was against facility policy, and it was unsafe. Interview with the Unit Manager on 12/17/2025 at 1:30 PM revealed that LPN4 violated facility policy which indicated medications and syringes should not be left unattended on top of carts. The UM stated LPN4 should have notified her that he was leaving the floor and that it was important that the policy was followed for resident safety. Interview with the Director of Nursing on 12/17/2025 at 2:30 PM revealed that medications should never be left unattended on top of medication carts. The DON stated this is a violation of policy and that all nurses are trained upon hire, and prior to passing medications.

Based on interview, review of the clinical record, and review of the facility policy, the facility failed to implement the resident(s) care plan interventions for 1 out of 9 resident(s) sampled for elopement risk, Resident (R)1.The facility admitted R1 on 07/08/2025 and was assessed to be a risk for elopement. The resident was required to reside on the secured memory care unit, which required supervision while on the unit. Per the policy and the resident's care plan, this was for the resident's safety. Additionally, the resident's care plan interventions included providing structured activities. On 09/15/2025, R1 left the facility unsupervised and without staff knowledge. Interviews with staff revealed the resident's care plan was not implemented due to staff providing care to other residents on the unit. Immediate Jeopardy (IJ) was identified on 10/24/2025 and was determined to exist on 09/15/2025 in 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 10/24/2025 at 2:14 PM.On 10/24/2025 at 2:14 PM, the facility's Administrator, and Interim Director of Nursing (DON) were provided a copy of the IJ Template and notified of the facility's failure to implement interventions of a person-centered care plan to ensure resident safety was likely to cause serious injury, impairment, or death.The facility provided an acceptable IJ Removal Plan on 10/28/2025 at 12:46 PM, alleging removal of the IJ on 09/17/2025, prior to the State Survey Agency (SSA) entrance to the facility. On 10/28/2025, the SSA validated the facility implemented their removal plan on 09/17/2025 and was determined to be past IJ. Refer to F689 The findings include:Review of the facility's policy, Elopements and Wandering Residents, reviewed/revised 02/13/2024, revealed residents at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk. Review of the facility's policy, titled, Comprehensive Care Plan, reviewed/revised on 12/23/2023, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident. The care plan was to be consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment.Review of the clinical record for R1 revealed the facility admitted the resident on 07/08/2025 with diagnoses of dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder.Review of the facility's Elopement/Wandering Risk Evaluation, dated 07/08/2025 at 4:36 PM, revealed the facility assessed R1 for elopement/wandering and the resident received a score of three, which indicated moderate risk for elopement. Review of R1's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment.Review of R1's Comprehensive Care Plan dated 07/09/2025 revealed the facility assessed the resident to reside on its secured unit, for her safety. Additionally, the Care Plan revealed the resident had impaired cognitive function/dementia or impaired thought processes. Continued review of the care plan revealed, under the focus of requiring the safety of the secured unit, the intervention was for the resident to be supervised while on the secured unit. Diversion interventions included to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, and pictures and memory boxes. Review of R1's Progress Notes, dated 09/12/2025, 09/14/2025, and 09/15/2025 revealed the resident expressed to staff her desire to go home. Review of the Progress Note dated, 09/15/2025, revealed the alarm went off on the female memory care unit and it was discovered that resident was not present. In an interview with the Sheriff Officer on 10/22/2025 at 12:05 PM, he stated he received a call from concerned citizens in the park around 8:33 PM and the call was dispatched around 8:35 PM. He stated the citizens reported they found a lady [R1] sitting on a park bench, stating she had been held captive for years and she ran way. Per the interview, the sheriff officer stated he did not know which facility the resident resided, so he started with the closest facility in proximity to the park. He stated he walked into the facility, told staff the resident's name, and asked if she was missing. He stated the staff reported, no, and informed him that the resident was in her room. The officer stated that when the staff went to R1's room, they noticed the resident was missing. He stated he communicated to the staff that the resident was found in the local park. He stated a nurse (LPN1) went with him to the park and convinced R1 to return to the facility with her. Further, he stated the resident did not want to return to the facility. The sheriff officer stated he was uncertain how long R1 was in the park before the 911 call came into dispatch. In continued interview, on 10/22/2025 at 12:05 PM, with the Sheriff Officer, he stated he believed R1 was able to exit the property by somehow figuring out how to unlock the gate connected to the privacy fencing. The officer stated that when he responded to the facility, no staff member reported to him that they were looking for or were missing a resident.During an interview with R1, on 10/21/2025 at 10:30 AM, she stated on the night she went to the park she prayed for an intervention from God and both exit doors opened. R1 stated the wood (fence slat) was faulty and she was able to get through it. She stated she was running as fast as she could. R1 stated that when she arrived at the park, she sat down on a bench. She stated she talked to a couple about her escape from the facility and they called the police. She stated she should not have told them because the police showed up and brought her back to this [facility] place. R1 continued to state that she was very unhappy in this place, adding, I don't belong here and if I am able to leave again, I will. In an interview with Certified Nursing Assistant (CNA)5 on 10/22/2025 at 1:57 PM, she stated she was assigned to work with the resident, on 09/15/2025, the night the resident went missing. She stated there were two CNAs and one nurse that worked the unit. Per the interview, CNA5 stated she was putting her residents to bed and had put R1 to bed twice. She stated that when she heard the alarm go off, she, along with CNA3 and Licensed Practical Nurse (LPN2) ran back to the exit door. CNA5 stated they looked for any other residents that may have gone outside and did not see anyone. She stated the nurse then turned the alarm off. Further, she stated she did not recall another alarm going off that evening. In continued interview with CNA5, she stated she did not implement the residents care plan, related to supervision of the resident while on the secure unit because she did not work the unit very often. Additionally, she stated that at the time the resident left the facility, she was giving a shower to two other residents and could not supervise the resident. In an interview with CNA3 on 10/21/2025 at 6:50 PM, she stated on the night of 09/15/2025 she was assigned the rooms on the women's memory care [secure] unit. However, CNA3 stated R1 was not assigned to her. Per the interview, she stated she was giving a shower to a resident when the alarm went off. The CNA stated she stopped what she was doing and went to the exit door. She stated she saw R1 standing at the exit door and she moved R1 to the dining room. CNA3 stated she did not know the code to stop the alarm, so she went and got LPN2 to assist with turning the alarm off. The CNA stated that during that time, the door did not lock right away. CNA3 stated she went back to assisting her assigned residents with showers. She stated that after she had completed her task, she noticed the unit was quiet adding that R1 could be loud. She stated it was around 8:00 PM when the police showed up and the LPN2 was in the middle of administering the residents their medications. Further, CNA3 stated no one was actively looking for R1 that night. In an interview with LPN2 on 10/22/2025 at 2:17 PM, he stated he was working on the night of 09/15/2025 on the secure memory care unit. He stated he was in the middle of rounding, on the men's memory care unit, when he heard the alarm go off on the women's side. He stated he responded to the alarm and checked the courtyard. He stated the courtyard was empty. LPN2 stated he stepped outside and did not see anyone. He stated he started to check the resident's rooms, as per policy. Further, he stated that when the police arrived at the facility, he was doing the bed checks of residents. He stated the officer came and asked if he knew R1 and that was when he knew the resident was out of the facility. LPN2 stated the resident was not gone long, probably about five or ten minutes. LPN2 stated the alarm went off only one time that night. LPN2 stated he was working with two CNAs that night. Further, he stated the CNAs were in the middle of doing things with other residents when he responded to the sound of the alarm that came from the women's secured unit. In an interview with Licensed Practical Nurse (LPN)1 on 10/22/2025 at 9:37 AM, she stated on 09/15/2025 she worked late on day shift and was finishing charting when she observed an officer at the door. She stated he asked her if the facility knew R1. LPN1 stated she showed him a picture of R1 from her computer and the officer confirmed that it was R1. Further, she stated the officer told LPN1 that R1 was at the park. She stated she went with the officer in his car to the park. She said that when they arrived at the park, the resident stated she did not want to return to the facility. She stated R1 reported she wanted her freedom. Per the interview, LPN1 stated R1 told bystanders she was being held captive. In an in interview on 10/23/2025 at 12:22 PM with the Minimum Data Set (MDS) nurse, she stated when the facility admitted a resident, a baseline care plan was triggered for an admission evaluation. As things change or progress, MDS would update the resident's care plan as needed, or update in a morning meeting. Per the interview, she stated she would update the care plans as staff developed the interventions for the care plans. Regarding the elopement incident with R1, she stated the facility reviewed the factors that lead to the resident's elopement. She stated the resident had increased anxiety, as a new resident. She stated staff updated the resident's care plan the night of the incident and came up with several interventions. Per the interview, she stated the resident was placed on 15-minute checks for 72 hours to see if her anxiety would decrease following the incident. After 72 hours, the facility determined R1 was no longer a risk, and her anxiety had decreased. In an interview on 10/23/2025 at 3:54 PM with the Director of Nursing, she stated regarding the elopement, she got a call from the LPN2 that R1 had gotten out the door. She stated anyone in nursing can develop a care plan. Per the interview, she stated care plans were developed or revised when there was a change in resident status prompting a change to the care plan. The DON stated staff that provided oversight of the care plans were the nursing department, nurses' staff, CNAs, social workers, anyone that participates in any level of care for the resident. The DON stated she believed redirection by implementing directional activities according to the care plan were performed that night. However, interviews with CNA5 on10/22/2025 at 1:57 PM, CNA3 on 10/21/2025 at 6:50 PM, and LPN2 on 10/22/2025 at 2:17 PM, revealed they were with other residents during the time the resident exited the facility unsupervised, which was a failure to implement the resident's care plan.In an interview on 10/23/2025 at 3:37 PM with the Administrator, he stated he got the call, regarding the elopement, in the evening 9:15 PM or 9:30 PM, on 09/15/2025. He stated R1 had interventions placed in her care plan. Per the interview, he stated R1 was pleasantly confused and have some sun downers. He stated the resident was placed on the secure unit for her safety. The Administrator stated R1 wanders. Further, he stated he did not recall a time the facility placed the resident on one-to-one supervision, but increase monitoring was provided on the first few days of the resident's admission. The Administrator stated staff were to provide diversional activities to the resident that were person centered adding the resident loved to dance, complete housework, and loved to preach. The Administrator stated he did not know if any of those interventions were offered to the resident the night of the elopement. Further, he stated the resident was care planned for diversional activities.The facility alleges removal of the Immediate Jeopardy as of 09/16/2025 and a copy of their removal plan is provided below verbatim:Date 10/24/25Regional Program ManagerCabinet for Health and Family Services 908 W. BroadwayLouisville, Kentucky 40203Re: [NAME] Crossing, LLCLetter of Notification of Removal of Immediate JeopardyAs required by state and federal law, please accept the following as [NAME] Crossing credible allegation of removal oflmmediate Jeopardy effective 9/17/2025. The facility submits this Allegation as it is required by Federal and State law. Submission of this Credible Allegation does not constitute an admission or agreement with the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The Facility reserves all rights to contest, appeal and dispute the IJ and the alleged facts and conclusions on which it is based. The following plan of action outlines immediate interventions employed by the Facility to abate immediate jeopardy.F656 Comprehensive Resident Centered Care Plan1. Actions Taken for Resident Affected/Immediate Intervention.Resident 1 's Care Plan was updated to include increased supervision by staff, q15 minute checks were immediately implemented, psychosocial visit/assessment 1 time per day for 3 days. Pain evaluation completed, no negative findings. Medication and Laboratory reviews conducted.Resident 1 was the only resident affected, at this time.Elopement drills conducted by Maintenance director on 9/16/2025 1 per shift (2 shifts) to ensure staff comprehension on elopement drill process. Staff acknowledged understanding via verbal validation.100% elopement evaluations on all facility residents by licensed nursing staff on 9/15/2025 completed on 9/16/2025.100% Elopement Care Plans by facility MOS Coordinator and Director of Nursing Services reviewed 9/15/2025 completed on 9/16/2025.100% staff education, including contract staff, on Elopement policy and procedure completed by Executive Director, Director of Nursing Services, and appropriate Department Heads on 9/15/2025 and 9/16/2025. Staff acknowledged understanding via verbal vaiidation.Staff education to Social Services staff and MDS Coordinator related to updating resident care plans and the implementation of interventions was completed by the Executive Director on 9/16/2025. Staff acknowledged understanding via verbal validation.2. Identification of Residents with Potential to be Affected/Immediate InterventionAll Residents' care plans were reviewed to ensure those at risk are reflected on the comprehensive care plan and Kardex by Executive Director/MOS/Regional [NAME] President of Clinical Services on 9/15/2025-9/16/2025. All care plans reviewed by Executive Director/MOS/Director of Nursing Services who trigger for 'at-risk' and 'high-risk' will have an elopement care plan.Revisions were made by MDS Coordinator to include residents at risk for elopement in residents' care plans. This task was completed by MDS Coordinator/Director of Nursing Services by 9/16/2025.Elopement Policy was reviewed by IDT to include individualized interventions for those residents at risk for elopement on 9/16/2025. IDT members include Executive Director, Director of Nursing Services, MDS Coordinator, Director of Rehab, Activity Director, Dietary Manager, and Clinical Managers.The DNS/ED will audit new admissions weekly X3/Months to ensure Elopement Risk and Interventions are in place and Care Plan and Kardex Updated accordingly. This was completed by DNS/ED on 9/16/2025.Education provided to nursing staff on updating Care Plans, Elopement Evaluation and Kardex as needed. This task was completed by DNS/ED by 9/16/2025. Nursing staff education to be continued by DNS/ED/Unit Manager/Staff Development Coordinator until complete with no new nursing staff working that is not educated after 9/16/2025. Nursing staff will not be able to work at the facility until educated, to include any new hires and contract staff. Staff acknowledged understanding via verbal validation.Elopement risk assessments completed by Director of Nursing Services/MOS Coordinator/Therapy Director on all residents. This task was completed by 9/16/2025.3. Systemic Measures/TrainingMOS/Social Services educated by 9/16/2025 regarding elopemei1t evaluation and implementing interventions based on evaluation findings; with individualized interventions related to supervision and observation, how to complete the elopement evaluations, importance of following care plan and Kardex and necessity of staff to be available and respond to aianns. Staff acknowledged and understanding via verbal validation.The DNS/StaffDevelopment Coordinator/Unit Managers educated 100% of staff by 9/16/2025 regarding the necessity to revise the care plan following the identification of at-risk residents per the elopement evaluation; with individualized interventions related to supervision and observation, how to complete the elopement evaluations, importance of following care plan and Kardex. Staff education to be continued by DNS/Staff Development Coordinator/Unit Managers until complete with no staff working that is not educated after 9/16/2025. Nursing staff will not be able to work at the facility until educated, to include any new hires and contract staff. Staff acknowledged understanding via verbal validation.The MOS Coordinator will review all baseline care plans and comprehensive care plans to ensure revision of the care plans following the identification of at-risk residents per the elopement evaluations; with individualized interventions related to supervision and observation. This task was completed by MOS by 9/16/2025.4. Quality Assurance Measures/MonitoringThe MOS Coordinator will review all Comprehensive Care Plans to ensure revision of the care plans following the identification of at-risk residents per the elopement evaluations; with individualized interventions related to supervision and observation. This task was completed by MOS on 9/16/2025.The DNS/ED will audit new admissions weekly X3/Months to ensure elopement risk and appropriate interventions are in place and care plan and Kardex updated accordingly. This was completed by Director of Nursing Services/ED by 9/16/2025.An Ad-Hoc QAPI meeting was held with the Executive Director, Medical Director, Director of Nursing Services, Social Services, MOS, Dietary Manager, HR Director, Maintenance Director Unit Managers to review the plan and findings. This action was completed by the Executive Director on 9/16/2025.Care Plan and Elopement Assessment audits will be forwarded to the Executive Director for review by the QAPI Committee (Executive Director, Medical Director, Director of Nursing Services, Maintenance Director, Food Service Director, and Business Office Manager). Monthly at a minimum of three months to ensure ongoing compliance.QAPI Meetings will be held Monthly. This will be completed by the Executive Director beginning on 9/16/2025.All monitoring will be audited and reviewed by the Executive Director and/or the Director of Nursing Services until ongoing compliance is achieved and maintained. Any deficient practices discovered during the monitoring process will be corrected immediately and referred to the QAPI Committee for further review and appropriate interventions.

Based on observation, interviews, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision for 1 out of 9 sampled residents. Resident (R)1.On 07/08/2025, the facility admitted R1 and assessed the resident to require the need to reside on its memory care [secure] unit with supervision provided while on the unit. According to the facility's policy and R1's care plan, this was for the safety of the resident. However, on 09/15/2025 the resident left the facility unsupervised. The resident was found at the park, approximately .4 miles away from the facility, by concerned citizens who called 911 to alert the police of the missing resident. When the [NAME] Officer questioned staff about the resident, staff stated they were unaware the resident had left the facility. Immediate Jeopardy (IJ) was identified on 10/24/2025 and was determined to exist on 09/15/2025, in 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 10/24/2025 at 2:14 PM.On 10/24/2025 at 2:14 PM, the facility's Executive Director and interim Director of Nursing (DON) were provided a copy of the IJ Template and was notified that the facility's failure to ensure the resident's supervision and safety was likely to cause serious injury, impairment, or death.The facility provided an acceptable IJ Removal Plan, on 10/28/2025 at 12:46 PM, alleging the removal of the IJ on 09/17/2025, prior to the State Survey Agency (SSA) initial entrance to the facility on [DATE]. The SSA validated removal of the IJ and determined the IJ to be past. The findings include:Review of the facility's policy, Elopements and Wandering Residents, reviewed/revised on 02/13/2024, revealed residents who were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk. Additionally, the facility was equipped with door locks/alarms to help avoid elopements. Continued review of the policy revealed alarms were not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. Further policy review revealed, the facility was to establish and utilize a systematic approach for monitoring and managing residents at risk for elopement. The systematic approach was to include identification and assessment of risk.implementing interventions to reduce hazards and risks and monitoring the effectiveness and modifying interventions when necessary. The policy further revealed the interventions to increase staff awareness of the resident's risk would be added to the resident's care plan and communicated to the appropriate staff.Review of the clinical record for R1 revealed the facility admitted the resident on 07/08/2025 with diagnoses of dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder. Further review of R1's discharge summary from the hospital revealed the resident required a secured unit, a locked unit, based on the resident's cognitive deficits, dementia, impaired safety decisions and poor safety awareness. Review of the facility's Elopement/Wandering Risk Evaluation, dated 07/08/2025 at 4:36 PM, revealed the facility assessed R1 to have a score of three, indicating R1 was a moderate risk for elopement. Review of the admission Minimum Data Set (MDS) revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of five, indicating R1 had severe cognitive impairment.Review of R1's Comprehensive Care Plan, dated initiated on 07/09/2025 and revised on 07/24/2025, revealed the goal of the resident's care plan was for the resident to maintain safety while residing on the secure unit. Further review revealed interventions included that Activities of interest would be provided to the resident and provide redirection as needed. Continued review revealed residents would be supervised while on the secured unit. Review of R1's Progress Notes, dated 09/12/2025, revealed the resident had behavioral issues .and constantly stated she wanted to go home. Continued review of the Progress Note dated 09/14/2025, revealed the resident yelled out for God to get her out .and constantly expressed a desire to go home. Review of R1's progress note dated 09/15/2025 at 8:50 PM revealed staff responded immediately to [an] alarm sounding on the female memory care unit. Review of the website www.underground.com revealed on 09/15/2025 the temperature at 8:56 PM was 82 degrees Fahrenheit. In an interview with the Sheriff Officer on 10/22/2025 at 12:05 PM, he stated he received a call from concerned citizens in the park around 8:33 PM and the call was dispatched around 8:35 PM. He stated the citizens reported they found a lady [R1] sitting on a park bench, stating she had been held captive for years and she ran way. Per the interview, the sheriff officer stated he did not know which facility the resident resided, so he started with the closest facility in proximity to the park. He stated he walked into the facility, told staff the resident's name, and asked if she was missing. He stated the staff reported, no, and informed the sheriff officer that the resident was in her room. The sheriff officer stated that when the staff went to R1's room, they noticed the resident was missing. He stated he communicated to the staff that the resident was found in the local park. He stated a nurse [LPN2] went with him to the park and convinced R1 to return to the facility with her. Further, he stated the resident did not want to return to the facility. The officer stated he was uncertain how long R1 was in the park before the 911 call came into dispatch. In continued interview, on 10/22/2025 at 12:05 PM, the Sheriff Officer stated R1 was appropriately dressed. He stated he believed R1 was able to exit the property by somehow figuring out how to unlock the gate connected to the privacy fencing. The sheriff officer stated that when he responded to the facility, no staff member reported to him that they were looking for or missing a resident.Observation on 10/21/2025 at 10:30 am of the secured memory care unit revealed R1's room was directly kitty cornered to the facility's exit door. Continued observation revealed the exit door opened only when the code was entered into its keypad. Outside the exit door was a tall wooden fence that surrounded the courtyard. Further observations revealed the distance from the facility to the local park was approximately 0.4 miles. During an interview with R1, on 10/21/2025 at 10:30 AM, she stated on the night she went to the park she prayed for an intervention from God and both exit doors, located by her room, opened. R1 stated the wood (gate, connected to the fence surrounding the courtyard) was faulty and she was able to get through it. She stated she was running as fast as she could. R1 stated that when she arrived at the park, she sat down on a bench. She stated she told a couple who were at the park about her escape, and they called the police. She stated she should not have done that because the police showed up and brought her back to this [facility] place. R1 continued to state that she was very unhappy residing in the facility, adding, I don't belong here and if I am able to leave again, I will. In an interview with R1's State Guardian, on 10/22/2025 at 10:26 AM, she stated R1 was a new client to her and R1 wanted to return home to be near family. The State Guardian stated the resident was upset and did not like the circumstances that lead to her becoming a resident within the facility. In an interview with Certified Nurse Assistant (CNA)5 on 10/22/2025 at 1:57 PM, she stated she was assigned to work with the resident, on 09/15/2025, the night the resident went missing. She stated there were two CNAs, which included herself, and one nurse who worked the unit with a total of 16 residents. Per the interview, CNA5 stated she was putting her residents to bed and had put R1 to bed twice. She stated that when she heard the alarm go off, she, along with CNA5, and LPN2 ran back to the exit door leading to the courtyard. She stated she saw a lady [a resident] in her wheelchair. She stated the resident in the wheelchair was moved out of the way. CNA5 stated they looked for any other residents that may have gone outside and did not see anyone. She stated LPN2 then turned the alarm off. Further, she stated she did not recall another alarm going off that evening. CNA5 stated the police came to the facility and asked if the resident had left the facility. Per the interview, CNA5 stated they were unaware the resident had left her room. CNA5 stated she had no idea how R1 was able to leave. She stated R1 must have gone through the exit door when the alarm went off.In a subsequent interview on 10/23/2025 at 3:06 PM with CNA5, she stated R1's behaviors included packing a suitcase and making statements of wanting to leave the facility. Per the interview, she stated that earlier that week, there was an issue with R1 pushing on the exit doors. She stated staff kept R1 up front to keep R1 from pushing on the doors. CNA5 stated that earlier that day, on 09/15/2025, the resident was antsy and wanted to get out. She stated the resident stated, I want to get out. Further, she stated she could not recall what R1 was wearing when she eloped. She stated R1 typically wore her clothes to bed, as this was her preference. CNA5 stated she had given R1 a shower at around 8:30 PM and placed a robe on her and assisted the resident to bed. She stated that after she placed the resident in her bed, the resident got up and went to the dining room and laid on the floor. CNA5 stated she got the resident up off the floor and escorted R1 back to her room. She stated that was the last time she saw the resident as she had to give showers to two other residents.In an interview with CNA3 on 10/21/2025 at 6:50 PM, she stated on the night of 09/15/2025 she was assigned the rooms of the women's memory care [secure] unit. However, CNA3 stated R1 was not assigned to her. Per the interview, she stated she was giving a shower to a resident when the alarm went off. The CNA stated she stopped what she was doing and went to the exit door. She stated she saw R1 standing at the exit door and she moved R1 to the dining room. CNA3 stated she did not know the code to stop the alarm, so she went and got LPN2 to assist with turning the alarm off. The CNA stated that during that time, the door did not lock right away. CNA3 stated she went back to providing a shower to a resident. She stated that after she had completed her task, she noticed the unit was quiet adding that R1 could be loud. She stated it was around 8:00 PM when the police showed up and the nurse (LPN2) was in the middle of administering the residents their medications. Further, CNA3 stated no one was actively looking for R1 that night.In an interview with Certified Nursing Assistant (CNA)1 on 10/21/2025 at 1:26 PM, she revealed she had not worked the night of the incident but was familiar with R1 as she had worked with her on the memory care unit. According to CNA1, R1 could read, and the door had a sign that stated to push [the door had a push bar] until the alarm sounded and the door would be opened in 15 seconds. Per the interview, CNA1 stated that was how the resident got out. CNA1 revealed the resident used to push on the door all the time and always looked at the door to see if someone would go out of it. Further, the CNA stated the resident continued to make statements of wanting to go home.In an interview with Licensed Practical Nurse (LPN)1 on 10/22/2025 at 9:37 AM, she stated on 09/15/2025 she worked late on day shift and was finishing charting when she observed an officer at the door. She stated he asked her if the facility knew R1. LPN1 stated she showed him a picture of R1 from her computer and the officer confirmed that it was R1. Further, she stated the officer told LPN1 that R1 was at the park. She stated she went with the officer in his car to the park. She said that when they arrived at the park, the resident stated she did not want to return to the facility. She stated R1 replied, she wanted her freedom. Per the interview, LPN1 stated R1 told bystanders she was being held captive. In an interview with LPN2 on 10/22/2025 at 2:17 PM, he stated he was working on the night of 09/15/2025 on the secure memory care unit. He stated he was in the middle of rounding, on the men's memory care unit, when he heard the alarm go off on the women's side. He stated he responded to the alarm and checked the courtyard. He stated the courtyard was empty. LPN2 stated he stepped outside and did not see anyone. He stated he started to check the resident's rooms, as per policy. Further, he stated that when the police arrived at the facility, he was doing the bed checks of residents. He stated the [NAME] officer came and asked if he knew R1 and that was when he knew the resident was out of the facility. LPN2 stated the resident was not gone long, probably about five or ten minutes. LPN2 stated the alarm went off only one time that night. LPN2 stated he did not report a missing resident to the sheriff officer. He stated that when the alarm went off, he had to leave the men's secure unit to report to the women's secure unit, which was one unit over, separated by a door with a keypad entrance. LPN2 stated he was working with two CNAs that night. The CNAs were in the middle of doing things with other residents when I was coming over from the men's side. LPN2 stated R1 was able to leave the facility by pushing open the gate from the courtyard.In interview on 10/21/2025 at 10:25 AM with the Maintenance Director, he stated the courtyard gate through which R1 used to exit the courtyard, after exiting the facility was decrepit. He stated R1 was able to push through the gate's wood boards and then place the boards back on the gate. Further, the Maintenance Director stated R1 placed empty plant pots against the gate on the opposite side to secure the gate, which was why the nurse [LPN2] thought it was secured when checked. He stated the gate was replaced the next morning by in-house staff using materials purchased locally. Further, he stated a magnetic lock with a keypad was also installed by a Contractor.In a follow-up interview with the Maintenance Director, on 10/23/2025 at 9:09 AM, he stated he did not fix or replace the gate prior to R1's elopement because it was still securing the lock, however, admitted ly he stated the actual wood boards to the gate were beginning to deteriorate. Per the interview with the Maintenance Director, he stated he did not realize this was a concern until the resident eloped from the facility. He stated that when R1 pushed through the gate, he knew it was time to fix it. In an interview with Social Services on 10/21/2025 at 11:46 AM, he stated when R1 initially arrived [to the facility] the resident was disoriented from the long ride to the facility in the ambulance and it took three weeks to develop a routine. Since then, Social Services stated R1 has improved with participation in activities. He stated the resident becomes agitated at times due to not being able to see her parents, who have passed away. Social Services stated that on the day of the resident's elopement, R1 stated to staff that she needed to get to her mother because she was dying. Social Services stated that on this day, R1 was not redirectable. Per the interview, Social Services stated a referral was made to the Nurse Practitioner (NP) related to the resident's increased agitation.In an interview with the Nurse Practitioner (NP) on 10/22/2025 at 12:28 PM, she stated that since the resident's arrival to the facility, she has made comments of not wanting to reside at the facility. She stated R1 often packs her suitcase frequently. She stated that if given the opportunity, R1 would try to leave again. The NP stated the resident would always be someone who would exit seek.In an interview on 10/23/2025 at 3:54 PM with the Director of Nursing (DON), she stated she received a call from LPN2, on 0915/2025 around 9:15 PM to 9:30 PM, to alert her of R1's elopement. She stated LPN2 started a head count of all the residents at that time and she came to the facility to assess the resident to ensure the resident was safe and not harmed from being away from the facility. In an interview on 10/23/2025 at 10:35 AM with the Administrator, he stated on R1's admission hospital records, it indicated she was an elopement risk. Per the interview, he stated the only room available on the unit was the one catty-cornered to the exit door. Per the interview, the Administrator stated that there was a sense of urgency to admit R1, based upon her family history, adding, it was not safe for her to return home. He stated the resident was placed on a secure unit, and it should not have mattered where the resident was placed. Further, he stated the resident was placed on the secure unit for her safety. In further interview, with the Administrator, on10/23/2025 at 10:35 AM, he stated he did not recall a time the facility placed the resident on one-to-one [1:1] supervision, but increase monitoring was provided on the first few days of the resident's admission. In continued interview with the Administrator, he stated staff were to provide diversional activities to the resident that were person centered adding, the resident loved to dance, complete housework, and loved to preach. The Administrator stated he did not know if any of those interventions were offered to the resident the night of the elopement, but staff should have implemented those interventions. Interviews, however, with CNA3 on 10/21/2025 at 6:50 PM; CNA5 on 10/22/2025 at 1:57 PM; and LPN2 on 10/22/2025 at 2:17 PM, revealed they were all with other residents providing care at the time of R1's elopement and thus could not provide supervision while on the secure unit nor diversional activity, as per the facility's policy and R1's plan of care. The facility's removal plan, alleging jeopardy removal on 09/16/2025 is copied below verbatim:Date 10/24/2025Regional Program Manager 908 [NAME] Broadway116 Commerce AvenueLouisville, Kentucky 40203Re: [NAME] Crossing, LLCLetter of Notification of Removal of Immediate JeopardyAs required by state and federal law, please accept the following as [NAME] Crossing credible allegation of removal oflmmediate Jeopardy effective 10/24/2025. The facility submits this Allegation as it is required by Federal and State law. Submission of this Credible Allegation does not constitute an admission or agreement with the facts alleged or the conclusions set forth in the verbal and written noticeof immediate jeopardy and/or any subsequent Statement of Deficiencies. The Facility reserves all rights to contest, appeal and dispute the IJ and the alleged facts and conclusions on which it is based. The following plan of action outlines immediate interventions employed by the Facility to abate immediate jeopardy.F689 Quality of Care: Accident & Incidents1. Actions Taken for Resident Affected/Immediate Intervention.Resident 1 was the only resident affected, at this time.Elopement drill conducted by Maintenance director on 9/16/2025 l per shift (3 shifts) to ensure staff comprehension on elopement drill process.100% audit of door and lock evaluations conducted, no negative findings conducted on 9/15/2025 100% elopement evaluations 9/15/2025 completed on 9/16/2025100% staff education, including contract staff, on Elopement policy and procedure and appropriate Resident supervision completed by Executive Director, Director of Nursing Services, and appropriate Department Heads on 9/15/2025 and 9/16/2025.The Executive Director and Director of Nursing Services initiated an investigation of the incident on 9/15/2025. The investigation included interviews with the following staff: [NAME], LPB, [NAME], LPN, CNAs [NAME], [NAME], and [NAME]. All of whom were on-shift at the time of the incident. Further, the investigation included a root cause analysis which detennined that the Resident admitted to the facility in an emergency situation due to APS initiating an investigation into the Resident's son related to abuse and neglect. A review of the Resident's admission revealed a likelihood of wandering or exit seeking. The Resident was admitted with noted cognitive impainnent and a BIMS of 8. Interventions were implemented at the time of admission, i.e., increased supervision, diversional activities, etal. During the course of the investigation, it was detennined that the Resident exited the facility through an alanned door leading to a gad courtyard. Facility staff responded to the alarm and initiated the facility's Elopement Policy. The investigation also revealed that the gate in the courtyard was defective. Facility staff and a licensed contractor repaired the gate on 9/16/2025. All doors, locks, and gates throughout the facility were inspected to ensure proper functioning.At the time of the incident on 9/15/2025, additional interventions were added to the Resident's care plan: increased supervision, q15 minute checks x 72 hours, and a review of medication and labs. Increased supervision includes adjusting the exit door on the Memory Care Unit to prevent delayed egress.It is also noted that a review of the Resident's activity log for the day of the incident and the two days prior reveal that the Resident participated in daily activities 15 times. The Resident participated in organized activities on the day of the incident 5 times, including Coffee Hour, Entertainment/Movie, Personal Care, Exercise Hour, Glam Nails, Bingo, and Social Hour Additional interventions in place during the time prior to the incident, included toileting, ambulation, water pass, meals, showers, and HS snacks, among others.Also part of the investigation included a review of staffing at the time of the incident. Staffing on the Women's Memory Care Unit included one LPN and two CNAs for a resident census of 16. The facility's scheduler, Director of Nursing, and the Executive Director review daily staffing to ensure sufficient staff is in place to ensure necessary supervision of Residents.2. Identification of Residents with Potential to be Affected/Immediate InterventionElopement Policy was reviewed by IDT to include individualized interventions for those residents at risk for elopement on 9/16/2025. IDT members include Executive Director, Director of Nursing Services, MDS Coordinator, Director of Rehab, Activity Director, Dietary Manager, and Clinical Managers.The DNS/ED will audit new admissions weekly X3/Months to ensure Elopement Risk and Interventions are in place accordingly. This was completed by DNS/ED on 9/16/2025.Elopement risk assessments completed by Director of Nursing Services/MDS Coordinator/Therapy Director on all residents. This task was completed by 9/16/2025.3. Systemic Measures/TrainingMDS/Social Services educated by 9/16/2025 regarding elopement evaluation and implementing interventions based on evaluation findings; with individualized interventions related to supervision and observation, how to complete the elopement evaluations, and necessity of staff to be available and respond to alanns.4. Quality Assurance Measures/MonitoringThe DNS/ED will audit new admissions weekly X3/Months to ensure elopement risk and appropriate interventions are in place. This was completed by Director of Nursing Services/ED by 9/16/2025.An Ad-Hoc QAPI meeting was held with the Executive Director, Medical Director, Director of Nursing Services, Social Services, MDS, Dietary Manager, HR Director, Maintenance Director Unit Managers to review the plan and findings. This action was completed by the Executive Director on 9/16/2025.Elopement Assessment audits will be forwarded to the Executive Director for review by the QAPI Committee (Executive Director, Medical Director, Director of Nursing Services, Maintenance Director, Food Service Director, and Business Office Manager). Monthly at a minimum of three months to ensure ongoing compliance.QAPI Meetings will be held Monthly. This will be completed by the Executive Director beginning on 9/16/2025. Any deficient practices identified by monitoring will be corrected immediately and reported to and reviewed by the QAPI Committee for fmiher action until ongoing compliance is achieved.Elopement drills completed by facility maintenance director/maintenance assistant each shift xl day and monthly ongoing, completed by 9/16/2025.

Based on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, it was determined the facility failed to store and serve food in a safe manner which had the potential to affect 126 residents who received food from the kitchen.The findings include:Review of the USDA web site https://www.fsis.usda.gov, undated, revealed when checking food temperatures, a food thermometer was to be placed in the thickest part of the food, away from bone, fat or gristle. Continued review revealed for thin foods, the food thermometer was to be inserted through the side until it reached the center of the food. Further review revealed always check each piece of food to ensure it reached the safe internal temperature.Observation of the [NAME] on 07/22/2025 at 11:25 AM, during the lunch meal tray line, revealed the [NAME] pushed the food thermometers through the plastic wrap of the creamed corn, pureed enchilada casserole and kernel corn on the steam table.In interview with the Interim Dietary Manager on 07/24/2025 at 10:05 AM, she stated staff were not to pierce food with the thermometer through the plastic wrap or foil, as there was a potential for cross contamination. She said doing that could also cause a choking hazard. In interview with the [NAME] on 07/24/2025 at 10:20 AM, he stated the proper way to take the food temperature was by pulling back the plastic or foil covering the food. The [NAME] stated taking food temperatures that way would prevent the potential for cross contamination of the food.In interview with the Director of Nursing (DON) on 07/25/2025 at 1:09 PM, she stated her expectation was for staff to follow best practices for food service. She further stated, Plastic wrap or saran wrap over food, if you punch it, could be a potential aspiration risk or choking hazard. The DON further stated staff were to ensure the thermometer is clean and dry and inspected prior to use. In interview with the Administrator on 07/25/2025 at 3:18 PM, he stated his expectation was for staff to follow best practices for food service. He reported, When it comes to temping food in the kitchen, if there is a barrier like plastic wrap over the food, first of all, food should be uncovered and temped correctly. The Administrator further stated, I hope that wouldn't happen. In the event that should occur, I would hope staff would remove plastic wrap, if contamination, food should be replaced. I could foresee outcomes like choking or aspiration if served.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision for two of 12 sampled residents, Residents (R) 400 and R401. On 01/21/2025, the facility admitted R401 and assessed the resident as at risk for elopement; however, failed to address that risk in the baseline care plan. Therefore, on 01/24/2025 at approximately 10:30 PM, R401 left the facility without facility knowledge (which could be considered an elopement) and was not located until the next morning (of 01/25/2025) at a local hospital. Additionally, the facility failed to assess R400 for smoking safety and falls in its initial assessment of the resident upon admission. Immediate Jeopardy (IJ) was identified on 02/12/2025 and was determined to exist on 01/21/2025, in the area of 42 CFR S483.25 Accidents, F689 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 02/12/2025 at 4:23 PM. On 02/12/2025 at 4:23 PM, the facility's Executive Director, Regional [NAME] President of Clinical (RVPC), and Regional [NAME] President (RVP) were provided a copy of the IJ Template and notified that the facility's failure to ensure the resident's safety is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 02/13/2025 at 2:47 PM, alleging removal of the IJ on 02/13/2025. The State Survey Agency (SSA) validated the IJ had been removed on 02/13/2025, as alleged, after an acceptable IJ Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D at F689. Refer to F655 The findings include: 1. Review of the facility's policy, Elopements and Wandering Residents, reviewed/revised 03/06/2024, revealed the facility ensured residents at risk for elopement received adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing unique factors contributing to elopement risk. Per review, elopement occurred when a resident left the premises or safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do that. Continued review revealed the facility was to establish and utilize a systematic approach for monitoring and managing residents at risk for elopement. The systematic approach was to include identification and assessment of risk .implementing interventions to reduce hazards and risks, and monitoring the effectiveness and modifying interventions when necessary. Further review of the facility's policy, Elopements and Wandering Residents, reviewed/revised 03/06/2024, revealed residents were to be assessed for risk of elopement upon admission by the interdisciplinary team (IDT). The policy review revealed the IDT was to evaluate unique factors contributing to the risk and to develop a person-centered care plan, with adequate supervision provided to help prevent elopements. In addition, charge nurses and unit managers were to monitor implementation of interventions, response to interventions, and document accordingly. Review further revealed if a resident was not located in the building or on the grounds, the Administrator or designee were to notify the police department, along with appropriate reporting to the State Survey Agency (SSA). Per the policy, documentation in the medical record was to include physician/family notification, care plan discussion, and consultant notes as applicable. Review of the facility's policy, Baseline Care Plan, reviewed/ revised 12/23/2023, revealed the facility was to develop and implement a baseline care plan (CP) for each resident. Per review, the baseline care plan was to include interventions to address the resident's current needs, including any safety concerns to prevent injury, such as elopement, and any identified needs for supervision. Review of the clinical record for R401 revealed the facility admitted the resident on 01/21/2025 with diagnoses of aphasia following cerebral infarction, epilepsy, hemiplegia and hemiparesis following cerebral infarction, and congestive heart failure (CHF). Review of the facility's, Wandering/ Elopement Risk Evaluation dated 01/21/2025 at 11:46 PM, revealed R401 was At Risk for Elopement. Review of R401's Progress Notes dated 01/21/2025, revealed R401 was noted as alert and oriented times one (x1). Review of the Care Plan (CP) dated 01/22/2025, for R401 revealed the facility identified the resident to require assistance with Activities of Daily Living (ADLs) related to impaired decision making and impaired cognition. Continued review of the CP revealed the facility also identified on 01/22/2025, the resident as a risk for falls, related to diminished safety awareness, cognitive impairment and wandering. However, further review of R401's CP revealed no documented evidence the facility addressed the resident's assessed risk for elopement. Review of the Speech Therapy SLP Evaluation and Plan of Treatment dated 01/22/2025, revealed R401's short term goals included to increase orientation to person, place, time, purpose, and caregivers. Per review, R401's previous level of functioning (PLOF) was 100%, and the baseline (on 01/22/2025) was 25%. Review revealed R401 had a diagnosis of stroke and increased confusion and cognitive decline. Continued review revealed the reasons R401 was referred to Speech Therapy (ST) included confusion and decreased cognition. Review revealed the resident's BIMS was noted as 12 out of 15, and the St. Louis University of Mental Status (SLUMS) score was noted as 6 out of 30, indicating severe cognitive impairment. Further review revealed R401 demonstrated severe cognitive deficits for short term memory, delayed recall, orientation, problem solving, and safety awareness. Review of the Speech Therapy Treatment Encounter Note dated 01/24/2025 at 12:48 PM, revealed R401 answered orientation questions with 25% accuracy with moderate visual cues. Continued review revealed the resident recalled information from a read story with 20% accuracy with moderate cues, and answered problem solving questions with 30% accuracy with moderate cues. Review of the undated facility, Timeline of Events Starting 8:30 PM 01/24/2025, revealed R401 had been observed at 8:30 PM, during the scheduled smoking session. Review of the Timeline revealed at 9:00 PM, staff observed R401 wearing a shirt, sweatshirt, jacket, pants, and shoes, and telling staff he was going out for cigarettes and waving his debit card to show he was going to buy smoking supplies. (However, the facility investigation summary noted R401 left the facility at approximately 8:45 PM.) Per review, at 10:00 PM the Unit Manager, was notified upon her arrival to the facility, R401 had not returned from getting smoking materials. Per review, the facility was immediately searched and a head count completed. Continued review revealed on 01/25/2025 at 12:25 AM, the Administrator was notified R401 had not returned from shopping and the DNS notified at 12:32 AM. Review revealed at 2:00 AM, the ED, DNS, Maintenance Director, and Staff Development Coordinator (SDC) arrived at the facility to assist in locating R401. Continued review of the undated facility, Timeline of Events Starting 8:30 PM 01/24/2025, revealed at 3:00 AM, the Maintenance Director audited 100% of the facility doors, door alarms, and windows to ensure proper functioning, and the door codes were changed. In addition, review revealed at 6:30 AM, the local hospital called the facility to notify them R401 was under their care and supervision. Further review revealed the EMS record noted R401 called 911 while out shopping and had been picked up by EMS at 2:00 AM. Review of the website www.wunderground.com temperature for the city R401 was picked up in by EMS on 01/25/2025 at 1:56 AM, revealed the temperature was 26 degrees Fahrenheit. Review of the local Emergency Medical Services (EMS) [Resident] Patient Care Record for R401 dated 01/25/2025, revealed EMS received a call on 01/25/2025 at 2:03 AM, for seizures. Per review, at 2:21 AM, EMS arrived to R401's location, an intersection approximately 7.79 straight line miles from the facility. Continued review revealed EMS personnel noted R401 had altered mental status and the primary impression was stroke. Further review revealed EMS transported R401 to the local hospital, approximately two to three blocks away. Review of the EMS record additionally revealed R401 told EMS, he had been discharged from a hospital, and described an area that did not have a hospital located there. The EMS Record further revealed R401 did not know what the year was. Review of the hospital's, ED Physician Notes Final Report for R401 dated 01/25/2025 at 11:14 AM, revealed the ED Physician Note documented R401 arrived at the hospital for upper extremity weakness, and had been previously seen for a stroke. Further review of the ED Physician Note revealed it documented stroke as most likely chronic, with a discharge diagnosis of History of Ischemic Stroke. In interview on 02/07/2025 at 1:47 PM, R401 stated he had not been to the hospital since being admitted to the facility. (He did not recall the incident on 01/24/2025). R401 stated he slipped on the ice before he was admitted to the hospital and that was why his left arm did not move. (However, he was admitted to the facility on [DATE], with a diagnosis of a stroke with hemiplegia and hemaparesis). R401 reported he was able to leave the facility whenever he liked and had done so about a week ago. He stated he went out with family once and left a second time by himself. In interview on 02/07/2025 at 2:34 PM, R401's family member (F)10 stated the resident got out of the facility one weekend and got lost. She stated he almost froze to death and ended up at a local hospital. F10 said she did not know how R401 got out of the facility, and he had not had a coat on at the time. She stated R401 got disoriented and she thought he had fallen in a ditch and someone called EMS for him. F10 reported the facility had called her, but she had her phone ringer turned down, but finally answered her phone at 4:00 AM. She further stated the facility asked her if R401 was with her and asked where he could be. F10 reported R401 ended up in the emergency room ; however, he did not remember what happened. In interview on 02/08/2025 at 8:17 AM, Licensed Practical Nurse (LPN) 7 stated he was told in report from the third shift nurse, R401 left the facility between 9:00 PM and 10:00 PM (on 01/24/2025). The LPN stated he did not receive in report what R401 went to the hospital for; however was told the resident eloped from the facility. Per LPN 7 in interview, when R401 returned from the hospital, the resident told him (the nurse) he went out the double door up the ramp (toward the front lobby) and went to a gas station or store. The LPN said R401 told him someone called 911 and the ambulance took him to the hospital. He reported R401 was placed on one to one (1:1) supervision upon return to the facility, although it was stopped prior to the next shift he (LPN) was back to work. The nurse further stated R401 had some cognitive impairment due to the stroke he suffered before he was admitted to the facility. In interview on 02/09/2025 at 1:42 PM, Certified Nurse Aide (CNA) 27 revealed she knew R401 went out once and returned from the hospital. She stated she did not think R401 was able to go out on his own, both physically and mentally. CNA 27 stated she had not received in report any information saying the resident could not go out on his own. In interview on 02/09/2025 at 1:57 PM, LPN 6 stated R401 was very impaired (cognitively). The LPN stated she could talk to the resident and thought he was cognitive (intact); however, as time went by she would begin to notice a change in his conversation. She said R401 would begin saying things that made no sense. She stated R401 was not able to come and go as he pleased. Observation of facility's exit doors on 02/09/2025 at 3:30 PM, revealed the exit doors on A hall, B hall (to the facility parking lot at the end of the driveway), C hall, the double doors to go up the ramp (toward the front lobby area) all had keypads. In interview on 02/10/2025 at 1:51 PM, the East Unit Manager (UM) stated the nurse completed multiple assessments of the resident, which included the risk assessment. She stated the Interdisciplinary Team (IDT) went over the new admission the next day and ensured everything had been completed. The East UM said she would expect to see a detailed note documented in R401's chart of the completed notifications (after he eloped), if the doctor gave any orders, how the resident was acting, and any details that made the nurse come to the assumption the resident had stroke-like symptoms. She reported whether a resident could come and go as they pleased or needed supervision was determined by the resident's BIMS score. She stated R401 was not safe to go out by himself without supervision based on his low BIMS scores and cognition. She further stated he could get hit by a car or kidnapped. In interview with LPN 12 on 02/11/2025 at 2:20 PM, she stated she did not know how R401 got out of the facility. LPN 12 said (on 01/24/2025) she had given R401 his medications at 8:30 PM, and she finished that hallway around 9:32 PM. She stated when she came back up the hallway around 10:30 PM, staff said they could not find R401. The nurse stated they looked everywhere for R401 and nobody had seen the resident. LPN 12 said we called the nurse that left late that night to see if R401 walked out behind her. The next morning, she stated she received a call from a local hospital saying R401 was in the emergency room (ER) for a stroke, and she informed the hospital the resident had walked away from the facility. LPN 12 said the facility tried to call R401's family member when they realized he was not there and tried several times with no answer. The nurse said from the time she got to work that night, R401 was asking about buying cigarettes. She reported she did not think any of the residents had gone out to smoke after 8:00 PM that night, due to the temperature being too cold. LPN 12 said she did not see the police the night R401 went missing. She stated she did not know where R401 had been located before he went to the hospital (after his elopement). In interview on 02/11/2025 at 3:08 PM, CNA 28 stated she was at the facility when R401 was admitted and he had been overly anxious and confused as it was a new place. She said he was there for a couple of days with no idea of the facility he was in. CNA 28 said R401 had been asking about leaving when she cared for him the first night and talked about his family member living in an apartment next door and about getting cigarettes. The CNA stated she had been working the night when R401 left the facility and she last saw him by the nurse's station. She reported the last time any staff saw R401 (on 01/24/2025) was around 11:30ish PM or 11:45 PM. CNA 28 said R401 went missing between that time and 1:00 AM, when he was discovered missing. Per the CNA in interview, we had no idea how long R401 had been missing. She stated when R401 returned, he said he left the facility behind someone as they exited out the door at the large parking lot end of the driveway. CNA 28 stated she was told R401 was a flight risk, but was also told by management that even though the resident scored at risk for elopement, he took care of his own affairs. She said the police were never called (when the resident went missing). In interview on 02/11/2025 at 3:49 PM, CNA 30 stated she worked the night R401 disappeared from the facility. She stated we did not know where he was. She stated before R401 went missing, she was not told he was at risk for elopement. The CNA said around 6:00 AM (the next morning) the nurse received a call from the local hospital saying the resident was there. CNA 30 reported she did not remember hearing a door alarm sound that night. In interview on 02/12/2025 at 9:53 AM, the Night Shift Manager stated her shift started at 10:00 PM the night R401 was missing, and she did not recall hearing any door alarms. She stated the CNAs reported to her when they were doing rounds around 11:30 PM, they had not seen R401. The Night Shift Manager said she checked the whole building, and then drove to apartment buildings nearby as the buildings had doors you could go into to get warm. She stated after they checked the building, she called the DNS and continued looking for R401. The Night Shift Manager said per hearsay, someone asked R401 how he left the building and he said he went out as a staff nurse left. She stated she did not know if the police were notified that night as that was the responsibility of the ED and DNS to determine. She reported R401's elopement risk assessment noted him as at risk; and he was considered at risk for elopement when he returned. The Night Shift Manager reported she was not asked to write a statement about that night. She further stated she had not heard how R401 ended up where he was when he was picked up or how he exited the facility. In interview on 02/12/2025 at 10:37 AM, the MDS Coordinator stated she and the other facility MDS Coordinator talked about if R401 was at risk for elopement when he first came to the facility. She stated however, she did not know R401 was assessed at risk by the admission nurse (on 01/21/2025). The MDS Coordinator stated she participated in the clinical meeting (the next morning after R401's admission) and did not recall if R401's risk for elopement was discussed. She reported she was called at 2:00 AM, (when R401 was missing) by the DNS and was told the resident had left the facility. The MDS Coordinator said when she got to the facility she called and spoke to R401's family member, who said she did not know where R401 was, and gave them some places to look. She stated she spoke to the nurse at the local hospital when the resident was located. The MDS Coordinator reported after R401 left the facility it was brought up in the clinical meeting; however, there was not a huge discussion about it. She further stated if a resident left the facility without staffs' knowledge the resident might not be safe. In interview on 02/12/2025 at 1:14 PM, the Staff Development Coordinator (SDC) stated she participated in the clinical meetings every morning. and there had been no discussion of R401's risk of leaving the facility when admitted . The SDC said however, the meeting did review R401's elopement risk assessment. She stated at risk meant the facility needed to keep an eye on him, pay special attention, and needed to have processes in place so the resident stayed in the facility for his safety. In interview on 02/12/2025 at 1:59 PM, the DNS stated when a resident triggered as at risk, the resident may or may not actually be an elopement risk, which varied from resident to resident, and was based on their diagnoses. The DNS said she could not remember what the facility policy said about that though. She stated she was first made aware R401 leaving the facility around midnight by the ED, and had been told the resident left to get cigarettes and had not returned. In continued interview on 02/12/2025 at 1:59 PM, the DNS stated she conducted the facility investigation which was a collaborative effort. She stated she asked R401 how he got out of the building and the resident told her a young fell ow let him out. The DNS said she did not know when R401 left the facility. She stated we verbally asked staff and no one saw him leave. The DNS reported however, she could not remember the names of the staff questioned and there were no written statements. She said she was not sure which door R401 went out. She stated if a resident was identified as at risk for elopement her expectation was for a care plan on elopement be implemented within 48 hours. The DNS reported she had not been able to determine who let the resident out the back door at the parking lot. She further stated R401 had last been seen by staff around 7:30 PM and 7:45 PM when he received his medicine. In interview on 02/12/2025 at 2:38 PM, the Interim Nurse Practitioner (NP) stated he supervised the former NP who reported to him no one at the facility notified her (the former NP) of R401 leaving the facility. He stated the former NP told him she had seen a sitter with R401 a couple of days later and when she asked why he had a sitter she was told he had gotten out. In interview on 02/12/2025 at 3:03 PM, the Administrator stated she had been notified by the Night Shift Manager, the night of 01/24/2025 or 01/25/2025, that R401 left the facility. She stated she called the DNS after being notified by the Night Shift Manager. The Administrator said the DNS, MDS Nurse, SDC, Maintenance Director, and herself, all came to the facility, where a thorough search for R401 was conducted. The Administrator stated facility staff called R401's family member who did not answer. She said the facility reached the family member at 4:00 AM, who said R401 was not with her, and gave staff ideas of where he could be. In continued interview on 02/12/2025 at 3:03 PM, the Administrator stated she had been informed by the DNS on 01/25/2025, the local hospital called to ask if the facility had a resident by the name of [R401]. The Administrator stated R401 also said he went out the back (of the facility) at the double doors (at the parking lot at the end of the driveway). Review of the facility's policy titled, Protocol: Smoking, date implemented and revised 11/01/2024, revealed the policy stated Smoking Safety Screens would be completed upon admission, re-admission, quarterly, annually, with a significant change, and as needed. Review of the facility's policy titled, Fall Prevention Program, date implemented and reviewed 02/01/2024, revealed that upon admission the nurse was to complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 2. Review of R400's EMR revealed the facility admitted the resident on 01/24/2025, with diagnoses of cerebral infarction with hemiplegia and hemiparesis, seizures, and diabetes type II. Review of R400's Admission Minimum Data Set (MDS) Assessment with an ARD of 01/30/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Further MDS review revealed the facility assessed the resident to require partial assistance for all transfers (bed to chair and bed to toilet). Continued review of R400's EMR revealed no documented evidence of a smoking assessment or fall risk assessment completed for R400 on her admission on 01/24/2025. Review of the CP for R400 revealed the facility developed a focus area for the resident liked to smoke, with a goal stating the resident would not suffer injury from unsafe smoking practices. Per review, the interventions included instructing R400 about smoking risks and hazards and about smoking cessation aids that were available. Continued CP review revealed the facility also developed a focus area for the resident as at risk for falls or falls related injuries related to decreased mobility and psychotropic medication use. Per review, the goal for the falls CP was for R400 to not sustain serious injury. Further review of the falls CP revealed interventions which included: making sure R400's call light was within reach and encourage the resident to use it to ask for assistance dated 01/25/2025. Additional review of the fall CP revealed other interventions included: R400 needed prompt response to all requests for assistance dated 02/04/2025; encourage use of non-skid footwear when out of bed dated 01/30/2025; encourage her to use the restroom in her own room dated 01/30/2025; and therapy to look at the need for footrests for R400's wheelchair dated 01/30/2024. Review of a Change in Condition Assessment in R400's EMR dated 01/29/2025, revealed on that date the resident sustained a fall. Per review, R400 was assessed and found to have no mental or physical changes. Continued review revealed the provider was notified, and ordered an x-ray for R400's left ankle. Further review revealed recommendations to prevent further falls were R400 needed to be supervised when transferring. Review of a Change in Condition assessment dated [DATE], revealed R400 sustained another fall. Per review, R400 was assessed and found to have no mental or physical changes. Continued review revealed the provider placed R400 on neurological (neuro) checks, with no new interventions put in place per the note. Continued review of R400's medical record revealed no fall risks had been completed prior to her fall on 01/29/2025. Per review, on 01/29/2025, a fall risk assessment was performed and the resident had scored a 16, which indicated a low risk of falling. Review of a second fall risk assessment was performed on 02/03/2025, and R400 scored 25, which indicated a moderate risk of falling. Review of the medical record revealed a Post Fall Assessment was performed and documented in R400's EMR on 02/03/2025. Review of the Post Fall Assessment revealed R400 had fallen while trying to transfer to the toilet. Further review revealed interventions were put in place for R400 to call for assistance when transferring and a consult was placed for both Physical Therapy (PT) and Occupational Therapy (OT) evaluations. Review of R400's Physician Orders in her EMR revealed an order for PT to consult and treat from 01/25/2025 through 02/21/2025. In addition, review of the Physician Orders revealed an order for OT to consult and treat R400 from 01/29/2025 through 02/26/2025. Observation on 02/04/2025 at 9:18 AM, of R400 revealed bruising observed to her right ankle. In interview, at the time of observation, R400 stated she had fallen. Observation on 02/10/2025 at 10:06 AM, revealed R400 was taken to the front lobby by a staff member and allowed to sign herself out to go unaccompanied outside to smoke. In additional interview with R400 on 02/04/2025 at 9:18 AM, she stated she had fallen while transferring to her wheelchair. R400 stated she was able to sign herself out and go off the facility property, and often did that and went outside to smoke. She reported the facility had been changing the rules on smoking since her admission. The resident said they were letting her go out by herself, but now told her she could only go out during resident smoke breaks. In interview on 02/06/2025 at 2:50 PM, CNA 2 stated R400 signed herself out and sat by the building doors at the end of Hall B to smoke. She said staff let her and her husband go in and out when they requested to do that. CNA 2 said she was not sure if R400 was assessed to be able to smoke unsupervised or not. She stated she was not sure who did residents' smoking assessments. The CNA said R400 had fallen trying to transfer to toilet twice. She reported the facility was trying to prevent further falls for R400 by educating her to press her call button and ask for assistance when going to the bathroom or when she was transferring from bed to wheelchair. CNA 2 further stated R400 had weakness on her right side due to a stroke and that was why she kept falling. In interview on 02/06/2025 at 3:16 PM, Registered Nurse (RN) 5 stated when R400 first came to the facility less than a month ago, staff let her go outside the doors at the end of hallway B to smoke, unsupervised. She said however, now R400 had been told she could no longer do that and needed to go out in the courtyard to smoke with the other residents during smoke breaks. RN 5 said smoking assessments were done quarterly in the EMR system, they pop up on the work list in the EMR when they need to be completed. She stated a smoking assessment should have been done on R400 upon her admission; however, she was unsure if one had been completed for her or not. The RN said R400 had experienced two falls since her admission to the facility, and both falls occurred during transfers to and from her wheelchair. She stated to prevent further falls for R400 they had educated the resident to use the call bell and ask for help with transferring to and from her wheelchair, bed, toilet, etc. RN 5 further stated they had instructed her not to transfer herself without assistance, and were also, keeping the resident's bed in a low position to help prevent falls when getting out of bed. In interview on 02/07/2025 at 8:58 AM, LPN 6 stated R400 was a smoker and when she first arrived at the facility, she was told she could go out into the parking lot and smoke. She said however, now R400 had to sign out and have someone with her when she went out to smoke. LPN 6 reported if R400 asked her to go outside to smoke unsupervised she would tell her she preferred she go out with the smoking group and have staff with her. She stated R400 should have had a smoking evaluation done upon admission and it could be found under the Evaluations tab in the EMR. The LPN said smoking evaluations were also done quarterly as part of the evaluations that came up to be done in the EMR. She reported R400 had weakness on the one side, and had trouble with her wheelchair fitting into the bathroom. LPN 6 stated R400's leg got tangled up in her wheelchair and she lost her balance which was the cause of one of her falls, and said however, she was not sure why the resident fell the second time. She additionally said the intervention they performed was to educate R400 to call for help before getting up. In interview with RN 1 on 02/07/2025 at 10:07 AM she stated she was the East UM for night shift. RN 1 stated R400 and her spouse did what they wanted to do, and had observed staff and learned the code to the doors in order to go in and out on their own. She said the couple had now been told they must sign in and out and get someone to go with them when they went out to smoke. RN 1 reported smoking assessments should be done on admission, quarterly, and if there was a change in a resident's condition. She said R400 had fallen over the foot pedal on her wheelchair with her first fall, and she had not heard about her falling again. The RN stated she was not sure of the interventions put in place to prevent R400 from falling again; however, would educate/ask the resident to call first, and staff would help her get to the toilet. In interview on 02/10/2025 at 8:14 AM, with the OT and PT they said R400 was currently getting PT, OT, and Speech Therapy (ST). The OT stated her assistant usually saw R400, whose goals for OT were grooming, toileting, and upper body and lower body dressing. The OT said for toileting that meant doing both transferring and performing hygiene. The OT said R400 had her OT evaluation on 01/27/2025, and her OT started after that initial assessment. The PT stated R400's PT assessment was done on 01/25/2025 and her PT started on that same day. During the interview a note from PT was reviewed which noted R400 had weight bearing issues and it was that issue that was preventing her from progressing. The PT said R400's ankle had been injured from the falls she experienced. The PT stated with the fall that occurred on 01/30/2025, R400 had received an x-ray which showed no fracture, but R400 refused to ambulate on 02/02/2025 due to pain in the ankle. The PT and OT said on 02/05/2025, they both asked for R400's weight bearing status from the provider. Per the therapists in interview, on Thursday, 02/06/2025, R400 had been deemed as non-weight bearing by the provider and was awaiting another x-ray per NP 6. Both OT and PT stated that R400 was agreeable to therapy but needed her pain controlled first. In interview on 02/12/2025 at 9:38 AM, the DON stated R400 had behaviors, and did whatever she wanted. She said R400 could and did sign h [TRUNCATED]

Based on observation, interview, review of the clinical record, and review of the facility policy the facility failed to develop the baseline care plan for 1 of 4 residents sampled for elopement and care plans out of the 33 total sampled residents, (Resident (R)401). The facility admitted R401 on 01/21/2025 and assessed the resident as at risk for elopement on that date. However, the facility failed to develop a baseline care plan with necessary interventions to address the resident's risk for elopement. R401 left the facility without staffs' knowledge on 01/24/2025. Immediate Jeopardy (IJ) was identified on 02/12/2025 and was determined to exist on 01/24/2025 in the area of 42 CFR S483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 02/12/2025 at 4:23 PM. On 02/12/2025 at 4:23 PM, the facility's Administrator, Regional [NAME] President of Clinical (RVPC), and Regional [NAME] President (RVP) were provided a copy of the IJ Template and notified that the facility's failure to ensure a baseline person-centered care plan was developed based on R401's admission assessment to ensure resident safety is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 02/13/2025 at 2:47 PM, alleging removal of the IJ on 02/13/2025. The State Survey Agency (SSA) validated the IJ had been removed on 02/13/2025, as alleged, after an acceptable IJ Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D at F655. Refer to F689 The findings include: Review of the facility's policy, Elopement and Wandering Residents, reviewed/ revised 03/06/2024, revealed residents who exhibited wandering behavior and/or were at risk for elopement were to receive adequate supervision to prevent accidents. Per the policy, residents were to receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Continued review revealed an elopement occurred when a resident left the premises or a safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy review revealed the facility was to establish and utilize a systematic approach to monitoring and managing residents at risk for elopement. Review of the policy revealed the facility's systematic approach was to include identification and assessment of risk and implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Further review revealed residents at risk were to be assessed for risk of elopement upon admission by the interdisciplinary care plan team (IDT), who were to evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Additional policy review revealed interventions to increase staff awareness of the resident's risk, modify resident behavior, or minimize risks associated with hazards were to be added to the resident's care plan and communicated to appropriate staff. Review further revealed charge nurses and unit managers were to monitor the implementation of interventions, response to interventions, and document accordingly. Review of the facility policy, Baseline Care Plan reviewed/ revised 12/23/2023, revealed the facility was to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Per review, the baseline care plan (CP) was to be developed within 48 hours of a resident's admission and was to include minimum healthcare information necessary to properly care for a resident. Continued review revealed the admitting nurse or supervising nurse on duty should gather information from the admission physical assessment, hospital transfer information. Further review revealed the admitting nurse or supervising nurse on duty was to establish initial goals for the resident and interventions should be initiated that addressed the resident's current needs including any safety concerns to prevent decline or injury, such as elopement. Additionally, policy review revealed a supervising nurse should verify within 48 hours a baseline CP has been developed. Review of the clinical record for R401 revealed the facility admitted the resident on 01/21/2025, with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction, epilepsy, aphasia following cerebral infarction, and chronic congestive heart failure. Review of the facility's, Wandering/Elopement Risk Evaluation, dated 01/21/2025 revealed the facility assessed R401 as at risk for elopement. Review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated 01/22/2025, revealed R401 was assessed through the St. Louis University Mental Status (SLUMS) examination. Per review, R401 was evaluated to have a SLUMS score of 6 out of 30 indicating severe cognitive impairment, but the resident's BIMS score was 12 out of 15, indicating moderate cognitive impairment. Continued review revealed R401 demonstrated severe cognitive deficits for short term memory, delayed recall, orientation, problem solving, and safety awareness. Per review, R401 required speech services to enhance cognitive skills, promote safety awareness/insight, facilitate immediate memory, enhance short term memory, and facilitate orientation abilities. Continued review revealed R401 was oriented to person, with thought orientation assessed as 25%; memory was severe, short -term memory was 25%, deductive reasoning 25%, and cause/effect 25%. The resident was confused but participatory. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/27/2025 revealed the facility assessed R401's Brief Interview for Mental Score (BIMS) as 14 out of 15, which indicated no cognitive impairment. Review of the facility's summary of its investigation, completed by the Director of Nursing Services (DNS), dated 01/26/2025, revealed R401 left the faciity on [DATE] at approximately 8:45 PM, to buy cigarettes, when the resident sustained a change in condition and was transported via Emergency Medical Services (EMS) to the hospital with stroke like symptoms. Review of the CP for R401 revealed the care plan initiated on 01/22/2025 included identified areas of skin breakdown, nutrition, pain, ADLs (activities of daily living), falls, diabetes, antiplatelet therapy, seizure disorder, and incontinence. Per review of the CP, the facility identified a problem for ADLS for R401 regarding his impaired decision making and impaired cognition. Continued review revealed the facility identified R401 as at risk for falls due to diminished safety awareness, cognitive impairment, and wandering. However, review of the CP revealed the facility had not developed it to provide interventions for wandering or risk for elopement. Continued review of R401's CP revealed on 02/04/2025, the facility developed a CP regarding the resident's impaired cognitive function related to impaired decision making with poor safety awareness and wandering. Further review of R401's CP revealed the facility had not addressed and provided interventions to address the resident's risk for elopement after he eloped on 01/24/2025. Observation on 02/07/2025 at 9:28 AM, of R401 revealed the resident stood and ambulated independently. Observation of R401 on 02/07/2025 at 9:42 AM revealed the resident sitting in a wheelchair (w/c) on the facility's smoking patio. In interview on 02/07/2025 at 1:47 PM, R401 stated he had not been to the hospital since he had been at the facility. He stated he slipped on the ice before he came to the facility which was the reason his left arm did not move (however, review of R401's hospital records revealed he had a stroke which affected the arm). R401 stated he could leave the facility when he liked and went out with family once and the second time he went out by himself about a week ago. He further stated he knew to sign out when he left with family or friends. In interview on 02/07/2025 at 2:34 PM, Family Member (F)10 stated R401 got out one weekend, got lost and almost froze to death a couple of weeks ago. She stated she did not know how he had gotten out and thought he fell in a ditch and someone called EMS (Emergency Medical System). F10 reported the facility called her and asked if R401 was with her and where he could be. She said R401 ended up in the emergency room (ER). She further stated the resident did not remember what happened. On 02/08/2025 at 8:17 AM, in interview Licensed Practical Nurse (LPN) 7 stated he was told in report R401 eloped from the facility. The nurse stated R401 had some cognitive impairment due to the stroke before he got there. He stated R401 could walk around without a walker. In interview on 02/09/2025 at 1:42 PM, Certified Nurse Aide (CNA) 27 stated the aides were aware of a resident's care plan interventions from the Kardex, usually in the computer. She stated she provided care for R401 and he was unable to use his left arm due to a stroke. The CNA stated she did not think R401 could go out of the facility on his own due to both mental and physical reasons. She stated R401 could walk, but after some time the resident would need a w/c as he did not have the strength to be gone for hours by himself. CNA 27 stated she did not know about the resident's mental capacity to go out of the facility on his own. In interview on 02/09/2025 at 1:57 PM, LPN 6 stated the resident's CP was to be updated by the nurse responsible for the resident when the resident returned from the hospital. She stated the charge nurse was responsible for residents' baseline care plans when they were a new admission. The LPN stated if the nurse was busy the unit manager would complete the baseline care plan. She stated she started employment at the facility in October and had not completed a baseline care plan yet. LPN 6 stated R401 was very impaired (cognitively), and as you talked to him she noticed a change in the conversation and he said things that did not make sense. She further stated R401 looked like he was a visitor and she thought he was a visitor before. The LPN also stated on admission we have to sign if it was felt the resident was at risk of wandering. She stated she always looked at the residents' care plans to see if there were any updates for the resident to ensure continuity of care. In interview on 02/09/2025 at 2:31 PM, LPN 15 stated she only worked nights at the facility. She stated she could not recall if she completed R401's admission as there were so many admissions and she worked on multiple units. The LPN stated R401's elopement risk assessment meant he was a wanderer. She stated management never told us to keep a close eye on R401 and management took care of everything related to a resident being at risk. LPN 15 stated normally the nurses completed residents' baseline care plans; however, the night shift supervisor typically did them on that shift. She stated she only updated the care plans with an immediate intervention if there was a fall, per the DNS's direction, otherwise, she did not really mess with the care plan. LPN 15 further stated R401 was not able to go out of the facility on his own, and she had not been informed he was an elopement risk. On 02/10/2025 at 1:51 PM, in interview the East Unit Manager (UM) stated when a resident was first admitted to the facility the nurse started the admission process which included the admission care plan. She stated the next day the admission was reviewed in the clinical IDT meeting to ensure everything had been done, the new resident's CP was completed in the IDT meeting to get into more detail and focus on that particular resident. The East UM stated if a resident had a change in condition, the next day the IDT reviewed the change and MDS would update the resident's care plan if warranted. The East UM stated if it was the weekend, the DNS would do it. She further stated R401 was not able to go out of the facility by himself without supervision as his cognitive scores were low on his BIMS. The East UM additionally stated if R401 did go out he could get hit by a car or kidnapped. In interview on 02/10/2025 at 2:56 PM, the Social Worker (SW) stated the nurses did the elopement assessment when a resident first came into the facility. He stated if the resident was assessed at risk for elopement, the resident should have a wanderguard (WG) in place. The SW stated the nurses did the elopement risk assessments; however, he managed that book. He stated he helped with the care planning for behavior programming, but the nurses did the at risk for wandering or elopement care plans. The SW reported when R401 returned to the facility (after the elopement), he was placed on one to one (1:1) supervision for a while. He further stated when R401 returned he did not put any additional interventions in place, as interventions were usually discussed in the IDT meeting. In interview on 02/11/2025 at 9:53 AM, the Night Shift Manager stated she did not know what R401's care plan information related to risk for elopement had been before he left (eloped from) the facility. She stated the comprehensive care plan was the responsibility of the MDS Nurse; however, the admission nurse was responsible for the baseline care plan when the resident was first admitted to the facility. The Night Shift Manager said the baseline care plan was how staff knew what the resident's needs were when they did not yet know the resident's care needs. She stated the baseline CP should be based off the History and Physical, resident history such as when the hospital mentioned fall risk or elopement risk. The Night Shift Manager stated the care plan was for the facility to follow to provide care and meet the resident's needs. She stated if the baseline care plan was not completed, staff would not know how to care for the resident and the resident could elope and anything could happen. In interview on 02/12/2025 at 10:37 AM, the MDS Coordinator stated any nurse could complete the baseline care plan; however, she usually did them herself the next day. She said there was an admission assessment (in the computer) and the baseline care plan could be done there. The MDS Coordinator stated she usually did the baseline care plan in the actual care plan section (in the computer) as it was the facility's version of the baseline care plan. She stated the baseline care plan was determined by the basic care plan such as ADLs and support needed, risk for pain, anything the resident was at risk for, and the nurse could update or change the care plan. The MDS Coordinator stated the care plan was updated with the comprehensive assessment and if there was a change in the resident's condition. She stated she thought the other MDS Coordinator started R401's baseline care plan. The MDS Coordinator said she and the other MDS Coordinator talked about R401 being at risk for elopement when he first came to the facility; however, his care plan for wandering was not initiated until 02/04/2025 based on the MDS Assessment. She stated she looked at different things for a resident's care plan needs including resident assessments and evaluations. The MDS Coordinator stated she had not known R401 was assessed by the admission nurse at risk for elopement and stated we would care plan that. She further stated she participated in the clinical meeting, but did not recall if R401 was discussed, as the other MDS Coordinator attended at times. On 02/12/2025 at 1:14 PM, in interview the Staff Development Coordinator (SDC) stated the nurse put in residents' baseline care plans in coordination with the MDS Coordinator and clinical team. She said she participated in the clinical meetings and reviewed R401's elopement risk assessment. The SDC reported being at risk meant to keep an eye on him through special attention, and have processes in place so he stayed in the facility for his safety. She stated the IDT meeting discussed updating R401's care plan after he returned to the facility. The SDC said the purpose of the baseline care plan was to provide care centered around the resident's needs. She stated if the baseline care plan was not developed or updated multiple things could fall through the cracks as that care plan was their guidelines for how to care for a resident and what their needs were. The SDC further stated if information was not in the care plan for staffs' knowledge, the resident could be harmed and it could be dangerous because staff would not know what the resident's needs were. In interview on 02/12/2025 at 1:59 PM, the DNS stated when a resident was newly admitted to the facility, the floor nurse at the time of admission was responsible to complete the resident's baseline care plan and had 48 hours to complete it. She stated the facility had a checklist to go over in the next morning's clinical IDT meeting. The DNS said the comprehensive care plan was initiated and updated by the MDS Coordinator the next day after the admission came in. She reported the clinical meeting reviewed residents for risk of elopement; however, could not recall if R401 was reviewed. The DNS stated when a resident triggered as at risk for elopement, the process would depend from resident to resident based on the diagnosis. In interview on 02/12/2025 at 3:03 PM, the Administrator stated R401's admission elopement risk assessment provided an automatic score and that could have been because of diagnoses of hemiparesis and history of stroke. She stated the IDT meeting decided if the resident was a true elopement risk, and had determined R401 was not a risk. The Administrator said she would have to look in the file to see if that was documented anywhere (however no documentation was provided to the State Survey Agency [SSA] Surveyor). She reported she did not expect to see a care plan for risk of elopement if the resident was not at risk; however, the elopement risk assessment was to determine if a resident was at risk. The Administrator stated if the (elopement risk) assessment was based off a wanderer and part of the diagnosis where the assessment talked about the symptoms, the resident would score higher. She stated the purpose of the baseline care plan was to tell about the resident, what risks and behaviors were exhibited and put interventions in place. The Administrator further stated if a resident at risk for elopement did not have care plan interventions, staff would not know the resident had the potential to be an elopement risk and could be a safety concern as the resident could get out and a lot could happen.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12-months for five out of five CNAs' personnel records reviewed, CNA #2, #18, #20, #31, and #32. Additionally, the facility failed to provide evidence of regular in-service education based on the outcome of these reviews for three of five records reviewed, CNA #18, #31, and #32. The findings include: The State Survey Agency requested a staffing policy on 02/11/2025 at 3:05 PM; however, the facility did not provide a policy. During an interview, at that time, with the Executive Director he stated the facility did not have a staffing policy. He stated they based staffing off the facility's assessment. Review of the facility's policy titled, Job Description; Certified Nursing Assistant, dated 02/01/2024, revealed CNAs were to attend a minimum of 12 hours of continuing education programs provided by the center in order to maintain certification. Review of CNA2's personnel file revealed a hire date of 02/25/2022 and 13.41 annual training hours completed. However, there was no documentation of a performance evaluation in the previous 12 months. Review of CNA18's personnel file revealed a hire date of 01/18/2021 and only 5.63 annual training hours completed. Further review revealed no performance evaluation documented in the previous 12 months. Review of CNA20's personnel file revealed a hire date of 11/01/2019 and 22.75 annual training hours completed but no documentation of a performance evaluation in the previous 12 months. Review of CNA31's personnel file revealed a hire date of 08/25/2023 and no annual training hours were documented. Further review revealed no documentation of a performance evaluation within the previous 12 months. Review of CNA32's personnel file revealed a hire date of 05/09/2022 and only one annual training hour was documented. Further review revealed no performance evaluation documented within the previous 12 months. In an interview with [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the facility had acquired new ownership, and trainings and education were provided through in-services, and skill fairs to ensure staff were meeting training needs. She stated the prior owners had provided the training/education documents but they had failed to provide the performance evaluations. In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership and facility processes. She stated if the performance evaluations were not completed, staff could not benefit from the provided feedback regarding the tasks they performed well or what areas that needed improvement. Additionally, she stated her expectations were that CNAs were evaluated when hired and annually to assess their competencies, skills, and knowledge and their required training would be met annually.

Based on observation, interviews, and record review the facility failed to ensure it electronically submitted complete and accurate direct care staffing information, to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters in 2024. The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September 2024. The findings include: Review of the facility's provided CMS Payroll Based Journal (PBJ) report which was based on the staffing data submitted by the facility revealed excessively low weekend staffing, no RN hours, and a failure to have licensed nursing coverage 24 Hours/Day triggered for August and September 2024. A request for the facility's staffing data submitted for the third quarter (July, August, September) PBJ was requested but no verification that it had been reported successfully was provided. The facility provided an Excel spreadsheet for August and September 2024 which included payroll data for all staff; however, no verification the information was submitted or received by CMS system was provided. Further, the facility could not provide the facility's assessment completed for 2024. In an interview with the [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the [NAME] President of Finance (VPF) advised her that the requested PBJ staffing data had not been submitted. She stated the VPF indicated that she (the VPF) had attempted to submit the data unsuccessfully. In an interview with the VPF, on 02/13/2025 at 3:30 PM, she stated she was responsible for submitting the payroll data to CMS for the PBJ Staffing Data Report. She stated during the third quarter there was a change of ownership and the data was entered into a new software program and could only conclude that there was an error in the software. She stated she submitted the information on 10/14/2024 but received an error message on 10/15/2024 which indicated the data was not submitted. She stated there was a lot of confusion with the third quarter because the data for July 2024 was submitted by the previous owners, but the new owners would submit the August and September 2024 data. She stated she had not contacted CMS because the error was realized after the deadline of 10/15/2024. In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership. She stated she was made aware the staffing data had not been submitted due to a software error. She stated she understood the importance of submitting the payroll data timely to CMS because it had affected the facility's survey outcome and also decreased the facility's star rating. She stated her expectation was that the facility submitted the required data timely to ensure the facility was in compliance.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide residents and/or guardians with resident personal funds account quarterly statements for 5 of 5 residents sampled for personal funds accounts, (Residents (R) 1, R6, R8, R22, and R49). The findings include: Review of the facility's policy, Resident Rights, dated 02/15/2024, revealed the facility must furnish to each resident a written description of (their) legal rights which included a description of a manner in protecting personal funds. Review of the facility's policy, Resident Personal Funds, dated 01/09/2024, revealed the facility was to ensure individual financial records were available to the resident through quarterly statements and upon request. 1. Review of R1's, Resident Statement dated 02/10/2025, revealed the resident had a credit of $1,344.00 at the end of the business day on 02/01/2025. Review of the facility's Surety Bond Certification dated 08/30/2024, revealed the facility was licensed and certified for $145,000.00. In interview with Representative 1 on 02/10/2025 at 10:19 AM, he stated he did not receive quarterly statements from the facility concerning R1's personal funds. Representative 1 stated he used an old quarterly statement, changed the date and mailed his payment in with the old quarterly statement. He stated he did receive a statement with what he owed the facility; however, the amounts never were the same each month. Representative 1 stated he just sent in $1,344.00 per month and he had no idea if he had any credits or owed money at that date and time. 2. In interview with R6 on 02/13/2025 at 10:45 AM, she stated she did not receive her quarterly statement unless she asked the Business Office Manager (BOM) for the statement. R6 stated when she withdrew money from her Resident Fund Account, she signed to confirm she received her money; however, the receipt did not give the balance of her account. 3. In interview on 02/09/2025 at 3:25 PM, R8 stated he had not received a quarterly statement. He stated he had to call the BOM to inquire about his balance. 4. In interview on 02/03/2025 at 1:52 PM, R22 stated he did not receive a quarterly statement from the Business Office. 5. In interview with R49's Representative on 02/10/2025 at 10:17 AM, she stated for some months she had not received a quarterly statement from the facility. Representative 49 stated she went to the facility to pick up the quarterly statement due to not receiving them by mail, as she requested. In interview with the BOM on 02/10/2025 at 1:37 PM, she stated she transferred to the current facility from a sister facility in June 2023. The BOM stated October 2024 was when the facility should have had quarterly statements. She stated however, the facility was bought by another company in August 2024 and did not transfer resident funds accounts until November 2024. The BOM stated the quarterly statements were mailed from the corporate office to residents and/or their guardian at the address on file with the facility. In interview with the Director of Nursing (DON) on 02/13/2025 at 10:23 AM, she stated residents could request to receive their quarterly statements at any time. She stated she was unaware residents were not receiving their quarterly statements. The DON stated not providing quarterly statements to the residents violated their rights. She stated the business office was responsible for sending out quarterly statements to the residents and guardians. The DON stated the facility had been bought by another company in August 2024. In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated residents had issues with receiving quarterly statements. However, residents had been receiving their statements since her hire date, 12/18/2024.

Based on observation, interview, and review of facility policy, the facility failed to ensure the residents' environment was safe, clean, comfortable, and homelike. The facility failed to provide a functional and comfortable environment for residents related to cold water temperatures for 14 out of 19 resident rooms. (Rooms 101, 102, 103, 105, 106, 107, 108, 109, 110, 121, 122, 124, 125, and 126). The findings include: Review of the facility's policy titled, Resident Rights, revised 02/15/2024, revealed the residents had a right to a safe, clean, comfortable, homelike environment, including but not limited to receiving treatment and support for daily living. Review of the facility's policy titled, Safe and Homelike Environment, revised 03/09/2024, revealed housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable environment. Further review of the policy revealed under General Considerations to report any unresolved environmental concerns to the Administrator. Observation on 02/03/2025 at 2:43 PM of the temperature of the sink's water in room [ROOM NUMBER] revealed when only the hot water was turned on it was cold to the touch. Further observation revealed that despite running the water for approximately five (5) minutes, there was no change in the temperature. Observation on 02/03/2025 at 3:16 PM of the temperature of the sink's water in room [ROOM NUMBER] revealed it was cold when only the hot water was turned on and ran for greater than five (5) minutes without any change in temperature. Observation on 02/03/2025 at 9:10 AM of the temperature of the sink's water in room [ROOM NUMBER] revealed it was cold if only the hot water tap was on and ran consistently for five (5) minutes. Observation of room water temperature in room [ROOM NUMBER], on 02/07/2025 at 2:44 PM revealed despite Licensed Practical Nurse (LPN) 6 allowing the water to run for eight (8) minutes during R20's wound care, the water never got warm. On 02/07/2025 at 9:43 AM an observation of the Hall A Shower room revealed the shower did not turn on and the water in the sink was cold and did not get hot despite letting it run for over five (5) minutes. Observation of room water temperatures on 02/09/2025 at 4:01 PM revealed the following: room [ROOM NUMBER]'s hot water temperature was 55 degrees Fahrenheit (F); room [ROOM NUMBER]'s hot water temperature was 50.4 degrees F; and, room [ROOM NUMBER]'s hot water temperature was 52 degrees F. Observation of the water temperature in Hall A Shower Room on the East Unit on 02/10/2025 at 10:00 AM revealed the hot water temperature for the sink was 48.7 degrees F and for the shower was 44 degrees F. Observation of the water temperatures for Hall B on the East Unit on 02/10/2025 at 10:03 AM revealed for rooms 121 through 126, no water temperatures were over 50 degrees F. Respectively in room number order they were: 48.4 F, 47.2 F, 44 F, 44.5 F, 44.1 F, and 46.1 F. On 02/09/2025 at 3:53 PM the water temperatures of the hot water in multiple rooms were checked. room [ROOM NUMBER]'s hot water temperature after running for 5 minutes was 55 degrees F. The hot water in room [ROOM NUMBER] after running for 5 minutes was 52 degrees F. The hot water in room [ROOM NUMBER] after running for 5 minutes was 50.4 degrees F. The hot water for the shower room on the 100 Hall sink, after running for 5 minutes was 56.8 degrees F, and the hot water from the shower after running for 5 minutes was 57.4 degrees F. In an interview with Resident (R) 20 on 02/03/2025 at 2:43 PM she stated she had no hot water in her sink for over a month. R20 stated this was why she had not been able to get her hair washed. In an interview with R6 on 02/03/2025 at 3:55 PM she stated she had met the new owner of the facility, and she made him aware of the lack of hot water in their rooms. R6 stated she had met with the Ombudsman over some issues as well, including the lack of hot water in the room. In an interview with R50 on 02/04/2025 at 9:01 AM he stated it took a long time for his water to get hot, if it ever did get hot. In an interview with R43 on 02/04/2025 at 9:10 AM he stated his water in his sink was always cold. In an interview with R83 on 02/04/2025 at 11:15 AM she stated they have had no hot water in their room for a month. In an interview with R72 on 02/04/2025 at 12:10 PM she stated was no hot water in their room for months. In an interview with R73 on 02/04/2025 at 12:30 PM she stated they have no hot water in their room, have not had any hot water for months. In an interview with R14 on 02/04/2025 at 4:00 PM she stated they have not had any hot water in their room for at least a month. In an interview with R51 on 02/04/2025 at 4:05 PM she stated they had no hot water in their room and haven't had any for a month. On 02/07/2025 at 9:47 AM in an interview with the Maintenance Director (MD) and the Assistant Maintenance Director (AMD) it was revealed they did not know that Hall A Shower Room shower was not working; nor did they know there was no hot water in rooms on Hall B. The MD said he did the water temperature checks last Friday, and they were fine. When asked how he does the water temperatures he stated that he picks a room on each hallway and takes the temperature of that room only. Each week he picks a different room for that hallway. He stated that he then records that number for the hallway in the facility's electronic maintenance record. The MD and AMD stated they had pipes burst and ceiling caved in due to extreme cold temperatures in January. He stated no residents lost heat or hot water during the incident. On 02/07/2025 at 10:07 AM the night shift unit manager for the East Unit, Registered Nurse (RN)1 stated she was not sure how long Hall A Shower Room had not worked or had hot water. On 02/07/2025 at 1:25 PM in an interview with the day shift Unit Manager (UM)10 for the East Unit, she stated Hall A Shower Room did not have hot water and that was why the staff used Hall D Shower Room. She stated Hall C Shower Room was currently being remodeled and was unsure how long it had been closed. She thought that both had been down since November or December. On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she stated they have had no hot water off and on for the last few weeks. The DON stated she understood why Hall A Shower Room could not be used due to the cold water. She stated she did think it was an issue that 72 residents were using the one shower room on the East Unit that worked. On 02/12/2025 at 10:31 AM in an interview with Social Services (SS), when the pipes burst some residents ran out of hot water due to the high demand for the one shower room and he would have to tell them to wait a half an hour until the water heated back up and try getting a shower again. He stated that for the female residents who were able to walk, the Certified Nursing Assistants (CNA) took them to the locked women's unit for a shower instead. On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated renovations were ongoing and they were currently working on three of the six shower rooms: [NAME] Unit Shower, East Unit Hall A Shower, and East Unit Hall C Shower. The reason there was no hot water was due to these renovations, but this issue had been fixed. She stated she was unaware of the cold water in residents' rooms and in Hall A Shower Room until this past Sunday when they were made aware and since then a plumber had come and fixed the issue. When asked if she felt one shower was sufficient for 72 residents, she stated the facility had three other showers residents could utilize.

Based on observation, interview, record review, and review of the facility's documentation and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections for 2 of 3 sampled residents (Resident (R) 20 and R67). Observations of Licensed Practical Nurse (LPN)6 of R20 and R67 during wound care revealed the LPN failed to perform hand hygiene when moving from a dirty task to a clean task. Additionally, the LPN failed to ensure a barrier was in place before placing supplies on the table. In an interview with the Wound Doctor, she stated this practice could contaminate the wound and cause an infection. The findings include: Review of the facility's policy titled, Wound Treatment and Management, with a date implemented of 02/01/2024 and a date revised of 02/14/2024, revealed the purpose of the policy was to promote wound healing of various types of wounds by providing evidence-based treatments in accordance with current standards of practice and physicians orders. Review of the facility's policy titled, Hand Hygiene, revised on 02/16/2024, revealed that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy outlined the technique for hand hygiene with alcohol based hand rub (ABHR), soap and water, and listed under what conditions each should be performed. Further review of the policy revealed the use of gloves did not replace hand hygiene. If the task required gloves, hand hygiene should be performed prior to donning gloves and immediately after removing gloves. Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/01/2024, revealed that it was the practice of the facility to implement Enhance Barrier Precautions (EBP) for the prevention and transmission of multidrug resistant organisms. Further review of the policy stated that clear signage should be posted on the resident's door stating the type of personal protective equipment (PPE) needed for high contact resident care activities. PPE, such as gown and gloves, would be made immediately available outside the room's door and ABHR should be both inside and immediately outside the resident's door. The policy outlined who would be placed on EBP and defined what activities were considered high contact resident care activities. 1. Review of R20's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/15/2022 with the medical diagnoses of chronic obstructive pulmonary disease (COPD), schizoaffective disorder, chronic pain syndrome, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025 revealed R20 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R20's Comprehensive Care Plan (CCP), undated, revealed the resident was care planned for the focus of altered skin integrity related to an abscess of left leg (resolved) and a wound on the left hip. The goal for this focus was R20's altered skin integrity would show signs of healing. R20 was also care planned for the focus of enhanced barrier precautions (EBP) due to altered skin integrity. The goal of this focus was resident would have a reduced likelihood of transmission of resistant organisms through target date. The interventions for this focus were to educate resident and/or family on the need for enhanced barrier precautions; enhanced barrier precautions implemented during high touch care activities; and staff must wear a gown and gloves when providing high touch care. Review of R20's Physician Orders in her EMR revealed she had an order for the abscess of the left hip/leg to cleanse with normal saline, pat dry, and apply calcium alginate with silver. The wound was to be covered with border gauze. Wound care was to be done daily. She also has an order for Enhanced Barrier Precautions (EBP) related to her wound. Observation of wound care for R20 on 02/07/2025 at 2:44 PM provided by Licensed Practical Nurse (LPN) 6 revealed that she hand sanitized and put on PPE prior to entering R20's room. Once in the resident's room, the LPN raised the resident's bed and moved other items in the room on the bedside table without washing her hands or changing her gloves. The table and sink that LPN6 placed her items on were not cleaned and a barrier was not placed. LPN6 then removed the dressing from the resident's wound and did not wash her hands or change her gloves prior to opening the sterile items needed for the wound care. After opening the bandages, she washed her hands and changed gloves, then reached into her pocket to remove her bottle of normal saline used to do the wound cleansing. She did not wash her hands or change her gloves. The wound was smaller than a dime in size and had yellow drainage. She cleaned the wound and only changed her gloves, however, did not wash her hands. Her gown touched against the open dressings on the table multiple times during wound care. She placed the calcium alginate on the wound and then put on the border gauze. She touched the resident's bed controls and bedside table prior to taking off her gloves and washing her hands. She then threw away the Normal Saline(NS) and all the other items left from the wound care. On 02/03/2025 at 2:43 PM in an interview with R20, she stated that she had a boil on her left hip, adding she has had one in the past, which had healed. In an interview with LPN4 on 02/06/2025 at 3:33 PM she said R20 had a boil on her left hip and was getting wound care for it. She stated she had only seen it once, so she was unable to state if it was healing or not. Per the interview, she stated the wound had drainage but no offensive odor. LPN4 stated R20's treatments were provided on day shift. She stated the resident's wound was cleaned with calcium alginate with border dressing. 2. Review of R67's Electronic Medical Record (EMR) revealed the facility admitted her on 10/14/2022 with medical diagnoses including cerebral infarction due to embolism of the left middle cerebral artery, dementia, type II diabetes mellitus, chronic diastolic heart failure, and chronic kidney disease stage 3A. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2024 revealed the facility did not conduct a BIMS score for the resident. The facility assessed R67 as having a pressure ulcer and at risk for developing pressure ulcers/injuries. Additionally, the record indicated R67 had one stage 2 and one stage 4 pressure ulcer. Further review revealed the facility assessed R67 as having 2 unstageable deep tissue injuries. Treatment for the PUs: pressure reducing device for bed, nutrition and hydration interventions, PU injury care, and applications of ointments/medications (other than to feet). Review of R67's current Comprehensive Care Plan (CCP) from 01/15/2025 revealed the facility care planned her for the focus of potential skin impairment related to incontinence, diabetes mellitus, current skin impairment, and limited mobility. The interventions for this focus were incontinence care every shift and as needed for incontinence episodes. Further review revealed the facility would ensure the resident received her treatments as ordered; complete observation of the resident's skin during care and report any concerns to the nurse. Review of a Wound Care Note from 02/06/2025 revealed a stage IV pressure ulcer on her sacrum that was 0.8-centimeter (cm) x 0.3 cm x 0.1 cm. The pressure ulcer on the sacrum was assessed as having a surface area of 0.24 cm squared, with moderate serous exudate. It had 90% granulating tissue and 10% slough. The pressure ulcer was noted to have improved as evidenced by the decreased surface area. The current treatment plan for the pressure ulcer was to cleanse with normal saline, pat dry and apply alginate rope and Leptospermum honey. Further review of the note revealed staff were to use a gauze island with border to cover the pressure ulcer. Further review of the note revealed that the pressure ulcer was not likely to heal and the wound physician had recommended an assessment for ultrasound mist therapy. Observation of wound care performed on 02/07/2025 at 2:05 PM by licensed practical nurse LPN6 for R67 revealed Certified Nursing Assistant (CNA) 9 and CNA11 were in the room to help roll R67. Both CNAs performed hand hygiene and put on gown and gloves. Continued observations revealed LPN6 performed hand hygiene and donned (put on) a gown and gloves prior to entering R67's room. She did not wipe off the bedside table nor place a barrier on the bedside table prior to placing the supplies for the wound treatment onto the table. An unopened dressing fell to the floor and LPN6 retrieved the package placed it back onto the table. LPN6 indicated she forgot to bring the normal saline for cleansing R67's wound. She removed her personal protective equipment (PPE) and left the room. When she returned, she had donned a new gown and had gloves in her hands and proceeded to put the gloves on inside the room and then lowered the head of R67's bed and uncovered R67. There was no dressing over the sacral wound as LPN6 explained it was removed just prior during incontinence care. LPN6 did not change her gloves or wash her hands after lowering the head of R67's bed and removing the resident's bed covers and brief. She proceeded to open the sterile wound care supplies with the same contaminated gloves. Continued observations revealed LPN6 wiped the wound with gauze moistened with NS and patted it dry. She did not change gloves or wash her hands after cleaning the wound; and then she used her gloved fingers to wipe the Leptospermum honey onto the wound. She then took off her gloves, washed her hands, and placed new gloves on. After donning new gloves, LPN6 pressed the silence button on the tube feed pump, and did not perform hand hygiene or change her gloves. She packed the calcium alginate rope into the wound and placed a border gauze undated and unlabeled over the wound. LPN6 labeled and dated the dressing after it was adhered to R67. In an interview on 02/07/2025 at 2:40 PM with LPN6 regarding the wound care treatment she provided to both R20 and R67, she stated she forgot to do some things during the wound treatment such as performing hand hygiene when she returned to the room after leaving to go and get the normal saline for the wound cleansing. LPN6 did not comment regarding her not washing her hands or changing gloves when she moved from a dirty task to a clean task (such as after cleaning the wound and then immediately putting the Leptospermum honey and calcium alginate onto the wound without washing her hands and changing her gloves). LPN6 stated she should remove her gloves, perform hand hygiene, and then put on new gloves when moving from dirty to clean in a wound care, such as after removing an old dressing. Further, LPN6 stated hand hygiene and a glove change should be done after cleansing the wound. Additionally, LPN6 stated she typically placed a barrier before placing supplies on a table and that she should have performed hand hygiene and donned fresh gloves after touching resident equipment and before opening clean wound care supplies. In an interview with the Director of Nursing (DON) on 02/12/2025 at 9:38 AM, she stated her expectation for wound care was for staff to have a clean field on which to do wound care. She stated there should be a barrier placed and staff should clean the table prior to placing the barrier. Further, she stated staff should clean their hands and put on new gloves after touching items in the room such as the bed controls, tube feed pump, or the resident. She stated staff should change gloves after cleaning the wound and wash their hands and/or use hand sanitizer each time their gloves were changed. The DON stated that she expected staff to wash their hands and sanitize after any dirty task and change gloves. In an interview with the Wound Care Nurse/Staff Development Coordinator (WCN/SDC) on 02/12/2025 at 1:17 PM, she stated it was her expectation of staff performing would care to clean the surface they were placing their barrier on with bleach wipes and allow it to dry the specified time before putting down a barrier like a chux. Then wound care supplies should be put on the clean chux. She stated staff should hand sanitize and/or hand wash before putting on PPE (gloves and gown) to enter the room for the wound treatment. Further, she stated staff should also change gloves and wash their hands when touching anything that was not clean or sterile. The SDC stated her expectation was that the Leptospermum honey would be applied to the wound with an applicator to prevent contaminating the wound and the Leptospermum honey bottle. She stated if proper hand hygiene and changing of gloves did not occur this could cause contamination of the wound and possible infection. In an interview on 02/13/2025 at 9:17 AM with the Wound Doctor, she stated she had been seeing R67 weekly for her pressure ulcer since she inherited the facility from the previous wound doctor. She stated her expectations for wound care was that nurses go into the resident's room with PPE on. She stated staff should perform hand hygiene and wear gloves for all wound care. Further, she stated gloves should be changed in between each wound. The Wound Doctor stated that if staffs' hands were soiled staff should wash their hands, otherwise, they could use hand sanitizer for hand hygiene. She stated she expected staff to change their PPE between residents. The Wound Doctor stated she expected staff to use hand sanitizer and put on new gloves after they clean the wound. Per the interview, she stated if staff touched anything in the room that was not clean or sterile, staff should complete hand hygiene and change gloves. Further, she stated barriers should be down when completing wound care, to put the supplies on. She stated if staff did not perform hand hygiene and change gloves appropriately, staff could contaminate the wound and cause an infection.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs were labeled in accordance with professional standards. Observations revealed undated, opened, unlabeled and expired medications in 1 of 5 medication carts and 1 of 2 treatment carts. Those medications included topical creams, and one oral pill. The findings include: Review of the facility's policy titled, Medication Storage, dated 02/01/2024, revealed The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. The medications are destroyed in accordance with our Destruction of Unused Drugs Policy. The policy did not address documenting on open/expiration dates, unlabeled medications, or the long-term storage of ointments/creams in the labeled, pharmacy supplied protective plastic storage bag. Review of the facility's policy titled, Medication Administration, dated 02/02/2024, revealed, Identify expiration dates. If expired, notify nurse manager. 1. During observation on 02/04/2025 at 10:57 AM of the men's memory care unit's treatment cart revealed one tube of Silvasorb gel topical medication used to treat a variety of skin wounds with an expiration date of 07/2024. This medication was not labeled and had no identifier. Additional observation revealed one tube of Diclofenac 1% topical medication used to treat arthritic pain without an open date and was not in a storage bag for Resident (R) 87. During an interview on 02/04/2025 at 10:57 AM with Registered Nurse (RN) 1, she stated that pharmacy usually go through the carts about once a month. 2. During observation of the medication cart for the B hall on 02/04/2025 at 3:50 PM, revealed a pill separated from the pack in the top drawer of the medication cart. Further observation revealed the medication was Cyclobenzaprine (a muscle relaxant) 5 milligrams (mg). The medication was unlabeled and had no resident identifier. During an interview on 02/04/2025 at 3:50 PM with Licensed Practical Nurse (LPN) 2, she stated that night shift must have left it and that she would destroy it immediately. During an interview on 02/06/2025 at 2:05 PM with the Unit Manager, she stated that expired medications were not to be in the carts and were to be discarded according to the facility's policy. She stated that the nursing staff were to go through the medication carts weekly and monthly, and that included the treatment carts. She stated medications were to be labeled with the open date and initials, and kept in their bag and separated individually. She stated that random or floating pills were expected to be wasted. She stated medications should be patient (resident) identifiable and in their individual containers. The Unit Manager stated there was too much of an opportunity for a negative outcome. During an interview on 02/06/2025 at 2:40 PM with Staff Development, she stated it was difficult to discern a medication for a resident if it was left unlabeled in the medication cart, which could result in a potential medication error. She stated that education was provided annually during the skills fair on medication administration and ordering medication from the pharmacy. She stated medications come prepackaged individually with the resident's name. She stated she teaches the rights of medication administration, locking the med carts, how to properly open medications, and how to properly discard medications. During an interview on 02/06/2025 at 2:15 PM with the Director of Nursing (DON), she stated it was her expectation that expired medications were not to be in the carts. She stated the nurses were expected to look at the dates prior to use and reorder the medication and dispose the expired medications. She stated that open dates and expiration dates should be written on the medications with either the 30 day after open date or the manufacture's date, whichever comes first. The DON stated the nurses were to look at the medications in the carts daily for expiration dates and the unit managers were to check once a week. She stated random pills in the medication carts were expected to dispose the medications. The DON stated medications were to be in their separate container with a resident identifier. During an interview on 02/06/2025 at 2:33 PM with the Administrator, she stated it was her expectation that expired medications should not be in the medication or treatment carts. She stated any nurse could check at least once a week and review the carts. She stated medications have to have open dates according to policy. The Administrator stated that loose, random medications in the carts must be destroyed. She stated medications could not be in medication carts without personal containers with identifiers needed. She stated a negative outcome could be death, the right medications needed to go to the right resident.

Based on observation, interview, record review and review of facility documentation, policies, and Plan of Correction (POC), the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the Revisit Survey from 04/01/2025 through 04/04/2025, the State Survey Agency (SSA) identified continued non-compliance for the facility in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761). Review of the facility's Plan of Correction (POC), which alleged substantial compliance as of 03/05/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was recited for the continued non-compliance at the highest Scope and Severity (S/S) of a D. (Refer to F607, F656, and F761). The findings include: Review of the facility's, Position Description: Executive Director, (more commonly referred to as Administrator), revised 02/01/2024, revealed the Administrator, was responsible for assuring the center operates in full compliance with Federal and State regulations, which will result in high levels of performance . Continued review of the Administrator's position description revealed the Administrator was responsible for planning and was accountable for all activities and departments. Further review revealed the Administrator was also subject to rules and regulations promulgated by government agencies to ensure the proper health care services for residents. Review additionally revealed the Administrator was to administer, direct, and coordinate all activities of the center (facility) to assure the highest degree of quality of care was consistently provided to residents. Review of the facility's POC for the Recertification/Abbreviated/Extended Survey, concluded on 02/13/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures in the facility through its Quality Assurance Performance Improvement (QAPI) process. Therefore, the facility continued to have noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761), following the Revisit Survey concluded on 04/04/2025. 1. Based on interview, record review, and facility policy review, the facility failed to ensure freedom from abuse, neglect, and exploitation regarding not completing the required pre-employment checks, specifically the criminal background, nurse aide abuse registry and Kentucky Vulnerable Adult Maltreatment Registry (KVAMR) checks for two of five personnel files reviewed. (Refer to F607). 2. Based on observation, interview, and record review, the facility failed to ensure the development and implementation of comprehensive resident centered care plans for three of 23 sampled residents. (Refer to F656). 3. Based on observation, interview, and record review, the facility failed to ensure all drugs were labeled in accordance with professional standards regarding expired ophthalmic drops and a loose, unlabeled pill found in two separate medication carts. (Refer to F761). In interview with the Assistant Director of Nursing (ADON) on 04/03/2025 at 4:11 PM, she stated the facility's POC was a team effort which was overseen by the Administrator and nursing team. She stated it was her expectation staff would find and discard any expired medications on the medication carts during the audits being performed. The ADON reported any loose medications were a definite issue and the breakdown in the process of implementing the facility's POC fell on the managers. In interview on 04/03/2025 at 4:54 PM, the Administrator stated she was responsible for ensuring all staff were educated and for ensuring all audits were completed as per the facility's POC. The Administrator said she expected education of staff to be performed, for staff to follow the facility's policies and perform all audits as required in the POC. She further stated she was ultimately responsible for making sure all sections of the facility's POC were followed.

Based on observation, interview, record review and review of facility documentation, policies, and Plan of Correction (POC), the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the Revisit Survey from 04/01/2025 through 04/04/2025, the State Survey Agency (SSA) identified continued non-compliance for the facility in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761). Review of the facility's Plan of Correction (POC), which alleged substantial compliance as of 03/05/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was recited for the continued non-compliance at the highest Scope and Severity (S/S) of a D. (Refer to F607, F656, and F761). The findings include: Review of the facility's, Position Description: Executive Director, (more commonly referred to as Administrator), revised 02/01/2024, revealed the Administrator, was responsible for assuring the center operates in full compliance with Federal and State regulations, which will result in high levels of performance . Continued review of the Administrator's position description revealed the Administrator was responsible for planning and was accountable for all activities and departments. Further review revealed the Administrator was also subject to rules and regulations promulgated by government agencies to ensure the proper health care services for residents. Review additionally revealed the Administrator was to administer, direct, and coordinate all activities of the center (facility) to assure the highest degree of quality of care was consistently provided to residents. Review of the facility's POC for the Recertification/Abbreviated/Extended Survey, concluded on 02/13/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures in the facility through its Quality Assurance Performance Improvement (QAPI) process. Therefore, the facility continued to have noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761), following the Revisit Survey concluded on 04/04/2025. 1. Based on interview, record review, and facility policy review, the facility failed to ensure freedom from abuse, neglect, and exploitation regarding not completing the required pre-employment checks, specifically the criminal background, nurse aide abuse registry and Kentucky Vulnerable Adult Maltreatment Registry (KVAMR) checks for two of five personnel files reviewed. (Refer to F607). 2. Based on observation, interview, and record review, the facility failed to ensure the development and implementation of comprehensive resident centered care plans for three of 23 sampled residents. (Refer to F656). 3. Based on observation, interview, and record review, the facility failed to ensure all drugs were labeled in accordance with professional standards regarding expired ophthalmic drops and a loose, unlabeled pill found in two separate medication carts. (Refer to F761). In interview with the Assistant Director of Nursing (ADON) on 04/03/2025 at 4:11 PM, she stated the facility's POC was a team effort which was overseen by the Administrator and nursing team. She stated it was her expectation staff would find and discard any expired medications on the medication carts during the audits being performed. The ADON reported any loose medications were a definite issue and the breakdown in the process of implementing the facility's POC fell on the managers. In interview on 04/03/2025 at 4:54 PM, the Administrator stated she was responsible for ensuring all staff were educated and for ensuring all audits were completed as per the facility's POC. The Administrator said she expected education of staff to be performed, for staff to follow the facility's policies and perform all audits as required in the POC. She further stated she was ultimately responsible for making sure all sections of the facility's POC were followed.

Based on interview, record review, and facility policy review, the facility failed to ensure its abuse prohibition policy was implemented by failing to verify and maintain documentation of screening and training, including criminal record checks required for pre-employment for 9 of 12 personnel files reviewed. The criminal background check, the nurse aide abuse registry check, and/or the Kentucky Adult Caregiver Misconduct Registry (KACMR) check was not completed for newly hired employees. Additionally, there was not documented evidence to support newly hired staff had received the abuse training required at the beginning of employment. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, revised 03/05/2024, revealed, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident's property. 1. Background, reference, and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Further review of the policy revealed the pre-employment checks were to be completed before the employee came to the facility for orientation. Further review of the policy revealed new employees would be educated on abuse, neglect, exploitation, and misappropriation of the resident's property during initial orientation. Existing staff would receive annual education through planned in-services and as needed. Review of the Kentucky Revised Statutes (KRS) 209.032, effective 07/15/2014 and amended on 07/15/2024, revealed a vulnerable adult services provider, such as a long-term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation - Administrative regulations - Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Registered Nurse (RN)4 revealed a hire date of 01/28/2025, but the nurse aide abuse registry and KACMR check was not completed until after RN4's hire date, on 01/30/2025. Also, there was no documentation to support RN4 had completed abuse training. 2. Review of the personnel file for RN9 revealed a hire date of 01/24/2025, but the nurse aide abuse registry and KACMR check were not completed until after RN9's hire date, on 02/05/2025. Also, there was no documentation to support RN9 had completed the abuse training. 3. Review of the personnel file for Certified Nursing Assistant (CNA)23 revealed a hire date of 01/24/2025, however, her nurse aide abuse registry and KACMR checks were not completed until 02/13/2025. Additionally, there was no documentation to support CNA23's abuse training was completed. 4. Review of the personnel file for CNA24 revealed a hire date of 01/24/2025, however, there was no evidence to support the employee's criminal background check or the nurse aide abuse registry check were completed. Further review revealed no documentation to support the KACMR was checked. Also, review of CNA24's personnel filed showed no documentation that the abuse training had been completed. 5. Review of the personnel file for CNA25 revealed a hire date of 02/04/2025. Continued review revealed no documentation to support the CNA had completed abuse training. 6. Review of the personnel file for CNA26 revealed a hire date of 02/11/2025. Further review revealed no documentation to support the CNA had completed the abuse training. 7. Review of the personnel file for CNA14 revealed a hire date of 11/13/2024. Continued review revealed no documentation to support a criminal background check, nurse aide abuse registry check, or KACMR check were completed. Also, there was no documentation to support the CNA had completed the abuse training. 8. Review of the personnel file for CNA19 revealed a hire date of 03/24/2024 with no documentation to support the facility had completed a criminal background check, nurse aide abuse registry check, or KACMR check. Further, there was no documented evidence to support the CNA had completed abuse training. 9. Review of the personnel file for the former administrator revealed no hire date was provided. Further review revealed no documented evidence to support the nurse aide abuse registry check was completed. Continued review of the personnel file revealed the facility had completed the KACMR check on 01/17/2024 with the criminal background check completed on 01/04/2024. Additionally, there was no documentation to support the administrator had received abuse training. In an interview with the Administrator, on 02/13/2025 at 11:00 AM, she stated the two staff persons in Human Resources were responsible for completing the required pre-employment checks for newly hired employees. The Administrator stated there was a background check, a CNA abuse registry check, and one other check required for all newly hired employees. She stated the reason for these checks was to ensure there was no one working in the facility who was convicted in a court of law for abuse, a felony, or certain drug charges. The Administrator stated her expectation of the staff was for these checks to be completed prior to the new employee stepping foot inside the building. She stated if these checks were not completed prior to a new employee reporting to work at the facility, it was possible for them to potentially hurt one or more of the residents. She stated the current owners of the facility took over on 09/01/2024, thus had no knowledge of the employees background checks who were hired before then Further, the Administrator stated abuse training was completed upon hire, during orientation. In an interview with the Regional [NAME] President of Talent and Acquisition, who was currently filling the Human Resources role until they hired a permanent Human Resources person, on 02/13/2025 at 11:05 AM, regarding the pre-employment checks required for newly hired employees, she stated she and the other Human Resource staff person were responsible for completing the required pre-employment checks. She stated they completed a criminal background check that included the Office of Inspector General (OIG) exclusions check, and she stated it was outsourced through a contracted agency. The Regional [NAME] President of Talent and Acquisition stated there was also a KBN misconduct check completed, along with a license verification. She stated these checks were required to be completed before the new employee was allowed to walk inside the building. Further, she stated if the checks were not completed before the orientation, the new employee would be sent home until all the proper checks were completed. In continued interview, she stated any employee who was hired prior to 09/01/2024 would have had their background checks completed by the previous owner of the facility and anyone hired after 09/01/2024 was processed through them.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made for one of five sampled residents (Resident (R) 79). On12/09/2024, Certified Nursing Assistant (CNA) 14 alleged that while changing R79, the resident become combative and CNA13 was observed to have choked the resident at approximately 5:20 AM. CNA 14 reported the alleged abuse at 8:37 PM to administration, which was approxmiately 15 hours after the incident was observed and delayed the facility's investigation of abuse. The findings include: Review of the Facility's policy titled, Abuse, Neglect, and Exploitation, date implemented 02/01/2024 and date revised 02/01/2024, revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Further review of the policy revealed the facility would have written procedures that included reporting of all alleged violation to the Administrator, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames: Immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse. Review of the Facility Investigation Initial Report dated 12/09/2024, revealed the incident occurred on 12/09/2024 at 5:24 AM but was not reported to the Administrator until 12/09/2024 at 8:37 PM. Family Member (F)4 was notified on 12/2024 at 9:00 PM (no day specified on the form). In a description of the incident, the Interim Administrator (IA) reported that at 8:37 PM on 12/09/2024, she received a call from the Staffing Coordinator (SC)19 who had a brief conversation with CNA14 CNA14 stated on the morning of 12/09/2024 around 5:20 AM she witnessed CNA13 choke R79, while providing care. CNA14 stated R79 had soiled her clothing and was being changed when she grabbed onto CNA13. CNA14 stated this made CNA13 angry and she reached over and forcibly choked R79. R79 gasped for air when the choke hold was released. CNA13 was not at work and was unable to be reached by phone. CNA13 was placed on suspension once reached. CNA14 was in-serviced after the reporting about the procedures on abuse identification and immediate reporting. Police were notified at 9:20 PM and arrived at the facility around 9:30 PM to take CNA14's statement. R79 was assessed at 10:30 PM on 12/09/2024 and there was no evidence of injury (bruising, scratches, bleeding, change in voice, hoarseness, or shortness of breath). The initial report was filed on 12/09/2024 (no time indicated) by IA. Review of the Facility's Five (5) day follow up investigation, dated 12/13/2024, revealed that R79 was examined by the Administrator, a CNA, and a Police Officer and there were no physical signs of abuse. The IA interviewed all staff on shift the night of the incident and Social Services (SS) reviewed all residents to be interviewed on the night shift assignments. The Director of Nursing (DON) with her team performed skin assessments on all vulnerable residents on the unit. No residents indicated any concerns and skin assessments were free from bruising or injury. Further review of the investigation packet only contained the interview sheets and not the skin assessments. There was only one witness to the incident (R14) who stated that CNA13 was cleaning up R79 and R79 began to fight. CNA13 stated she did not choke R79 and did not know why someone would report her as doing so. She stated that R79 had a bowel movement and that CNA14 came in to help her clean up R79. They bathed and dressed R79. The two nurses (no names given in the report) that normally supervised CNA13 and CNA14 stated that there were no known or alleged complaints against either CNA. Both nurses stated they were in and out of residents' rooms all night and never witnessed any concerns with resident care. Per a statement made by an unnamed nurse and CNA13, she was in the room while CNA13 was giving R79 a bed bath. All staff working the night of the incident were trained again on abuse and immediate reporting requirements. The Incident Investigation packet had a list of all staff that received this training on 12/09/2024. Review of R79's Electronic Medical Record (EMR) revealed R79 was admitted to the facility on [DATE] with the medical diagnoses of dementia, hypertension, and hyperparathyroidism. Review of R79's quarterly Minimum Data Set (MDS) from 10/10/2024 revealed that R79 had a Brief Interview for Mental Status (BIMS) of 03, severe cognitive impairment. The State Survey Agency (SSA) surveyor requested the Police Investigation Report from responding police department on 02/10/2025 at 11:28 AM. However, no report was provided for review. Observation of R79 on 02/04/2025 at 10:37 AM revealed the resident was sitting in the common area of the locked women's unit, dressed and clean. There were no signs of bruising or injury noted. She was not able to be interviewed. She only smiled when the SSA surveyor spoke with her. In an interview with F4 on 02/06/2025 at 9:12 AM he stated the facility called and notified him that R79 was placed in the shower by her caregiver when the resident became agitated and aggressive. He stated the facility reported the resident's caregiver choked R79. Further, he stated he was not aware of any mistreatment of the resident since. On 02/10/2025 at 10:54 AM, the State Survey Agency (SSA) surveyor attempted to call the witness, CNA14. The CNA no longer worked at the facility and the phone number provided was no longer in service. On 02/10/2025 at 10:56 AM in a phone interview with CNA13 she stated that she took care of R79 the entire thirteen (13) months she was employed at the facility. CNA13 stated that R79 was often combative with staff when they were trying to change her after incontinence or when she was getting a shower. She stated she was suspended over an incident that occurred with R79 and was not allowed to return to work until the incident was investigated. Per the interview, she stated the CNA (CNA14) reported to staff that she had been rough and hit the resident. CNA13 stated the facility had unsubstantiated the incident. On 02/10/2025 at 2:01 PM in a phone interview with the Interim Administrator (IA), she stated she remembered making the report. She stated the original verbal report of the choking incident went to Staffing Coordinator (SC). She stated the SC called her at approximately 8:30 PM on 12/09/2024 to report the incident of abuse. The IA stated she had just arrived home and turned around and went back to the facility and took the statement from CNA14. The IA stated she then called the police, and they came and did an exam of R79 with the IA. Per the interview, she stated the police looked for marks that would signify any abuse. The officer used a flashlight to look at R79's neck. She further stated that once the police officer left the facility, she instructed her staff to complete another exam to make sure nothing was missed. The IA stated she could not found any evidence of the abuse. In continued interview, with the Interim Administrator (IA), on 02/10/2025 at 2:01 PM, she stated she talked to all the staff and no one reported they saw or heard anything (on the day of the alleged incident). The IA stated that after this incident they suspended a couple of CNAs. CNA13 was also placed on suspension. She stated that she left before the investigation was completed on CNA13. The Administrator stated the police officer contacted her on her last day at the facility and stated he did not believe the abuse occurred but thought that staff made up allegations to get back at the other. The IA stated CNA14 delayed her reporting of the incident. On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she said that CNA14 reported she was in the room with another CNA (CNA13) when R79 became combative. She stated CNA14 reported CNA13 had placed her hands on R79's neck and choked her. Per the interview, the DON stated her expectation of the staff was for staff to report allegations of abuse immediately. The DON stated staff should ensure the resident was out of harms way. Then, after ensuring the safety of the resident, the nurse , DON, or Administrator should be contacted. Further, she stated the reporting CNA (CNA14) was sent home and CNA13, the alleged perpetrator, was put on leave. She stated the allegation was not substantiated and CNA13 was brought back on day shift at the recommendation of Human Resources (HR). On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated that she was not employed at the facility when the incident with CNA13 and R79 occurred. Her expectation was if there was an allegation of abuse staff should make sure the resident was safe and tell the nurse about the allegation immediately. Then the nurse would make her aware of the situation. The staff member that was the alleged perpetrator would be taken off work until the allegations were investigated.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 22 sampled residents, (Resident (R) 22). The facility failed to develop R22's comprehensive care plan regarding a SoftPro Ambulating ankle foot orthoses (AFO) Boot (an ankle foot orthoses used to treat mild to moderate lost range of motion of the ankle/foot and to facilitate assisted weight bearing). The finding include: Review of the facility's policy, Comprehensive Care Plan Guideline, dated 05/22/2018, revealed the facility ensured appropriateness of services and communication that met the resident's needs, severity/stability of condition, impairment, disability, or disease in accordance with state and federal guidelines. Review of the facility's policy, Resident Rights Guidelines, dated 02/15/2024, revealed the facility ensured resident rights were respected and protected and provided an environment on which they could be exercised. Review of R22's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 05/25/2020, with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, cerebral infarction and dementia. Review of R22's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/02/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he was cognitively intact. Review of the comprehensive-person centered care plan for R22, dated 01/02/2025, revealed no documented evidence of a care plan to address the resident wearing a SoftPro Ambulating AFO boot on his left foot. Observation on 02/03/2025 at 1:35 PM, revealed R22 could not self-ambulate in his wheelchair due to wearing a broken SoftPro Ambulating AFO Boot on his left foot. Further observation revealed R22's wheelchair footrest was not elevated to keep the resident's foot from dragging on the floor. Observation on 02/03/2025 at 3:15 PM, revealed R22 was wearing a SoftPro Ambulating AFO boot on his left foot, asking staff to lift his foot and place it on the footrest of his wheelchair. Observation between 02/03/2025 and 02/12/2025 at various times revealed R22 was wearing the SoftPro Ambulating AFO boot around the facility. In interview with R22 on 02/06/2025 at 9:10 AM, he stated his SoftPro Ambulating AFO boot was broken, and the Director of Nursing (DON) informed him she was going to order him a new boot. In interview with the DON on 02/06/2025 at 9:23 AM, she stated she was aware R22's SoftPro Ambulating AFO Boot was broken, and she had ordered another boot. The DON stated she was unaware of Resident 22 not being care planned for the boot. The DON stated she assumed the resident was care planned for the boot as he had been wearing it for sometime. In an interview with Minimum Date Set Coordinator (MDSC) on 02/12/25 at 10:37 AM stated she has been at the facility for almost two years. The MDSC stated she completes the care plans and that all nurses in facility have access to complete a care plan. The MDS Coordinator stated if a resident was admitted she completed the care plan the next day. The MDS Coordinator stated nurses could complete the care plan under evaluations then select the admission assessment located where they could complete a baseline care plan. The MDS Coordinator stated the facility's version of baseline consist of basic activities of daily living, support need, and anything a resident may be at risk. In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated comprehensive care plans should be updated within 24 hours of admission, so the correct care could be provided for the resident. The Administrator stated baseline and comprehensive care plans were very important for patient care. She stated the facility provided the best quality of care to all residents and R22's care plan not being developed (to include the AFO) could just possibly be an oversight. In additional interview with the DON on 02/13/2025 at 10:23 AM, she stated it was very critical any resident's baseline and comprehensive care plans were developed or updated in a timely manner. The DON stated comprehensive care plans should be completed seven days after the completed comprehensive (MDS) assessment. Additionally, the DON stated documentation in the progress notes for R22 should have included any occupational and physical therapy notes regarding the use of the SoftPro Ambulating AFO Boot the resident was issued and wearing.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were treated with dignity and respect in a manner that enhanced the residents quality of life for one (1) of nineteen (19) sampled residents (Resident #66). On 06/22/2023, Resident #66 was found in his/her room, with his/her clothing, brief, linens, and bed saturated with urine which was also puddled on the floor. Two (2) staff proceeded to place Resident #66 into a blanket fashioned hammock style and carried the resident out of his/her room into the hallway to the shower room. Interview on 06/29/2023 at 10:15 AM, revealed Resident #66 expressed he/she was embarrassed, upset, and cried. The findings include: Review of the facility's policy titled, Resident Rights, dated February 2021, revealed employees were to treat all residents with kindness, respect, and dignity. Continued review revealed all residents were guaranteed basic rights which included: a dignified existence; to be treated with respect; kindness; and dignity. Review of Resident #66's Admission Record revealed the facility admitted him/her on 12/06/2019, with diagnoses of Schizoaffective Disorder, Anxiety Disorder, Major Depressive Disorder, Dementia, Bladder Disorder and Bipolar Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Continued review of the MDS, section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed rejection of care behavior occurred one (1) to three (3) days in the past fourteen (14) days. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, 1/2 inch wide on his/her left upper arm. When the SSA Surveyor asked Resident #66 if he/she was currently in pain, the resident shook his/her head side to side indicating no. Resident #66 additionally stated he/she cried and had been embarrassed and upset. In an interview on 06/29/2023 at 10:05 AM, Resident #1 stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 stated, his/her roommate did not want them (staff) to take him/her to the shower, so they slid him/her across the floor. Resident #1 further stated Resident #66 cried that night and staff kept him/her (Resident #1) awake that night cleaning the room up. In an interview on 06/28/2023 at 2:35 PM, Certified Nurse Aide (CNA) #104 stated sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she kept smelling the odor of urine on the C-wing Hall. CNA #104 stated she had looked in on Resident #66; however, had not physically checked the resident for incontinence care since starting her shift at 7:00 PM. CNA #104 stated she had not received report from the off going staff at shift change at 7:00 PM. CNA #104 reported as soon as starting her shift, she assisted with passing out residents' dinner trays and feeding residents. She stated sometime around 7:15-7:20 PM, the CNAs began picking up garbage, getting dirty laundry to the laundry room and getting their carts. The CNA stated she went to the door of Resident #66's room around 8:30-9:00 PM, to just to lay eyes on him/her; however, she did not go into the resident's room. She stated she was doing her other cleaning duties and kept smelling urine. In a continued interviewed with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated on the morning of 06/22/2023, sometime between 1:00 AM and 2:00 AM, the CNA went into Resident #66's room to check on him/her. She stated when she turned on the light she immediately saw urine soaked sheets and when she checked Resident #66, the resident was curled up in a fetal position, had on a shirt, pants and a brief, and his/her head was at the foot of the bed. According to CNA #104, Resident #66's brief was swelled up and the resident was soaked, wet from head to toe in urine, and the floor was also wet with urine, and there were several gnats flying around. CNA #104 stated she tried to assist Resident #66 to get up so she could change him/her; however, Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked them for assistance. CNA #104 stated CNA #120 came to assist her and they wanted to get Resident #66 into a wheelchair; however, the resident stayed curled in a fetal position and refused to get into the wheelchair to go to take a shower. She stated they tried coaxing, tried promising Resident #66 a soft drink, but could not get him/her to get up, and when she tried to assist the resident to sit up, he/she kicked at them. The CNA stated Resident #66 kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. In additional interview on 06/28/2023 at 2:35 PM, CNA #104 stated after numerous attempts to get Resident #66 cleaned up she and CNA #120 decided to just carry the resident in his/her blankets to the shower room. She stated they picked Resident #66 up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from the resident's room. The CNA stated Resident #66 did not seem upset and did not fight or curse once they lifted him/her in the blanket. CNA #104 stated they carried Resident #66 into the shower room, sat him/her on the floor on his/her bottom, then got on each side of the resident and lifted him/her up to the shower chair and completed a shower. She stated after the shower they wheeled Resident #66 back to his/her room, and Resident #66 sat in the shower chair while they cleaned the resident's room. According to CNA #104, the mattress had to be thrown out due to having a split in it and being saturated with urine. CNA #104 further stated she completed the shower sheet for Resident #66, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders from being wet for so long. In an interview on 06/28/2023 at 1:21 PM, CNA #120 stated she assisted CNA #104 with carrying Resident #66 into the shower room in a blanket cradle, in the early morning hours of 06/22/2023, due to the resident refusing to get out of bed to be cleaned up. CNA #120 stated she felt at the time that was the safest way they could have transported Resident #66, due to him/her kicking at them and refusing to stand up. She stated once she and CNA #104 were into the shower room with Resident #66, CNA #84 went back to resident's room and began mopping and cleaning in the room. CNA #120 stated there had been urine dripping from the bed mattress, onto the floor, and under the bed, in the bed and Resident #66 had been completely saturated in urine. She stated Resident #66 kept stating, I can't touch the floor, I will die. Further interview, on 06/28/2023 at 1:21 PM, with Certified Nurse Aide (CNA) #120, she stated there was so much urine everywhere they were afraid of being shocked due to the bed being plugged in to the electrical outlet, so they unplugged the bed. Per CNA #120, they tried to clean half the floor in order to get Resident #66 out of the room; however, they could not get the resident to get up out of the bed. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused by the way they transferred him/her, and transferring the resident by blanket cradle was the only choice they had at that time. CNA #120 further stated she was asked about the incident on Thursday night when she worked her next shift and was contacted by phone on Friday at 8:56 PM by [NAME] President (VP) of Operations who told her that she was suspended. In an interview on 06/27/2023 at 5:12 PM, Licensed Practical Nurse (LPN) #37 stated she assisted CNA #120 and CNA #104, and CNA #84 with Resident #66 the night of the incident. LPN #37 stated Resident #66 had been refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with the staff. LPN #37 stated normally if Resident #66 refused care, they could bribe him/her with drinks or a snack; however, could not bribe him/her at that time. The LPN further stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, they did not drag the resident, and he/she was not kicking or resisting in the blanket. LPN #37 additionally stated she held the door open to the shower room. The LPN stated the mattress was wet and had to be thrown away, and all of Resident #66's clothing was soaking wet. LPN #37 further stated she had never seen the resident that wet. In an interview on 06/29/2023 at 8:21 AM, with CNA #84 when she, CNA #120, and CNA #104 initially went to Resident #66's room they were attempting to get Resident #66 up so they could clean him/her up. CNA#84 stated Resident #66 was curled in a fetal position, was saturated in urine, including his/her clothes and shoes, and would not get up for staff. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed to go get another CNA on the other hall to assist and by the time she got back to Resident #66's room, CNA #120 and CNA #104 already had Resident #66 in a blanket, and were carrying him/her to the shower room. The CNA stated Resident #66 was not resisting or fighting, but was stating, I am not alive, I am dead. CNA #84 stated she went in the shower room with them and assisted with getting Resident #66 into the shower chair and it was difficult to maneuver the resident into the shower chair. Continued interview with the Certified Nurse Aide (CNA) #84, on 06/29/2023 at 8:21 AM, she stated she then went to Resident #66's room and began cleaning the room. CNA #84 stated urine was everywhere, and it appeared to also was coming from inside the mattress and leaking onto the floor. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats flying around in the room. The CNA stated when she took the mattress out of the room there was a wet trail from it down the hall, and she had to mop that area also. CNA #84 stated no matter anyone's mental capacity, they should stay clean, and Resident #66 needed out of that room and into the shower. CNA #84 stated it would have been neglect if we had left Resident #66 in that condition. During an interview on 06/29/2023 at 4:23 PM, CNA #88 stated she cared for Resident #66 on 06/21/2022 on the 7:00 AM to 7:00 PM shift, before CNA #104 took over the resident's care. CNA #88 stated she checked and changed Resident #66's brief the last time around 4:00 PM (CNA #104 went to change the resident's brief between 1:00 AM and 2:00 AM, approximately nine [9] to [10] hours after he/she was last changed). The CNA further stated she then passed residents' dinner trays and completed other tasks and left the facility around 7:00-7:15 PM. In an interview on 06/28/2023 a 4:00 PM, the Director of Nursing (DON) stated she was contacted by Registered Nurse (RN) #11 on 06/22/2023, with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed the RN to go do a skin assessment on Resident #66. She stated that RN #11 contacted her after the skin assessment and reported only a small red area to the side of Resident #66's face. The DON stated although the way the resident was transported was not the conventional way to transport residents, staff felt it had been the safest way. She stated staff should have reached out to the nurse or thought the incident out further before proceeding. The DON further stated that she did not feel it had been deficient practice because taking everything into consideration she felt staff had done the best they could at the time. The DON additionally stated she was more bothered that Resident #66 and his/her bed had been wet. In an interview on 06/29/2023 at 10:40 AM, the [NAME] President of Operations (VPO) stated he had been contacted on the morning of 06/22/2023 by the [NAME] President of Clinical Services (VPCS), and the DON. The VPO stated at that time the incident was presented as one (1) staff overhearing a conversation between two (2) other staff. VPO stated he interviewed Resident #66 on 06/23/2023, and the resident had no recollection of the shower incident. Further, the VPO stated he reviewed the facility's video footage and determined the resident was carried by staff to the shower room, in a hammock fashioned blanket. In an interview on 06/28/2023 at 11:28 AM, the Executive Director (ED) stated she was not notified of the incident involving Resident #66 until Saturday 06/23/2023 as she had been off work.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report immediately, but no later than two (2) hours allegations of abuse for one (1) out of nineteen (19) sampled residents (Resident #66). Registered Nurse (RN) #11 reported to the Director of Nursing (DON) on 06/22/2023 that she overheard staff state Resident #66 was dragged to the shower, sprayed off, and thrown in his/her bed. Further, she noted the resident had a reddened area to his/her face. Additionally, observations by the State Survey Agency (SSA) surveyor revealed a light brownish discolored area approximately one (1) inch long, and 1/2 inch wide on the resident's left upper arm, which the resident stated occurred during the transfer to the shower. However, the allegations were not reported to the SSA until 06/24/2023, approximately two (2) days after the incident occurred. In an interview with the resident's roommate (Resident #1) he/she stated the resident was crying and kept him/her up all night. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, not dated, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed willful, as used in this definition of abuse, meant the individual acted deliberately, not that the individual intended to inflict injury or harm. Further review revealed that all allegations of abuse would be 1.) reported to the Executive Director (ED) immediately. 2.) The facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required. Further review revealed the timing of reporting events that caused the suspicion of abuse that resulted in serious bodily injury was to be reported immediately, but not later than two (2) hours after forming the suspicion; and if the event did not result in serious bodily injury, the individual was to report the suspicion not later than twenty-four hours after forming the suspicion. Review of Resident #66's Admission Record revealed the facility admitted the resident on 12/06/2019 with diagnoses to include: Schizoaffective Disorder, Bipolar, Anxiety Disorder, Major Depressive Disorder, Dementia, and Bladder Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of MDS section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed the resident was assessed to reject his/her care one (1) to three (3) days in the past fourteen (14) days. Review of the facility's initial investigation dated 06/24/2023 completed by the [NAME] President of Operations (VPO), revealed an allegation of physical abuse was received on 06/24/2023, which alleged that upon providing incontinent care to Resident #66, the resident was transferred with a blanket cradle to the shower room versus traditional shower chair. Continued review of the investigation revealed Certified Nurse Aides (CNAs) #120, #104, #84, and Licensed Practical Nurse (LPN) #37 completed the transfer. A skin assessment had been completed with mild redness noted on the resident's right side of his/her face. Further review revealed that all staff who were involved in the transfer had been suspended pending investigation. Review of the Facility's 5-day investigation, that was incorrectly dated for 07/21/2023 (as this date had not yet occurred) revealed a shower sheet was completed post shower that showed red areas of irritation. In an interview with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated she completed the shower sheet for Resident #66, the morning of 06/22/2023, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders. Review of the facility's witness statements attached with the facility's investigation were signed with completion dates of 06/23/2023. Review of the email confirmation provided by the facility revealed the state agency was notified, on 06/24/2023 at 2:38 PM, of alleged physical abuse. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, 1/2 inch wide on his/her left upper arm. Interview on 06/29/2023 at 10:05 AM with Resident #1, he/she stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 further stated he/she did not want them to take him/her to the shower, so they slid him/her across the floor. Resident #1 stated, I couldn't sleep for them (staff) cleaning and him/her (Resident #66) crying. Interview on 06/28/2023 at 2:35 PM with Certified Nurse Aide (CNA) #104 revealed sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she smelled a urine odor around the C-wing Hall. CNA #104 stated she had looked in on Resident #66 but had not checked to see if the resident needed incontinent care. CNA #104 further stated she did not receive a report from the off-going staff at shift change at 7:00 PM. According to the CNA, Resident #66 would get up around two (2) AM and come out of his/her room holding onto the top of his/her pants/brief. She stated she would assist with changing the resident at that time. Further, CNA #104 stated on the morning of 06/22/2023, Resident #66 did not get up so sometime between 1:00-2:00 AM, she went into Resident #66's room to check on him/her and when she turned on the lights, she immediately saw soaked sheets. She stated the resident was curled in the fetal position, had on a shirt, pants, and a brief, and his/her head was at the foot of his/her bed. Certified Nurse Aide (CNA) #104 stated, on 06/28/2023 at 2:35 PM, Resident #66's brief was swelled up and she/he was wet from head to toe, and the floor was wet. CNA #104 further stated she tried to assist Resident #66 to get up so she could change him/her but Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked for assistance. She stated she and CNA #120 could not encourage Resident #66 to go to the shower. CNA#104 stated they wanted to get Resident #66 into a wheelchair, but the Resident stayed curled in a fetal position. CNA #104 further stated she, along with, CNA #120, and CNA #84 tried coaxing, tried promising him/her a soft drink and could not get him/her to get up. CNA #104 stated she tried to assist Resident #66 to get up and Resident #66 tried to kick at them, and the Resident kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. After numerous attempts to get Resident #66 cleaned up, she stated they decided to carry Resident #66 in his/her blankets to the shower room. During the interview, the CNA stated she and CNA #120 picked the resident up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from Resident #66's room. CNA #104 stated they carried the resident to the shower room and sat the resident on the floor on his/her bottom. She stated staff got on each side of the resident and lifted him/her to the shower chair and completed the resident's shower. During an interview on 06/28/2023 at 1:21 PM with Certified Nurse Aide (CNA) #120, she stated she assisted CNA #104 with carrying Resident #66 into the shower in a blanket cradle, in the early morning hours of 06/22/2023. She stated Resident #66 refused to get out of bed to be cleaned. CNA #120 further stated she felt that was the safest way they could transport the resident due to him/her kicking at them and refusing to stand. CNA #120 stated that while she and CNA #104 transported Resident #66 to the shower, CNA #84 was mopping and cleaning the resident's room. CNA #120 stated there was urine on the floor, under the bed, in the bed, dripping from the mattress, and Resident #66 was completely saturated. She further stated the Resident was stating I can't touch the floor, I will die. The CNA #84 stated there was so much urine on the floor, they were afraid of being shocked as the bed was plugged into the electrical outlet. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused and transferring the resident by a blanket cradle was the only choice they had at the time. CNA #120 stated the [NAME] President of Operations (VPO) contacted her by phone on Thursday night, 06/22/2023, on the next shift she worked, and questioned her about the incident. She further stated the VPO contacted her again by phone on Friday, on 06/23/2023 at 8:56 PM, and she was notified that she had been suspended. Interview on 06/29/2023 at 8:21 AM, with Certified Nurse Aide (CNA) #84, she stated when CNA #120, and CNA #104 went into Resident #66's room, he/she was curled in a fetal position and would not get out of bed. CNA #84 stated Resident #66 was saturated in urine, including his/her clothes and shoes. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed by CNA #104 to go get another CNA on the other hall to assist and by the time CNA #84 got back to Resident #66's room, CNA #120 and CNA #104 had already had Resident #66 in a blanket, and they were carrying him/her out of the resident's room to the shower room. CNA #84 stated Resident #66 was not resisting or fighting but was stating, I am not alive, I am dead. CNA #84 stated she went into the shower room with them and assisted with getting Resident #66 into the shower chair and added, it was difficult to maneuver the resident into the shower chair. CNA #84 stated that she then went to Resident #66's room and began cleaning the room. She stated there was urine everywhere, and that urine appeared to be coming from inside of the mattress. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats in the room. CNA #84 further stated that when she took the mattress out of the room there was a wet trail down the hall, and she also had to mop that area. CNA #84 stated, no matter anyone's mental capacity, they should stay clean, and the resident needed out of that room. CNA #84 stated it would have been negligent if the staff had left Resident #66 in the condition, he/she was found in and therefore was not abuse. During an interview with Licensed Practical Nurse (LPN) #37, on 06/27/2023 at 5:12 PM, she stated she had assisted CNA #120, CNA #104, and CNA #84 with Resident #66. LPN #37 stated that Resident #66 was refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with them. Per the interview, LPN #37 stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, adding, they did not drag him/her. Further, LPN #37 stated she held the door open as CNA #104 and CNA #120 brought the resident to the shower room. In an interview on 06/29/2023 at 9:51 AM with Registered Nurse (RN) #11, she stated that on 06/22/2023 around 6:50 PM, she overheard CNAs (unknown) discussing Resident #66 being dragged to the shower room, sprayed off, then thrown into bed by staff. RN #11 stated she immediately contacted the Director of Nursing (DON) and made her aware. She stated she was instructed by the DON to complete a head-to-toe assessment of Resident #66 and to report her findings to the DON. RN #11 further stated that the only area she noted was a reddened area to the resident's face. Further, she stated Resident #66's roommate (Resident #1) and Resident #66 both corroborated the same scenario that Resident #66 was dragged. RN #11 further stated that Resident #1 stated that Resident #66 kept him/her up all night crying. Interview on 06/28/2023 at 4:00 PM, with the Director of Nursing (DON), she stated she was contacted by RN #11 on 06/22/2023 with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed RN #11 to complete a skin assessment on Resident #66. She stated RN #11 contacted her after the skin assessment and reported only a small, reddened area on the side of Resident #66's face. She further stated that although this was not the conventional way to transport residents, she felt this was the safest way staff could transfer the resident to the shower. The DON stated that the staff should have reached out to the nurse or thought the incident out further. She further stated that she did not feel this was deficient practice but taking everything into consideration she felt staff did the best they could at the time. The DON stated she was more bothered that the resident and his/her bed were wet. In an interview with the Executive Director, on 06/28/2023 at 11:28 AM, she stated she was unaware of the alleged allegations of abuse until she was notified on 06/23/2023. Per the interview, the Executive Director stated she was on vacation at the time the incident occurred. In an interview on 06/29/2023 at 10:40 AM with the [NAME] President of Operations (VPO), he stated he had been contacted on the evening of 06/22/2023 around 7:00-7:30 PM by the [NAME] President of Clinical Services (VPCO), who had just been notified by the DON. Per the interview, he stated that at that time the incident was presented, it was communicated as one staff overhearing a conversation between two other staff. The VPO stated he interviewed Resident #66 on 06/23/2023 and the resident had no recollection of the shower incident. The VPO stated he emailed the State Survey Agency (SSA) on 06/24/2023, to report the allegations of alleged abuse. He further stated that his delay in reporting was because the allegation was reported to him as hearsay. However, review of the facility's policy revealed, the timing of reporting events that caused the suspicion of abuse was to be reported immediately, but no later than two (2) hours after forming the suspicion.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were provided routine respiratory and cardiac assessments per professional standards of practice, and per the resident's person-centered plan of care for two (2) of nineteen (19) sampled residents (Residents #32, and #107). 1. The facility care planned Resident #107 for management of Congestive Heart Failure (CHF) and fluid overload related to his/her diagnosis of Chronic Obstructive Pulmonary Disease (COPD). However, the facility failed to provide routine nursing assessments for Resident #107's respiratory, cardiac, or fluid status. Per interview with Licensed Practical Nurse (LPN) #40 regarding Resident #107's condition on 06/21/2023 and 06/23/2023, the nurse stated the resident had gurgling sounds in his/her chest on 06/21/2023, which worsened on 06/23/2023. When Resident #107's Physician assessed the resident on the afternoon of 06/23/2023, he stated the resident was in fluid overload and gave orders for the resident to be transferred to the hospital. Resident #107 was transferred to the hospital's Emergency Department (ED). Resident #107 was diagnosed with Acute Respiratory Failure with Hypoxia, Acute Renal Failure, Congestive Heart Failure and was admitted to the hospital. 2. Resident #32's Comprehensive Care Plan, initiated 11/13/2022, for altered cardiovascular status revealed the interventions included to monitor/document/report as needed any changes such as edema; and coronary artery disease interventions such as monitor/document/report excessive swelling, dependent edema, and color/warmth of extremities. However, the facility failed to provide documented evidence of provision of routine cardiac assessments for the resident. Interview with a licensed nurse assigned to Resident #32 on 06/26/2023, on the 7:00 AM to 7:00 PM shift, revealed she had not assessed the resident's bilateral lower extremities for edema during her shift. She stated however, she had been asked by the nurse relieving her at 7:00 PM to look at the resident's feet at the time of shift change. The nurse stated she and the other nurse assessed Resident #32 together and the resident was observed to have edema in his/her foot/ankle and no pedal pulse could be felt in either foot. She could not recall which foot, or the color or temperature of the resident's foot. Resident #32 was transferred and admitted to the hospital on 06/26/2023 for right lower extremity edema. Resident #32 was still hospitalized at time of the survey exit. The findings include: In an interview on 06/26/2023 at 11:04 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the facility had no policy to address respiratory assessments, and no criteria for completing Respiratory Assessment Evaluation forms. 1. Review of Resident #107's Admission Record revealed the facility admitted the resident on 09/29/2022. Diagnoses included Unspecified Injury of the Head, Dementia, Atherosclerotic Heart Disease, COPD, Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Kidney Disease, Stage 3, and Congestive Heart Failure. Review of Resident #107's Quarterly Minimum Data Set (MDS) Assessment, dated 05/01/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of status 99 which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed the resident as having disorganized thinking behaviors present that fluctuated and varied in severity. Review of Resident #107's Comprehensive Care Plan revealed the facility care planned the resident related to his/her cardiac and respiratory status, altered due to diagnoses of Coronary Artery Disease (CAD), Hypertension (HTN), CHF initiated on 10/12/2022. Further review revealed a goal for the resident to be free from complications of cardiac problems through the next review date. Continued review revealed interventions included to monitor, document, and report as needed any signs/symptoms of CAD: chest pain or pressure especially with activity; heartburn; nausea and vomiting; shortness of breath; excessive sweating; dependent edema; changes in capillary refill; and color/warmth of extremities. Record review revealed additional interventions included: medications administered as per Physician's order; monitor vital signs as ordered and as needed and notify Physician of significant abnormalities. Review of Resident #107's Care Plan revealed the facility added a new focus on 04/26/2023, noting the resident was at risk for fluid overload related to CHF and pulmonary edema. Per review, the goal was for Resident #107 to remain free of signs and symptoms of fluid overload through the next review date, as evidenced by a decrease in or absence of: edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea, vomiting, dyspnea, congestion, orthopnea, being easily fatigued, and jugular vein distension (JVD). Continued review of the care plan revealed the interventions included: observe for signs/symptoms of fluid overload: anxiety, mood/behavior changes, confusion, edema, shortness of breath, difficulty breathing, increased respirations, difficulty breathing when lying flat, congestion, cough, fatigue, JVD, and sudden weight gain. In addition, review revealed the interventions included to obtain labs/x-rays as per Physician order, and raise head of bed as needed to facilitate breathing. Review of Resident #107's Comprehensive assessment dated [DATE] and signed at 8:55 AM by the Advanced Registered Nurse Practitioner (ARNP) #1 revealed the resident's Chief Complaint was noted as follow up on his/her breathing and CHF. Per review, Resident #107 was on oxygen that day; had Lasix (diuretic medication) 20 milligram (mg) ordered once a day; however, the resident appeared to be in acute overload this morning. Continued review revealed the resident had edema in his/her lower extremities, his/her lung sounds had wheezing scattered throughout, with crackles, and rhonchi throughout; however, was not in respiratory distress. In addition, review revealed ARNP #1 noted Resident #107's acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was unstable, and the resident's Lasix would be increased to twice a day (BID) and his/her laboratory (labs) levels were to be checked on 06/07/2023. Review of Resident #107's Comprehensive Encounter dated 06/07/2023, noted by Advanced Registered Nurse Practitioner (ARNP) #1 as a follow up after changing the resident's Lasix to BID (twice a day) and related to his/her swelling. Per review, Resident #107 was off his/her oxygen and his/her oxygen saturation (O2 sats) were 95% per the nursing documentation. Continued review revealed his/her bilateral extremities had 1-2+ pitting edema. Record review revealed Resident #107 was in no respiratory distress and continued to have rhonchi throughout which sounded slightly better. Further review revealed ARNP #1 was to reduce the evening dose of Lasix, and check the resident's labs on Monday, 06/12/2023. Review of Resident #107's Dietary Progress Nutrition Note dated 06/10/2023 at 11:57 AM, documented during the Nutrition at Risk (NAR) meeting by the Interdisciplinary Team (IDT), revealed the resident's current weight was 140.2 pounds, which was a weight gain of twelve (12) pounds in a five (5) day period. Continued review revealed edema had been noted by the ARNP, who had increased Resident #107's Lasix from 20 mg daily to BID and then due to his/her lab results, the Lasix had been reduced to daily again. Further review revealed due to the multiple diuretic changes with resultant fluid load weight change was as expected. In addition, review revealed continue with weekly weights and nutrition plan of care (POC). Review of the Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac or fluid status after the IDT NAR meeting on 06/10/2023. Review of Resident #7's Comprehensive Assessment note dated 06/12/2023, by ARNP #1 after the resident sustained a fall revealed he/she did not exhibit signs or symptoms of respiratory distress; however, had lung sounds with crackles, rhonchi throughout, two plus (2+) swelling to the bilateral lower extremities. Review of Resident #107's Nurse Progress note dated 06/12/2023 at 10:00 AM, revealed the resident had fallen and was transferred to emergency room (ER) via ambulance. Further review of the note revealed an O2 sat of 97%; however; additional review revealed no documented evidence the nurse further assessed the resident's cardiac, respiratory, or fluid status. Review of Resident #107's Comprehensive Encounter dated 06/13/2023, noted by ARNP #1 revealed the visit was a follow up after the resident sustained a fall and was sent to the emergency room (ER). Per review, Resident #107 had left sided more than right pleural effusions (unusual amount of fluid around the lung), nodular density at the right upper lung with follow-up advised. Continued review revealed there was no convincing evidence for acute Pneumonia or CHF exacerbation. Review revealed Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, crackles, rhonchi throughout unlabored breathing pattern. Review of Resident #107's Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac, or fluid status assessments. Review of Resident #107's 06/15/2023 Comprehensive Encounter Dated 06/15/2023 by ARNP #1 revealed Resident #107 exhibited no signs of respiratory distress; however, had wheezing and rhonchi throughout. Per review, Resident #107 had a decrease in swelling to the bilateral lower extremities, at 1+ pitting edema. Review of Resident #107's Dietary Progress Note dated 06/17/2023 at 12:54 PM, revealed a Nutrtionally at Risk (NAR) note stated the resident's current weight was 138.4 pounds, which was a weight loss of 1.8 pounds from last week. Continued review revealed multiple diuretic changes with resultant fluid load and weight change as expected. Review further revealed there would be continued weekly weights, a nutrition plan of care, and follow by NAR. Review of Resident #107's Nurse Progress Notes revealed however, no documented evidence of nursing staff noting the resident's respiratory, cardiac, or fluid (edema) status. Review of Resident #107's Comprehensive Encounter dated 06/19/2023, noted by ARNP #1 revealed it was a follow up on COPD. Per review, Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, and rhonchi throughout. Continued review revealed Resident #107's COPD was stable, and his/her O2 sats were 97% per nursing documentation. Edema had improved to one plus (1+) non pitting. Review of Resident #107's Nurse Progress notes revealed however, no documented evidence of nursing staff's assessments of the resident's respiratory, cardiac, or edema (fluid) retention. Review of Resident #107's Nurse Progress note dated 06/20/2023 at 4:59 AM, revealed the resident was on one to one (1:1) supervision related to his/her behavior/fall. Continued review revealed Resident #107's lung sounds were clear to auscultation, the resident was sleeping at the time of report, and staff were to continue to monitor. However, further record review revealed no documented evidence staff continued to monitor the resident's condition on 06/20/2023. Review of Resident #107's Respiratory Evaluation dated 06/20/2023 at 3:51 PM, documented by the ADON as a Late Entry revealed there had been no change in the resident's condition. Per review, Resident #107 was confused, experiencing signs of short-term memory loss, required cues; however, his/her current state of confusion was baseline for the resident. Continued review revealed Resident #107's respiratory status was noted as no sign of difficulty breathing, with left lung sounds throughout left lung on inspiration, and wheezes on auscultation, and he/she was not utilizing oxygen. Review of Resident #107's Comprehensive Encounter Note dated 06/22/2023 at 4:00 PM, documented by ARNP #1 revealed a therapist stopped the ARNP to assess the resident's legs which had been swelling off and on for several weeks. Per review, Resident #107's legs had 2-3+ pitting edema with the left weeping fluid from a wound to the left outer calf. Continued review revealed Resident #107 had crackles, and rhonchi throughout (his/her lungs); however, did not exhibit signs of respiratory distress. Further review revealed orders for oxygen as needed and staff to keep the resident's O2 sats greater than 91%. Review of the Nurse Progress note dated 06/22/2023 at 5:00 PM, documented by Registered Nurse (RN) #11 revealed Resident #107 was noncompliant with his/her breathing treatments and Aero chamber use. Continued review revealed Resident #107 continued to remove his/her nasal cannula, had rhonchi throughout all his/her lung lobes, and was hitting at the nurse during his/her breathing treatment. Further review revealed however, no documented evidence RN #11 notified the ARNP or Physician of Resident #107's respiratory status, that he/she kept removing his/her oxygen, and was noncompliant with his/her breathing treatment and Aero chamber use. Review of Resident #107's electronic medication administration record (eMar) revealed on 06/22/2023 at 5:17 PM, the order for Aero Chamber, give 1 unit by mouth every six (6) hours for use with albuterol/Atrovent inhalers, RN #11 noted the resident was hitting at the nurse and chewing on the aero chamber. Review of a Physician's Order dated 04/13/2023 and time 10:45 AM, revealed orders for Oxygen (O2) at two (2) liters per minute (lpm) as needed, keep the resident's O2 saturations (sats) above 91%. However, review of Resident #107's medical record revealed those orders did not flow over to his/her Medication Administration Record (MAR) or Treatment Administration Records (TAR) for the months of May or June 2023. Review of Resident #107's Treatment Administration Record (TAR) dated 06/23/2023 at 7:00 AM revealed his/her O2 sat was noted as 90%. Further review revealed however, no documented evidence the Physician was notified of the resident's decreased O2 sat as ordered. Continued review of the Nurse Progress notes revealed no documented evidence of the nurses assessing and monitoring the resident's respiratory, cardiac, or fluid status on 06/22/2023. Review of Resident #107's MAR for the date of 06/23/2023, revealed an order for Lasix 20 mg dose written at 9:00 AM by ARNP #1 which was given at 12:40 PM by LPN #40. Review of Resident #107's Nurse Progress note dated 06/23/2023 at 3:54 PM, documented by LPN #40 revealed the resident had a one (1) time order related to weeping of his/her left leg; no complaints of pain or discomfort; and continued on antibiotic therapy for cellulitis with no signs or symptoms of adverse reactions noted. Further review revealed however, no documented evidence of the nurse having performed an assessment of Resident #107's respiratory, cardiac or fluid status to include vital signs and O2 sats. Review of the facility's Admission/Discharge/Transfer/Appointment Late Entry Note for Resident #107 dated 06/23/2023 at 4:50 PM, revealed the resident was transferred to the hospital related to shortness of air (SOA). Per review, the transfer was ordered by Physician #60. Review of the hospital emergency room (ER) report dated 06/23/2023 revealed upon arrival to the ER, Resident #107's O2 saturation level was 70% on room air (values under 90% can lead to serious deterioration in a person's health status). In an interview on 06/26/2023 at 10:46 AM RN #11, who cared for Resident #107 on 06/22/2023 on the 7:00 AM to 7:00 PM, stated she did not know too much about the resident; however, recalled he/she refused to wear his/her oxygen often. RN #11 stated at shift change report she was only informed of how residents took their medications, and not really anything about their condition. Per RN #11, she was aware Resident #107 had oxygen because she was the person who contacted the Physician to obtain the order for it a few months back. She stated Resident #107 was on breathing treatments, and usually there was an area on the MAR that had to be completed after giving the respiratory treatments. RN #11 stated she did not perform a head-to-toe assessment of Resident #107, she only assessed his/her lung sounds and documented rhonchi throughout all lobes. She stated she was not aware of Resident #107 having edema, although she normally looked at resident's extremities; however, she had not assessed the resident for edema on that date. According to RN #11, if she observed anything abnormal during an assessment of the resident she would have put it in the progress notes. RN#11 stated that per her documentation in the progress notes for Resident #107, which referred to him/her being non-compliant with the breathing treatment, chewing on the Aero chamber, removing his/her oxygen, and hitting at her, was nothing out the ordinary for the resident. She further stated she should have charted more of Resident #107's abnormal respiratory sounds. In an interview on 06/26/2023 at 1:15 PM, Physical Therapy Assistant (PTA) #1 stated he reported to nursing staff on multiple occasions that the resident had a heart rate of 45-60 and low O2 sats of 63-74%. PTA #1 stated therapy saw Resident #107 five (5) times weekly and the resident always had edema to his/her bilateral lower extremities. In an interview on 06/26/2023 at 1:55 PM, LPN #40 stated she usually got to work at 6:30 AM, did her narcotics count and got report from the off going staff, then checked blood sugars and passed medications. LPN #40 stated she had not seen Resident #107 right away the morning of 06/23/2023, as she started passing medication on the front hall and was working her way toward the back hall where Resident #107's room was located. She stated the CNA reported to her that morning that Resident #107's legs were weeping, and the Therapist had also voiced concerns to her about the resident's legs weeping. The LPN stated she was not sure what time she was initially able to assess Resident #107, and when she did it was hard to get an accurate O2 sat reading as his/her fingers were cold which was normal, and staff always had to warm his/her hands to get the reading. During further interview LPN #40 stated that she wasn't sure of what time she initially assessed Resident #107. LPN #40 further stated that Resident #107's lung sounds usually had gurgle sounds; however, on the day he/she went to hospital the gurgling was a lot worse. LPN #40 stated the facility's process for residents experiencing a change in condition was to contact Physician or ARNP, and contact the ADON and/or DON. She further stated she did not contact anyone because she knew ARNP #1 had seen Resident #107 that morning and made medication changes. In an additional interview on 06/26/2023 at 4:37 PM, LPN #40 stated Resident #107 was noted to be short of air (SOA), and his/her O2 sats were 90%, while sitting in the common area at that time. LPN #40 stated when staff took Resident #107 to his/her room, she put the resident's oxygen on him/her. She stated she did not document the O2 reading in the resident's record because she kept all her information on a piece of paper she carried with her and wrote everything on it. According to LPN #40, she documented on her paper that Resident #107's O2 sats were 90 % and his/her hands were cold as ice and she kept all her papers at home and stated she could send a photo of her notes to the State Surveyors, at the end of her shift. She stated she just overlooked putting the information in the computer in the resident's record. LPN #40 stated she had received report that morning that Resident #107 was not feeling well and the night shift nurse had given him/her a breathing treatment. LPN #40 stated it was important to document assessments and treatments in residents' records, so others would know what was going on with the residents. LPN #40 further stated I should have documented the changes in resident's medical record. In an interview on 06/20/2023 at 5:20 PM, the DON stated she expected nursing staff to perform consistent assessments of residents and document their findings in the medical records. The DON stated she expected her nursing staff to use good nursing judgement, and if any change in condition was picked up on to take action. She stated because the longer you waited the worse a resident's condition would get if action was not taken. The DON further stated she expected the nurses' documentation to be accurate and thorough. In an interview on 06/25/2023 at 3:18 PM, ARNP #1 stated she expected that staff would abide by the facility's policy as far as nursing assessments, and documentation of those assessments went. ARNP #1 stated she relied on the nursing documentation in the residents' chart for when she was assessing and treating the residents. She stated she had not been made aware of Resident #107 chewing on his/her Aero chamber or that he/she had been combative during the breathing treatments. The ARNP stated that was abnormal behavior for Resident #107. According to ARNP #1, when she made changes to a resident's treatment, she told the nurse and if the nurse was not available, she made the ADON aware of the changes. ARNP #1 stated when she listened to Resident #107's lungs and his/her lung sounds were horrible, that was when the extra Lasix dose was ordered. In an additional interview on 06/26/2023 at 10:20 AM, ARNP #1 stated she felt the nursing information regarding the resident's O2 saturation levels and vital signs were accurate during the time she was making medication changes due to the resident's edema and abnormal lung sounds. ARNP #1 stated she did recall receiving a call from nursing staff before Thursday, 06/22/2023, that Resident #107's O2 sats were 75-78 %, and she instructed staff to place oxygen on the resident and the resident's O2 sats came up to 94%; however, there was no documentation in the medical record noting any of this. She stated when she saw Resident #107 on 06/24/2023, she noted Resident #107 was on the schedule for Physician #60 to see the next day and she gave report to ARNP #2 (who worked with Physician #60) regarding Resident #107, as Physician #60 was Resident #107's primary Physician. In an interview on 06/26/2023 at 9:20 AM, the Medical Director stated he relied 100 % on the nurse's documentation to ensure appropriate resident care. The Medical Director stated he expected the nurses to assess residents within their scope of practice and to document their assessments. He stated that if residents were not assessed and the assessments documented that could potentially cause increased risk for residents to get sick or sicker. The Medical Director stated residents needed to be closely monitored, because all the folks had chronic diseases some more that others, and the nurses could quickly pick up on changes in the residents. In an interview with Physician #60 on 06/28/2023 at 10:49 AM, he stated he was very familiar with Resident #107, and felt the resident declined very quickly on 06/23/2023. Physician #60 stated Resident #107 had last been seen on 06/22/2023 by ARNP #1 and she had made some changes. He stated when he saw Resident #107 on 06/23/2023, the resident was pale, cold, fatigued, his/her perfusion was not the best, so he did not waste any time getting the resident to the hospital. Physician #60 further stated he relied heavily on the nurse's documentation to review. The Physician stated he felt Resident #107 was being closely monitored as he/she was being seen by the ARNP #1 three (3) consecutive days. 2. Record review revealed the facility admitted Resident #32 on 10/28/2022, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, and Dementia. Review of Resident #32's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of four (4), which indicated severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident to require one (1) person physical assistance for transfers and ambulation. Observation, on 06/25/2023 at approximately 9:48 AM, revealed Resident #32 lying on his/her bed. CNA #112 was observed to come into the room and assist Resident #32 to a sitting position on his/her bed. Review of Resident #32's Comprehensive Care Plan initiated on 11/13/2022, revealed the facility care planned the resident for altered cardiovascular status with interventions to monitor/document/report as needed any changes in lung sounds on auscultation, edema, changes in weight. Continued review revealed the facility's interventions included monitoring/documenting/reporting any signs and symptoms of coronary artery disease such as excessive swelling, dependent edema, changes in capillary refill, and color/warmth of extremities. Review of Resident #32's Comprehensive Encounter note dated 06/21/2023, documented by the ARNP, revealed the resident was unsteady when he/she walked to the common area. Continued review revealed Resident #32 had some tenderness when his/her right shoe was put on his/her foot. Review of an imaging report dated 06/22/2023 at 12:54 PM, revealed soft tissue swelling of the right ankle. Review of a Telehealth Evaluation note dated 06/26/2023 at 7:04 PM, revealed Resident #32 had two to three plus (2-3 +) pitting edema to the right foot, a pedal pulse could not be found in either foot, and the patient wasn't feeling well overall. Continued review revealed orders were received to send Resident #32 to the ER for evaluation. Further review revealed Resident #32's admitting diagnosis was confirmed on 06/28/2023 to be right lower extremity edema. Resident #32 was still hospitalized at the time of the Survey exit, and the State Survey Agency (SSA) Surveyors were unable to obtain further information. In an interview on 06/27/2023 at approximately 4:37 PM, CNA #78 stated she had been running late for her shift on 06/26/2023, and arrived just before Resident #32 was sent out to the hospital. She stated she was in the room when the ambulance arrived to transport the resident and the resident's foot and ankle were really swollen and the nurse was really concerned about a blood clot. During an interview on 06/27/2023 at approximately 6:00 PM, LPN #45 stated Resident #32 was a little touchy, feely and she kept as far away as possible from the resident. LPN #45 stated she did not believe she had performed an assessment of the resident on the date she worked and was assigned to his/her care. She further stated she used to complete a head to toe assessment on her residents; however, since computer charting had started, we are glued to our computers all the time and she was no longer able to do that. During an interview on 06/28/2023 at approximately 9:41 AM, LPN #40 stated she had taken care of Resident #32 on 06/26/2023 from 7:00 AM to 7:00 PM. She stated she had assessed Resident #32's vital signs including his/her blood sugar; however, had not assessed the resident for edema. The LPN stated she had not charted any assessment of the resident's heart/lung sounds and had not checked the resident for edema that day and therefore, had not charted that either. She stated when the nurse came in to relieve her at 7:00 PM, asked her to check Resident #32's pedal pulses with her she observed the resident had 2-3+ edema to his/her foot. LPN #40 stated neither she or the other nurse could find a pedal pulse on either of Resident #32's feet. She further stated the other nurse immediately got an order to send the resident to the hospital. During an interview on 06/28/2023 at approximately 11:15 AM, CNA #34 stated she had taken care of Resident #32 on 06/24/2023, and the resident had complained of right ankle pain, and his/her ankle was very swollen. She further stated she had told the nurse; however, was unsure if the nurse did anything or what if anything was done after that. During an interview on 06/28/2023 at approximately 11:20 AM, CNA #35 stated she took care of Resident #32 on 06/25/2023, and the resident complained of right ankle pain at that time. CNA #35 stated Resident #32's ankle appeared to be so swollen it was bigger than his/her other foot. She further stated she informed the nurse Resident #32's right ankle pain complaint and of it being really swollen; however, was not sure if the nurse did anything or was not sure what happened after that. During an interview on 06/28/2023 at approximately 3:51 PM, the DON #4 stated she was taught if a resident had a respiratory diagnosis, the nurse should complete and document a full respiratory assessment. She further stated the day shift nurse (LPN #40) should have performed a full assessment of Resident #32 on 06/26/2023, and the resident should have been assessed when he/she complained of pain. During an interview on 06/28/2023 at approximately 5:23 PM, the current Medical Director stated Resident #32 was one (1) of the residents he had under his care. He stated he recalled when Resident #32 fell ; however, did not remember the resident receiving x-rays. He stated his services overlapped with the ARNP in house and he did not always receive calls when the ARNP gave orders on the residents. The Medical Director stated x-rays would show fractures; however, not ligament issues or deep bruises. He further stated he would have expected the nurses to have assessed Resident #32's right lower extremity and monitor it for any changes and document their findings. During an interview on 06/28/2023 at approximately 5:32 PM, Executive Director (ED) #2 stated she would expect nurses to use good nursing judgement, and they should pick up on any issues with residents. ED #2 stated if nurses did not pick up on issues with residents, a delay in care could cause the resident to have a worsened condition. She further stated good documentation assisted with continuity of care and a large part of the nurses' jobs were to assess and monitor residents and document their findings. 47852

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan was implemented for seven (7) of nineteen (19) sampled residents, (Residents #5, #15, #32, #44, #81, #102, and #107). 1. Resident #32's Comprehensive Care Plan included interventions for fall prevention such as being supervised while residing on the secured unit, assisting with physical activity, and ensuring he/she wore appropriate footwear when out of bed. On 06/20/2023 and 06/21/2023, Resident #32 was found sitting on the floor in his/her room. The facility failed to provide the supervision and assistance Resident #32 required as per his/her Comprehensive Care Plan. In addition, Resident #32's Comprehensive Care Plan included interventions for the resident's cardiovascular status such as monitoring, documenting, and reporting as needed dependent edema, changes in lung sounds on auscultation, excessive swelling, and color/warmth of extremities. However, the facility failed to provide documented evidence of routine cardiac assessments. On 06/26/2023, Resident #32 was transferred and admitted to the hospital for right lower extremity edema. 2. Resident #107's Comprehensive Care Plan included interventions for the resident's risk for falls. On 06/12/2023, Resident #107 sustained a witnessed fall from a wheelchair in the common area when trying to pick something up off the floor. Resident #107 sustained a small laceration to the left side of his/her forehead, and two (2) small skin tears to his/her right arm, complained of pain to his/her hip and was sent out to the emergency room for evaluation and treatment. 3. Review of Resident #44's Comprehensive Care Plan revealed care plan interventions for fall prevention which included to assist the resident to bed if experiencing lethargy. On 06/21/2023, Resident #44 went to sleep in a chair in the common area, with his/her head leaning on his/her rolling walker and sustained a fall which resulted in a bruise to his/her chin. Resident #44's Comprehensive Care Plan revealed interventions for the resident's Activities of Daily Living (ADL) which included to set up and assist with oral care daily and as needed. Observation of Resident #44, on 06/25/2023 revealed the resident had food particles caked onto his/her teeth and crumbs noted to be coming out of his/her mouth when he/she was speaking. 4. Resident #5's Comprehensive Care Plan included interventions for fall prevention such as wearing nonskid socks when out of bed and to have a fall mat beside his/her bed. However, on 06/17/2023 at 3:30 AM, revealed Resident #5 sustained a fall and was found sitting on the floor in his/her room. Resident #5 was not wearing nonskid socks, and a fall mat was not in place by the resident's bed as per his/her care plan. 5. Resident #15's Comprehensive Care Plan included interventions for fall prevention such as ensuring the resident's call light was within reach, and encourage him/her to use it, and an intervention added on 06/16/2023, for the resident to have every fifteen (15) minute checks. Observation on 06/24/2023, at approximately 9:15 AM revealed Resident #15 lying on his/her bed with eyes closed, and his/her call light lying over the arm of the resident's recliner located at the foot of the bed, out of the resident's reach. Review of Resident #15's every fifteen (15) minute Check Sheet revealed no documentation the checks had been completed as care planned since 06/24/2023 at 5:15 AM, a four (4) hour period. 6. Review of Resident #81's Comprehensive Care Plan revealed care plan interventions for the resident's risk for falls such as, wearing nonskid socks, keep frequently used items in reach, and keep water on nightstand beside bed. On 06/14/2023, Resident #81 sustained a fall and was found by staff sitting on the floor in his/her room. However, Resident #81 was not wearing nonskid socks and his/her bedside table was not in reach from the bed as per the resident's care plan. 7. Resident #102's Comprehensive Care Plan included interventions for the resident's risk for falls which included assist him/her with proper sitting position while in chair, have his/her walking cane within arm's reach, and appropriate nonskid footwear when out of bed. On 06/17/2023, Resident #102 sustained a witnessed fall in the common area while sitting in a hard back chair in the lounge area with his/her walking cane in hand. Resident #102 was seen by a CNA to pull his/her legs back and then to slip down onto his/her knees onto the floor. The facility failed to ensure the resident was properly positioned in the chair. On 06/23/2023, Resident #102 sustained an unwitnessed fall in the room, and was found lying on the floor. Resident #102 reported he/she had been trying to go to the bathroom when he/she fell , and complained of his/her head hurting after the fall. The findings include: Review of the facility's Comprehensive Care Plan Policy, effective date 01/13/2018, revealed the purpose of the Comprehensive Care Plan was the provision of services to enable residents to live with dignity and have their goals, choices, and preferences supported which included, but was not limited to, goals related to their daily routines. Continued review revealed the Comprehensive Care Plan described the services which were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In addition, review further revealed the resident had the right to receive or refuse the services and/or items included in the plan of care (when such refusals were made, documentation would be entered into the resident's clinical record). 1. Review of Resident #32's Admission Record revealed the facility admitted the resident on 10/28/2022, with diagnoses which included Dementia, Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, and Anemia. Review of Resident #32's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident as requiring one (1) person physical assistance for transfers and ambulation. Review of Resident #32's Comprehensive Care Plan initiated on 10/28/2022, revealed the resident required the safety of residing on a secured unit related to Dementia and impaired safety to surroundings with a goal for the resident to maintain safety while residing on a secured unit. Further review revealed the interventions included to be supervised while on the secured unit. Continued review of Resident #32's Comprehensive Care Plan revealed the resident was at risk for falls related to impaired safety awareness, and Dementia. The goal was to ensure the resident would not experience serious injury from a fall. Review of the care plan revealed the interventions included to ensure appropriate footwear when out of bed, which was initiated on 11/01/2022. Review of the Nurse's Note, dated 06/20/2023 at 3:19 PM, revealed Resident #32 had an unwitnessed fall on 06/20/2023 and was found sitting on the floor in his/her room without non-skid socks. Continued review of the Nurse's Note dated 06/21/2023 at 6:08 PM, revealed Resident #32 had an unwitnessed fall and had been found sitting on the floor in his/her room on 06/21/2023. The root cause analysis of the resident fall was the resident was not oriented to his/her current functional ability. Observation on 06/25/2023 at 9:48 AM, revealed Resident #32 lying on his/her bed with his/her walker and overbed table on the other side of the room by the roommate's bed. Continued observation revealed Certified Nurse Aide (CNA) #112 came into the room and assisted Resident #32 to a sitting position on his/her bed and left the room without moving the walker within the resident's reach. Review of Resident #32's Comprehensive Care Plan, initiated 11/13/2022, for altered cardiovascular status revealed a goal to include the resident would be free of complications of cardiac problems. Continued review revealed interventions included to monitor, document, and report as needed any changes in the resident's lung sounds on auscultation, changes in weight, and any signs and symptoms of coronary artery disease such as excessive swelling, dependent edema, changes in capillary refill, and the color/warmth of extremities. Review of a Comprehensive Encounter Note dated 06/21/2023, entered by the APRN revealed Resident #32 was unsteady when he/she walked to the common area and had some tenderness when his/her right shoe was put on his/her foot. Review of an imaging report, dated 06/22/2023 at 12:54 PM, revealed soft tissue swelling of the right ankle. Review of a Telehealth Evaluation note dated 06/26/2023 at 7:04 PM, revealed Resident #32 had two to three plus (2-3+) pitting edema to the right foot, a pedal pulse could not be found in either foot, and the patient wasn't feeling well overall. Continued review revealed new orders were received to send the resident to the emergency room (ER) for evaluation. Further review revealed the admitting diagnosis was confirmed on 06/28/2023 to be right lower extremity edema. In interview on 06/27/2023 at 4:37 PM, CNA #78 stated she had been running late for her shift on 06/26/2023, and arrived just before Resident #32 was sent out to the hospital. She stated she was in the room when the ambulance arrived to transport the resident. CNA #78 stated the resident's foot and ankle were really swollen and the nurse was really concerned about a blood clot. During interview on 06/27/2023 at 6:00 PM, Licensed Practical Nurse (LPN) #45 stated she took care of Resident #32 a day or two (2) after his/her fall; however she did not believe she had done an assessment of the resident that day. Per interview, the resident was a little touchy, fell y and she kept far away from the resident. She stated she used to complete a head to toe assessment on all her residents; however, since nurses had started computer charting, We are glued to our computers., and she did not have time. LPN #45 further stated she was unaware of Resident #32's care plan intervention for cardiopulmonary assessments. In interview on 06/28/2023 at 9:41 AM, LPN #40 stated she had taken care of Resident #32 on 06/26/2023 from 7:00 AM to 7:00 PM. She stated she had assessed Resident #32's vital signs including his/her blood sugar; however, she had not assessed the resident for edema. The LPN stated she had not charted any assessment of the resident's heart or lung sounds. She stated when the nurse came in to relieve her at 7:00 PM, the nurse asked her to check Resident #32's pedal pulses with her and she noted the resident had two to three plus (2-3+) edema to his/her foot and neither nurse could find a pedal pulse on either of the resident's feet. LPN #40 further stated the other nurse immediately sent Resident #32 out to the hospital. The LPN was unable to state any of Resident #32's diagnoses and was not aware of what his/her care plan interventions included. In interview on 06/28/2023 at 11:15 AM, CNA #34 stated she had taken care of Resident #32 on 06/24/2023, and the resident had complained of right ankle pain, and his/her ankle was very swollen. She stated she told a nurse; however,she was not sure which nurse she told and was unsure what was done for the resident after that. In interview on 06/28/2023 at 11:120 AM, CNA #35 stated she had taken care of Resident #32 on 06/25/2023, and the resident complained of right ankle pain at that time. CNA #35 stated Resident #32's ankle appeared swollen as it was bigger than the other foot. She stated she informed a nurse; however, she was not sure which nurse and what occurred after that. In interview on 06/28/2023 at 3:51 PM, Director of Nursing (DON) #4, the current DON, stated she was taught if a resident had a respiratory diagnosis, the nurse should do a respiratory assessment. She stated the day shift nurse (LPN #40) should have performed a respiratory assessment on 06/26/2023, and the resident should have been assessed when he/she complained of pain. The DON further stated staff should follow residents' care plan interventions. 2. Review of the Resident #107 medical record revealed the facility admitted him/her on 09/29/2022. Continued review of the medical record revealed Resident #107's diagnoses included: Congestive Heart Failure (CHF); Chronic Obstructive Pulmonary Disease (COPD); Dementia; Atherosclerotic Heart Disease, Hemiplegia and Hemiparesis following Cerebral Infarction; and Chronic Kidney Disease, Stage 3. Review of Resident #107's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS' score of ninety-nine (99) which indicated four (4) or more items were coded zero (0) because the individual chose not to answer or gave a nonsensical response. Review of Resident #107's Care Plan dated 09/30/2022, revealed the facility care planned the resident as at risk for falls related to a history of falls, impaired cognition, and impaired mobility, with a goal for the resident to have no unidentified falls through the next review period. Continued review revealed the interventions included: keep call device within reach, keep frequently used items within reach, provide/monitor use of assistive devices; ensure appropriate non-skid footwear when out of bed; Dycem (non-stick rubber material used to stabilize) to wheelchair initiated on 03/10/2023. Review of the facility's incident report dated 06/12/2023 at 9:50 AM, completed by Registered Nurse (RN) #6 revealed Resident #107 had sustained a witnessed fall from a wheelchair in the common area. Continued review revealed Resident #107 thought he/she saw something on the floor and was trying to pick it up. Further review revealed the resident was unable to tell staff what he/she observed on the floor. Review of Resident #107's Nurse Progress note dated 6/12/2023 at 10:00 AM, entered by RN #36 revealed the resident sustained a witnessed fall in the common area which was witnessed by CNA #103. Review revealed Resident #107 complained of pain to the left arm and a skin tear to the left hand, and a dry dressing was applied to the skin tear to stop the bleeding. Further review revealed Resident #107 also complained of pain to his/her left hip, and a laceration to his/her left forehead was observed. Review further revealed Nurse Practitioner #1 was notified, assessed the resident and ordered him/her to be sent to the hospital. Review also revealed the DON was notified and informed staff Resident #107 was to be provided one to one (1:1) supervision upon arrival back to facility. In interview on 06/26/2023 at 10:46 AM, RN #11, who cared for Resident #107 on 06/22/2023 from 7:00 AM to 7:00 PM, she did not do a head-to-toe assessment of the resident, she only assessed his/her lung sounds and documented rhonchi throughout all lobes. RN #11 stated she had not been aware of Resident #107 having edema, although she normally looked at the resident's extremities. She stated however, she had not assessed for edema on 06/22/2023. RN #11 stated if anything was abnormal she would have documented it in the progress notes 3. Review of Resident #44's Admission Record revealed Resident #44 was admitted on [DATE] with diagnoses to include Malignant Neoplasm of the Brain, Osteoarthritis, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Unsteadiness on Feet. Review of Resident #44's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of ninety-nine (99), which indicated the resident chose not to participate or gave nonsensical answers. Further review of the MDS revealed the facility assessed Resident #44 to require extensive assistance of one (1) person for transfers and hygiene. (a). Review of Resident #44's Comprehensive Care Plan initiated 03/30/2022, revealed the facility care planned the resident as at risk for falls related to severe cognitive impairment, impaired safety awareness, impaired mobility, and incontinence with a goal to include the resident would not experience a fall with injury. Review of the care plan revealed the interventions included to assist the resident to bed if experiencing lethargy. Continued review of the Comprehensive Care Plan, initiated 04/11/2022, revealed the facility care planned the resident for Activities of Daily Living (ADL) self-care performance deficit related to Dementia, muscle weakness, and Anxiety Disorder with a goal for the resident to improve and then maintain his/her level of function in ADLs. Further review of the ADL care plan revealed the interventions included to set up and assist the resident with his/her oral care daily and as needed. Review of Resident #44's Nurses' Progress Note dated 06/21/2023 at 2:07 PM, revealed the resident had been leaning forward on his/her rolling walker and fell to the floor on his/her left side sustaining bruising to the left side of his/her chin. Review of Resident #44's Nurses' Interdisciplinary Team (IDT) Note, dated 06/21/2023 at 4:59 PM, revealed the resident had been leaning his/her head down on the walker, fell asleep, the walker moved, and the resident fell forward from the chair while CNA #28 was sitting next to the resident. Review of Resident #44's Comprehensive Encounter Note entered by the APRN dated 06/22/2023 at 3:40 PM, revealed the resident was seen because of a fall on 06/21/2023, which resulted in a large ecchymosis to his/her left chin. Per review of the Note, the resident did have a history of a nondisplaced odontoid fracture type two (2), a break occurring through a specific part of the second bone in the neck. Review of Resident #44's cervical x-ray report results dated 06/22/2023, revealed a limited examination was performed as the cervical spine was only well seen to cervical five (C5). Further review revealed the conclusion was no acute fracture or dislocation up to C5. In interview on 06/23/2023 at 4:35 PM, CNA #28 stated on 06/21/2023, she had been sitting in the common area beside Resident #44 when the resident, who had been rocking back and forth and fidgeting with the walker, leaned forward, the walker rolled, and the resident fell to the floor on his/her left side. CNA #28 stated Resident #44 was awake and alert before the fall and had no injury observed at the time of the fall; however, later on the resident had a bruise to his/her chin and the left side of his/her face. The CNA stated the resident was still awake and alert following the fall. She stated after the fall she notified a nurse, but could not remember which nurse, after making sure Resident #44 was safe. In interview on 06/23/2023 at 4:40 PM, CNA #9 stated she was standing approximately five (5) feet from Resident #44 when he/she fell on [DATE]. CNA #9 stated Resident #44 had been sitting in a chair with his/her arms on his/her knees rocking back and forth and fell forward, then the walker rolled. She stated she went to see if Resident #44 was okay, then went to get the nurse; however, she stated she could not recall who the nurse was, and the nurse came and assessed the resident. The CNA stated Resident #44 was then assisted by staff onto the couch in the common area. In interview on 06/24/2023 at 8:33 AM, Registered Nurse (RN) #11 stated she was caring for Resident #44 on 06/21/2023, and had just finished passing medications when a CNA, told her the resident was on the floor. She stated she assessed Resident #44 who had no apparent injuries. The RN stated she was told by CNAs that Resident #44 was sitting in a chair leaning forward with his/her elbows on his/her knees and, before the CNA could catch the resident, he/she fell forward. She stated when she assessed Resident #44 she noticed his/her walker was upright and not turned over, it appeared as if it had slid forward. RN #11 stated a CNA first told her Resident #44 fell asleep like that, then changed the story to the resident was moving/twitching so he/she could not have been asleep. She stated DON #4 was present to hear the CNA's description of how the resident fell . In interview on 06/25/2023 at 1:27 PM, with Resident #44's Family Member #44 revealed she received a phone call from the facility on 06/21/2023, and was notified the resident had been trying to get up when the walker moved causing the resident to fall and hit his/her chin. The Family Member stated she was told the facility was going to do a scan because Resident #44 was already in a neck collar from a previous fracture of his/her neck. She stated she asked to be updated if anything changed and expected a phone call after the scan. However, she had not received any follow up calls from the facility. Family Member #44 further stated she was not aware Resident #44 had any injury from the fall, including any bruising. (b). Continued review of Resident #44's Comprehensive Care Plan initiated 04/11/2022, of the ADL care plan revealed the interventions included to set up and assist the resident with his/her oral care daily and as needed. However, observation of Resident #44 on 06/25/2023 at approximately 1:52 PM, revealed the resident had food particles caked onto his/her teeth and crumbs were noted to be coming out of the resident's mouth when he/she was talking. Continued observation revealed no visual evidence of food in the resident's vicinity at that time. In interview on 06/25/2023 at 4:50 PM, CNA #8 stated third (3rd) shift staff were responsible for getting residents up in the mornings, providing personal hygiene, including brushing residents' teeth. She stated day shift staff assisted residents with oral care as needed throughout the day. CNA #8 further stated good hygiene was important for residents' dignity and for prolonging how long they could keep their own teeth. In interview on 06/26/2023 at 10:36 AM, with LPN #40 stated she was not sure what the policy was at the facility regarding oral care. She stated the resident's dentures were soaked overnight; however, she was unsure what interventions were on the care plan. In interview on 06/26/2023 at 11:05 AM, DON #4 stated staff should assist residents with brushing their teeth before assisting them to the dining room in the mornings, after meals, and at bedtime. She stated staff should make sure food was not clinging to a resident's teeth and ensure there was no build up on the resident's teeth. The DON further stated she expected her staff to follow the residents' care plans. 4. Review of the medical record for Resident #5 revealed the facility admitted the resident on 05/10/2021, with diagnoses which included Dementia, Unsteadiness on feet, Major Depression, Cognitive Communication Deficit, and Impaired Vision related to Macular Degeneration. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #5 as having a BIMS score of ninety-nine (99), which indicated the resident was severely cognitively impaired. Continued review of Section G, the functional status revealed the facility assessed Resident #5 to require physical assist of one (1) person for walking, and not stable without assistance. Further review revealed Resident #5 required mobility devices of a wheelchair or walker with one (1) person physical assist. Review of Resident #5's Comprehensive Care Plan dated 06/03/2021, revealed the facility care planned the resident for clinically unavoidable risk for falls related to severe cognitive impairment, balance issues, and the resident demonstrated impulsiveness to stand without assistance at times. Continued review of the care plan revealed the goals included the resident would not experience falls with major injury. Further review revealed the interventions included: call light within reach for assistance dated 06/03/2021; bed in low position when in bed dated 03/24/2023; ensure resident was wearing proper nonskid footwear when out of bed dated 11/15/2021; Dycem to wheelchair to promote safety dated 02/03/2023; and a fall mat to right side of bed dated 11/15/2021. Review of Resident #5's visual bedside Kardex report dated 06/22/2023, revealed interventions for: call light in reach for assistance, and respond promptly to requests for assistance; bed in low position when resident in bed; resident to wear non-skid footwear when out of bed; and fall mat to right side of bed. Review of the facility's fall investigation dated 06/17/2023 at 3:30 AM, revealed Resident #5 had been found sitting on the floor in his/her room. Continued review revealed Resident #5 had a history of waking up and attempting to get out of bed. Further review revealed Resident #5 had not been wearing non-skid socks, and the fall mat was not in place as per the resident's care plan. In interview on 06/23/2023 at 9:07 AM and on 06/27/2023 at 12:06 PM, CNA #9 stated Resident #5 required two (2) staff assist with use of gait belts for transfer. She stated Resident #5's care plan interventions were for a fall mat to bedside, non-skid socks on when out of bed, shoes, and ant-tippers to the wheelchair. CNA #9 further stated the residents' Kardex provided information concerning a resident's care needs for CNAs to use. In interview on 06/27/2023 at 12:09 PM, CNA #28 stated information regarding residents' care was found on the Kardex and staff needed to follow them. She stated Resident #5 required two (2) staff with use of gait belts for transfers. She stated Resident #5 seemed to fall mainly in the mornings and she made sure precautions were in place. CNA #28 further stated Resident #5 had been on one to one (1:1) and directly in sight supervision. The CNA additionally stated staff redirected the resident to prevent falls and placed his/her items in reach. 5. Review of Resident #15's Admission Record revealed the facility admitted the resident on 04/30/2020, with diagnoses which included Alzheimer's Disease, Parkinson's Disease, Cerebral Infarction (Stroke), Schizophrenia, Personal History of Traumatic Brain Injury, Psychosis, and Convulsions. Review of Resident #15's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of eight (8) out of fifteen (15), which indicated moderate cognitive impairment. Further review of the MDS revealed the facility assessed Resident #15 to require one (1) person physical assist with transfers and ambulation. Review of Resident #15's Comprehensive Care Plan revealed a focus for risk for falls related to unsteady gait, psychotropic medication use, and cognitive impairment, initiated on 05/01/2020, with a goal noting the resident would not have any falls with injury. Continued review revealed the interventions included: ensuring Resident #15's call light was within reach and encourage him/her to use it for assistance as needed; and providing the prompt response the resident needed to all requests for assistance. Further review revealed an intervention, initiated on 06/16/2023, for the resident to have every fifteen (15) minute checks. Review of the facility's Incident Report dated 06/16/2023 at 7:45 AM, completed by the Assistant Director of Nursing (ADON), revealed Resident #15 sustained an unwitnessed fall while walking to his/her room to get cream and sugar. Per review, Resident #15 stumbled and fell and was assessed to have no signs of injury. Further review revealed the predisposing physiological factors were noted as the resident was confused, had recent changes in cognition, and impaired memory. Review of Resident #15's Comprehensive Encounter Note dated 06/16/2023 at 4:45 PM, entered by the Advanced Practice Registered Nurse (APRN) revealed the resident sustained a fall after breakfast and fell to the floor. Further review revealed the diagnosis was unspecified injury of the head. Review of Resident #15's Five (5) Why's Root Cause Analysis dated 06/16/2023, revealed the resident had been in the [NAME] Hallway returning to his/her room when he/she turned around, lost his/her balance, and fell because his/her balance was off. Observation on 06/24/2023 at 9:15 AM, revealed Resident #15 lying on his/her bed with his/her eyes closed and his/her call light lying over the arm of the resident's recliner located at the foot of the bed, and not in his/her reach as per the care plan. Review of the facility's Fifteen (15) Minute Check Sheet for Resident #15 revealed no documented evidence staff had signed as having conducted the every fifteen (15) minute checks since 06/24/2023 at 5:15 AM . Interview on 06/24/2023 at 9:25 AM, with Certified Nursing Assistant (CNA) #10, he stated he had been up and down the hall and had checked on Resident #15: however, he had not had time to document the fifteen (15) minute checks. He stated, everything had been good with Resident #15 and he had last checked on the resident at approximately 9:15 AM. The CNA stated he should have completed the sheet to prove he had completed the every fifteen (15) minutes as he had done them. He further stated he was unsure why the night shift staff had not completed the sheet from 5:15 AM until he started his shift at 7:00 AM. CNA #10 stated he had moved Resident #15's call light earlier; however, he must have forgotten to put it back within reach next to the resident. He further stated he should have followed Resident #15's Care Plan interventions. In an interview on 06/24/2023 at 9:28 AM, Registered Nurse (RN) #4 stated she expected the CNAs to complete one-on-one (1:1) and every fifteen (15) minute check duties as ordered. RN #4 stated she was unaware the every fifteen (15) minute check paperwork had not been completed for Resident #15 since 5:15 AM that morning. She stated she expected staff to do their jobs and she did not micromanage them. However, the fifteen (15) minute checks should have been completed and the resident's call light should have been in reach as per his/her care plan. RN #4 stated Resident #15's interventions for the checks and call light to be in reach were to provide necessary supervision and discourage the resident from getting up on his/her own. She further stated she expected all nursing staff to follow residents' Care Plans. In an interview on 06/24/2023 at 10:30 AM, Director of Nursing (DON) #4, the current DON, stated the nurses were to oversee the staff on the units to ensure staff were implementing residents' care plan interventions appropriately. She stated she expected: Resident #15's call light to be in reach; the every fifteen (15) checks to be completed at the times they were due; and the nurse should be supervising to make sure they were completed. The DON stated staff should follow the interventions on residents' Care Plans to provide good care for the residents. The DON further stated staff needed more education and she did not have any processes in place to monitor if staff were providing interventions such as the fifteen (15) minute checks; however, she would implement new monitoring in the future. 6. Review of the medical record for Resident #81 revealed the facility admitted the resident on 01/03/2022, with diagnoses including Dementia, Bipolar Disorder, and Major Depressive Disorder. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #81 as having a BIMS score of seven (7) out of fifteen (15) indicating he/she was severely cognitively impaired. Further review of the MDS, Section G the functional status revealed the facility assessed Resident #81 to require set up of one (1) for walking. In addition, review further revealed the facility assessed Resident #81 to require no assistive device for ambulation. Review of Resident #81's Comprehensive Care Plan dated 02/01/2021, revealed the facility care planned the resident for falls related to a history of falls, weakness, impaired cognition, and incontinence, and o [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, and review of the Plan of Correction for the 03/16/2023 and 04/04/2023 surveys, it was determined the facility failed to develop and implement care plans with individualized person-centered interventions for ten (10) of thirty-three (33) sampled residents: to prevent falls for six (6) residents (Residents #20, #35, #90, #97, #146, and #821). 1 a) The facility admitted Resident #821 on 12/22/2022 with a history of falls. Resident #821 regularly tried to ambulate to the bathroom without assistance. One fall that occurred on 03/03/2023 resulted in a hematoma to the head which measured approximately ten (10) centimeters in size. On 04/13/2023, 04/14/2023 and 04/15/2023 there was no evidence the facility assisted the resident to the bathroom to help reduce the opportunity for falls. The fall that occurred on 04/15/2023, resulted in Resident #821 sustaining a subdural hematoma and required the resident to be admitted to the Intensive Care Unit (ICU). 1 b) Resident #20 had a known history of falls which the facility care planned the resident with interventions for staff to assist Resident #20 to his/her wheelchair and to the common area as needed initiated on 04/03/2023. However, on 05/19/2023 at 9:45 PM, staff failed to implement the care plan intervention to assist Resident #20 to his/her wheelchair and to the common area. Resident #20 was found on the floor in his/her room, unable to move his/her right arm which was painful. Resident #20 was sent to the hospital where he/she was diagnosed with a fractured right arm. 1 c) Review of Resident #90's medical record revealed he/she had sustained three (3) falls, one on 04/15/2023, two (2) within twenty minutes of each other on 04/15/2023 and one on 05/25/2023, without the care plan developed to prevent the falls. 1 d) Review of Resident #97's medical record revealed he/she sustained five (5) falls between 04/21/2023 and 05/27/2023. However, there was no evidence the facility developed a care plan with individualized person-centered interventions and failed to implement interventions to prevent Resident #97's falls. Review of the resident's care plan revealed an intervention following the 04/21/2023 fall for every fifteen (15) minute checks and an intervention on 05/05/2023 for one (1) hour checks. However, there was no documentation these interventions were implemented. 1 e) Resident #146 sustained eleven (11) falls while in the facility's care since his/her admission on 10/26/2022 through 04/28/2023. On 05/01/2023, the facility initiated a care plan intervention for Resident #146's bed to be in the low position. However, on 05/22/2023, observation revealed Resident #146 was attempting to self-transfer from the bed, which was not in the low position as care planned, to ambulate. The State Survey Agency (SSA) Surveyor intervened and called for staff to come and assist the resident. 1 f) Review of Resident #35's Comprehensive Care Plan (CCP) revealed staff was to monitor and assist the resident while he/she used assistive devices. However, staff left Resident #35 alone while he/she was sitting in the wheelchair. Resident #35 sustained a fall on 04/30/2023, which resulted in a laceration above his/her eye approximately two (2) to three (3) inches in length. The resident was sent to the emergency room (ER) for an evaluation and returned to the facility the same evening. The ER Physician used glue to close the laceration. 2. In addition, the facility failed to ensure Resident #22 had a Bilevel Positive Airway Pressure (BIPAP) machine that helped the resident get more air into the lungs. The facility failed to develop a care plan for the use of a BiPAP machine. Review of Resident #22's Care Plan revealed he/she was care-planned for refusal to wear the Bi-PAP when napping or sleeping. However, further review of the Care Plan dated 04/19/2023, revealed there were no person-centered interventions documented such as more frequent monitoring for Bi-PAP mask usage. 3. Further, the facility failed to ensure Resident #57's care plan was developed to include his/her love for his/her baby doll, which made the resident happy. 4. In addition, the facility failed to ensure the residents care plan related to activities was followed for the following residents (Residents #89, #35, #57, #95, and #821). The facility's failure to develop and implement care plans with individualized person-centered interventions to prevent falls has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 04/13/2023 and is ongoing in the areas of 42 CFR 483.10 Resident Rights (F578), Formulate Advanced Directives at a Scope and Severity (S/S) of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K and (F657), Review and Revise Care Plans, both at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The findings include: Review of the facility's Comprehensive Care Plan policy, effective January 2017, revealed the Care Planning/Interdisciplinary Team (IDT) reviewed and updated residents' care plan. When there was a significant change in the resident's condition; when the desired outcome as not met; when the resident was readmitted to the facility from a hospital stay; and at least quarterly. Review of the facility's Care Plan policy, revised March 2022, revealed the Interdisciplinary team (IDT) developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions would be derived from a thorough analysis of the information gathered as part of the comprehensive assessment and would reflect currently recognized standards of practice for problem areas and conditions. Continued review revealed assessments of residents would be ongoing and care plans were to be revised as information about the resident(s) and the resident(s) conditions changed. Additional review of the Care Plan policy revealed the Interdisciplinary team reviewed and updated the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. 1 a) Review of Resident #821's Admission Record revealed the facility admitted the resident on 12/21/2022 with diagnoses of dementia, malnutrition, urinary retention, and multiple falls. Review of Resident #821's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) of six (6), which indicated the resident had severe cognitive impairment. The facility assessed the resident for one (1) person's physical assistance for bed mobility, toileting, dressing, eating and personal hygiene. The facility assessed the resident for two (2) person physical assistance for transfers with extensive assistance. Resident #821 was noted to be unsteady on his/her feet and only able to stabilize with the assistance of staff. The resident was assessed to use a walker and/or a wheelchair. Review of Resident #821's Comprehensive Care Plan (CCP) initiated by the facility on 12/22/2022, revealed on 04/14/2023, an intervention for staff to take the resident to the bathroom before meals and at bedtime as needed for bowel movements was created. Continued review revealed on 04/17/2023, an intervention was created for a perimeter mattress with defined edges and for the resident to be sent to the emergency room (ER) for evaluation. Further review of the CCP revealed the facility placed Resident #821 on one-to-one (1:1) supervision when he/she returned from the hospital on 04/18/2023. Review of the facility's Fall Event #2093, dated 04/13/2023 at 3:01 PM, revealed Resident #821 was found lying on the floor in his/her room, next to the bed. Per review, Resident #821 had attempted to ambulate to the restroom without assistance. Continued review revealed a new intervention noted for staff to assist Resident #821 to the toilet after meals, at bedtime and as needed for bowel movements. Further review revealed the Interdisciplinary Team (IDT) determined the Root Cause (RC) for the fall as the resident's poor safety awareness and forgetting his/her limitations secondary to Dementia. In addition, the Fall Event also noted Resident #821 recently experienced a room change. Review of the facility's Fall Event #2094, dated 04/14/2023 at 11:15 AM, revealed Resident #821 was found by staff lying on the floor on his/her side in the doorway of his/her room. Continued review revealed Resident #821 told staff he/she had been going to the restroom and fell in the doorway of his/her room. Per review, the facility determined the RC again as, Resident #821's poor safety awareness and forgetting his/her limitations secondary to Dementia. Further review revealed the facility changed the intervention to sit Resident #821 on the toilet before meals and at bedtime instead of after meals. Review of the facility's Fall Event #2097 documentation, completed by the Assistant Director of Nursing (ADON), on 04/15/2023 at 7:03 PM, revealed Resident #821 sustained an unwitnessed fall and was found lying on the floor next to his/her bed. Per review, Resident #821 was unaware of his/her limitations and attempted to ambulate without assistance. Continued review revealed documentation noting Resident #821 had Dementia, a history of Pneumonia and urinary retention. Further review revealed the ADON noted Resident #821 was alert and at his/her baseline cognitively. In addition, review further revealed the ADON also noted Resident #821 thought he/she hit his/her head. In an interview with the Director of Nursing on 06/02/2023 at 1:23 PM, she said they did not identify Resident #821's falls might be related to him/her trying to ambulate to the bathroom without assistance until the 04/14/2023 fall. She said they identified the falls were related to the resident's poor safety awareness related to Dementia. She stated since they have had the resident on one-to-one (1:1) supervision since 04/18/2023, the resident had not sustained any new falls. In an interview with the Executive Director (ED) on 06/02/2023 at 2:00 PM, she stated resident behaviors were the cause of the high number of falls in the facility. She said it was hard to prevent falls for residents who had behaviors and tried to ambulate themselves when they required assistance. 1 b) Review of Resident #20's Admission Record revealed the facility admitted the resident on 01/05/2023, with diagnoses of Difficulty in Walking, Unsteadiness on Feet, and Dementia with Agitation. Review of Resident #20's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of ninety-nine (99), which indicated the resident was unable to complete the interview. Review of Resident #20's Comprehensive Care Plan (CCP) revealed on 01/05/2023 the facility developed a care plan for the resident's risk for falls related to receiving psychotropic medications, muscle weakness, unsteady gait/balance, Dementia with agitation, poor safety awareness, and forgot to utilize wheelchair due to Dementia. Interventions included staff to turn bathroom light on at night initiated on 02/19/2023 and assist Resident #20 to her wheelchair and out to the common area as needed initiated on 04/03/2023. Review of the Fall Evaluation Progress Note dated 04/03/2023 at 10:48 PM, revealed Resident #20 had sustained an unwitnessed fall and told staff that he/she was trying to ambulate without his/her wheelchair. Continued review revealed Resident #20 was assessed to have no apparent trauma, no head trauma, and no skin breakdown. Further review revealed his/her care plan was updated with an intervention initiated on 04/03/2023 to assist Resident #20 to his/her wheelchair and out to the common area as needed. Review of the Progress Note dated 05/19/2023 at 9:45 PM, revealed Resident #20 was found in a sitting position on the bedroom floor, and it was unwitnessed. Further review revealed Resident #20's Primary Care Provider was notified and recommended the resident be sent to the hospital, where the resident was diagnosed with a right humeral fracture. During interview on 05/22/2023 at 12:10 PM the Director of Nursing stated Resident #20's bathroom light was not on the night he/she fell and broke his/her arm, but it should have been per his/her care plan. 1 c) Record review of Resident #90's face sheet revealed the facility admitted Resident #90 on 04/05/2023 with diagnosis to include Alzheimer's Disease, Muscle Weakness, Difficulty Walking, Dementia, and Repeated Falls. Review of Resident #90's Quarterly MDS Assessment, dated 04/07/2023, revealed the facility assessed the resident to have a BIMS score of three (3), indicating severe cognitive impairment. Review of Resident #90's Fall Risk assessment dated [DATE], revealed a score of eighteen (18) indicating the resident was at risk for falls because his/her vision status was poor. Review of Resident #90 Comprehensive Care Plan (CCP) dated 09/15/2022, revealed he/she was assessed to reside on a secured unit related to the diagnosis of Dementia and impaired safety to surroundings. Intervention placed on 01/20/2023, was the resident to be supervised while on secured unit, no revision date given. Continued review of the CCP revealed Resident #90 was assessed to be at risk for falls related to impaired safety awareness and impaired vision increasing risk of injury. The date initiated was 09/15/2022, and it was revised on 03/21/2023. Additional interventions placed were individualized activities to reduce outside stimulation, and the resident had impaired vision causing hearing to be more sensitive to loud noises and outside distractions initiated on 10/21/2022 and revised on 03/09/2023. Continued review of Resident #90's CCP revealed an intervention initiated on 09/15/2022 and revised on 03/09/2023 was to perform a fall assessment upon admission and at least quarterly. Observation of Resident #90 on 05/25/2023 at 9:15 AM revealed resident sitting in chair with other residents in common area and appeared to be dozing. Further observation revealed bruising was noted to the left eye orbital area. Review of Resident #90's medical record, dated 04/21/2023 at 6:45 AM, revealed the resident was attempting to sit in his/her chair located in the dayroom and missed the chair falling to the floor; no injuries were noted. Further review of Resident #90's medical record revealed on 04/22/2023 ecchymosis (bruising) was noted to the resident's buttock area. Continued review of facility's medical records for Resident #90 revealed order was still active as of 04/05/2023 stating resident to see ophthalmologist placed 09/15/2022 upon admission. Further review of the facility's medical record for Resident #90's Physical Therapy Evaluation and Plan of Treatment dated 04/06/2023 noted patient factors included poor scanning of environment and history of wandering around on unit. A new goal was to provide verbal cues for the use of compensatory strategies due to low/reduced vision. Continued review of Physical Therapy Evaluation and Plan of Treatment revealed functional mobility assessment for gait included deviations of inconsistently scanning environment and difficulty with object negotiation below waist level. Review of Resident #90 Comprehensive Care Plan (CCP) dated 09/15/2022 revealed he/she was assessed to have impaired visual function and uses walls as guides. Continued review of the CCP revealed interventions placed on 10/11/2022 with no revision date given, included to arrange consultation with eye care practitioner as required, assist with Activities of Daily Living (ADLs) as needed and consistently tell the resident where items are placed. Further review of Resident #90's CCP revealed interventions placed on 09/15/2022 and revised on 05/31/2023 was for the facility to provide services according to the plan of care to enhance optimal well-being. During interview with CNA #87 on 05/25/2023 at 9:30 AM she stated Resident #90 was a little unsteady when walking and had sustained a fall on night shift and had bruising to his/her left eye. Further observation revealed the resident was not wearing his/her glasses. In an interview with Licensed Practical Nurse (LPN) on 05/30/2023 at 11:20 AM she stated she had never seen Resident #90 wearing glasses. In interview with Social Worker (SW) #1 on 05/31/2023 at 2:30 PM she stated appointments had been set up for routine visits of residents in the facility, but 360 Eye Care had declined coming to the facility since the State Survey Agency Surveyors were in the building: moving the appointments to 06/21/2023. She added she did not know if the previous SW had made any appointments for Resident #90 to be seen by eye doctors. Upon review of the CCP with the SW, the CCP had been initiated on 09/15/2022 and revised on 03/21/2023 for Resident #90 to see eye care for impaired vision increasing risk for injury. However, interviews and record review revealed the resident's care plan was not implemented related to the resident's impaired vision and risk for falls. 1 d). Review of Resident #97's medical record revealed the facility admitted the resident on 10/26/2021 and readmitted the resident on 02/10/2023 with diagnoses of Weakness, Parkinson's Disease, Muscle Weakness, Unsteadiness on Feet, and Dementia. Review of Resident #97's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated moderate cognitive impairment. Review of Resident #97's medical record and event report revealed the resident fell on [DATE] at 5:23 PM while trying to transfer himself/herself from the bedside commode to the wheelchair. New intervention stated was to apply non-skid strips to floor in front of bedside commode. Review of the resident's Situation-Background-Assessment-Recommendation (SBAR) for Providers, dated 04/21/2023 at 5:39 PM, revealed the resident was placed on every fifteen (15) minute checks. However, there was no evidence this intervention was placed on the resident's Fall Care Plan. Review of the resident's Fall Care Plan revealed an intervention initiated on 04/24/2023 and revised on 05/02/2023 for non-skid strips in front of the bedside commode to promote safety. Review of Progress Note, dated 05/17/2023 at 7:50 AM, revealed the nurse had previously spoken with therapy to remove the bedside commode because it had been deemed a fall risk, and the resident was to be assisted to the toilet in the shower room for a bowel movement and to use a urinal for urination. Review of Resident #97's medical record and event report revealed the resident had an unwitnessed fall on 04/30/2023 at 9:00 PM when the resident said he/she was trying to get out of bed while not wearing non-skid footwear. New intervention added was to encourage use of non-skid socks when not in shoes, which was noted as an intervention created on the resident's care plan on 05/01/2023. Review of an IDT Note, dated 05/02/2023 at 4:57 PM, for Resident #97 revealed the root cause analysis (RCA) was the resident had poor safety awareness, forgot limitations, and was not wearing non-skid footwear. Review of Resident #97's medical record and event report revealed the resident had an unwitnessed fall on 05/04/2023 at 7:35 PM while staff members were picking up trays, causing scattered abrasions to bilateral lower front leg areas. New intervention added was to offer the resident the choice to eat meals in bed as he/she wished, which was noted to be added as an intervention on the care plan on 05/04/2023. Additional care plan intervention initiated on 05/05/2023 was for one (1) hour checks which were continued as an active intervention as of 05/30/2023. However, the facility was not able to provide hourly check documentation for any day except 05/05/2023 from 10:15 AM to 11:45 PM. Review of Resident 97's Progress Note dated 05/04/2023 at 8:29 PM revealed the unit CNA was sitting outside the resident's room for increased monitoring. IDT note dated 05/05/2023 at 11:52 AM revealed the RCA was the resident had poor safety awareness, forgot limitations, was impulsive, and overestimated his/her abilities. However, review of the resident's care plan revealed the facility failed ensure the resident's care plan was developed to include poor safety awareness and need for increased monitoring. Review of Resident #97's Physical Therapy Evaluations, dated 01/09/2023, 03/10/2023, and 05/29/2023 revealed the resident was non-ambulatory. Review of Resident #97's Fall Care Plan revealed an intervention for stand by assist when toileting initiated on 04/23/2023 and revised on 04/24/2023, non-skid strips to floor beside bed initiated on 10/21/2022 and revised on 03/19/2023, offer assistance to toilet after meals initiated on 07/25/2022, offer to assist resident to bed after meals initiated on 01/26/2023, offer to assist with transfers prior to meal times from bed to chair and, if resident refuses, provide stand by assist initiated on 01/18/2023, offer to deliver tray at the start of tray pass initiated 03/24/2023, and encourage appropriate footwear when out of bed initiated on 10/27/2021 and revised on 03/08/2023. The facility failed to ensure the resident's care plan was developed to include the resident's assessment of being non-ambulatory, as per review of the Physical Therapy Evaluations. Interview with State Registered Nurse Assistant (SRNA) #8, on 05/17/2023 at 1:15 PM, revealed Resident #97 was unable to ambulate, and stood for pivot transfers. She stated the resident had not attempted to self-transfer during her shift, and she was unsure if he/she ever attempted to self-transfer. During an interview with the DON, on 05/31/2023 at 10:15 AM, she stated she was unaware the resident required increased monitoring, as per review of the 05/05/2023 Progress Note. 1 e) Review of Resident #146's Admission Record revealed the facility admitted the resident on 10/26/2022 with diagnoses that included Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care and Cognitive Communication Deficit. The facility assessed Resident #146, in a Quarterly MDS Assessment, dated 02/10/2023, with a BIMS score of three (3) of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #146's Comprehensive Care Plan, initiated on 10/27/2022, revealed the resident had been care planned for a Focus of falls related to history of falls, received psychotropic medications, Dementia with moderate mood disorder, muscle weakness, impaired mobility, unsteady gait, severe cognitive impairment, communication deficit, vitamin D deficiency, Osteoarthritis (OA), mood disorder, and lack of safety awareness secondary to Dementia. The Goal was Resident #146 would have no falls through the next review date. Interventions included keep call light within reach, initiated on 10/27/2022. Review of Progress Notes revealed Resident #146 had sustained eleven (11) falls since admission to the facility in October 2022. No falls resulted in injury. Review of Resident #146's care plan revealed on 05/01/2023 the facility initiated the intervention for his/her bed to be in low position. Observation on 05/22/2023 at 10:30 AM revealed Resident #146 was in bed in his/her room, and the resident's bed was in high position. Resident #146 then began attempting to transfer himself/herself from the bed to ambulate as his/her legs were observed moving off the bed. Resident #146's feet were not touching the floor. Since no staff were near Resident #146 at that time, the State Survey Agency (SSA) Surveyor had to call staff to assist. Upon entering Resident #146's room, CNA #87 lowered Resident #146's bed to its lowest position. During an interview with CNA #87 on 05/22/2023 at 10:40 AM, she stated she did not know if Resident #146's care plan indicated his/her bed should be in the lowest position because she did not have a computer login. CNA #23, during an interview on 06/01/2023 at 9:43 AM, stated it was important to know what was on each resident's care plan because she wanted to know how to best care for the residents, and the care plan was the final word on how to care for residents. The facility failed to implement Resident #146's care plan intervention of bed to be in low position to prevent falls for Resident #146. 1 f) Review of Resident #35's Admission Record revealed the facility admitted the resident on 09/09/2021 with diagnoses of Dementia, Malnutrition, and a History of Falls. Review of Resident #35's record showed the resident was hospitalized from 02/06/2023 to 03/08/2023 with aspiration pneumonia. Review of the resident's Electronic Medical Record (EMR) revealed the resident sustained a fall on 03/09/2023 which resulted in a subdural hematoma. Review of the Admission MDS Assessment, dated 03/13/2023, revealed the resident required a two (2) person physical assistance for transfers, dressing, and toileting. The resident required one (1) person physical assistance with bed mobility and personal hygiene. Resident #35 was assessed for the use of a wheelchair only. The Admission MDS Assessment revealed the resident had a BIMS score of zero-zero (00), signifying the resident was severely cognitively impaired. Review of Resident #35's CCP, initiated on 09/10/2021, revealed the facility care planned the resident for at risk for falls with interventions which included staff to assist the resident with his/her walker/wheelchair for ambulation as needed and assist with bed mobility, transfers and toileting as needed. Review of the CCP revealed those interventions were still active on 05/18/2023. Continued review revealed the fall interventions included on 09/10/2021, for the resident to have on appropriate footwear and for staff to provide/monitor use of assistive devices, which were also still active on 05/18/2023. Review further revealed the interventions included: on 03/09/2023, the resident's bed to be in a low position and a fall mat next to the bed; on 03/15/2023, staff to assist the resident with standing when he/she showed interest; on 03/22/2023, offer him/her a nighttime snack while he/she was in bed; and on 05/01/2023, increased supervision at mealtime. Review of Resident #35's progress notes, revealed on 05/02/2023, the DON noted during an Interdisciplinary Team (IDT) meeting, staff were busy transporting other residents from the dining room; when they returned, resident noted on the floor. It was noted a new intervention was established for the resident to have increased supervision at mealtimes. In an interview with Certified Nursing Assistant (CNA) #62 on 05/17/2023 at 8:55 AM, she stated Resident #35 was unpredictable because of his/her Dementia and staff needed to have their eyes on him/her all the time. She stated when a resident had a very low BIMS, he/she really did not know what they were doing and that made a person high risk to get hurt. In an interview with the DON on 05/25/2023 at 12:30 PM, she stated when the resident sustained the fall on 04/30/2023, there were no staff members in the dining room because they were busy transporting other residents back to the common area, and she determined that was the root cause of the resident's fall. The DON stated there should have been more information noted on the fall the resident had on 04/30/2023. She stated the facility had not increased the resident's supervision. In an interview with the ED, on 06/02/2023 at 1:23 PM, she stated she expected facility staff to follow the facility's policies and procedures. She stated staff was expected to follow residents' care plans because that was created to ensure the residents got the best care. The ED stated care plans were to be updated/revised anytime the team determined an intervention no longer worked. She said it was the previous administration who would not use one-to-one (1:1) supervision for residents; however, she did not mind using it for residents who really needed it. She also stated one-to-one (1:1) supervision could not be provided for every resident who was high risk. 2. Review of Resident #22's clinical record revealed the facility admitted him/her on 02/10/2020, with diagnoses that included Acute/Chronic Respiratory Failure with Hypercapnia (build-up of carbon dioxide (CO2) in the blood), and Chronic Obstructive Pulmonary Disease (COPD). The facility assessed Resident #22, in a Quarterly Minimum Data Set (MDS), dated [DATE], as a twelve (12) of fifteen (15) on Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of Resident #22's care plan, dated 03/28/2023, revealed a Focus that included at risk for decline related to his/her refusal for care as ordered, that included wearing the Bi-PAP mask; he/she understood the risk of refusing to wear the mask but did not like wearing the Bi-PAP mask. The Goals included Resident #22 would not experience significant decline related to choices to refuse care and treatments as ordered through next review date. There was no resident centered interventions observed on the care plan. During observations on 05/16/2023, at 3:38 AM, Resident #22 was observed to be in bed, with eyes closed. His/her Bi-PAP mask and Oxygen (O2) nasal cannula were both off. During an interview with Registered Nurse (RN) #15, on 05/16/2023, at 3:47 AM, she stated she would make resident rounds with medication administration and every two (2) hours but to her knowledge, there was not a process to ensure Resident #22 received more frequent rounding to ensure compliance with wearing the Bi-PAP mask. She stated she was aware Resident #22 would frequently remove the mask because he/she did not like wearing it but was unaware if there were care plan interventions for more frequent rounding to ensure compliance of wearing the mask. During an interview with the Assistant Director of Nursing (ADON), on 05/16/2023, at 7:15 AM, she stated she was unaware if the facility had policies concerning care of Residents with respiratory diseases, nor was she aware if Resident #22 was care planned for more frequent monitoring for compliance to wear the Bi-PAP mask. RN #6, during an interview on 05/17/2023, at 1:55 PM, stated she was unaware if increased monitoring for Resident #22 was ordered, or care planned. During an interview with the Director of Nursing (DON), on 05/18/2023, at 10:55 AM, she stated she was unaware if increased monitoring and documentation for compliance to wear the Bi-PAP mask was care planned for Resident #22. 3. Review of Resident #57's Admission Record revealed the facility admitted the resident on 07/05/2022 with diagnoses that included Alzheimer's Disease, Muscle Weakness, Difficulty in Walking, and Unsteadiness on Feet. The facility assessed Resident #57, in a Quarterly MDS assessment dated [DATE], with a BIMS score of four (4) of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #57's Progress Notes revealed staff had documented his/her affection and love for the baby doll. On 01/04/2023 staff noted Resident #57 was happy holding my baby. On 02/27/2023 staff wrote Resident #57 said I love this baby and on 03/01/2023 staff documented Resident #57 was fine and said, My baby is good. Review of Resident #57's Comprehensive Care Plan, initiated on 07/05/2023, revealed the resident had

Based on observation, interview, record review, review of the facility's policy and Plan of Correction, it was determined the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents. The facility failed to identify risks and hazards; failed to establish root cause analyses of previous falls; and failed to implement and evaluate interventions to prevent further falls for six (6) of thirty-three (33) sampled residents (Residents #20, #35, #90, #97, #146 and #821). Additionally, the facility failed to ensure potentially harmful cleaning products were kept locked and not accessible to residents. 1. Review of Resident #821's hospital discharge summary, dated 04/18/2023, revealed the resident sustained an unwitnessed fall and hit his/her head on 04/15/2023 which required hospitalization in the Intensive Care Unit (ICU) related to a subdural hematoma. Through investigation and interview with Certified Medication Technician (CMT) #1, on 05/11/2023 at 11:12 AM, it was determined the resident fell on [DATE] at approximately 5:52 PM; however, the fall was not reported to management until approximately 7:00 PM, by Licensed Practical Nurse (LPN) #38 when she arrived for her evening shift. LPN #38 reported she informed the Assistant Director of Nursing (ADON) who was still on site. Emergency Medical Services (EMS) were called at 8:10 PM; they left the facility at 8:30 PM, in route to the emergency room (ER). 2. Review of Resident #20's Fall Event report revealed the resident fell , without injury, on 04/03/2023 because he/she was ambulating without assistance and also was not using his/her wheelchair. Review of the facility's Progress Notes for Resident #20, dated 05/19/2023 at 11:18 PM, revealed the resident was found in the bedroom floor, had an unwitnessed fall, was sent to the ER, and sustained a fractured right humerus (arm). The facility failed to implement interventions on the resident's care plan to prevent the fall. 3. Review of the facility's medical record for Resident #90 revealed, on 05/25/2023 at 4:15 AM, he/she was found on the floor in the resident's room with sheets wrapped around his/her feet. Skin assessment revealed a small area for blood from an old scab and two (2) small knots noted on the left side of the resident's face. The resident was not sent to the hospital. Continued review revealed, on 04/21/2023 at 6:45 AM, Resident #90 was attempting to sit in a chair located in the dayroom and missed the chair, falling to the floor, with no injuries noted. Additional review revealed, on 04/22/2023, ecchymosis (bruising) was noted to the resident's buttock area. On 04/15/2023 at 1:52 PM, the resident had two (2) falls within twenty (20) minutes, hit the back of his/her head, and was sent to the local emergency room (ER) with a final diagnosis of Contusion of the Scalp. 4. Review of Resident #97's medical record revealed the resident had falls on 04/21/2023, 04/30/2023, 05/04/2023, 05/20/2023, and 05/27/2023. All of the falls occurred while the resident was self-transferring without assistance. In addition, Resident #97's care plan was not fully developed with interventions to prevent the multiple falls. 5. Resident #146 was observed being transferred from a bed that was not in low position with one (1) person assist, but was assessed and care planned for two (2) person assist and for the bed to be in low position. Also, during the resident transfer from bed to wheelchair, staff did not use a gait belt per policy. 6. Review of the facility's Fall Event for Resident #35, revealed the resident was left unattended by staff on 04/30/2023 as they transported residents from the dining room back to the common area. Staff found the resident flat on his/her face and determined the resident tried to stand up from his/her wheelchair unassisted and had a fall. The resident was noted with a laceration above the eyebrow which measured two (2) to three (3) inches in length. The resident was sent to the emergency room (ER). He/She returned to the facility the same day, with the injury glued shut. Review of the discharge summary, revealed staff were to observe the resident for any signs and symptoms of a worsening condition to include nausea/vomiting. The facility did not complete seventy-two (72) hours of neuro checks as per their policy. On 05/01/2023, the resident was noted to have nausea/vomiting but the facility related it to his/her colostomy and distended stomach. The facility's failure to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 04/13/2023 and is ongoing in the areas of 42 CFR 483.10 Resident Rights (F578), Formulate Advanced Directives at a Scope and Severity (S/S) of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K and (F657), Review and Revise Care Plans, both at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. 7. In addition, observation on 05/18/2023 at 9:35 AM, revealed an unlocked and unattended housekeeping cart with bleach spray hanging on the outside and multiple cleaning products on the inside. Additionally, observation revealed a container of Micro-Kill Germicidal Bleach Wipes in the windowsill of a resident's room. (Refer to F656, F657, F835, F837, and F867) The findings include: Review of the facility's Fall Management Policy, dated 09/01/2022, revealed a fall may be witnessed, reported by the resident or an observer or identified when a resident was observed on the floor or ground. Injury related to a fall also included any injury recognized within a short period of the fall (e.g. hours to a few days) after the fall and attributed to the fall. Injury (except major) includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall related injury that caused the resident to complain of pain. A major injury includes bone fractures, joint dislocations, and closed head injuries with altered consciousness, subdural hematoma. Continued review of the Fall Management policy revealed the fall risk observations determined the resident's fall risk and was to be completed on admission, quarterly, annually and with a significant change in condition. The fall risk observation along with the Minimum Data Set (MDS) should initiate triggers to be discussed in the interdisciplinary team (IDT) meeting and be used to develop a care plan. Fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk for falls. The policy revealed when staff responded to a fall, the resident was to be monitored and evaluated for seventy-two (72) hours post fall. A neurological (neuro) assessment was to be completed for any unwitnessed fall or a fall in which the resident hit his/her head. If an emergency situation, staff were to initiate Emergency Medical Services (EMS) response, and remain with resident until EMS arrived. Staff were to complete a root cause analysis and determine an intervention based on the root cause and the intervention was to be implemented immediately after the fall. As the investigation continued the root cause analysis may trigger additional interventions to be added to the resident's plan of care. Review of the facility's Standard Re-Certification/Abbreviated/Extended Survey Plan of Correction (PoC), with an exit date of 04/04/2023 and correction date of 04/16/2023, revealed beginning on 03/10/2023, visual observations utilizing a rounding tool would be conducted by the Executive Director (ED), Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), Staff Development Coordinator (SDC) or Minimum Data Set (MDS) nurse, to determine if residents' needs were met to prevent accidents; which included falls. These observations would be conducted daily for two weeks including weekends, then three weeks for 2 weeks, then weekly for eight weeks then monthly for one month then observations would be ongoing thereafter. The observation audit results would be submitted to the Quality Assurance Performance Improvement (QAPI) Committee monthly for six months for any additional follow up and or inservicing needs until the issue was resolved, and ongoing thereafter, as determined by the QAPI committee. Review of the 04/17/2023 audit tool revealed it contained audit information related to the previously cited deficient practice at F689, which directed staff to randomly pick ten (10) residents to audit daily. They were to audit to ensure the Kardex was followed by aides as the plan of care, call lights were answered timely, and residents' supervision needs were being met, along with gait belts use during transfer 1. Review of Resident #821's admission record revealed the facility admitted the resident on 12/21/2022, with diagnoses of Dementia, Malnutrition, Urinary Retention, and Multiple Falls. Review of Resident #821's hospital Discharge Summary dated 12/21/2022, revealed the resident had been hospitalized for a history of falls at a prior facility. Review of Resident #821's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), signifying severe cognitive impairment. Continued review revealed the facility assessed Resident #821 to have one (1) person physical assistance for bed mobility, toileting, dressing, eating and personal hygiene. Per MDS review, the facility assessed Resident #821 to have extensive two (2) person physical assistance for transfers. Review of the MDS revealed the facility also assessed Resident #821 as unsteady on his/her feet and only able to stabilize with the assistance of staff, and to use a walker and/or a wheelchair for mobility. Further review of Resident #821's Quarterly MDS Assessment revealed Resident #821 had an indwelling catheter related to his/her urine retention and was frequently incontinent of bowels. Review of Resident #821's Comprehensive Care Plan (CCP) initiated, on 12/22/2022, revealed on 04/14/2023, an intervention for staff to take the resident to the bathroom before meals and at bedtime as needed for bowel movements was created. Continued review revealed on 04/17/2023, an intervention was created for a perimeter mattress with defined edges and for the resident to be sent to the emergency room (ER) for evaluation. Further review of the CCP revealed the facility placed Resident #821 on one-to-one (1:1) supervision when he/she returned from the hospital on 04/18/2023. Review of the facility's Fall Event #2093, dated 04/13/2023 at 3:01 PM, revealed Resident #821 was found lying on the floor in his/her room, next to the bed. Per review, Resident #821 had attempted to ambulate to the restroom without assistance. Continued review revealed a new intervention noted for staff to assist Resident #821 to the toilet after meals, at bedtime and as needed for bowel movements. Further review revealed the Interdisciplinary Team (IDT) determined the Root Cause (RC) for the fall as the resident's poor safety awareness and forgetting his/her limitations secondary to Dementia. In addition, the Fall Event also noted Resident #821 recently experienced a room change. Review of the facility's Fall Event #2094, dated 04/14/2023 at 11:15 AM, revealed Resident #821 was found by staff lying on the floor on his/her side in the doorway of his/her room. Continued review revealed Resident #821 told staff he/she had been going to the restroom and fell in the doorway of his/her room. Per review, the facility determined the RC again as, Resident #821's poor safety awareness and forgetting his/her limitations secondary to Dementia. Further review revealed the facility changed the intervention to sit Resident #821 on the toilet before meals and at bedtime instead of after meals. Review of the facility's Fall Event #2097 documentation, completed by the Assistant Director of Nursing (ADON), on 04/15/2023 at 7:03 PM, revealed Resident #821 sustained an unwitnessed fall and was found lying on the floor next to his/her bed. Per review, Resident #821 was unaware of his/her limitations and attempted to ambulate without assistance. Continued review revealed documentation noting Resident #821 had Dementia, a history of Pneumonia and urinary retention. Further review revealed the ADON noted Resident #821 was alert and at his/her baseline cognitively. In addition, review further revealed the ADON also noted Resident #821 thought he/she hit his/her head. Review of the neuro checks sheet for Resident #821, dated 04/15/2023, revealed the ADON started the checks at 7:00 PM, and completed the checks every fifteen (15) minutes until Emergency Medical Services (EMS) arrived on the scene to transport the resident to the hospital. Review of emergency room (ER) records for Resident #821 on 04/15/2023, revealed the resident was sent out for an unwitnessed fall from the nursing home. It was noted the resident was currently taking Plavix (an anticoagulant). Record review revealed a computed tomography (CT) scan of the head without contrast showed a left parafalcine subdural hematoma (a type of bleed in the brain) measuring 2.8 centimeter (cm) x 0.8 cm. Further review of the ER records revealed neurosurgery was consulted from the emergency department, and recommended the patient be admitted to the Intensive Care Unit. (ICU). Review of Resident #821's Progress Reports revealed on 04/21/2023 the ADON completed a Change in Condition (CIC) for the resident related to a cabinet door which had fallen and hit the resident in his/her head while an aide was providing his/her care. Review of the IDT Note entered by the DON on 04/25/2023, revealed Resident #821 had been hit in the head by a cabinet door which had fallen off after an aide bumped it with her head. Continued review of the IDT Note revealed Resident #821 had a raised area to the top of his/her head. Further review revealed Resident #821 was sent out to the emergency room (ER) and returned later that same evening. In an interview with CMT #1, on 05/11/2023 at 11:12 AM, she stated she worked on 04/15/2023 from 7:00 AM to 7:00 PM. She stated she recalled telling Licensed Practical Nurse (LPN) #38 at shift change, that Resident #821 had sustained a fall during her shift. According to CMT #1, she took Resident #821's vital signs while the resident was still on the floor, seated upright, and leaning against her leg. She stated the time of the vital signs would have been approximately at the time the fall happened. CMT #1 further stated there had been two (2) agency nurses working that day and they knew Resident #821 had fallen. Further interview revealed she left as soon as LPN #38 arrived and took over the medication cart from her. In an interview with LPN #38 on 5/11/2023 at 9:53 AM, she stated she arrived to work on 04/15/2023 at 7:00 PM, her scheduled time to begin her shift, to relieve CMT #1. She stated her usual process was to get report first and then do the medication count because staff did not stay to give report once the medication count had been completed. Per LPN #38, during report on 04/15/2023, when CMT #1 reached Resident #821's name on the list she stated, Oh, you had a fall (indicating the resident had fallen); however, did not indicate the time of the fall. She stated she asked CMT #1 who all knew about Resident #821's fall and whether she started neuro checks. LPN #38 further stated she went to the B Hall and talked to LPN #37 to find out if she had started neuro checks for Resident #821 and/or entered a Progress Note regarding the resident's fall and was informed she had not. In continued interview with LPN #38 on 05/11/2023 at 9:53 AM, she stated she went to report the incident to the ADON who was still at the facility. She stated she did not count the cart until after that. According to LPN #38, the ADON looked in the system to figure out what happened and then went and checked on Resident #821. She stated they determined Resident #821 needed to be sent out to the hospital and EMS was called. LPN #38 stated she was very upset to find out Resident #821 had sustained a fall and was put back to bed without any neuro checks or any further follow-up. The LPN stated Resident #821 was left all alone in his/her room. She stated Resident #821 left the faciity on a stretcher with EMS at 8:30 PM on 04/15/2023. LPN #38 further stated she called the hospital around 2:00 AM and was informed Resident #821 had a brain bleed and had been admitted to the Intensive Care Unit (ICU). LPN #38 stated the ADON told her not to document anything she would do it all. Record review revealed there was not a skin assessment completed other then what was noted on the Fall Event. The ADON did not do any documentation until 04/17/2023. In further interview with LPN #38 on 05/11/2023 at 9:53 AM, she stated when there was an incident with a resident, everything should have been documented when it happened, and neuro checks should have been started immediately. She stated staff were told to call management immediately when a fall occurred that was a concern. The LPN stated she could not ever reach the Director of Nursing (DON) at night and would have to call the ADON or the Human Resources Business Partner. LPN #38 additionally stated she was not ever given the Executive Director's (ED) phone number and there were not any signs up with the ED's phone number listed on it when she worked at the facility. In an interview on 05/11/2023 at 1:00 PM, with the ADON she stated, her job duties were to do rounds and do anything the DON needed her to do. She stated when there was a fall in the facility, staff were to notify the DON immediately, and follow the facility's fall protocol, for a head injury or unwitnessed fall that meant to start neuro checks immediately. The ADON stated she was informed close to 7:00 PM on 04/15/2023, by LPN #38 that CMT #1 told her during report, Resident #821 had a fall during the 7:00 AM to 7:00 PM shift. She stated LPN #38 wanted her assistance down the D Hall, and she went to that part of the facility at about 6:45 PM. According to the ADON, she started everything at 7:00 PM. The ADON stated there had been two (2) agency nurses working that part of the facility on the 7:00 AM to 7:00 PM shift, and she interviewed the B Hall nurse. The ADON stated the nurse looked at the resident; however, refused to do any paperwork related to Resident #821's fall and was placed on the Do not return list for agency staff. She stated when she arrived at Resident #821's room, the resident was seated in a chair and had no bleeding, no trauma, and appeared to be doing okay. Per the ADON, she stated she called the Medical Director and he said to send Resident #821 to the emergency room (ER). The ADON stated she completed the paperwork, skin assessment, neuro checks and called the DON regarding Resident #821's fall. She also stated, if the fall happened at 5:52 PM, the facility's fall protocol was not followed. The ADON further stated EMS was called and the resident was sent out to the ER at 8:30 PM and was complaining of head pain as he/she patted the top of his/her head. She stated CMT #1 was reeducated to follow the facility's fall protocol. The ADON additionally stated she was sure the Executive Director (ED) and DON completed an investigation of the fall. In an additional interview, on 05/11/2023 at 1:44 PM, with the DON, she stated she was responsible for oversight of the facility's clinical department and all staff as part of the management team and ensuring residents got the care they needed. She stated if a resident sustained falls, staff were to call the nurse on call, inform the Unit Manager (UM), and/or Staff Coordinator (SC). The DON stated the facility did not have a House Supervisor. She stated nurses on duty were to oversee the aides. She said the facility used a hierarchy approach, aides were overseen by nurses and nurses by management. The DON reported she often received calls from staff about Resident #821. She stated the ADON told her the fall on 04/15/2023 happened at 7:00 PM, and the resident thought he/she had hit his/her head. The DON stated she believed the ADON also reported to her Resident #821 had a red spot on the top of his/her head, and an abrasion on his/her knee. The DON pulled up Resident #821's EMR and confirmed the resident was on Plavix (an anticoagulant medication) 75 milligrams (mg) and Aspirin 81 mg daily at the time of the fall. In a further interview with the DON on 05/11/2023 at 1:44 PM, she stated after a fall the nurse on duty was to evaluate the resident involved, check for injuries, check if the floor was dry, see what shoes the resident had on and try to determine what caused the fall. She stated the same nurse was expected to fill out the Risk Management Fall Event. The DON said after the resident was taken care of, staff were to contact the Medical Director and family, and do a Change in Condition (CIC) Note. She stated if the fall was unwitnessed or if the resident hit his/her head, neuro checks were to be started immediately. According to the DON, if the resident's roommate witnessed the fall and had a high enough BIMS' score, the roommate could account for what happened. The DON stated her investigation did not determine Resident #821's fall happened at 5:52 PM; however, in fact at 7:00 PM, when the ADON was notified and notified her. She further stated the facility followed its fall protocol on 04/15/2023. In an additional interview with the DON on 05/17/2023 at 2:23 PM, she stated the facility had not identified any trends related to the number of falls within the facility since 04/16/2023. She stated they also had not determined or identified any trend for Resident #821's falls. In addition, the DON stated some of the residents with Dementia forgot they could not do the things they used to be able to do. In an interview with the [NAME] President of Maintenance (VPM) on 05/11/2023 at 8:25 AM, he stated he did not recall the incident specifically; however, he did recall being made aware of a cabinet falling off in one (1) of the residents' shower rooms. The State Survey Agency (SSA) Surveyor and the VPM went to the shower room near Resident #821's, Room and observed a rubber cabinet the facility put up in all the shower rooms for extra storage. The VPM stated at that time that he recalled the incident involving the door hitting a resident in the head. He stated he checked every shower room to ensure the cabinets were secured to the wall and the doors were properly placed to prevent them from falling off. The VPM stated he was unable to determine why the cabinet moved when the aide bumped her head on it. He further stated the cabinets had been put up by the previous maintenance team, all of whom had been terminated for poor work quality, and other things such as problems with background checks. In an interview with the Executive Director (ED), on 05/18/2023 at 2:40 PM, she said she expected staff to follow the facility's fall protocol. She explained, staff were to immediately assess a resident for any injuries after a fall, notify the doctor and family, determine if the resident needed any other interventions related to the fall and initiate what was needed in reference to the fall in a timely manner. The ED stated if the fall happened late in the evening, she might not find out about the fall until the next day. She stated she expected the nurse assigned to the resident to initiate the Risk Management Fall Event and complete the form. According to the ED, the event was to be discussed the next day in the clinical meeting. She explained they discussed the fall as it occurred and ensured the facility's fall protocol was followed. She stated the DON reviewed the Fall Event and determined the root cause (RC) and it was then discussed as a team to see if everyone agreed on the RC. The ED stated, starting neuro checks was up to the nurse doing the assessment and she believed the policy required neuro checks based on the type of injury. She stated she tried to do something nice for the residents by adding more cabinets in the shower room, and then Resident #821 got bumped on the head. The ED further stated she expected her previous Maintenance Director and team to have provided quality work; however, it did not appear they had done so. In interview with the Medical Director on 06/02/2023 at 11:56 AM, he stated he attended the QAPI Committee meetings and he was familiar with the audit tools, but was not involved in their development. He stated many concerns had been reported to him by the ED and the DON including the Immediate Jeopardy (IJs) the facility was given last week related to falls, which was a big concern. He then added he planned on providing an inservice addressing falls, since he was really concerned about residents' safety. 2. Review of Resident #20's Admission Record revealed the facility admitted the resident on 01/05/2023, with diagnoses of Difficulty in Walking, Unsteadiness on Feet, and Dementia with Agitation. Review of Resident #20's Quarterly MDS Assessment, dated 04/20/2023, revealed the facility assessed the resident with a BIMS' score of ninety-nine (99) which indicated the resident was unable to complete the interview. Review of the Interdisciplinary Team (IDT) General Progress Note, dated 04/05/2023 at 12:12 PM, revealed Resident #20 was at risk for falls related to muscle weakness, unsteady gait, dementia with agitation, transient ischemic attack (TIA), seizure disorder, mood disorder, and poor safety awareness secondary to dementia. Review of Resident #20's Comprehensive Care Plan (CCP) revealed on 01/05/2023 the facility developed a care plan for the resident's risk for falls related to receiving psychotropic medications, muscle weakness, unsteady gait/balance, Dementia with agitation, poor safety awareness, and forgot to utilize his/her wheelchair and attempting to ambulate on his/her own. Interventions included staff to turn the bathroom light on at night initiated on 02/19/2023; assist Resident #20 to her wheelchair and out to common area as needed initiated on 04/03/2023; and ensure bed was in low position initiated on 04/05/2023. Review of the Fall Evaluation Progress Note, dated 04/03/2023 at 10:48 PM, revealed Resident #20 had sustained an unwitnessed fall, and told staff that he/she was trying to ambulate without his/her wheelchair. Continued review revealed Resident #20 was assessed to have no apparent trauma, no head trauma and no skin breakdown. Further review revealed his/her care plan was updated with an intervention initiated on 04/03/2023 to assist Resident #20 to his/her wheelchair and out to the common area as needed. Review of the facility's Risk Management Fall Event report for Resident #20, dated 04/03/2023 at 9:30 PM, revealed the incident occurred in Resident #20's room. The Nursing description stated Resident #20 was noted to be sitting on the floor on his/her bottom with no changes in range of motion (ROM). Resident #20 denied hitting his/her head. Neurological (Neuro) check was within normal limits (WNL). Resident #20 was wearing non-skid socks. Further review revealed Resident #20 was ambulating in his/her room without using his/her wheelchair. After evaluation, Resident #20 was assisted up to his/her wheel chair. Resident #20 was able to bear weight. The Resident Description section of the report noted Resident #20 said he/she was trying to walk. The Description of the Immediate Action Taken was Resident #20's plan of care was updated to assist Resident #20 up to w/c and out to common areas as needed. The Root Cause Analysis of Resident #20's, 04/03/2023 fall was documented that Resident #20 was ambulating without assistance and also was not using his/her wheelchair. Further review of the IDT General Progress Note, dated 04/05/2023 at 12:12 PM, revealed the Root Cause Analysis (RCA) of the 04/03/2023 fall was ambulating without using his/her wheelchair and without assistance. In an interview with CNA #15 on 05/11/2023 at 1:00 PM, he stated he worked on the Adjacent Memory Care Unit (AMCU) and thought the staff on the memory care unit (MCU) needed to pay more attention to their residents. CNA #15 stated when he got a break he would sometimes go to the MCU. He stated, when there, he had seen residents there without any staff present on the unit and that greatly concerned him. Review of the Progress Note, dated 05/19/2023 at 9:45 PM, revealed Resident #20 was found in a sitting position on the bedroom floor. Per review of the Note, the Nursing Assessment concluded Resident #20 was unable to move his/her right arm and was in pain upon palpation of his/her right upper extremity. Further review revealed Resident #20's Primary Care Provider was notified and recommended the resident be sent to the hospital. Review of the emergency room (ER) records dated 05/19/2023, revealed Resident #20 was admitted to the hospital with a diagnosis of a closed supracondylar fracture of the right humerus (a fracture of the humerus near the elbow) from an unwitnessed fall. During interview, on 05/22/2023 at 12:10 PM, the Director of Nursing (DON) stated Resident #20's bathroom light was not on the night he/she fell and broke his/her arm. She stated Resident #20's bathroom light should have been on per the resident's care plan. CNA #23, during interview on 06/01/2023 at 9:43 AM, stated it was important to know what was on each resident's care plan because she wanted to know how to best care for the residents, and the care plan was the final word on how to care for residents. In an interview with the DON on 05/25/2023 at 10:15 AM, she stated Resident #20 liked to be up in the common area sometimes, and if he/she wanted to be up, then he/she could be up. The DON stated Resident #20 had his/her snack the night of the incident, then wanted to go to bed. She stated the resident had been in bed about fifteen (15) minutes and nobody heard anything related to the fall. In an interview with the Executive Director (ED), on 05/18/2023 at 2:40 PM, she said she expected staff to follow the facility's fall protocol. She explained, for any resident who sustained an unwitnessed fall or hit his/her head, the nurse assigned to the resident would start neuro checks immediately. For other falls, the nurse would determine if the resident needed neuro checks and would start them. The ED stated if the nurse determined a new intervention was needed, she was to update the care plan at that time. She also stated the nurse on duty was the staff member to initiate the Risk Management Fall Event. She stated the DON reviewed the Fall Event and determined the root cause (RC), and it was then discussed in the IDT meeting to see if everyone agreed on the RC. 3. Review of Resident #90's face sheet revealed the facility admitted the resident on 04/05/2023, with diagnoses that included Alzheimer's Disease, Muscle Weakness, difficulty walking, Dementia and repeated falls. Review of the Quarterly MDS Assessment, dated 04/07/2023, revealed the facility assessed the resident to have a BIMS' score of three (3) out of fifteen (15) which indicated severe impairment. Review of the Fall Risk Assessment (FRA), a document developed by the facility with eight (8) areas listed to determine a resident's risk for falls. Review of Resident #90's FRA, dated 05/31/2023, revealed a score of eighteen (18), which indicated the resident was at risk for falls. The FRA determined the resident was a fall risk because of his/her vision status being classified as poor, with or without glasses. Review of Resident #90's

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure care plans were revised to provide proper care and supervision to residents to prevent falls/accidents for two (2) of thirty-three (33) sampled residents (Residents #146 and #821). Resident #821 sustained a fall on 04/13/2023, and was found lying on the floor after trying to transfer to the bathroom; there were no updates made to his/her care plan. The facility determined the root cause of the fall as poor safety awareness due to Dementia. On 04/14/2023, Resident #821 was again found on the floor while trying to toilet he/she stated; the care plan was revised with an intervention to toilet before meals and at bedtime related to trying to toilet without assistance. The resident sustained an unwitnessed fall on 04/15/2023 at approximately 5:52 PM, staff did not report the fall to management until approximately 7:00 PM and neuro checks were not started until 7:00 PM. The facility sent the resident to the emergency room (ER) to be evaluated and he/she was admitted to the Intensive Care Unit (ICU) with a subdural hematoma. Resident #146 sustained eleven (11) falls since admission to the facility in October 2022. On 04/28/2023, the resident was found with his/her face twisted on the floor at 10:16 PM, and was noted to be tachycardia (increased heart rate) and complained of a headache. On 04/29/2023 at 3:10 AM, the resident was noted with skin impairment to the right rear shoulder and scapula and was sent to the ER for a CT of the head and spine. On 05/22/2023, observation revealed Resident #146 was attempting to transfer from the bed to ambulate, at which time the State Survey Agency (SSA) Surveyor had to call staff to assist. The facility determined the root cause of the 04/29/2023 fall was poor safety awareness, however no increase in supervision or monitoring had been added to the care plan after Resident #146's 04/28/2023 fall. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 04/13/2023 and is ongoing in the areas of 42 CFR 483.10 Resident Rights (F578), Formulate Advanced Directives at a Scope and Severity (S/S) of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K and (F657), Review and Revise Care Plans, both at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The findings include: Review of the facility's Comprehensive Care Plan policy effective January 2018 revealed the Care Planning/Interdisciplinary Team (IDT) was responsible for reviewing and updating of care plans when there was a significant change in a resident's condition, when the desired outcome was not met, or when the resident was readmitted to the facility from a hospital stay, and at least quarterly. 1. Review of Resident #821's Admission Record revealed the facility admitted the resident on 12/21/2022, with diagnoses of Multiple Falls, Dementia, Malnutrition, and Urinary Retention. Review of Resident #821's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) which indicated severe cognitive impairment. Continued review revealed the facility assessed Resident #821 to have one (1) person physical assistance with bed mobility, toileting, dressing, eating and personal hygiene. Per MDS review, the facility assessed Resident #821 to have two (2) person extensive physical assistance with transfers. Review revealed Resident #821 had been assessed as unsteady on his/her feet and only able to stabilize with assistance of staff. In addition, review revealed the facility assessed Resident #821 to use a walker and/or a wheelchair. Continued review revealed the facility assessed Resident #821 as having an indwelling catheter related to his/her urine retention and as frequently incontinent of bowels. Review of Resident #821's hospital discharge summary dated 12/21/2023, revealed the resident had a history of falls at his/her previous nursing facility. Review of Resident #821's Comprehensive Care Plan (CCP) for falls initiated on 12/22/2022, revealed the focus area identified the resident as at risks for falls related to a new environment, history of falls, weakness, current medications/potential side effects, diminished safety awareness, incontinence, and balance problem. Continued review revealed interventions established on 12/22/2022,were for staff to keep the call light and personal items within personal reach; ensure proper footwear was on while out of bed; refer the resident to Physical, Occupational, and/or Speech Therapy as needed; perform a fall assessment on admission and at least quarterly; and educate/remind the resident about safety awareness of locking brakes on the wheelchair. Review of Resident #821's CCP additionally revealed other interventions were attempted such as: assisting the resident to the dayroom when he/she was restless (02/07/2023), dycem to wheelchair and fall mat next to bed (02/19/2023), lay resident down to rest before meals ( 02/26/2023), and a low bed intervention (03/21/2023). Review of the facility's Fall Risk Assessments for Resident #821 revealed the facility assessed the resident on 01/12/2023 with a score of eleven (11); on 02/07/2023 with a score of thirteen (13); and on 03/07/2023 with a score of thirteen (13), which all indicated the resident was a high risk for falls. However, there was no documented evidence of a fall assessment for the fall the resident sustained on 04/15/2023. Review of Resident #821's previous history of falls, revealed the resident fell out of bed on 02/19/2023, 02/26/2023 and again on 03/03/2023 which resulted in a hematoma to his/her head approximately ten (10) centimeters (cm) in size. Review of Resident #821's electronic medical record (EMR) revealed the resident sustained falls on 04/13/2023, and 04/14/2023. However, review revealed there was no record the facility revised the care plan on 04/13/2023 with the intervention of sitting the resident on the toilet after meals, as noted on the facility's Fall Event documentation. Therefore, continued review revealed Resident #821 sustained a fall again on 04/15/2023 which resulted in a subdural hematoma, and he/she was sent out to the hospital, and subsequently admitted to the Intensive Care Unit (ICU). Further review revealed Resident #821 was readmitted to the facility on [DATE] and was placed on 1:1 supervision. In an interview with Certified Nursing Assistant (CNA) #19 on 05/17/2023 at 1:10 PM, she stated Resident #821 let staff know when he/she needed to have a bowel movement on most occasions. She stated with Resident #821 it was helpful to ask him/her regularly if he/she needed to use the bathroom. CNA #19 stated making sure Resident #821 used the bathroom as needed would help decrease the number of falls he/she had. The CNA stated since Resident #821 had been on 1:1 supervision, he/she had not experienced any further falls. In addition, she stated Resident #821 was still on 1:1 supervision when the State Survey Agency (SSA) team exited the facility on 06/02/2023. In an interview with CNA #7 on 05/19/2023 at 10:00 AM, she said she was a regular 1:1 sitter for Resident #821. She stated the resident liked to rest in bed most of the day; however, she encouraged Resident #821 to get up to his/her wheelchair after meals. CNA #7 stated Resident #821 told her when he/she needed to use the bathroom. She stated the resident was a proud person and liked to be very clean. The CNA said Resident #821 required more supervision than just every two (2) hours to check him/her for needing to go to the bathroom. CNA #7 additionally stated when interventions no longer worked, they needed to be changed or resolved and new ones needed to be tried. In an interview with the MDS Coordinator #1 on 05/17/2023 at 3:20 PM, she stated she attended the IDT meetings, and assisted the IDT with residents' care plans; however, every member of the IDT was able to write a care plan. She stated she now had an office in the facility instead of working remotely, as she previously had. She stated the facility had a skilled meeting weekly and she read the provider notes, and the twenty-four (24) hour notes in the facility's computerized point click care (PCC) system to check for necessary information. The MDS Coordinator reported while doing quarterly/annual assessments, she looked at all care plan interventions for accuracy. She said all staff members were responsible to ensure residents' care plans were reviewed and revised. The MDS Coordinator stated it was possible for something to be on the care plan and not match the MDS Assessment, because it could have been something the MDS had not triggered for. She further stated interventions should be updated on the care plan when it was something that would be a long-term intervention. In an interview with the Director of Nursing (DON) on 05/25/2023 at 11:30 AM, she stated the facility could not put every resident on fifteen (15) minute checks or one on one (1:1) supervision. She said the facility determined the root cause of Resident #821's falls to be his/her lack of safety awareness and Dementia. She explained the IDT did believe taking Resident #821 to the bathroom more often would decrease his/her falls, however, she explained they did not determine any patterns as to what caused the residents' falls aside from his/her poor memory and low BIMS score. The DON stated the care plan needed to be revised any time an intervention was changed, and if an intervention was found to no longer be effective. The DON further stated the MDS Coordinator was be present at morning meetings and would update interventions at that time. 2. Review of Resident #146's Admission Record revealed the facility admitted the resident on 10/26/2022, with diagnoses that included Muscle Weakness, Cognitive Communication Deficit, Difficulty in Walking, and Need for Assistance with Personal Care. Review of the Quarterly MDS Assessment for Resident #146 dated 05/08/2023, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), which indicated severe cognitive impairment. Continued review revealed the facility assessed Resident #146 to require physical assistance of two (2) plus staff to transfer to or from the bed, chair, wheelchair, or standing position; excluding transfer to or from the bath or toilet. Review of Resident #146's CCP initiated on 10/27/2023, revealed the facility care planned with a focus for falls related to a history of falls, receiving psychotropic medications, muscle weakness, impaired mobility, unsteady gait, and lack of safety awareness secondary to Dementia. Continued review revealed the Goal was for Resident #146 to have no falls through the next review date, with interventions which included bed in low position, initiated on 05/01/2023. Further review of Resident #146's CCP, initiated on 10/27/2023 and revised on 04/06/2023, revealed the facility also care planned Resident #146 to require assistance as needed with bed mobility, transfers, dressing, personal hygiene and toileting by one (1) person. Review of Resident #146's Progress Notes revealed after the facility admitted him/her on 10/26/2022, he/she sustained eleven (11) falls at the facility on the following dates: 11/03/2022, 11/26/2022, 01/07/2023, 01/20/2023, 01/27/2023, 01/31/2023, 02/02/2023, 02/03/2023, 02/05/2023, 04/03/2023 and 04/28/2023. Review of Resident #146's Progress Notes dated 04/28/2023 at 11:44 PM revealed the resident was assessed with a head injury after the fall. Continued review revealed Resident #146 was at risk for falls due to Dementia, and had been found on the floor, was tachycardia (increased heart rate) and complained of a headache. Further review revealed the medical provider ordered Resident #146 to be sent to the hospital. Review of the Progress Note dated 04/29/2023 at 4:29 AM revealed documentation noting Resident #146 arrived back at the facility from the hospital at 3:30 AM. Continued review revealed the hospital emergency room (ER) nurse reported Resident #146's computed tomography (CT) scan results of his/her head and cervical spine were reported as normal. Observation on 05/22/2023 at 9:44 AM, revealed Resident #146 attempting to self-transfer from the bed to ambulate with no staff present. Continued observation revealed Resident #146's bed was not in the low position as care planned. The SSA Surveyor, aware of Resident #146's risk for falls and history of numerous falls, called staff to come assist Resident #146 and possibly prevent Resident #146 from a fall from a bed that was not in low position. Further observation revealed CNA #87 transferred Resident #146 from the bed to the wheelchair by herself without assistance of another person as per the resident's most recent MDS Quarterly MDS Assessment. In an interview with CNA #87 on 05/22/2023 at 9:50 AM, she stated she did not know if Resident #146 required two (2) persons assist with transfers from the bed to the wheelchair because she could not look at the resident's care plan on the computer. She stated she did not have a computer login and therefore was unable to look at the resident's care plan. The Minimum Data Set (MDS) Coordinator stated in interview on 05/17/2023 at 1:15 PM stated all the facility's nurses had the ability to update care plans, but she was not sure if they all knew how to update care plans. During observation on 05/19/2023 at 9:30 AM the Executive Director (ED) reported in the morning meeting to the facility's administrative team there were no changes in care plan meetings. During interview on 05/25/2023 at 10:15 PM the DON stated if residents' care plans were not revised or correct, staff or residents could be injured. In an interview with the Executive Director on 06/02/2023 at 1:23 PM, she stated she expected facility staff to follow the facility's policies and procedures. She stated staff were expected to follow residents' care plans because that was created to ensure the residents got the best care. The ED stated care plans were to be updated/revised anytime the team determined an intervention no longer worked. She said it was the previous administration who would not use 1:1 supervision for residents; however, she did not mind to use it for residents who really needed it. The ED further stated Resident #821 had done much better since being placed on 1:1 supervision. 43694 44486

Based on observation, interview, record review, and review of the standardized Emergency Medical Service (EMS) Do Not Resuscitate (DNR) Order, it was determined the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, and to formulate an Advanced Directive for three (3) of four (4) sampled State Guardianship residents (Resident #2, Resident #23, and Resident #89). Review of Resident #2's, Resident #23's and Resident #89's medical records revealed he/she had a DNR order. However, there was no evidence that EMS DNR forms had been completed for the residents. The facility's failure to ensure the EMS DNR forms were completed for Resident #2, Resident #23, and Resident #89 has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] and is ongoing in the areas of 42 CFR 483.10 Resident Rights (F578), Formulate Advanced Directives at a Scope and Severity (S/S) of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K and (F657), Review and Revise Care Plans, both at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The findings include: Observation, on [DATE] at 4:43 PM, of the facility's Code Status binders revealed there were no Kentucky (KY) EMS DNR forms signed for Resident #2, Resident #23, or Resident #89. The binders included State Guardianship letters stating the residents' code status was DNR. Review of the facility's policy titled, Advance Directives, revised [DATE], revealed residents had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The nurse supervisor was required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of the advance directive or Physician's Order for Life Sustaining Treatment (POLST) when transferred from the facility via ambulance or by other means. Review of the standardized Emergency Medical Service Do Not Resuscitate Order instructions revealed it was developed and approved by the Kentucky Board of Medical Licensure in conjunction with the Cabinet for Human Resources. Additional review revealed the original, completed EMS DNR Order or the EMS DNR Bracelet must be readily available to EMS personnel for the EMS DNR Order to be honored. 1. Review of Resident #2's Medical Record revealed the facility admitted the resident, on [DATE], with diagnoses that included Dementia, Adult Failure to Thrive, and Displaced Fracture of the Right Femur. Further review of the medical record revealed the resident was eighty-six (86) years old at the time of admission. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was severely cognitively impaired. Record review revealed Resident #2 had a letter from State Guardianship, dated [DATE], which changed his/her code status to DNR. Further review revealed the resident's face sheet code status was noted as DNR Comfort Care. However, record review revealed the facility had not completed the required EMS DNR form. Without this required form, in the event the resident went into Cardiopulmonary Arrest (his/her heart and/or breathing stopped), the resident would have Cardiopulmonary Resuscitation (CPR) performed instead of honoring the resident's wish to Do Not Resuscitate. 2. Review of Resident #23's Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included Acute Respiratory Failure with Hypercapnia, Aphasia, Dysphagia, and Dementia. Further review of the medical record revealed the resident was seventy-two (72) years old at the time of admission. Review of Resident #23's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of ninety-nine (99), which indicated the resident was severely cognitively impaired. Record review revealed Resident #23 had a letter from State Guardianship, dated [DATE], which changed his/her status to comfort measures in addition to having changed to DNR status on [DATE]. Further review revealed the resident's face sheet code status was DNR. However, further review revealed no documentation of a Physician's Order or was care planned. Record review revealed the facility did not have the required EMS/DNR form completed and in the record. In the event the resident went into Cardiopulmonary Arrest, the resident would have Cardiopulmonary Resuscitation (CPR) performed instead of honoring the resident's wish to Do Not Resuscitate. 3. Review of Resident #89's Medical Record revealed the facility admitted him/her on [DATE] with diagnoses that included Cognitive Communication Deficit, Schizophrenia, Dementia, Traumatic Brain Injury and Respiratory Failure. Review of Resident #89's Quarterly MDS, dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 00. Review of the resident's, [DATE] Quarterly MDS, revealed the facility assessed the resident with a BIMS' score of 99, which indicated the resident had severe cognitive impairment. Review of Physician's Orders, dated [DATE], revealed a Do Not Resuscitate (DNR) order. However, there was no documented evidence Resident #89 had a Code Status order prior to [DATE]. Clinical record review revealed Resident #89 had a letter from State Guardianship, dated [DATE], which changed the resident's code status from Full Code to DNR. However, review of Resident #89's Care Plan that was available to the State Survey Agency (SSA), upon entry, dated [DATE] revealed Resident #89 had a Focus of Full Code, a Goal of Advanced directives would be provided as per the resident's wish and care coordinated as indicated, dated [DATE]. Interventions included Full Code, Call 911 and start CPR with an initiation date of [DATE]. Record review the care plan noted the resident was as 'Full CODE on [DATE]. However, the State Guardian had changed the resident's code status to DNR on [DATE]. With a Full Code status, in the event the resident went into Cardiopulmonary Arrest, the resident would have Cardiopulmonary Resuscitation (CPR) performed instead of honoring the resident's wish to Do Not Resuscitate. During interview with Social Worker #1, on [DATE] at 3:03 PM, she stated she oversaw Advanced Directives and, if a resident chose to have a DNR order, the facility went by the KY EMS DNR form. She stated the Interdisciplinary Team (IDT) reviewed each resident's code status at every formal meeting, such as quarterly care plan meetings. She stated she care planned the resident for their code status. Social Worker #1 stated all residents with a DNR order had an EMS DNR form in the binders at the nurses' stations. She stated the code status form was scanned into the resident's medical record, but the KY EMS DNR form was not, as EMS required an original form. Social Worker #1 stated she did not want the staff to print it out of the medical record. Additionally, she stated she was responsible for making sure the EMS DNR form was placed in the binders. She stated the letter from State Guardianship stating the resident's code status served as the EMS DNR form. The Social Worker stated she had called American Medical Response (AMR) Emergency Services, and ambulance personnel were agreeable to accept this letter as the resident's DNR form. She further stated she was unsure if all ambulance personnel statewide accepted this letter. However, upon interview, with the AMR Emergency Medical Technician (EMT) Supervisor, on [DATE] at 12:35 PM, he stated EMS had to have an original EMS DNR form or they were required to call their medical director for further instructions. He stated EMS would be required to perform Cardiopulmonary Resuscitation (CPR) on a resident if an EMS DNR form was not presented to ambulance personnel upon arrival to transport a resident. Messages were left with two (2) State Guardianship Case Workers, on [DATE] at 3:15 PM and 3:30 PM, without a return call. Upon interview with Social Worker #1, on [DATE] at 3:35 PM, the State Survey Agency Surveyor informed her of an interview with the AMR EMT Supervisor. She stated she had called AMR last July, and she did not routinely call EMS to verify if they accepted the State Guardianship Letter as a substitute for the EMS DNR form. She stated the local Fire and Rescue was the closest EMS provider to the facility, and EMS personnel were not consistent in which form they required. During interview with a Major at the Fire and Rescue, on [DATE] at 4:07 PM, he/she stated EMS must have an original KY EMS DNR form upon arrival to transport a resident because it was a state mandated form. He/she further stated the resident would be treated as having a full code order and given CPR without an EMS DNR form. During interview, on [DATE] at 9:30 AM, the Executive Director (ED) reported in the morning meeting to the facility's administrative team she had no concerns with Residents' Rights, and Advanced Directives were all good that week. The Executive Director (ED), stated during interview, on [DATE] at 3:46 PM, that she thought the proper form to use was the EMS DNR form. She stated she had questioned the Social Services Director (SSD) regarding use of the form when she started at the facility. The ED stated the SSD said she had called EMS and they expressed they would take the State Guardianship letter in lieu of the KY EMS DNR form, and the ED stated she accepted this. She stated she expected the SSD and all staff to use the correct form. She additionally stated it was her job to audit, and she was more aware now and would be increasing her audits. The ED stated there was no direct corporate staff over Social Services, and it was the her job to assure the SSD used the proper forms. 47852

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were provided routine respiratory and cardiac assessments per professional standards of practice, and per the resident's person-centered plan of care for two (2) of nineteen (19) sampled residents (Residents #32, and #107). 1. The facility care planned Resident #107 for management of Congestive Heart Failure (CHF) and fluid overload related to his/her diagnosis of Chronic Obstructive Pulmonary Disease (COPD). However, the facility failed to provide routine nursing assessments for Resident #107's respiratory, cardiac, or fluid status. Per interview with Licensed Practical Nurse (LPN) #40 regarding Resident #107's condition on 06/21/2023 and 06/23/2023, the nurse stated the resident had gurgling sounds in his/her chest on 06/21/2023, which worsened on 06/23/2023. When Resident #107's Physician assessed the resident on the afternoon of 06/23/2023, he stated the resident was in fluid overload and gave orders for the resident to be transferred to the hospital. Resident #107 was transferred to the hospital's Emergency Department (ED). Resident #107 was diagnosed with Acute Respiratory Failure with Hypoxia, Acute Renal Failure, Congestive Heart Failure and was admitted to the hospital. 2. Resident #32's Comprehensive Care Plan, initiated 11/13/2022, for altered cardiovascular status revealed the interventions included to monitor/document/report as needed any changes such as edema; and coronary artery disease interventions such as monitor/document/report excessive swelling, dependent edema, and color/warmth of extremities. However, the facility failed to provide documented evidence of provision of routine cardiac assessments for the resident. Interview with a licensed nurse assigned to Resident #32 on 06/26/2023, on the 7:00 AM to 7:00 PM shift, revealed she had not assessed the resident's bilateral lower extremities for edema during her shift. She stated however, she had been asked by the nurse relieving her at 7:00 PM to look at the resident's feet at the time of shift change. The nurse stated she and the other nurse assessed Resident #32 together and the resident was observed to have edema in his/her foot/ankle and no pedal pulse could be felt in either foot. She could not recall which foot, or the color or temperature of the resident's foot. Resident #32 was transferred and admitted to the hospital on [DATE] for right lower extremity edema. Resident #32 was still hospitalized at time of the survey exit. The findings include: In an interview on 06/26/2023 at 11:04 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the facility had no policy to address respiratory assessments, and no criteria for completing Respiratory Assessment Evaluation forms. 1. Review of Resident #107's admission Record revealed the facility admitted the resident on 09/29/2022. Diagnoses included Unspecified Injury of the Head, Dementia, Atherosclerotic Heart Disease, COPD, Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Kidney Disease, Stage 3, and Congestive Heart Failure. Review of Resident #107's Quarterly Minimum Data Set (MDS) Assessment, dated 05/01/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of status 99 which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed the resident as having disorganized thinking behaviors present that fluctuated and varied in severity. Review of Resident #107's Comprehensive Care Plan revealed the facility care planned the resident related to his/her cardiac and respiratory status, altered due to diagnoses of Coronary Artery Disease (CAD), Hypertension (HTN), CHF initiated on 10/12/2022. Further review revealed a goal for the resident to be free from complications of cardiac problems through the next review date. Continued review revealed interventions included to monitor, document, and report as needed any signs/symptoms of CAD: chest pain or pressure especially with activity; heartburn; nausea and vomiting; shortness of breath; excessive sweating; dependent edema; changes in capillary refill; and color/warmth of extremities. Record review revealed additional interventions included: medications administered as per Physician's order; monitor vital signs as ordered and as needed and notify Physician of significant abnormalities. Review of Resident #107's Care Plan revealed the facility added a new focus on 04/26/2023, noting the resident was at risk for fluid overload related to CHF and pulmonary edema. Per review, the goal was for Resident #107 to remain free of signs and symptoms of fluid overload through the next review date, as evidenced by a decrease in or absence of: edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea, vomiting, dyspnea, congestion, orthopnea, being easily fatigued, and jugular vein distension (JVD). Continued review of the care plan revealed the interventions included: observe for signs/symptoms of fluid overload: anxiety, mood/behavior changes, confusion, edema, shortness of breath, difficulty breathing, increased respirations, difficulty breathing when lying flat, congestion, cough, fatigue, JVD, and sudden weight gain. In addition, review revealed the interventions included to obtain labs/x-rays as per Physician order, and raise head of bed as needed to facilitate breathing. Review of Resident #107's Comprehensive assessment dated [DATE] and signed at 8:55 AM by the Advanced Registered Nurse Practitioner (ARNP) #1 revealed the resident's Chief Complaint was noted as follow up on his/her breathing and CHF. Per review, Resident #107 was on oxygen that day; had Lasix (diuretic medication) 20 milligram (mg) ordered once a day; however, the resident appeared to be in acute overload this morning. Continued review revealed the resident had edema in his/her lower extremities, his/her lung sounds had wheezing scattered throughout, with crackles, and rhonchi throughout; however, was not in respiratory distress. In addition, review revealed ARNP #1 noted Resident #107's acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was unstable, and the resident's Lasix would be increased to twice a day (BID) and his/her laboratory (labs) levels were to be checked on 06/07/2023. Review of Resident #107's Comprehensive Encounter dated 06/07/2023, noted by Advanced Registered Nurse Practitioner (ARNP) #1 as a follow up after changing the resident's Lasix to BID (twice a day) and related to his/her swelling. Per review, Resident #107 was off his/her oxygen and his/her oxygen saturation (O2 sats) were 95% per the nursing documentation. Continued review revealed his/her bilateral extremities had 1-2+ pitting edema. Record review revealed Resident #107 was in no respiratory distress and continued to have rhonchi throughout which sounded slightly better. Further review revealed ARNP #1 was to reduce the evening dose of Lasix, and check the resident's labs on Monday, 06/12/2023. Review of Resident #107's Dietary Progress Nutrition Note dated 06/10/2023 at 11:57 AM, documented during the Nutrition at Risk (NAR) meeting by the Interdisciplinary Team (IDT), revealed the resident's current weight was 140.2 pounds, which was a weight gain of twelve (12) pounds in a five (5) day period. Continued review revealed edema had been noted by the ARNP, who had increased Resident #107's Lasix from 20 mg daily to BID and then due to his/her lab results, the Lasix had been reduced to daily again. Further review revealed due to the multiple diuretic changes with resultant fluid load weight change was as expected. In addition, review revealed continue with weekly weights and nutrition plan of care (POC). Review of the Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac or fluid status after the IDT NAR meeting on 06/10/2023. Review of Resident #7's Comprehensive Assessment note dated 06/12/2023, by ARNP #1 after the resident sustained a fall revealed he/she did not exhibit signs or symptoms of respiratory distress; however, had lung sounds with crackles, rhonchi throughout, two plus (2+) swelling to the bilateral lower extremities. Review of Resident #107's Nurse Progress note dated 06/12/2023 at 10:00 AM, revealed the resident had fallen and was transferred to emergency room (ER) via ambulance. Further review of the note revealed an O2 sat of 97%; however; additional review revealed no documented evidence the nurse further assessed the resident's cardiac, respiratory, or fluid status. Review of Resident #107's Comprehensive Encounter dated 06/13/2023, noted by ARNP #1 revealed the visit was a follow up after the resident sustained a fall and was sent to the emergency room (ER). Per review, Resident #107 had left sided more than right pleural effusions (unusual amount of fluid around the lung), nodular density at the right upper lung with follow-up advised. Continued review revealed there was no convincing evidence for acute Pneumonia or CHF exacerbation. Review revealed Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, crackles, rhonchi throughout unlabored breathing pattern. Review of Resident #107's Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac, or fluid status assessments. Review of Resident #107's 06/15/2023 Comprehensive Encounter Dated 06/15/2023 by ARNP #1 revealed Resident #107 exhibited no signs of respiratory distress; however, had wheezing and rhonchi throughout. Per review, Resident #107 had a decrease in swelling to the bilateral lower extremities, at 1+ pitting edema. Review of Resident #107's Dietary Progress Note dated 06/17/2023 at 12:54 PM, revealed a Nutrtionally at Risk (NAR) note stated the resident's current weight was 138.4 pounds, which was a weight loss of 1.8 pounds from last week. Continued review revealed multiple diuretic changes with resultant fluid load and weight change as expected. Review further revealed there would be continued weekly weights, a nutrition plan of care, and follow by NAR. Review of Resident #107's Nurse Progress Notes revealed however, no documented evidence of nursing staff noting the resident's respiratory, cardiac, or fluid (edema) status. Review of Resident #107's Comprehensive Encounter dated 06/19/2023, noted by ARNP #1 revealed it was a follow up on COPD. Per review, Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, and rhonchi throughout. Continued review revealed Resident #107's COPD was stable, and his/her O2 sats were 97% per nursing documentation. Edema had improved to one plus (1+) non pitting. Review of Resident #107's Nurse Progress notes revealed however, no documented evidence of nursing staff's assessments of the resident's respiratory, cardiac, or edema (fluid) retention. Review of Resident #107's Nurse Progress note dated 06/20/2023 at 4:59 AM, revealed the resident was on one to one (1:1) supervision related to his/her behavior/fall. Continued review revealed Resident #107's lung sounds were clear to auscultation, the resident was sleeping at the time of report, and staff were to continue to monitor. However, further record review revealed no documented evidence staff continued to monitor the resident's condition on 06/20/2023. Review of Resident #107's Respiratory Evaluation dated 06/20/2023 at 3:51 PM, documented by the ADON as a Late Entry revealed there had been no change in the resident's condition. Per review, Resident #107 was confused, experiencing signs of short-term memory loss, required cues; however, his/her current state of confusion was baseline for the resident. Continued review revealed Resident #107's respiratory status was noted as no sign of difficulty breathing, with left lung sounds throughout left lung on inspiration, and wheezes on auscultation, and he/she was not utilizing oxygen. Review of Resident #107's Comprehensive Encounter Note dated 06/22/2023 at 4:00 PM, documented by ARNP #1 revealed a therapist stopped the ARNP to assess the resident's legs which had been swelling off and on for several weeks. Per review, Resident #107's legs had 2-3+ pitting edema with the left weeping fluid from a wound to the left outer calf. Continued review revealed Resident #107 had crackles, and rhonchi throughout (his/her lungs); however, did not exhibit signs of respiratory distress. Further review revealed orders for oxygen as needed and staff to keep the resident's O2 sats greater than 91%. Review of the Nurse Progress note dated 06/22/2023 at 5:00 PM, documented by Registered Nurse (RN) #11 revealed Resident #107 was noncompliant with his/her breathing treatments and Aero chamber use. Continued review revealed Resident #107 continued to remove his/her nasal cannula, had rhonchi throughout all his/her lung lobes, and was hitting at the nurse during his/her breathing treatment. Further review revealed however, no documented evidence RN #11 notified the ARNP or Physician of Resident #107's respiratory status, that he/she kept removing his/her oxygen, and was noncompliant with his/her breathing treatment and Aero chamber use. Review of Resident #107's electronic medication administration record (eMar) revealed on 06/22/2023 at 5:17 PM, the order for Aero Chamber, give 1 unit by mouth every six (6) hours for use with albuterol/Atrovent inhalers, RN #11 noted the resident was hitting at the nurse and chewing on the aero chamber. Review of a Physician's Order dated 04/13/2023 and time 10:45 AM, revealed orders for Oxygen (O2) at two (2) liters per minute (lpm) as needed, keep the resident's O2 saturations (sats) above 91%. However, review of Resident #107's medical record revealed those orders did not flow over to his/her Medication Administration Record (MAR) or Treatment Administration Records (TAR) for the months of May or June 2023. Review of Resident #107's Treatment Administration Record (TAR) dated 06/23/2023 at 7:00 AM revealed his/her O2 sat was noted as 90%. Further review revealed however, no documented evidence the Physician was notified of the resident's decreased O2 sat as ordered. Continued review of the Nurse Progress notes revealed no documented evidence of the nurses assessing and monitoring the resident's respiratory, cardiac, or fluid status on 06/22/2023. Review of Resident #107's MAR for the date of 06/23/2023, revealed an order for Lasix 20 mg dose written at 9:00 AM by ARNP #1 which was given at 12:40 PM by LPN #40. Review of Resident #107's Nurse Progress note dated 06/23/2023 at 3:54 PM, documented by LPN #40 revealed the resident had a one (1) time order related to weeping of his/her left leg; no complaints of pain or discomfort; and continued on antibiotic therapy for cellulitis with no signs or symptoms of adverse reactions noted. Further review revealed however, no documented evidence of the nurse having performed an assessment of Resident #107's respiratory, cardiac or fluid status to include vital signs and O2 sats. Review of the facility's Admission/Discharge/Transfer/Appointment Late Entry Note for Resident #107 dated 06/23/2023 at 4:50 PM, revealed the resident was transferred to the hospital related to shortness of air (SOA). Per review, the transfer was ordered by Physician #60. Review of the hospital emergency room (ER) report dated 06/23/2023 revealed upon arrival to the ER, Resident #107's O2 saturation level was 70% on room air (values under 90% can lead to serious deterioration in a person's health status). In an interview on 06/26/2023 at 10:46 AM RN #11, who cared for Resident #107 on 06/22/2023 on the 7:00 AM to 7:00 PM, stated she did not know too much about the resident; however, recalled he/she refused to wear his/her oxygen often. RN #11 stated at shift change report she was only informed of how residents took their medications, and not really anything about their condition. Per RN #11, she was aware Resident #107 had oxygen because she was the person who contacted the Physician to obtain the order for it a few months back. She stated Resident #107 was on breathing treatments, and usually there was an area on the MAR that had to be completed after giving the respiratory treatments. RN #11 stated she did not perform a head-to-toe assessment of Resident #107, she only assessed his/her lung sounds and documented rhonchi throughout all lobes. She stated she was not aware of Resident #107 having edema, although she normally looked at resident's extremities; however, she had not assessed the resident for edema on that date. According to RN #11, if she observed anything abnormal during an assessment of the resident she would have put it in the progress notes. RN#11 stated that per her documentation in the progress notes for Resident #107, which referred to him/her being non-compliant with the breathing treatment, chewing on the Aero chamber, removing his/her oxygen, and hitting at her, was nothing out the ordinary for the resident. She further stated she should have charted more of Resident #107's abnormal respiratory sounds. In an interview on 06/26/2023 at 1:15 PM, Physical Therapy Assistant (PTA) #1 stated he reported to nursing staff on multiple occasions that the resident had a heart rate of 45-60 and low O2 sats of 63-74%. PTA #1 stated therapy saw Resident #107 five (5) times weekly and the resident always had edema to his/her bilateral lower extremities. In an interview on 06/26/2023 at 1:55 PM, LPN #40 stated she usually got to work at 6:30 AM, did her narcotics count and got report from the off going staff, then checked blood sugars and passed medications. LPN #40 stated she had not seen Resident #107 right away the morning of 06/23/2023, as she started passing medication on the front hall and was working her way toward the back hall where Resident #107's room was located. She stated the CNA reported to her that morning that Resident #107's legs were weeping, and the Therapist had also voiced concerns to her about the resident's legs weeping. The LPN stated she was not sure what time she was initially able to assess Resident #107, and when she did it was hard to get an accurate O2 sat reading as his/her fingers were cold which was normal, and staff always had to warm his/her hands to get the reading. During further interview LPN #40 stated that she wasn't sure of what time she initially assessed Resident #107. LPN #40 further stated that Resident #107's lung sounds usually had gurgle sounds; however, on the day he/she went to hospital the gurgling was a lot worse. LPN #40 stated the facility's process for residents experiencing a change in condition was to contact Physician or ARNP, and contact the ADON and/or DON. She further stated she did not contact anyone because she knew ARNP #1 had seen Resident #107 that morning and made medication changes. In an additional interview on 06/26/2023 at 4:37 PM, LPN #40 stated Resident #107 was noted to be short of air (SOA), and his/her O2 sats were 90%, while sitting in the common area at that time. LPN #40 stated when staff took Resident #107 to his/her room, she put the resident's oxygen on him/her. She stated she did not document the O2 reading in the resident's record because she kept all her information on a piece of paper she carried with her and wrote everything on it. According to LPN #40, she documented on her paper that Resident #107's O2 sats were 90 % and his/her hands were cold as ice and she kept all her papers at home and stated she could send a photo of her notes to the State Surveyors, at the end of her shift. She stated she just overlooked putting the information in the computer in the resident's record. LPN #40 stated she had received report that morning that Resident #107 was not feeling well and the night shift nurse had given him/her a breathing treatment. LPN #40 stated it was important to document assessments and treatments in residents' records, so others would know what was going on with the residents. LPN #40 further stated I should have documented the changes in resident's medical record. In an interview on 06/20/2023 at 5:20 PM, the DON stated she expected nursing staff to perform consistent assessments of residents and document their findings in the medical records. The DON stated she expected her nursing staff to use good nursing judgement, and if any change in condition was picked up on to take action. She stated because the longer you waited the worse a resident's condition would get if action was not taken. The DON further stated she expected the nurses' documentation to be accurate and thorough. In an interview on 06/25/2023 at 3:18 PM, ARNP #1 stated she expected that staff would abide by the facility's policy as far as nursing assessments, and documentation of those assessments went. ARNP #1 stated she relied on the nursing documentation in the residents' chart for when she was assessing and treating the residents. She stated she had not been made aware of Resident #107 chewing on his/her Aero chamber or that he/she had been combative during the breathing treatments. The ARNP stated that was abnormal behavior for Resident #107. According to ARNP #1, when she made changes to a resident's treatment, she told the nurse and if the nurse was not available, she made the ADON aware of the changes. ARNP #1 stated when she listened to Resident #107's lungs and his/her lung sounds were horrible, that was when the extra Lasix dose was ordered. In an additional interview on 06/26/2023 at 10:20 AM, ARNP #1 stated she felt the nursing information regarding the resident's O2 saturation levels and vital signs were accurate during the time she was making medication changes due to the resident's edema and abnormal lung sounds. ARNP #1 stated she did recall receiving a call from nursing staff before Thursday, 06/22/2023, that Resident #107's O2 sats were 75-78 %, and she instructed staff to place oxygen on the resident and the resident's O2 sats came up to 94%; however, there was no documentation in the medical record noting any of this. She stated when she saw Resident #107 on 06/24/2023, she noted Resident #107 was on the schedule for Physician #60 to see the next day and she gave report to ARNP #2 (who worked with Physician #60) regarding Resident #107, as Physician #60 was Resident #107's primary Physician. In an interview on 06/26/2023 at 9:20 AM, the Medical Director stated he relied 100 % on the nurse's documentation to ensure appropriate resident care. The Medical Director stated he expected the nurses to assess residents within their scope of practice and to document their assessments. He stated that if residents were not assessed and the assessments documented that could potentially cause increased risk for residents to get sick or sicker. The Medical Director stated residents needed to be closely monitored, because all the folks had chronic diseases some more that others, and the nurses could quickly pick up on changes in the residents. In an interview with Physician #60 on 06/28/2023 at 10:49 AM, he stated he was very familiar with Resident #107, and felt the resident declined very quickly on 06/23/2023. Physician #60 stated Resident #107 had last been seen on 06/22/2023 by ARNP #1 and she had made some changes. He stated when he saw Resident #107 on 06/23/2023, the resident was pale, cold, fatigued, his/her perfusion was not the best, so he did not waste any time getting the resident to the hospital. Physician #60 further stated he relied heavily on the nurse's documentation to review. The Physician stated he felt Resident #107 was being closely monitored as he/she was being seen by the ARNP #1 three (3) consecutive days. 2. Record review revealed the facility admitted Resident #32 on 10/28/2022, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, and Dementia. Review of Resident #32's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of four (4), which indicated severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident to require one (1) person physical assistance for transfers and ambulation. Observation, on 06/25/2023 at approximately 9:48 AM, revealed Resident #32 lying on his/her bed. CNA #112 was observed to come into the room and assist Resident #32 to a sitting position on his/her bed. Review of Resident #32's Comprehensive Care Plan initiated on 11/13/2022, revealed the facility care planned the resident for altered cardiovascular status with interventions to monitor/document/report as needed any changes in lung sounds on auscultation, edema, changes in weight. Continued review revealed the facility's interventions included monitoring/documenting/reporting any signs and symptoms of coronary artery disease such as excessive swelling, dependent edema, changes in capillary refill, and color/warmth of extremities. Review of Resident #32's Comprehensive Encounter note dated 06/21/2023, documented by the ARNP, revealed the resident was unsteady when he/she walked to the common area. Continued review revealed Resident #32 had some tenderness when his/her right shoe was put on his/her foot. Review of an imaging report dated 06/22/2023 at 12:54 PM, revealed soft tissue swelling of the right ankle. Review of a Telehealth Evaluation note dated 06/26/2023 at 7:04 PM, revealed Resident #32 had two to three plus (2-3 +) pitting edema to the right foot, a pedal pulse could not be found in either foot, and the patient wasn't feeling well overall. Continued review revealed orders were received to send Resident #32 to the ER for evaluation. Further review revealed Resident #32's admitting diagnosis was confirmed on 06/28/2023 to be right lower extremity edema. Resident #32 was still hospitalized at the time of the Survey exit, and the State Survey Agency (SSA) Surveyors were unable to obtain further information. In an interview on 06/27/2023 at approximately 4:37 PM, CNA #78 stated she had been running late for her shift on 06/26/2023, and arrived just before Resident #32 was sent out to the hospital. She stated she was in the room when the ambulance arrived to transport the resident and the resident's foot and ankle were really swollen and the nurse was really concerned about a blood clot. During an interview on 06/27/2023 at approximately 6:00 PM, LPN #45 stated Resident #32 was a little touchy, feely and she kept as far away as possible from the resident. LPN #45 stated she did not believe she had performed an assessment of the resident on the date she worked and was assigned to his/her care. She further stated she used to complete a head to toe assessment on her residents; however, since computer charting had started, we are glued to our computers all the time and she was no longer able to do that. During an interview on 06/28/2023 at approximately 9:41 AM, LPN #40 stated she had taken care of Resident #32 on 06/26/2023 from 7:00 AM to 7:00 PM. She stated she had assessed Resident #32's vital signs including his/her blood sugar; however, had not assessed the resident for edema. The LPN stated she had not charted any assessment of the resident's heart/lung sounds and had not checked the resident for edema that day and therefore, had not charted that either. She stated when the nurse came in to relieve her at 7:00 PM, asked her to check Resident #32's pedal pulses with her she observed the resident had 2-3+ edema to his/her foot. LPN #40 stated neither she or the other nurse could find a pedal pulse on either of Resident #32's feet. She further stated the other nurse immediately got an order to send the resident to the hospital. During an interview on 06/28/2023 at approximately 11:15 AM, CNA #34 stated she had taken care of Resident #32 on 06/24/2023, and the resident had complained of right ankle pain, and his/her ankle was very swollen. She further stated she had told the nurse; however, was unsure if the nurse did anything or what if anything was done after that. During an interview on 06/28/2023 at approximately 11:20 AM, CNA #35 stated she took care of Resident #32 on 06/25/2023, and the resident complained of right ankle pain at that time. CNA #35 stated Resident #32's ankle appeared to be so swollen it was bigger than his/her other foot. She further stated she informed the nurse Resident #32's right ankle pain complaint and of it being really swollen; however, was not sure if the nurse did anything or was not sure what happened after that. During an interview on 06/28/2023 at approximately 3:51 PM, the DON #4 stated she was taught if a resident had a respiratory diagnosis, the nurse should complete and document a full respiratory assessment. She further stated the day shift nurse (LPN #40) should have performed a full assessment of Resident #32 on 06/26/2023, and the resident should have been assessed when he/she complained of pain. During an interview on 06/28/2023 at approximately 5:23 PM, the current Medical Director stated Resident #32 was one (1) of the residents he had under his care. He stated he recalled when Resident #32 fell; however, did not remember the resident receiving x-rays. He stated his services overlapped with the ARNP in house and he did not always receive calls when the ARNP gave orders on the residents. The Medical Director stated x-rays would show fractures; however, not ligament issues or deep bruises. He further stated he would have expected the nurses to have assessed Resident #32's right lower extremity and monitor it for any changes and document their findings. During an interview on 06/28/2023 at approximately 5:32 PM, Executive Director (ED) #2 stated she would expect nurses to use good nursing judgement, and they should pick up on any issues with residents. ED #2 stated if nurses did not pick up on issues with residents, a delay in care could cause the resident to have a worsened condition. She further stated good documentation assisted with continuity of care and a large part of the nurses' jobs were to assess and monitor residents and document their findings.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life. The facility failed to ensure residents had a right to communicate with and had access to persons and services inside and outside the facility for two (2) of thirty-three (33) sampled residents (Residents #821 and #6). Record review revealed the transferring hospital was not able to communicate with the facility by telephone, to give report when Resident #821 was ready to return to the facility. Resident #821's Power-of-Attorney, stated she was unsuccessful when she attempted to communicate with the facility via telephone. Resident #6's Representative also stated she was not able to communicate with the facility via telephone. Staff stated that the ringers were being turned down at the Nurses' Station telephones, which was confirmed by the Maintenance Director (MD). Multiple attempts were made by the State Survey Agency (SSA) Surveyor to call the facility, on 05/25/2023 and 05/26/2023, which went to a voicemail message informing the caller they would return the call on the next business day. Observation, on 05/30/2023, at the D Hall Nurses' Station revealed there was a cordless phone residents used to make personal calls. However, the phone was missing from its base. Observation, on 05/17/2023, revealed the facility failed to ensure a dignity cover was in place to cover Resident #821's catheter bag. The findings include: Review of the facility's policy titled, Resident Rights, last revised February 2021, revealed staff shall treat all residents with kindness, respect, and dignity. Per the policy, federal and state laws guaranteed certain basic rights to all residents, including a dignified existence and communication with and access to people and services, both inside and outside of the facility. 1.A. Review of Resident #821's document titled, After Visit, dated 04/14/2023, revealed a handwritten note, from the hospital. Further review revealed at the top of the document it stated, Attempted to call report 3x (to the facility), no answer, any questions please call (telephone number). During an interview with Resident #821's Power of Attorney (POA), on 05/08/2023 at 5:00 PM, she stated she was not able to reach the facility when she called to check on her loved one. She stated she had called several times and only reached the answering service, and many times, the voice mailbox was full. The family member stated she did not receive a call back from a nurse or the Executive Director. On 05/25/2023 at 8:39 AM, the State Survey Agency (SSA) Surveyor called the facility's published telephone number. The phone rang for approximately twenty-five (25) seconds, then a voice stated, If you know your party's extension you may enter it at any time, otherwise please continue to hold. Thank you for calling (the facility's name). If this is an emergency please hang up and call 911, otherwise please leave a message and we will return your call the next business day. Again, on 05/26/2023 between 3:40 PM and 4:30 PM, three (3) attempts were made by the SSA Surveyor to call the facility to reach the Executive Director (ED). All three (3) times the calls were not answered, and they went to the voice mail. The SSA Surveyor finally reached the ED by calling the ED's cellular (cell) phone. During an interview with Resident #6's Representative, on 05/31/2023 at 10:37 AM, she stated she was not successful when she called the facility to check on her loved one. She stated it got to the point she gave up because she could not reach anyone. Resident #6's Representative stated she was very concerned about her loved one, and she wanted to move him/her to a different facility, but she did not know how to facilitate the process. She also stated she believed Resident #6 was in the last days of his/her life and not being able to call and talk with staff was very upsetting to her. Receptionist #1, during an interview on 05/30/2023 at 11:06 AM, stated if she took a telephone call at her desk from a family member, who could not reach the resident directly, she would transfer the call to the nurses' station at the unit. She stated, if no one answered the transferred call, she would write on a sticky note that the family member wanted to speak to the resident and take the sticky note down to the unit. Further, Receptionist #1 stated when she took a break from answering the facility's telephone, she had no list of staff names whom she could ask to answer the facility's telephone in her absence. B. Observation, on 05/30/2023 at 2:51 PM, revealed the display of the B Hall Nurses' Station desk telephone showed three (3) new missed calls and a flashing red light. During an interview, on 05/30/2023 at 2:55 PM, with Registered Nurse (RN) #6 at the B Hall Nurses' Station, she stated she had not reviewed the missed telephone calls to see who had called the facility or if the three (3) displayed missed calls had been returned by any other staff. C. Observation at the D Hall Nurses' Station, on 05/30/2023 at 3:54 PM, while the SSA Surveyor was conducting an interview with Registered Nurse #28, revealed the desk phone rang on three (3) separate occasions and was not answered. During an interview with Registered Nurse (RN) #28, on 05/30/2023 at 4:20 PM, she stated the phone call she answered was the hospital giving report on a resident who was returning around 5:00 PM that evening. She stated she did not answer the phone on the previous three (3) occasions because she thought someone else would have answered it. RN #28 stated it was important for staff to answer the phone to ensure report was received and to be able to talk to family members about the residents. She also stated families might want to talk to the residents. The Pharmacy Delivery person, in an interview on 05/16/2023 at 3:58 AM, who was onsite, stated sometimes he was not able to gain access to the facility, and the longest he had to wait was twenty (20) minutes. He stated he had to ring the facility's loud musical door bell which sounded throughout the building, until someone answered it. During an interview with Licensed Practical Nurse (LPN) #15, on 05/16/2023 at 3:45 AM, she stated the phone at the desk did not always work, and the blue cord (land line connector) often fell out of it. She stated she had sent a maintenance request about the phone, but she could not remember when she made the request RN #4 stated, during an interview on 05/30/2023 at 11:20 AM, that the volume on the B Hall Nurses' Station desk telephone could be turned down so the ringer on the telephone could not be heard by staff or residents. During an interview, on 05/30/2023 at 12:15 PM, the Maintenance Director (MD) stated he had previously received a text message from a staff member who had telephoned the facility trying to reach the facility's B Hall Nurses' Station, and the staff member was not able to get anyone to answer the telephone. He stated after he received that text message, he went to the B Hall Nurses' Station and found the station's phone had the volume control turned all the way down so that the telephone ring from incoming calls could not be heard. The MD stated he then turned the phone ring volume back up, tested the phone, and confirmed ringing from incoming telephone calls to the B Hall Nurses' Station could be heard. The Maintenance Director stated he could not find the text message and could only recall that the staff member who had trouble reaching the facility was female and had texted him on an afternoon in early May 2023. The Director of Nursing (DON) in an interview, on 05/11/2023 at 1:44 PM, stated the facility lost their receptionist recently, and different staff had been stationed at the front office to monitor the phones. The DON stated that after hours, the nurses on duty were supposed to answer the phones. She stated she had been informed this day of the phone ringers being turned off. The DON stated it was important for staff to answer the phone to ensure hospitals could give report and family members could check on residents and talk to them if so desired. The ED stated, during interview on 05/30/2023 at 11:00 AM, if the receptionist did not answer the telephone it would ring to the B Hall Nurses Station. She stated if it was not answered there, the call would go to voice mail, and the caller could leave a message. 2. Observation, on 05/30/2023 at 2:48 PM, of the facility's D Hall Nurses' Station revealed a cordless telephone base, but the accompanying cordless telephone was not on the base. Review of the facility's document Grievance/Concern Form revealed a facility maintenance work order had been completed on 03/02/2023 which verified at least one (1) cordless phone was working. The MD stated, during an interview on 05/30/2023 at 11:30 AM, that the 03/02/2023 Grievance/Concern Form for the cordless telephone completed work order he held in his hand might not have actually been completed. He stated one (1) of the facility's cordless phones might be still broken or missing. Registered Nurse (RN) #4, stated during interview on 06/02/2023 at 11:18 AM, that the facility's D Hall Nurses' Station cordless telephone had not yet been found, although a thorough search had been made by nursing and maintenance staff. RN #4 stated she looked yesterday for the phone that fit the empty cordless telephone base on her nurses' station desk, B Hall, and thought it was lost. However, she stated the MD found that phone, and it was now operational. The RN stated if a resident wanted to make a telephone call in privacy, she let the resident use her own personal cell phone so he/she could take her cell phone away from the frequently occupied nurses' station. 3. Observation of Resident #821, on 05/17/2023 at 8:55 AM, revealed the resident's catheter bag was hung on his/her bed by only one (1) hook which caused it to touch the floor. Further observation revealed the dignity bag did not cover the entire bag. The dignity bag was bunched up at the top of the catheter, and the regular catheter bag had urine present, which was observed from the hallway. Certified Nursing Assistant (CNA) #62, in an interview on 05/17/2023 at 8:55 AM, stated the catheter bag should not touch the floor, and the dignity bag should cover the whole catheter bag. She explained when therapy returned the resident to the room, they did not hang the bag correctly on the side of the bed and that resulted in the bag touching the floor. CNA #2 stated the dignity bag was new, and it was pulled down from the top of the catheter. She stated the old dignity bag the facility used to use, was pulled up from the bottom. The CNA stated she was not used to the new bag. CNA #62 stated she should have fixed the dignity bag when she saw it. She stated she received reeducation about the importance of the dignity bag, and it was to be kept covered. The Director of Nursing (DON), stated during interview, on 05/11/2023 at 1:44 PM, stated all residents were to be treated with respect and dignity, provided good care, and treated with love and kindness. During an interview with the Executive Director (ED), on 06/02/2023 at 1:23 PM, she stated staff should treat all residents with dignity and respect. She stated this was important because the facility was the residents' home, and they should be comfortable here. The ED stated she was not aware of Resident #821's dignity bag not being covered on 05/17/2023, and it had not been brought to her attention. She also stated she was not aware the facility was using a new type of dignity bag. The ED stated staff completed daily audits to ensure residents with catheters had dignity bags in place. She stated nothing had been identified through the daily audits. 14936 Surveyor: [NAME], Gae Surveyor: [NAME], [NAME] Surveyor: [NAME], [NAME] 44486

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report immediately, but no later than two (2) hours allegations of abuse for one (1) out of nineteen (19) sampled residents (Resident #66). Registered Nurse (RN) #11 reported to the Director of Nursing (DON) on 06/22/2023 that she overheard staff state Resident #66 was dragged to the shower, sprayed off, and thrown in his/her bed. Further, she noted the resident had a reddened area to his/her face. Additionally, observations by the State Survey Agency (SSA) surveyor revealed a light brownish discolored area approximately one (1) inch long, and 1/2 inch wide on the resident's left upper arm, which the resident stated occurred during the transfer to the shower. However, the allegations were not reported to the SSA until 06/24/2023, approximately two (2) days after the incident occurred. In an interview with the resident's roommate (Resident #1) he/she stated the resident was crying and kept him/her up all night. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, not dated, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed willful, as used in this definition of abuse, meant the individual acted deliberately, not that the individual intended to inflict injury or harm. Further review revealed that all allegations of abuse would be 1.) reported to the Executive Director (ED) immediately. 2.) The facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required. Further review revealed the timing of reporting events that caused the suspicion of abuse that resulted in serious bodily injury was to be reported immediately, but not later than two (2) hours after forming the suspicion; and if the event did not result in serious bodily injury, the individual was to report the suspicion not later than twenty-four hours after forming the suspicion. Review of Resident #66's Admission Record revealed the facility admitted the resident on 12/06/2019 with diagnoses to include: Schizoaffective Disorder, Bipolar, Anxiety Disorder, Major Depressive Disorder, Dementia, and Bladder Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of MDS section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed the resident was assessed to reject his/her care one (1) to three (3) days in the past fourteen (14) days. Review of the facility's initial investigation dated 06/24/2023 completed by the [NAME] President of Operations (VPO), revealed an allegation of physical abuse was received on 06/24/2023, which alleged that upon providing incontinent care to Resident #66, the resident was transferred with a blanket cradle to the shower room versus traditional shower chair. Continued review of the investigation revealed Certified Nurse Aides (CNAs) #120, #104, #84, and Licensed Practical Nurse (LPN) #37 completed the transfer. A skin assessment had been completed with mild redness noted on the resident's right side of his/her face. Further review revealed that all staff who were involved in the transfer had been suspended pending investigation. Review of the Facility's 5-day investigation, that was incorrectly dated for 07/21/2023 (as this date had not yet occurred) revealed a shower sheet was completed post shower that showed red areas of irritation. In an interview with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated she completed the shower sheet for Resident #66, the morning of 06/22/2023, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders. Review of the facility's witness statements attached with the facility's investigation were signed with completion dates of 06/23/2023. Review of the email confirmation provided by the facility revealed the state agency was notified, on 06/24/2023 at 2:38 PM, of alleged physical abuse. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, 1/2 inch wide on his/her left upper arm. Interview on 06/29/2023 at 10:05 AM with Resident #1, he/she stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 further stated he/she did not want them to take him/her to the shower, so they slid him/her across the floor. Resident #1 stated, I couldn't sleep for them (staff) cleaning and him/her (Resident #66) crying. Interview on 06/28/2023 at 2:35 PM with Certified Nurse Aide (CNA) #104 revealed sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she smelled a urine odor around the C-wing Hall. CNA #104 stated she had looked in on Resident #66 but had not checked to see if the resident needed incontinent care. CNA #104 further stated she did not receive a report from the off-going staff at shift change at 7:00 PM. According to the CNA, Resident #66 would get up around two (2) AM and come out of his/her room holding onto the top of his/her pants/brief. She stated she would assist with changing the resident at that time. Further, CNA #104 stated on the morning of 06/22/2023, Resident #66 did not get up so sometime between 1:00-2:00 AM, she went into Resident #66's room to check on him/her and when she turned on the lights, she immediately saw soaked sheets. She stated the resident was curled in the fetal position, had on a shirt, pants, and a brief, and his/her head was at the foot of his/her bed. Certified Nurse Aide (CNA) #104 stated, on 06/28/2023 at 2:35 PM, Resident #66's brief was swelled up and she/he was wet from head to toe, and the floor was wet. CNA #104 further stated she tried to assist Resident #66 to get up so she could change him/her but Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked for assistance. She stated she and CNA #120 could not encourage Resident #66 to go to the shower. CNA#104 stated they wanted to get Resident #66 into a wheelchair, but the Resident stayed curled in a fetal position. CNA #104 further stated she, along with, CNA #120, and CNA #84 tried coaxing, tried promising him/her a soft drink and could not get him/her to get up. CNA #104 stated she tried to assist Resident #66 to get up and Resident #66 tried to kick at them, and the Resident kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. After numerous attempts to get Resident #66 cleaned up, she stated they decided to carry Resident #66 in his/her blankets to the shower room. During the interview, the CNA stated she and CNA #120 picked the resident up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from Resident #66's room. CNA #104 stated they carried the resident to the shower room and sat the resident on the floor on his/her bottom. She stated staff got on each side of the resident and lifted him/her to the shower chair and completed the resident's shower. During an interview on 06/28/2023 at 1:21 PM with Certified Nurse Aide (CNA) #120, she stated she assisted CNA #104 with carrying Resident #66 into the shower in a blanket cradle, in the early morning hours of 06/22/2023. She stated Resident #66 refused to get out of bed to be cleaned. CNA #120 further stated she felt that was the safest way they could transport the resident due to him/her kicking at them and refusing to stand. CNA #120 stated that while she and CNA #104 transported Resident #66 to the shower, CNA #84 was mopping and cleaning the resident's room. CNA #120 stated there was urine on the floor, under the bed, in the bed, dripping from the mattress, and Resident #66 was completely saturated. She further stated the Resident was stating I can't touch the floor, I will die. The CNA #84 stated there was so much urine on the floor, they were afraid of being shocked as the bed was plugged into the electrical outlet. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused and transferring the resident by a blanket cradle was the only choice they had at the time. CNA #120 stated the [NAME] President of Operations (VPO) contacted her by phone on Thursday night, 06/22/2023, on the next shift she worked, and questioned her about the incident. She further stated the VPO contacted her again by phone on Friday, on 06/23/2023 at 8:56 PM, and she was notified that she had been suspended. Interview on 06/29/2023 at 8:21 AM, with Certified Nurse Aide (CNA) #84, she stated when CNA #120, and CNA #104 went into Resident #66's room, he/she was curled in a fetal position and would not get out of bed. CNA #84 stated Resident #66 was saturated in urine, including his/her clothes and shoes. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed by CNA #104 to go get another CNA on the other hall to assist and by the time CNA #84 got back to Resident #66's room, CNA #120 and CNA #104 had already had Resident #66 in a blanket, and they were carrying him/her out of the resident's room to the shower room. CNA #84 stated Resident #66 was not resisting or fighting but was stating, I am not alive, I am dead. CNA #84 stated she went into the shower room with them and assisted with getting Resident #66 into the shower chair and added, it was difficult to maneuver the resident into the shower chair. CNA #84 stated that she then went to Resident #66's room and began cleaning the room. She stated there was urine everywhere, and that urine appeared to be coming from inside of the mattress. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats in the room. CNA #84 further stated that when she took the mattress out of the room there was a wet trail down the hall, and she also had to mop that area. CNA #84 stated, no matter anyone's mental capacity, they should stay clean, and the resident needed out of that room. CNA #84 stated it would have been negligent if the staff had left Resident #66 in the condition, he/she was found in and therefore was not abuse. During an interview with Licensed Practical Nurse (LPN) #37, on 06/27/2023 at 5:12 PM, she stated she had assisted CNA #120, CNA #104, and CNA #84 with Resident #66. LPN #37 stated that Resident #66 was refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with them. Per the interview, LPN #37 stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, adding, they did not drag him/her. Further, LPN #37 stated she held the door open as CNA #104 and CNA #120 brought the resident to the shower room. In an interview on 06/29/2023 at 9:51 AM with Registered Nurse (RN) #11, she stated that on 06/22/2023 around 6:50 PM, she overheard CNAs (unknown) discussing Resident #66 being dragged to the shower room, sprayed off, then thrown into bed by staff. RN #11 stated she immediately contacted the Director of Nursing (DON) and made her aware. She stated she was instructed by the DON to complete a head-to-toe assessment of Resident #66 and to report her findings to the DON. RN #11 further stated that the only area she noted was a reddened area to the resident's face. Further, she stated Resident #66's roommate (Resident #1) and Resident #66 both corroborated the same scenario that Resident #66 was dragged. RN #11 further stated that Resident #1 stated that Resident #66 kept him/her up all night crying. Interview on 06/28/2023 at 4:00 PM, with the Director of Nursing (DON), she stated she was contacted by RN #11 on 06/22/2023 with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed RN #11 to complete a skin assessment on Resident #66. She stated RN #11 contacted her after the skin assessment and reported only a small, reddened area on the side of Resident #66's face. She further stated that although this was not the conventional way to transport residents, she felt this was the safest way staff could transfer the resident to the shower. The DON stated that the staff should have reached out to the nurse or thought the incident out further. She further stated that she did not feel this was deficient practice but taking everything into consideration she felt staff did the best they could at the time. The DON stated she was more bothered that the resident and his/her bed were wet. In an interview with the Executive Director, on 06/28/2023 at 11:28 AM, she stated she was unaware of the alleged allegations of abuse until she was notified on 06/23/2023. Per the interview, the Executive Director stated she was on vacation at the time the incident occurred. In an interview on 06/29/2023 at 10:40 AM with the [NAME] President of Operations (VPO), he stated he had been contacted on the evening of 06/22/2023 around 7:00-7:30 PM by the [NAME] President of Clinical Services (VPCO), who had just been notified by the DON. Per the interview, he stated that at that time the incident was presented, it was communicated as one staff overhearing a conversation between two other staff. The VPO stated he interviewed Resident #66 on 06/23/2023 and the resident had no recollection of the shower incident. The VPO stated he emailed the State Survey Agency (SSA) on 06/24/2023, to report the allegations of alleged abuse. He further stated that his delay in reporting was because the allegation was reported to him as hearsay. However, review of the facility's policy revealed, the timing of reporting events that caused the suspicion of abuse was to be reported immediately, but no later than two (2) hours after forming the suspicion.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report immediately, but no later than two (2) hours allegations of abuse for one (1) out of nineteen (19) sampled residents (Resident #66). Registered Nurse (RN) #11 reported to the Director of Nursing (DON) on 06/22/2023 that she overheard staff state Resident #66 was dragged to the shower, sprayed off, and thrown in his/her bed. Further, she noted the resident had a reddened area to his/her face. Additionally, observations by the State Survey Agency (SSA) surveyor revealed a light brownish discolored area approximately one (1) inch long, and ½ inch wide on the resident's left upper arm, which the resident stated occurred during the transfer to the shower. However, the allegations were not reported to the SSA until 06/24/2023, approximately two (2) days after the incident occurred. In an interview with the resident's roommate (Resident #1) he/she stated the resident was crying and kept him/her up all night. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, not dated, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed willful, as used in this definition of abuse, meant the individual acted deliberately, not that the individual intended to inflict injury or harm. Further review revealed that all allegations of abuse would be 1.) reported to the Executive Director (ED) immediately. 2.) The facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required. Further review revealed the timing of reporting events that caused the suspicion of abuse that resulted in serious bodily injury was to be reported immediately, but not later than two (2) hours after forming the suspicion; and if the event did not result in serious bodily injury, the individual was to report the suspicion not later than twenty-four hours after forming the suspicion. Review of Resident #66's admission Record revealed the facility admitted the resident on 12/06/2019 with diagnoses to include: Schizoaffective Disorder, Bipolar, Anxiety Disorder, Major Depressive Disorder, Dementia, and Bladder Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of MDS section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed the resident was assessed to reject his/her care one (1) to three (3) days in the past fourteen (14) days. Review of the facility's initial investigation dated 06/24/2023 completed by the [NAME] President of Operations (VPO), revealed an allegation of physical abuse was received on 06/24/2023, which alleged that upon providing incontinent care to Resident #66, the resident was transferred with a blanket cradle to the shower room versus traditional shower chair. Continued review of the investigation revealed Certified Nurse Aides (CNAs) #120, #104, #84, and Licensed Practical Nurse (LPN) #37 completed the transfer. A skin assessment had been completed with mild redness noted on the resident's right side of his/her face. Further review revealed that all staff who were involved in the transfer had been suspended pending investigation. Review of the Facility's 5-day investigation, that was incorrectly dated for 07/21/2023 (as this date had not yet occurred) revealed a shower sheet was completed post shower that showed red areas of irritation. In an interview with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated she completed the shower sheet for Resident #66, the morning of 06/22/2023, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders. Review of the facility's witness statements attached with the facility's investigation were signed with completion dates of 06/23/2023. Review of the email confirmation provided by the facility revealed the state agency was notified, on 06/24/2023 at 2:38 PM, of alleged physical abuse. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, ½ inch wide on his/her left upper arm. Interview on 06/29/2023 at 10:05 AM with Resident #1, he/she stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 further stated he/she did not want them to take him/her to the shower, so they slid him/her across the floor. Resident #1 stated, I couldn't sleep for them (staff) cleaning and him/her (Resident #66) crying. Interview on 06/28/2023 at 2:35 PM with Certified Nurse Aide (CNA) #104 revealed sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she smelled a urine odor around the C-wing Hall. CNA #104 stated she had looked in on Resident #66 but had not checked to see if the resident needed incontinent care. CNA #104 further stated she did not receive a report from the off-going staff at shift change at 7:00 PM. According to the CNA, Resident #66 would get up around two (2) AM and come out of his/her room holding onto the top of his/her pants/brief. She stated she would assist with changing the resident at that time. Further, CNA #104 stated on the morning of 06/22/2023, Resident #66 did not get up so sometime between 1:00-2:00 AM, she went into Resident #66's room to check on him/her and when she turned on the lights, she immediately saw soaked sheets. She stated the resident was curled in the fetal position, had on a shirt, pants, and a brief, and his/her head was at the foot of his/her bed. Certified Nurse Aide (CNA) #104 stated, on 06/28/2023 at 2:35 PM, Resident #66's brief was swelled up and she/he was wet from head to toe, and the floor was wet. CNA #104 further stated she tried to assist Resident #66 to get up so she could change him/her but Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked for assistance. She stated she and CNA #120 could not encourage Resident #66 to go to the shower. CNA#104 stated they wanted to get Resident #66 into a wheelchair, but the Resident stayed curled in a fetal position. CNA #104 further stated she, along with, CNA #120, and CNA #84 tried coaxing, tried promising him/her a soft drink and could not get him/her to get up. CNA #104 stated she tried to assist Resident #66 to get up and Resident #66 tried to kick at them, and the Resident kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. After numerous attempts to get Resident #66 cleaned up, she stated they decided to carry Resident #66 in his/her blankets to the shower room. During the interview, the CNA stated she and CNA #120 picked the resident up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from Resident #66's room. CNA #104 stated they carried the resident to the shower room and sat the resident on the floor on his/her bottom. She stated staff got on each side of the resident and lifted him/her to the shower chair and completed the resident's shower. During an interview on 06/28/2023 at 1:21 PM with Certified Nurse Aide (CNA) #120, she stated she assisted CNA #104 with carrying Resident #66 into the shower in a blanket cradle, in the early morning hours of 06/22/2023. She stated Resident #66 refused to get out of bed to be cleaned. CNA #120 further stated she felt that was the safest way they could transport the resident due to him/her kicking at them and refusing to stand. CNA #120 stated that while she and CNA #104 transported Resident #66 to the shower, CNA #84 was mopping and cleaning the resident's room. CNA #120 stated there was urine on the floor, under the bed, in the bed, dripping from the mattress, and Resident #66 was completely saturated. She further stated the Resident was stating I can't touch the floor, I will die. The CNA #84 stated there was so much urine on the floor, they were afraid of being shocked as the bed was plugged into the electrical outlet. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused and transferring the resident by a blanket cradle was the only choice they had at the time. CNA #120 stated the [NAME] President of Operations (VPO) contacted her by phone on Thursday night, 06/22/2023, on the next shift she worked, and questioned her about the incident. She further stated the VPO contacted her again by phone on Friday, on 06/23/2023 at 8:56 PM, and she was notified that she had been suspended. Interview on 06/29/2023 at 8:21 AM, with Certified Nurse Aide (CNA) #84, she stated when CNA #120, and CNA #104 went into Resident #66's room, he/she was curled in a fetal position and would not get out of bed. CNA #84 stated Resident #66 was saturated in urine, including his/her clothes and shoes. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed by CNA #104 to go get another CNA on the other hall to assist and by the time CNA #84 got back to Resident #66's room, CNA #120 and CNA #104 had already had Resident #66 in a blanket, and they were carrying him/her out of the resident's room to the shower room. CNA #84 stated Resident #66 was not resisting or fighting but was stating, I am not alive, I am dead. CNA #84 stated she went into the shower room with them and assisted with getting Resident #66 into the shower chair and added, it was difficult to maneuver the resident into the shower chair. CNA #84 stated that she then went to Resident #66's room and began cleaning the room. She stated there was urine everywhere, and that urine appeared to be coming from inside of the mattress. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats in the room. CNA #84 further stated that when she took the mattress out of the room there was a wet trail down the hall, and she also had to mop that area. CNA #84 stated, no matter anyone's mental capacity, they should stay clean, and the resident needed out of that room. CNA #84 stated it would have been negligent if the staff had left Resident #66 in the condition, he/she was found in and therefore was not abuse. During an interview with Licensed Practical Nurse (LPN) #37, on 06/27/2023 at 5:12 PM, she stated she had assisted CNA #120, CNA #104, and CNA #84 with Resident #66. LPN #37 stated that Resident #66 was refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with them. Per the interview, LPN #37 stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, adding, they did not drag him/her. Further, LPN #37 stated she held the door open as CNA #104 and CNA #120 brought the resident to the shower room. In an interview on 06/29/2023 at 9:51 AM with Registered Nurse (RN) #11, she stated that on 06/22/2023 around 6:50 PM, she overheard CNAs (unknown) discussing Resident #66 being dragged to the shower room, sprayed off, then thrown into bed by staff. RN #11 stated she immediately contacted the Director of Nursing (DON) and made her aware. She stated she was instructed by the DON to complete a head-to-toe assessment of Resident #66 and to report her findings to the DON. RN #11 further stated that the only area she noted was a reddened area to the resident's face. Further, she stated Resident #66's roommate (Resident #1) and Resident #66 both corroborated the same scenario that Resident #66 was dragged. RN #11 further stated that Resident #1 stated that Resident #66 kept him/her up all night crying. Interview on 06/28/2023 at 4:00 PM, with the Director of Nursing (DON), she stated she was contacted by RN #11 on 06/22/2023 with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed RN #11 to complete a skin assessment on Resident #66. She stated RN #11 contacted her after the skin assessment and reported only a small, reddened area on the side of Resident #66's face. She further stated that although this was not the conventional way to transport residents, she felt this was the safest way staff could transfer the resident to the shower. The DON stated that the staff should have reached out to the nurse or thought the incident out further. She further stated that she did not feel this was deficient practice but taking everything into consideration she felt staff did the best they could at the time. The DON stated she was more bothered that the resident and his/her bed were wet. In an interview with the Executive Director, on 06/28/2023 at 11:28 AM, she stated she was unaware of the alleged allegations of abuse until she was notified on 06/23/2023. Per the interview, the Executive Director stated she was on vacation at the time the incident occurred. In an interview on 06/29/2023 at 10:40 AM with the [NAME] President of Operations (VPO), he stated he had been contacted on the evening of 06/22/2023 around 7:00-7:30 PM by the [NAME] President of Clinical Services (VPCO), who had just been notified by the DON. Per the interview, he stated that at that time the incident was presented, it was communicated as one staff overhearing a conversation between two other staff. The VPO stated he interviewed Resident #66 on 06/23/2023 and the resident had no recollection of the shower incident. The VPO stated he emailed the State Survey Agency (SSA) on 06/24/2023, to report the allegations of alleged abuse. He further stated that his delay in reporting was because the allegation was reported to him as hearsay. However, review of the facility's policy revealed, the timing of reporting events that caused the suspicion of abuse was to be reported immediately, but no later than two (2) hours after forming the suspicion.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were provided routine respiratory and cardiac assessments per professional standards of practice, and per the resident's person-centered plan of care for two (2) of nineteen (19) sampled residents (Residents #32, and #107). 1. The facility care planned Resident #107 for management of Congestive Heart Failure (CHF) and fluid overload related to his/her diagnosis of Chronic Obstructive Pulmonary Disease (COPD). However, the facility failed to provide routine nursing assessments for Resident #107's respiratory, cardiac, or fluid status. Per interview with Licensed Practical Nurse (LPN) #40 regarding Resident #107's condition on 06/21/2023 and 06/23/2023, the nurse stated the resident had gurgling sounds in his/her chest on 06/21/2023, which worsened on 06/23/2023. When Resident #107's Physician assessed the resident on the afternoon of 06/23/2023, he stated the resident was in fluid overload and gave orders for the resident to be transferred to the hospital. Resident #107 was transferred to the hospital's Emergency Department (ED). Resident #107 was diagnosed with Acute Respiratory Failure with Hypoxia, Acute Renal Failure, Congestive Heart Failure and was admitted to the hospital. 2. Resident #32's Comprehensive Care Plan, initiated 11/13/2022, for altered cardiovascular status revealed the interventions included to monitor/document/report as needed any changes such as edema; and coronary artery disease interventions such as monitor/document/report excessive swelling, dependent edema, and color/warmth of extremities. However, the facility failed to provide documented evidence of provision of routine cardiac assessments for the resident. Interview with a licensed nurse assigned to Resident #32 on 06/26/2023, on the 7:00 AM to 7:00 PM shift, revealed she had not assessed the resident's bilateral lower extremities for edema during her shift. She stated however, she had been asked by the nurse relieving her at 7:00 PM to look at the resident's feet at the time of shift change. The nurse stated she and the other nurse assessed Resident #32 together and the resident was observed to have edema in his/her foot/ankle and no pedal pulse could be felt in either foot. She could not recall which foot, or the color or temperature of the resident's foot. Resident #32 was transferred and admitted to the hospital on 06/26/2023 for right lower extremity edema. Resident #32 was still hospitalized at time of the survey exit. The findings include: In an interview on 06/26/2023 at 11:04 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the facility had no policy to address respiratory assessments, and no criteria for completing Respiratory Assessment Evaluation forms. 1. Review of Resident #107's Admission Record revealed the facility admitted the resident on 09/29/2022. Diagnoses included Unspecified Injury of the Head, Dementia, Atherosclerotic Heart Disease, COPD, Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Kidney Disease, Stage 3, and Congestive Heart Failure. Review of Resident #107's Quarterly Minimum Data Set (MDS) Assessment, dated 05/01/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of status 99 which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed the resident as having disorganized thinking behaviors present that fluctuated and varied in severity. Review of Resident #107's Comprehensive Care Plan revealed the facility care planned the resident related to his/her cardiac and respiratory status, altered due to diagnoses of Coronary Artery Disease (CAD), Hypertension (HTN), CHF initiated on 10/12/2022. Further review revealed a goal for the resident to be free from complications of cardiac problems through the next review date. Continued review revealed interventions included to monitor, document, and report as needed any signs/symptoms of CAD: chest pain or pressure especially with activity; heartburn; nausea and vomiting; shortness of breath; excessive sweating; dependent edema; changes in capillary refill; and color/warmth of extremities. Record review revealed additional interventions included: medications administered as per Physician's order; monitor vital signs as ordered and as needed and notify Physician of significant abnormalities. Review of Resident #107's Care Plan revealed the facility added a new focus on 04/26/2023, noting the resident was at risk for fluid overload related to CHF and pulmonary edema. Per review, the goal was for Resident #107 to remain free of signs and symptoms of fluid overload through the next review date, as evidenced by a decrease in or absence of: edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea, vomiting, dyspnea, congestion, orthopnea, being easily fatigued, and jugular vein distension (JVD). Continued review of the care plan revealed the interventions included: observe for signs/symptoms of fluid overload: anxiety, mood/behavior changes, confusion, edema, shortness of breath, difficulty breathing, increased respirations, difficulty breathing when lying flat, congestion, cough, fatigue, JVD, and sudden weight gain. In addition, review revealed the interventions included to obtain labs/x-rays as per Physician order, and raise head of bed as needed to facilitate breathing. Review of Resident #107's Comprehensive assessment dated [DATE] and signed at 8:55 AM by the Advanced Registered Nurse Practitioner (ARNP) #1 revealed the resident's Chief Complaint was noted as follow up on his/her breathing and CHF. Per review, Resident #107 was on oxygen that day; had Lasix (diuretic medication) 20 milligram (mg) ordered once a day; however, the resident appeared to be in acute overload this morning. Continued review revealed the resident had edema in his/her lower extremities, his/her lung sounds had wheezing scattered throughout, with crackles, and rhonchi throughout; however, was not in respiratory distress. In addition, review revealed ARNP #1 noted Resident #107's acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was unstable, and the resident's Lasix would be increased to twice a day (BID) and his/her laboratory (labs) levels were to be checked on 06/07/2023. Review of Resident #107's Comprehensive Encounter dated 06/07/2023, noted by Advanced Registered Nurse Practitioner (ARNP) #1 as a follow up after changing the resident's Lasix to BID (twice a day) and related to his/her swelling. Per review, Resident #107 was off his/her oxygen and his/her oxygen saturation (O2 sats) were 95% per the nursing documentation. Continued review revealed his/her bilateral extremities had 1-2+ pitting edema. Record review revealed Resident #107 was in no respiratory distress and continued to have rhonchi throughout which sounded slightly better. Further review revealed ARNP #1 was to reduce the evening dose of Lasix, and check the resident's labs on Monday, 06/12/2023. Review of Resident #107's Dietary Progress Nutrition Note dated 06/10/2023 at 11:57 AM, documented during the Nutrition at Risk (NAR) meeting by the Interdisciplinary Team (IDT), revealed the resident's current weight was 140.2 pounds, which was a weight gain of twelve (12) pounds in a five (5) day period. Continued review revealed edema had been noted by the ARNP, who had increased Resident #107's Lasix from 20 mg daily to BID and then due to his/her lab results, the Lasix had been reduced to daily again. Further review revealed due to the multiple diuretic changes with resultant fluid load weight change was as expected. In addition, review revealed continue with weekly weights and nutrition plan of care (POC). Review of the Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac or fluid status after the IDT NAR meeting on 06/10/2023. Review of Resident #7's Comprehensive Assessment note dated 06/12/2023, by ARNP #1 after the resident sustained a fall revealed he/she did not exhibit signs or symptoms of respiratory distress; however, had lung sounds with crackles, rhonchi throughout, two plus (2+) swelling to the bilateral lower extremities. Review of Resident #107's Nurse Progress note dated 06/12/2023 at 10:00 AM, revealed the resident had fallen and was transferred to emergency room (ER) via ambulance. Further review of the note revealed an O2 sat of 97%; however; additional review revealed no documented evidence the nurse further assessed the resident's cardiac, respiratory, or fluid status. Review of Resident #107's Comprehensive Encounter dated 06/13/2023, noted by ARNP #1 revealed the visit was a follow up after the resident sustained a fall and was sent to the emergency room (ER). Per review, Resident #107 had left sided more than right pleural effusions (unusual amount of fluid around the lung), nodular density at the right upper lung with follow-up advised. Continued review revealed there was no convincing evidence for acute Pneumonia or CHF exacerbation. Review revealed Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, crackles, rhonchi throughout unlabored breathing pattern. Review of Resident #107's Nurse Progress notes revealed no documented evidence of the resident's respiratory, cardiac, or fluid status assessments. Review of Resident #107's 06/15/2023 Comprehensive Encounter Dated 06/15/2023 by ARNP #1 revealed Resident #107 exhibited no signs of respiratory distress; however, had wheezing and rhonchi throughout. Per review, Resident #107 had a decrease in swelling to the bilateral lower extremities, at 1+ pitting edema. Review of Resident #107's Dietary Progress Note dated 06/17/2023 at 12:54 PM, revealed a Nutrtionally at Risk (NAR) note stated the resident's current weight was 138.4 pounds, which was a weight loss of 1.8 pounds from last week. Continued review revealed multiple diuretic changes with resultant fluid load and weight change as expected. Review further revealed there would be continued weekly weights, a nutrition plan of care, and follow by NAR. Review of Resident #107's Nurse Progress Notes revealed however, no documented evidence of nursing staff noting the resident's respiratory, cardiac, or fluid (edema) status. Review of Resident #107's Comprehensive Encounter dated 06/19/2023, noted by ARNP #1 revealed it was a follow up on COPD. Per review, Resident #107 did not exhibit signs of respiratory distress; however, had wheezing, and rhonchi throughout. Continued review revealed Resident #107's COPD was stable, and his/her O2 sats were 97% per nursing documentation. Edema had improved to one plus (1+) non pitting. Review of Resident #107's Nurse Progress notes revealed however, no documented evidence of nursing staff's assessments of the resident's respiratory, cardiac, or edema (fluid) retention. Review of Resident #107's Nurse Progress note dated 06/20/2023 at 4:59 AM, revealed the resident was on one to one (1:1) supervision related to his/her behavior/fall. Continued review revealed Resident #107's lung sounds were clear to auscultation, the resident was sleeping at the time of report, and staff were to continue to monitor. However, further record review revealed no documented evidence staff continued to monitor the resident's condition on 06/20/2023. Review of Resident #107's Respiratory Evaluation dated 06/20/2023 at 3:51 PM, documented by the ADON as a Late Entry revealed there had been no change in the resident's condition. Per review, Resident #107 was confused, experiencing signs of short-term memory loss, required cues; however, his/her current state of confusion was baseline for the resident. Continued review revealed Resident #107's respiratory status was noted as no sign of difficulty breathing, with left lung sounds throughout left lung on inspiration, and wheezes on auscultation, and he/she was not utilizing oxygen. Review of Resident #107's Comprehensive Encounter Note dated 06/22/2023 at 4:00 PM, documented by ARNP #1 revealed a therapist stopped the ARNP to assess the resident's legs which had been swelling off and on for several weeks. Per review, Resident #107's legs had 2-3+ pitting edema with the left weeping fluid from a wound to the left outer calf. Continued review revealed Resident #107 had crackles, and rhonchi throughout (his/her lungs); however, did not exhibit signs of respiratory distress. Further review revealed orders for oxygen as needed and staff to keep the resident's O2 sats greater than 91%. Review of the Nurse Progress note dated 06/22/2023 at 5:00 PM, documented by Registered Nurse (RN) #11 revealed Resident #107 was noncompliant with his/her breathing treatments and Aero chamber use. Continued review revealed Resident #107 continued to remove his/her nasal cannula, had rhonchi throughout all his/her lung lobes, and was hitting at the nurse during his/her breathing treatment. Further review revealed however, no documented evidence RN #11 notified the ARNP or Physician of Resident #107's respiratory status, that he/she kept removing his/her oxygen, and was noncompliant with his/her breathing treatment and Aero chamber use. Review of Resident #107's electronic medication administration record (eMar) revealed on 06/22/2023 at 5:17 PM, the order for Aero Chamber, give 1 unit by mouth every six (6) hours for use with albuterol/Atrovent inhalers, RN #11 noted the resident was hitting at the nurse and chewing on the aero chamber. Review of a Physician's Order dated 04/13/2023 and time 10:45 AM, revealed orders for Oxygen (O2) at two (2) liters per minute (lpm) as needed, keep the resident's O2 saturations (sats) above 91%. However, review of Resident #107's medical record revealed those orders did not flow over to his/her Medication Administration Record (MAR) or Treatment Administration Records (TAR) for the months of May or June 2023. Review of Resident #107's Treatment Administration Record (TAR) dated 06/23/2023 at 7:00 AM revealed his/her O2 sat was noted as 90%. Further review revealed however, no documented evidence the Physician was notified of the resident's decreased O2 sat as ordered. Continued review of the Nurse Progress notes revealed no documented evidence of the nurses assessing and monitoring the resident's respiratory, cardiac, or fluid status on 06/22/2023. Review of Resident #107's MAR for the date of 06/23/2023, revealed an order for Lasix 20 mg dose written at 9:00 AM by ARNP #1 which was given at 12:40 PM by LPN #40. Review of Resident #107's Nurse Progress note dated 06/23/2023 at 3:54 PM, documented by LPN #40 revealed the resident had a one (1) time order related to weeping of his/her left leg; no complaints of pain or discomfort; and continued on antibiotic therapy for cellulitis with no signs or symptoms of adverse reactions noted. Further review revealed however, no documented evidence of the nurse having performed an assessment of Resident #107's respiratory, cardiac or fluid status to include vital signs and O2 sats. Review of the facility's Admission/Discharge/Transfer/Appointment Late Entry Note for Resident #107 dated 06/23/2023 at 4:50 PM, revealed the resident was transferred to the hospital related to shortness of air (SOA). Per review, the transfer was ordered by Physician #60. Review of the hospital emergency room (ER) report dated 06/23/2023 revealed upon arrival to the ER, Resident #107's O2 saturation level was 70% on room air (values under 90% can lead to serious deterioration in a person's health status). In an interview on 06/26/2023 at 10:46 AM RN #11, who cared for Resident #107 on 06/22/2023 on the 7:00 AM to 7:00 PM, stated she did not know too much about the resident; however, recalled he/she refused to wear his/her oxygen often. RN #11 stated at shift change report she was only informed of how residents took their medications, and not really anything about their condition. Per RN #11, she was aware Resident #107 had oxygen because she was the person who contacted the Physician to obtain the order for it a few months back. She stated Resident #107 was on breathing treatments, and usually there was an area on the MAR that had to be completed after giving the respiratory treatments. RN #11 stated she did not perform a head-to-toe assessment of Resident #107, she only assessed his/her lung sounds and documented rhonchi throughout all lobes. She stated she was not aware of Resident #107 having edema, although she normally looked at resident's extremities; however, she had not assessed the resident for edema on that date. According to RN #11, if she observed anything abnormal during an assessment of the resident she would have put it in the progress notes. RN#11 stated that per her documentation in the progress notes for Resident #107, which referred to him/her being non-compliant with the breathing treatment, chewing on the Aero chamber, removing his/her oxygen, and hitting at her, was nothing out the ordinary for the resident. She further stated she should have charted more of Resident #107's abnormal respiratory sounds. In an interview on 06/26/2023 at 1:15 PM, Physical Therapy Assistant (PTA) #1 stated he reported to nursing staff on multiple occasions that the resident had a heart rate of 45-60 and low O2 sats of 63-74%. PTA #1 stated therapy saw Resident #107 five (5) times weekly and the resident always had edema to his/her bilateral lower extremities. In an interview on 06/26/2023 at 1:55 PM, LPN #40 stated she usually got to work at 6:30 AM, did her narcotics count and got report from the off going staff, then checked blood sugars and passed medications. LPN #40 stated she had not seen Resident #107 right away the morning of 06/23/2023, as she started passing medication on the front hall and was working her way toward the back hall where Resident #107's room was located. She stated the CNA reported to her that morning that Resident #107's legs were weeping, and the Therapist had also voiced concerns to her about the resident's legs weeping. The LPN stated she was not sure what time she was initially able to assess Resident #107, and when she did it was hard to get an accurate O2 sat reading as his/her fingers were cold which was normal, and staff always had to warm his/her hands to get the reading. During further interview LPN #40 stated that she wasn't sure of what time she initially assessed Resident #107. LPN #40 further stated that Resident #107's lung sounds usually had gurgle sounds; however, on the day he/she went to hospital the gurgling was a lot worse. LPN #40 stated the facility's process for residents experiencing a change in condition was to contact Physician or ARNP, and contact the ADON and/or DON. She further stated she did not contact anyone because she knew ARNP #1 had seen Resident #107 that morning and made medication changes. In an additional interview on 06/26/2023 at 4:37 PM, LPN #40 stated Resident #107 was noted to be short of air (SOA), and his/her O2 sats were 90%, while sitting in the common area at that time. LPN #40 stated when staff took Resident #107 to his/her room, she put the resident's oxygen on him/her. She stated she did not document the O2 reading in the resident's record because she kept all her information on a piece of paper she carried with her and wrote everything on it. According to LPN #40, she documented on her paper that Resident #107's O2 sats were 90 % and his/her hands were cold as ice and she kept all her papers at home and stated she could send a photo of her notes to the State Surveyors, at the end of her shift. She stated she just overlooked putting the information in the computer in the resident's record. LPN #40 stated she had received report that morning that Resident #107 was not feeling well and the night shift nurse had given him/her a breathing treatment. LPN #40 stated it was important to document assessments and treatments in residents' records, so others would know what was going on with the residents. LPN #40 further stated I should have documented the changes in resident's medical record. In an interview on 06/20/2023 at 5:20 PM, the DON stated she expected nursing staff to perform consistent assessments of residents and document their findings in the medical records. The DON stated she expected her nursing staff to use good nursing judgement, and if any change in condition was picked up on to take action. She stated because the longer you waited the worse a resident's condition would get if action was not taken. The DON further stated she expected the nurses' documentation to be accurate and thorough. In an interview on 06/25/2023 at 3:18 PM, ARNP #1 stated she expected that staff would abide by the facility's policy as far as nursing assessments, and documentation of those assessments went. ARNP #1 stated she relied on the nursing documentation in the residents' chart for when she was assessing and treating the residents. She stated she had not been made aware of Resident #107 chewing on his/her Aero chamber or that he/she had been combative during the breathing treatments. The ARNP stated that was abnormal behavior for Resident #107. According to ARNP #1, when she made changes to a resident's treatment, she told the nurse and if the nurse was not available, she made the ADON aware of the changes. ARNP #1 stated when she listened to Resident #107's lungs and his/her lung sounds were horrible, that was when the extra Lasix dose was ordered. In an additional interview on 06/26/2023 at 10:20 AM, ARNP #1 stated she felt the nursing information regarding the resident's O2 saturation levels and vital signs were accurate during the time she was making medication changes due to the resident's edema and abnormal lung sounds. ARNP #1 stated she did recall receiving a call from nursing staff before Thursday, 06/22/2023, that Resident #107's O2 sats were 75-78 %, and she instructed staff to place oxygen on the resident and the resident's O2 sats came up to 94%; however, there was no documentation in the medical record noting any of this. She stated when she saw Resident #107 on 06/24/2023, she noted Resident #107 was on the schedule for Physician #60 to see the next day and she gave report to ARNP #2 (who worked with Physician #60) regarding Resident #107, as Physician #60 was Resident #107's primary Physician. In an interview on 06/26/2023 at 9:20 AM, the Medical Director stated he relied 100 % on the nurse's documentation to ensure appropriate resident care. The Medical Director stated he expected the nurses to assess residents within their scope of practice and to document their assessments. He stated that if residents were not assessed and the assessments documented that could potentially cause increased risk for residents to get sick or sicker. The Medical Director stated residents needed to be closely monitored, because all the folks had chronic diseases some more that others, and the nurses could quickly pick up on changes in the residents. In an interview with Physician #60 on 06/28/2023 at 10:49 AM, he stated he was very familiar with Resident #107, and felt the resident declined very quickly on 06/23/2023. Physician #60 stated Resident #107 had last been seen on 06/22/2023 by ARNP #1 and she had made some changes. He stated when he saw Resident #107 on 06/23/2023, the resident was pale, cold, fatigued, his/her perfusion was not the best, so he did not waste any time getting the resident to the hospital. Physician #60 further stated he relied heavily on the nurse's documentation to review. The Physician stated he felt Resident #107 was being closely monitored as he/she was being seen by the ARNP #1 three (3) consecutive days. 2. Record review revealed the facility admitted Resident #32 on 10/28/2022, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, and Dementia. Review of Resident #32's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of four (4), which indicated severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident to require one (1) person physical assistance for transfers and ambulation. Observation, on 06/25/2023 at approximately 9:48 AM, revealed Resident #32 lying on his/her bed. CNA #112 was observed to come into the room and assist Resident #32 to a sitting position on his/her bed. Review of Resident #32's Comprehensive Care Plan initiated on 11/13/2022, revealed the facility care planned the resident for altered cardiovascular status with interventions to monitor/document/report as needed any changes in lung sounds on auscultation, edema, changes in weight. Continued review revealed the facility's interventions included monitoring/documenting/reporting any signs and symptoms of coronary artery disease such as excessive swelling, dependent edema, changes in capillary refill, and color/warmth of extremities. Review of Resident #32's Comprehensive Encounter note dated 06/21/2023, documented by the ARNP, revealed the resident was unsteady when he/she walked to the common area. Continued review revealed Resident #32 had some tenderness when his/her right shoe was put on his/her foot. Review of an imaging report dated 06/22/2023 at 12:54 PM, revealed soft tissue swelling of the right ankle. Review of a Telehealth Evaluation note dated 06/26/2023 at 7:04 PM, revealed Resident #32 had two to three plus (2-3 +) pitting edema to the right foot, a pedal pulse could not be found in either foot, and the patient wasn't feeling well overall. Continued review revealed orders were received to send Resident #32 to the ER for evaluation. Further review revealed Resident #32's admitting diagnosis was confirmed on 06/28/2023 to be right lower extremity edema. Resident #32 was still hospitalized at the time of the Survey exit, and the State Survey Agency (SSA) Surveyors were unable to obtain further information. In an interview on 06/27/2023 at approximately 4:37 PM, CNA #78 stated she had been running late for her shift on 06/26/2023, and arrived just before Resident #32 was sent out to the hospital. She stated she was in the room when the ambulance arrived to transport the resident and the resident's foot and ankle were really swollen and the nurse was really concerned about a blood clot. During an interview on 06/27/2023 at approximately 6:00 PM, LPN #45 stated Resident #32 was a little touchy, feely and she kept as far away as possible from the resident. LPN #45 stated she did not believe she had performed an assessment of the resident on the date she worked and was assigned to his/her care. She further stated she used to complete a head to toe assessment on her residents; however, since computer charting had started, we are glued to our computers all the time and she was no longer able to do that. During an interview on 06/28/2023 at approximately 9:41 AM, LPN #40 stated she had taken care of Resident #32 on 06/26/2023 from 7:00 AM to 7:00 PM. She stated she had assessed Resident #32's vital signs including his/her blood sugar; however, had not assessed the resident for edema. The LPN stated she had not charted any assessment of the resident's heart/lung sounds and had not checked the resident for edema that day and therefore, had not charted that either. She stated when the nurse came in to relieve her at 7:00 PM, asked her to check Resident #32's pedal pulses with her she observed the resident had 2-3+ edema to his/her foot. LPN #40 stated neither she or the other nurse could find a pedal pulse on either of Resident #32's feet. She further stated the other nurse immediately got an order to send the resident to the hospital. During an interview on 06/28/2023 at approximately 11:15 AM, CNA #34 stated she had taken care of Resident #32 on 06/24/2023, and the resident had complained of right ankle pain, and his/her ankle was very swollen. She further stated she had told the nurse; however, was unsure if the nurse did anything or what if anything was done after that. During an interview on 06/28/2023 at approximately 11:20 AM, CNA #35 stated she took care of Resident #32 on 06/25/2023, and the resident complained of right ankle pain at that time. CNA #35 stated Resident #32's ankle appeared to be so swollen it was bigger than his/her other foot. She further stated she informed the nurse Resident #32's right ankle pain complaint and of it being really swollen; however, was not sure if the nurse did anything or was not sure what happened after that. During an interview on 06/28/2023 at approximately 3:51 PM, the DON #4 stated she was taught if a resident had a respiratory diagnosis, the nurse should complete and document a full respiratory assessment. She further stated the day shift nurse (LPN #40) should have performed a full assessment of Resident #32 on 06/26/2023, and the resident should have been assessed when he/she complained of pain. During an interview on 06/28/2023 at approximately 5:23 PM, the current Medical Director stated Resident #32 was one (1) of the residents he had under his care. He stated he recalled when Resident #32 fell ; however, did not remember the resident receiving x-rays. He stated his services overlapped with the ARNP in house and he did not always receive calls when the ARNP gave orders on the residents. The Medical Director stated x-rays would show fractures; however, not ligament issues or deep bruises. He further stated he would have expected the nurses to have assessed Resident #32's right lower extremity and monitor it for any changes and document their findings. During an interview on 06/28/2023 at approximately 5:32 PM, Executive Director (ED) #2 stated she would expect nurses to use good nursing judgement, and they should pick up on any issues with residents. ED #2 stated if nurses did not pick up on issues with residents, a delay in care could cause the resident to have a worsened condition. She further stated good documentation assisted with continuity of care and a large part of the nurses' jobs were to assess and monitor residents and document their findings.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for fourteen (14) of ninety-two (92) sampled residents. (Residents #5, #17, #32, #56, #61, #73, #74, #89, #93, #97, #112, #138, #271, and #821). The facility assessed Resident #138 as a fall risk, however, did not implement care plan interventions which resulted in Resident #138 sustaining multiple falls. The resident fell on [DATE], requiring sutures to his/her head. Resident #138 had two (2) more falls that resulted in trauma to the same sutured area. Resident #138 had additional falls and was hospitalized from [DATE] through [DATE], with bilateral subdural hematomas. In addition, the resident experienced two (2) additional falls after returning to the facility. Resident #138 expired on [DATE]. Review of Resident #93's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility identified the resident had wandering behaviors. However, the facility failed to develop an elopement care plan, and on [DATE], the resident eloped (left the facility, unsupervised, and without staff awareness). Review of Resident #89's wound care notes revealed on [DATE], the resident developed a stage three (3) pressure wound on the sacrum while in the facility. On [DATE] the sacrum wound deteriorated to a stage four (4). From [DATE] to [DATE] recommendations from the Wound Care Physician were to the turn the resident from side to side and front to back in bed every one (1) to two (2) hours. However, review of the medical record revealed the resident was not turned for 17 days. In addition, surveyor observation revealed resident was not turned as ordered, and interview with the certified nursing assistant revealed she had only turned the resident two times during her twelve hour shift. The facility's failure to have an effective system in place for developing and implementing Comprehensive Care Plans (CCPs) that were person centered, and based on assessments for elopement risk and root cause analysis of falls, in order to prevent further falls with injury, has caused or is likely to cause serious harm, serious impairment, or death of other residents. The facility assessed forty-five (45) residents as at risk for falls. the census was 120 at the time of the survey. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, IJ was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of an L; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a K and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, IJ was identified on [DATE] at 42 CFR 483.25 Quality of Care (F689), at the highest S/S of an L and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, IJ was identified on [DATE] at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600) at the highest S/S of a K, and 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, IJ was identified on [DATE] at 42 CFR 483.35 Nursing Services (F725) at the highest S/S of a L and was determined to exist on [DATE] and is ongoing. In addition, IJ was identified on [DATE] at 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686) at the highest S/S of a J and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600); 42 CFR 483.25 Quality of Care (F684); 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686); and 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). The findings include: Review of the facility's Comprehensive Care Plan (CCP) Policy, dated [DATE], revealed its purpose was to ensure that the resident or resident representative was included in all aspects of person-centered care planning and that planning included the provision of services that enabled the resident to live with dignity and supported the resident's goals, choices, and preferences including, but was not limited to, goals related to the their daily routines and goals to potentially return to a community setting. Continued review revealed the Care Planning/Interdisciplinary Team (IDT) reviewed and updated care plans when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly. 1. Record review revealed the facility admitted Resident #138's on [DATE], with diagnoses of Dementia without Behavioral Disturbance, Paranoid Schizophrenia, and Obsessive-Compulsive Behavior. Continued review of revealed Resident #138 sustained twelve (12) falls from [DATE]-[DATE] with a fall on [DATE] which resulted in bilateral Sub-[NAME] Hematomas. Review of Resident #138's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated moderate cognitive impairment. Continued review revealed the resident required extensive assistance with Activities of Daily Living (ADL's) and required two (2) person physical assist with transfers. Further review revealed the resident had verbal behaviors directed towards others and other behavior symptoms not directed towards others. Review of Resident #138's fall risk evaluation dated [DATE] revealed a score of fourteen (14) which indicated the resident was a high risk for falls. Continued review revealed the resident's level of consciousness/mental state was disoriented at all times. The resident was chair bound, and had balance problems with standing and walking. Review of Resident #138's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the resident was at risk for falls related to a history of falls, weakness, current medications/potential side effects, and diminished safety awareness. Interventions included offer assistance to the bathroom as needed, offer/assistance to common areas when resident appeared restless in his/her room, offer reassurance the supra- pubic catheter functioned properly, and keep frequently used items within reach. Review of Resident #138's Falls Comprehensive Care Plan (CCP), dated [DATE], revealed interventions such as educate the resident to lock the brakes on the wheelchair, encourage the resident to ask for help before transfers, and assist the resident with ambulation when he/she allowed. Review of Progress Notes revealed the nursing staff documented the interventions were not working as the resident did not understand them. Review of the facility's Fall Risk Investigation Reports, dated [DATE], [DATE], [DATE], [DATE] (2 falls), [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed Resident #138 had confusion, memory impairment, and poor safety awareness Review of Resident #138's Closed Medical Record, revealed the resident had sustained a fall, on [DATE], resulting in a laceration to forehead that required sutures. Review of the CCP updated on [DATE], revealed offer one to one conversation or diversions when restlessness was noted, offer snacks, offer tactile cat, and therapy to review positioning in wheelchair to determine if wheelchair modifications were needed. Review of the CCP, updated on [DATE], revealed psych services for medication review. Review of the CCP, updated on [DATE], revealed lay resident down after meals, and place a Dycem to wheelchair for positioning and safety. Record review revealed on [DATE], Resident #138 fell and hit his/her head in the already sutured area from the prior fall on [DATE]. The fall resulted in a hospital stay with diagnoses that included: Multi-focal Bilateral Subdural Hematoma's and Intraventricular hemorrhage. 2. Review of the face sheet in Resident #93's clinical record, revealed the facility admitted the resident on [DATE] with diagnoses of Paranoid Schizophrenia, Hallucinations and Dysphagia. Review of Resident #93's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating he/she was cognitively intact. Further review revealed the resident had episodes of wandering one (1) to three (3) times that week. Resident #93 was also noted to be delusional, had physical and verbal behaviors to others for one (1) to three (3) days, and behaviors directed to self for one (1) to three (3) days. Review of the hospital discharge paperwork, dated [DATE], revealed the resident was found sleeping on the side of the interstate and was taken to the emergency room (ER). Review of Resident #93's Guardianship papers revealed the resident had a State Appointed Guardian and did not have the ability to make decisions on his/her own pertaining to leaving the hospital at will. Continued review revealed the facility scanned the discharge documents into their electronic records system on [DATE]. However, the facility failed to identify the resident was at risk for elopement, therefore an Elopement Risk Care Plan was not developed. Review, Resident of #93's Elopement Risk Assessments, dated [DATE], [DATE], [DATE], and [DATE], revealed the facility did not identify Resident #93 was at risk for elopement. Review of the facility's investigation into the elopement, dated [DATE] and signed by the Executive Director (ED), revealed Resident #93 had not asked permission to sign out; however the resident had a State Guardian and was unable to sign himself/herself out of a healthcare setting. Further, Resident 93's care plan did not indicate the resident could not sign himself/herself out of the facility. In addition, Resident #93 was care planned for the Medical Director (MD) to consult with the pharmacy to consider dosage reduction when clinically appropriate, at least quarterly. The facility did not provide the necessary documentation to show Resident #93's medications were reviewed monthly, for the months of ,d+[DATE] and ,d+[DATE]. 3. Observation on [DATE] at 4:00 PM, of Resident #89's wound care by Wound Doctor of Osteopathic Medicine (DOM), revealed the resident had a stage three (3) pressure wound on the right lower medial shin, a left knee stage three (3) pressure wound, and a stage four (4) pressure wound on the sacrum. The DOM used a scalpel to remove a small piece of necrotic tissue, no pain behaviors were present. The State Survey Agency (SSA) Surveyor observed a scar on the right buttock. The DOM sprayed a numbing solution on the area and used a [NAME] to remove necrotic tissue from the wound. The resident did not exhibit any signs of pain. Observation on [DATE] from 9:10 AM to 10:55 AM, revealed the resident laid on his/her right side for two (2) hours and forty-five (45) minutes. Also, Resident #89 was observed on his/her back from 12:10 PM to 3:50 PM for an additional total of three (3) hours and forty (40) minutes. Observation on [DATE] from 9:00 AM to 3:00 PM, revealed Resident #89 remained on his/her back the entire time. Record review revealed the facility admitted Resident #89's on [DATE] with diagnoses of schizophrenia, personal history of traumatic brain injury, and dementia. The Resident was ambulatory on admission. The admission skin assessment revealed Resident #89 was free of skin lesions. Review of Resident #89's hospital discharge summary, dated [DATE], revealed Resident #89's condition declined, and she/he was admitted to the hospital from [DATE] to [DATE]. The resident's condition further declined and he/she was again admitted to the hospital from [DATE] to [DATE]. The resident returned with a Percutaneous Endoscopic Gastrostomy (PEG) tube inserted. Further, Resident #89 returned with two (2) pressure ulcers, a stage 2 pressure wound on the left medial thigh and a stage three (3) pressure wound on the right buttock. Review of Resident #89's wound care notes revealed on [DATE] the resident developed a stage three (3) pressure wound on the sacrum while in the facility. The thigh and right buttock wounds were documented as healed on [DATE]. On [DATE] the sacrum wound deteriorated to a stage four (4). From [DATE] to [DATE] recommendations from the Wound Care Physician were to the turn the resident from side to side and front to back in bed every one (1) to two (2) hours, if able. Review of Resident #89's CCP revised on [DATE] did not include interventions to off-load the wound and turn every two (2) hours. Review of the resident's treatment record revealed there was no documentation that the resident was turned and repositioned at least every two (2) hours until [DATE]. Review of the Treatment Administration Record (TAR) revealed the resident was not turned every two (2) hours on seventeen (17) of the nineteen (19) days in November of 2022 to include [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE];[DATE]; [DATE]; [DATE]; [DATE]; [DATE] ;[DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. On [DATE] at 3:33 PM, during interview with CNA #42, reevaled she did not have time to look at the care plan and was not aware the resident required turning every two hours. She said she turned Resident #89 twice this twelve (12) hour shift. Interview with the MDS Coordinator, on [DATE] at 5:40 PM, revealed she did not think the care plans needed to be more specific about prevention of pressure ulcers. 4. Review of the admission record for Resident #73 revealed the facility admitted the resident on [DATE] with diagnoses Alzheimer's Disease late onset, Muscle Weakness, Difficulty walking, and Cognitive Communication Deficit. Review of the Admission MDS Assessment, dated [DATE], revealed the resident was a one (1) person physical assist for bed mobility, transfers, and locomotion on and off the unit. The resident required supervision and one-person physical assist for ambulation. The facility assessed the resident to have BIMS score of nine (9) out of a possible fifteen (15) indicating the resident was moderately cognitively impaired. Review a progress note in Resident #73's clinical record revealed the resident sustained two (2) falls from [DATE] to [DATE]. Resident #73 fell while walking with a walker which resulted in chipping both front teeth and a lip laceration. Review of Resident #73's Comprehensive Care Plan (CCP), dated [DATE], revealed the resident ambulated with a walker and needed the assistance of staff. Record review revealed the resident was using a walker without the assistance of staff when the fall occurred. Review of the facility's Fall Risk Evaluation, dated [DATE] and [DATE], revealed Resident #73 was assessed as at high risk for falls. Review of Resident #73's Comprehensive Care Plan (CCP) revealed a focus for falls initiated on [DATE], which included diminished safety awareness with a goal the resident would not experience significant injury from a fall. Interventions included keeping the call device within reach, keeping frequently used items within reach, and completing a fall risk assessment upon admission and at least quarterly, ensuring appropriate footwear when out of bed, referring resident to Physical Therapy (PT) as needed, and to educating and reminding the resident of safety awareness such as locking brakes on wheelchair, asking for assistance before transferring and using the call light. On [DATE] Resident #73's CCP was updated to include interventions for activities of interest, redirection provided as needed, and to be supervised while on the secure unit. On [DATE], Resident #73's CCP was updated to include interventions to assist with ambulation when he/she appeared restless. On [DATE] the facility updated Resident #73's CCP, so the resident would use the walker to ambulate, and for safety staff was to assist the resident. It was noted Resident #73 often ambulated without assistance related to cognitive impairment. Review of Progress Note, dated [DATE] at 9:03 PM, entered by Licensed Practical Nurse (LPN) #23, revealed the resident was found sitting on the floor in the dayroom eating a snack. No injuries were noted after being assessed, Vital Signs were stable, and respirations were even/unlabored. The Resident was assisted to a chair in the dayroom while he/she finished his/her snack. Review of a Progress Note, dated [DATE] at 6:23 PM, revealed Resident #73 ambulated with his/her walker down to the dining room when he/she tripped and fell . The resident chipped his/her two (2) front teeth and had a laceration to bottom lip. 5. Record review revealed the facility admitted Resident #5's on [DATE] with diagnoses of dementia, difficulty walking, and muscle weakness. Review of Resident #5's Quarterly Minimum Data Set Assessment, dated [DATE], revealed the facility was unable to obtain a Brief Interview for Mental Status (BIMS) assessment and scored the resident at zero, which indicated he/she suffered from severe cognitive impairment. Resident #5 was assessed on [DATE], [DATE] and [DATE] for a one person assist when walking. Review of facility provided document, titled Incidents by Incident Type, dated [DATE], revealed Resident #5 had eleven (11) falls from [DATE] through [DATE]. Observation of Resident #5, on [DATE] at 9:35 AM, and again on [DATE] at 5:40 PM, revealed the resident was in bed, but the facility failed to place padding to the left side of the resident's wall, and staff had not placed the fall mat next to the bed, as directed by the plan of care. Observations made from [DATE] through [DATE], revealed Resident #5 was observed self-propelling down the hallway in his/her wheelchair. The resident was not accompanied nor supervised by staff. Observation of Resident #5, on [DATE] at 10:00 AM, revealed the resident was in the common area without staff supervision. Review of Resident #5's care plan dated, [DATE], revealed the resident was at clinically unavoidable risk for falls related to confusion and balance issues. Fall interventions noted on the care plan included staff was to place a fall mat to the right side of the resident's bed ([DATE]), a thick mat was to be placed on the wall next to the resident's bed ([DATE]), and the resident required the safety of a secured unit related to the dementia diagnosis and poor safety awareness. Additionally, Resident #5 was to be supervised by staff while on the secured unit. Resident #5 was noted to be frequently incontinent of bladder related to impaired cognition; however, the resident's plan of care did not include toileting interventions. Review of the facility's self-reported allegation of an Injury of Unknown Origin investigation, dated [DATE], revealed Resident #5's wall was padded with a thick padded mat. However, observations throughout the survey revealed there was no such padding in the resident's room. Review of Resident #5's progress note, dated [DATE] at 1:23 PM, completed by Registered Nurse (RN) #10 revealed thick padding was placed to the left side of bed to aide in safety when the resident was in bed. Interview with Registered Nurse (RN) #10, on [DATE] at 05:20 PM, revealed she had no memory of the incident or of Resident #5. Interview with Certified Nurse Aide (CNA) #30, on [DATE] at 07:25 PM, revealed there had never been padding placed to left side of the wall in Resident #5's room and she did not know why a fall mat had not been placed since she knew Resident #5 was a fall risk. 6. Observation, on [DATE] at 8:48 AM, revealed Resident #61 was seated in his/her wheelchair (w/c), and the resident attempted to stand up three (3) times in front of the w/c, it was not until the last time did staff in the nurses station came out into the common area to address. Observations of Resident #61, on [DATE] at 9:06 AM, on [DATE] at 2:04 PM, on [DATE] at 9:30 AM, on [DATE] at 1:30 PM, on [DATE] at 11:00 AM, on [DATE] at 3:30 PM, on [DATE] at 9:00 AM, on [DATE] at 2:00 PM, on [DATE] at 8:46 AM, on [DATE] at 12:25 PM, and on [DATE] at 8:50 AM, revealed no staff present in the area, providing supervision to resident. Record review revealed the facility admitted Resident #61's on [DATE] with diagnoses of Dementia, Insomnia, Abnormal Gait, Difficulty Walking, and Cognitive Deficit. Review of Resident #61's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident with a BIMS score of six (6) out of fifteen (15) indicating the resident had severe cognitive impairment. The resident required two (2) person physical assistance for bed mobility, transfers, toileting and one (1) person physical assistance for dressing, eating, and personal hygiene. The resident was noted with impairment to both lower extremities, and required the use of a wheelchair. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility could not establish a BIMS score (99), and the resident required the physical assistance of two (2) staff for toileting and eating, and required the use of a wheelchair for mobility. Review of Resident #61's CCP, dated [DATE], revealed staff were to offer to move the resident to a recliner in the common area when he/she was restless. The resident was to be supervised while on the unit, and it was noted the resident enjoyed sitting with peers and should have been coupled with peers for activities ([DATE]). However, observations of the resident during survey did not reveal the care plan intervention was followed by staff. Interview with Certified Nursing Assistance (CNA) #2, on [DATE] at 10:10 AM, revealed the care plan was used to tell staff what care a resident required. She stated it was important for staff to follow the care plan to prevent the resident from getting hurt and to ensure he/she got the best care possible. She stated it was important for aides to let the nurses know if they discovered an intervention was not working so the care plan could be reviewed. She also said it was important to get the pass down information from the night before to ensure if the resident had special or new needs for that day, she would be able to meet those needs. Interview with Licensed Practical Nurse (LPN) #19, on [DATE] at 10:20 AM, revealed she knew the residents well but she still needed to review the care plan each day to ensure the care for the resident had not changed. She stated the care plan was used to drive the care for the resident and interventions were developed and put in place by the Interdisciplinary Team (IDT). LPN #19 revealed it was important for all staff to follow the care plan, to ensure the residents received the best care possible and hopefully to decrease any chance of harm to the resident. She stated if the care plan was not followed, there could be negative results to the resident. For example, if a resident was care planned to be a two (2) staff physical assist and one (1) staff moved the resident, the resident could fall and get hurt. She said, the care plan had to be followed. 7. Observation of Resident #821 on [DATE] at 9:00 AM, revealed the resident was very thin, he/she was seated in a wheelchair on the Men's Memory Care Unit, dressed in pajama pant bottoms and a coat. The resident had a large bruise that covered the entire right side of his/her head, around the eye brow and ear. Record review revealed the facility admitted Resident #821, on [DATE] with diagnoses of Dementia with mood disturbance, history of anticoagulants and anxiety. Review of Resident #821's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as requiring extensive assistance for bed mobility and dressing, limited assistance for transfers, walking in the room and in the corridor and supervision only for eating. Review of the Admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS of six (6) out of fifteen (15) showing severe cognitive impairment. The facility also assessed the resident to require the physical assistance of two (2) staff for bed mobility and personal hygiene, one (1) person physical assistance for locomotion on the unit, dressing, eating and toileting. The resident was totally dependent on staff for bathing. Resident #821 was noted to be absent of upper/lower extremity impairments and was assessed to use a wheelchair only for mobility. Review of Resident #821's CCP, dated [DATE], revealed the facility care planned the resident as at risk for falls with care plan interventions that included: fall risk assessments on admission and at least quarterly; ensure the resident had on appropriate footwear while out of bed; refer the resident to PT/OT/ST as needed; educate and remind the resident of safety awareness such as locking breaks on the wheelchair; asking for assistance before transferring; and to use his/her call light. On [DATE], the care plan was revised to keep frequently used items close to the resident and keep his/her call light within reach; on [DATE], with a new intervention to assist the resident to the dayroom; on [DATE] to place a fall mat to side of his/her bed; on [DATE] to place Dycem to his/her wheelchair; on [DATE] to assist the resident to the dayroom before meals; on [DATE] to provide a room close to the nurse's station. Review of the facility's Risk Management Report, dated [DATE] at 12:14 AM, revealed the resident was found on the floor in the room and complainted of shoulder pain. The Root Cause Analysis (RCA) revealed the resident attempted a self-transfer, lost his/her balance and fell . LPN #7 noted the resident required the assistance of one (1) staff member for all transfers and the resident was wheelchair bound. LPN #7 noted on the RMR a fall mat was placed next to the resident's bed. LPN #7 also noted assessed for injuries, none found except a bump to the right side of the forehead, about a nickel size. Review of Resident #821's Risk Management Report (RMR), dated [DATE], revealed the resident fell from the bed and had bruises from a previous fall. Review of additional RMRs dated [DATE] at 5:12 PM, [DATE] at 5:17 PM and [DATE] at 11:41 PM, revealed the resident sustained three (3) additional unwitnessed falls in a short period of time. The State Survey Agency (SSA) Surveyor attempted to reach LPN #7 who assessed Resident #821 when he/she fell [DATE]. Attempts were made on [DATE] at 3:00 PM, [DATE] at 5:00 PM and [DATE] at 1:00 PM, however, contact was not made. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 5:54 PM, revealed the resident was found on the floor next to his/her bed and complained of shoulder pain to bilateral shoulders, on [DATE]. She said she meant to put in an order for an x-ray but did not do so because she was too busy through the shift. She put the order in at 6:00 PM on [DATE]. The ADON stated Resident #821 was confused, had recent illness, and had impaired memory. Interview with the MDS Coordinator #2, on [DATE] at 9:20 AM, revealed care plans were to be followed by all nursing staff. She said any falls or behaviors needed to be addressed on the care plan immediately. MDS Staff #2 revealed care plans were to be reviewed quarterly and when there was a significant change. She stated the MDS Nurse went through the progress notes, daily, looked at the twenty-four (24) hour report, and if she was not able to physically be in the meeting she tried to get on a conference call with the team. MDS Staff #2 stated if the care plan was not created with the appropriate interventions to match the resident assessment, the resident would not get the care he or she deserved, or could result in potential harm of the resident. Interview with the Executive Director (ED), on [DATE] at 11:00 AM, revealed it was important to keep the residents busy as that would help prevent wandering, and hopefully decrease falls and cut back on resident to resident incidents. She also stated the residents' care plans should be followed as well as the facility policies to ensure the residents got the best possible care. 8. Record review revealed the facility admitted Resident #97 on [DATE] with diagnoses of Dementia with moderate mood disturbance, Parkinson's Disease and Dysphagia. Review of Resident #97's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of fifteen (15) and required the assistance of one (1) staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was absent upper/lower extremities impairments and used a wheelchair to for mobility. Review of Resident #97's progress notes revealed the resident sustained falls on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the resident's CCP dated [DATE] revealed the resident was at risk for and had a history of falls related to new environment, weakness, current medications/potential side effects, diminished safety awareness, and incontinence. The care plan revealed there were to be nonskid strips on the floor next to the resident's bed as a fall prevention intervention. Observation on [DATE] at 11:21 AM, [DATE] at 9:55 AM, [DATE] at 9:00 AM, [DATE] at 12:34 PM, [DATE] at 12:25 PM, [DATE] at 8:45 AM, [DATE] at 8:20 AM and [DATE] at 9:02 AM, revealed Resident #97 was in bed, with eyes close or eating. In addition, observations revealed the facility had not placed the nonskid strips next to the resident's bed to prevent falls per the plan of care. Interview with the MDS Coordinator #2 on [DATE] at 9:20 AM, revealed if care plans were not created with the appropriate interventions to match the resident assessment, the resident would not get the care he or she deserved, or could result in potential harm of the resident. Interview with the ED on [DATE] at 11:00 AM, revealed Resident #97's care plan should have been followed to ensure they receive the best possible care. 9. Record review revealed the faciltiy admitted Resident #32's on [DATE] with diagnoses of Dementia, Diabetes, and Anxiety. Review of Resident #32's Admission MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Using the MDS, the facility assessed the resident as one who wandered daily, which placed the resident at significant risk of harm/danger from other residents and hazards throughout the facility. Additional review of the MDS assessment revealed the resident intruded on the p [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' environment was as free of accident hazards as possible and failed to provide the necessary supervision to avert accidents for fifteen (15) of ninety-four (94) sampled residents. (Residents #5, #61, #73, #74, #80, #93, #96, #97, #106, #128, #131, #134, #138, #371 and #821). 1. The facility failed to ensure it had a system in place for adequate supervision and monitoring to prevent accidents/falls, to determine the root cause of falls, to evaluate falls and implement individualized interventions and to monitor the effectiveness of interventions to prevent additional falls for fourteen (14) of ninety-four (94) sampled residents (Residents #5, #61, #73, #74, #80, #96, #97, #128, #131, #134, #138, #371, #106, and #821). (a). On [DATE], Resident #138 sustained a fall, requiring sutures to his/her head. Resident #138 had two (2) more falls that resulted in trauma to the same sutured area. Resident #138 had multiple falls and was hospitalized from [DATE] through [DATE] at which time the resident was diagnosed with bilateral subdural hematoma. Resident #138 experienced two (2) additional falls after returning to the facility. Resident #138 expired on [DATE]. (b). Resident #131 fell multiple times from [DATE] through [DATE]. On [DATE], Resident #131 sustained a fall that resulted in a Sub-[NAME] Hematoma (collection of blood within the brain) with brain compression, and a midline shift (brain pushed off center). (c). Review of Resident #134's Progress Note, dated [DATE] at 7:21 AM, revealed the resident became combative with CNA (Certified Nurse Aide) #60. CNA #60 stated she let go of the resident and he/she fell and hit his/her face on the bedframe. The nurse assessed the resident, who had complaints of pain and swelling to the left cheekbone below his/her eye and a laceration. Emergency Medical Services (EMS) was called to transport the resident to the emergency room (ER). Resident #134 was diagnosed with a facial laceration that required sutures and a mild head injury. (d). Record review revealed Resident #5 sustained a witnessed fall, on [DATE] at 6:33 PM. The resident tripped and hit his/her head on the walker. Further review revealed he/she sustained a laceration to the left eyebrow, nosebleed, skin tear to the bridge of his/her nose, bruising to both hands, right arm, and darkened area on the left palm. (e). On [DATE] at 6:23 PM, Resident #73 was ambulating with a walker down to the dining room when he/she tripped and fell chipping his/her two (2) front teeth and causing a laceration to his/her bottom lip. (f). Resident #80 fell on [DATE] and sustained an approximate four (4) centimeter (cm) laceration to his/her lateral right eyebrow. The resident was sent to the ER and returned on [DATE] with sutures to the lacerated area. Resident #80 sustained a fall again on [DATE] at 2:00 AM, and an x-ray noted the resident had a fracture of his/her right femur. Resident #80 was sent to the hospital for hip repair. (g). Resident #821 experienced falls and on [DATE] at 11:41 PM, the resident sustained another fall from the bed and complained of shoulder pain. The Assistant Director of Nursing (ADON) documented in the progress notes she placed an order for an x-ray. However, the ADON did not submit the order until 6:00 PM on [DATE], after the State Survey Agency (SSA) Surveyors brought it to her attention. (h). Review of the Progress Notes revealed on [DATE], Resident #97 was found lying on the floor and was observed to have an abrasion to his/her hip. Review of the Progress Note dated [DATE], revealed Resident #97 was found lying on the floor, and had attempted to self-transfer with regular socks on. Review of the Progress Note, dated [DATE], revealed Resident #97 was found lying on the floor next to the toilet and told staff he/she attempted to go to the bathroom. Continued review of the Progress Notes revealed on [DATE], Resident #97 was found lying on the floor. Further review revealed documentation that noted Resident #97 refused to use his/her call light to obtain assistance. Review of the Progress Notes revealed on [DATE], Resident #97 was again found lying on the floor, with documentation noting the resident fell out of his/her bed when he/she tried to reposition in the bed. (i). Review of Resident #106's Fall investigation, dated [DATE] revealed at 12:00 PM he/she was asleep in his/her wheelchair (W/C) in the common area and fell from the W/C. The fall was witness by a Certified Nurse Aide who was unable to stop the fall. (j). Observation revealed Resident #96 attempted to get up and stand on [DATE] at 12:28 AM and fell landing on his/her side and complained of severe pain in left hip area. The resident was diagnosed with a fractured hip and sent to the hospital for repair of the fracture. (k). Record review revealed Resident #371 was admitted for rehabilitation services after having frequent falls related to Lewy Body Dementia. Continued record review revealed the resident fell approximately seven (7) times, during his/her first (1st) fifty (50) days in the facility, resulting in head lacerations which required his/her wounds to be stapled. (l). Review of Resident #61's Facility Self-Reported incident revealed Resident #61 had fallen out of his/her bed on [DATE], and the nurse did not complete an assessment or report the incident. Review of Resident #61 clinical record revealed he/she had forty-three (43) documented falls from [DATE] to [DATE], and one (1) undocumented fall. The resident had a total of forty-four (44) falls, within a span of one and a half (1 and ,d+[DATE]) years. (m). Record review revealed the facility admitted Resident #128 on [DATE]. Further review revealed the resident sustained five (5) falls between [DATE] and [DATE]. On [DATE] Resident #128 sustained a fall resulting in a laceration to the back left side of his/her head and was transported to the hospital. Subsequently, on [DATE] the resident sustained another fall which resulted in a laceration to the right side of the resident's head, a fracture to the frontal sinuses that went through the cranial vault (skull fracture) and the resident was sent to the hospital; however, did not return to the facility. Resident #128 passed away at the hospital on [DATE]. (n). Record review revealed Resident #74 sustained a total of eight (8) falls between [DATE] and [DATE]. On [DATE] the resident was noted to have a large hematoma on the right side of his/her forehead. 2. The facility failed to ensure a safe environment and failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of ninety-four (94) sampled residents. Resident #93 exited the facility, without staff's knowledge on [DATE] at approximately 4:20 PM. The facility did not locate Resident #93, until [DATE] at 1:10 AM, three (3) miles away. 3. The facility failed to ensure the residents' environment remained free of accident hazards related to water temperatures outside the acceptable range. Observation of water temperatures on [DATE] with checks initiated at 2:52 PM revealed water temperatures in rooms 102, 105, 106, 116, 118, 122, 125, 126, 130, 140, and 234, were not within the acceptable parameters for ensuring resident safety. The water temperatures ranged between 110.4 degrees to 121.1 degrees Fahrenheit (F). Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, IJ was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of an L; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a K and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, IJ was identified on [DATE] at 42 CFR 483.25 Quality of Care (F689), at the highest S/S of an L and was determined to exist on [DATE] and is ongoing. The facility was notified of the Immediate Jeopardy on [DATE] and is ongoing. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). The findings include: Review of the facility's policy titled, Fall and Fall Risk Managing - Investigating and Reporting, revised [DATE], revealed based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the facility's policy titled, Fall Management, dated [DATE], revealed a fall risk observation was used to identify individuals who were at high risk for falls, as well as those individuals who had any risk factors for falls. Per policy review, the observation (assessment) would be completed on a resident's admission to the facility, Quarterly, Annually, and with any Significant Change in Condition. Continued review revealed fall prevention would be achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. Policy review revealed response to a resident's fall was to include: evaluating and monitoring the resident for seventy-two (72) hours post fall; assess the resident's level of consciousness, vital signs and range of motion; and look for lacerations, abrasions, and obvious deformities. Further review revealed additional responses to a resident's fall included: If an emergency situation existed, initiate the Emergency Medical System (EMS) response; contact the provider and resident's family; remain with the resident until EMS arrives; complete a root cause analysis (RCA) and determine an intervention based on the root cause determined; implement interventions (immediately) after the fall. Additionally, as the investigation of the fall continued the root cause analysis might trigger other interventions to the resident's plan of care; update the care plan; and Certified Nurse Aide (CNA) communication form with the new intervention. 1 (a). Review of Resident #138's closed record revealed the facility admitted the resident on [DATE], with diagnoses which included: Dementia without Behavioral Disturbance, Paranoid Schizophrenia, and Obsessive-Compulsive Behavior. Continued review of the closed record revealed Resident #138 sustained twelve (12) falls from [DATE] through [DATE], with a fall on [DATE] which resulted in the resident experiencing bilateral subdural hematoma (bleeding in the brain usually caused by a serious head injury). Review of Resident #138's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated moderate cognitive impairment. Continued review revealed the facility assessed Resident #138 as requiring extensive assistance with activities of daily living (ADL's), and to require two (2) persons assist with transfers. Further review revealed the facility assessed Resident #138 to have verbal behaviors directed towards others and other behavior symptoms not directed towards others. Review of the facility's Fall Risk Evaluation for Resident #138, dated [DATE], revealed the facility assessed the resident to have a score of fourteen (14) which indicated the resident was a high risk for falls. Continued review revealed Resident #138's level of consciousness/mental state was assessed as disoriented to person, time and place, at all times. Further review revealed the facility assessed Resident #138 as chair bound, to require restraints, and as needing assist with elimination. Review of the facility's Fall Risk Investigation Reports for Resident #138's falls, dated [DATE], [DATE], [DATE], [DATE] for two (2) falls, [DATE], [DATE], [DATE], [DATE] thru [DATE], revealed the facility noted Resident #138 to have confusion, memory impairment and poor safety awareness. Review of Resident #138's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the facility care planned the resident with a focus for risk for and history of falls, weakness, and diminished safety awareness status. Continued review revealed the care plan goal included the resident not to experience significant injury from a fall. Per the care plan review, the interventions included: offering Resident #138 assistance to the bathroom as needed; offer/assist the resident to common areas when he/she appeared restless in his/her room; offer reassurance that the supra-pubic catheter was functioning properly; and keep frequently used items within reach. Review of Resident #138's CCP updated on [DATE], revealed an intervention to encourage Resident #138 to ask for assistance prior to self-transfers and encourage him/her to lock his/her wheelchair brakes prior to transfers. Further review of CCP updated on [DATE] revealed an intervention to assist Resident #138 to ambulate when he/she attempted to stand up or was restless. Review of Resident #138's Progress Note, dated [DATE] at 1:23 AM, documented by Registered Nurse (RN) #23, revealed staff found the resident lying on the floor beside his/her bed, with the bed in the lowest position. Continued review of the Note revealed Resident #138 reported to the nurse that he/she had been trying to urinate. Further review revealed Resident #138 had a small abrasion to the top of his/her head, which the RN was unable to assess whether the scratch was a result of the fall or self- inflicted. In addition, review of the Note revealed RN #23 documented she would monitor Resident #138 closely throughout her shift. Review of the facility's Change in Condition (CIC) Note, dated [DATE] at 3:38 AM, revealed when Resident #138 fell out of his/her bed, the bed had been in the lowest position. Review of the CIC Note revealed documentation that noted, will monitor the resident frequently throughout shift for any distress. Review of the Progress Note dated [DATE] at 8:24 AM, documented by LPN #33, revealed staff had found Resident #138 lying on the floor on his/her back beside his/her bed. Continued review of the Note revealed documentation noting Resident #138 needed to be redirected not to stand up. Further review revealed Resident #138 was somewhat confused and believed he/she could do more than he/she was able to do. Review of the facility's Interdisciplinary Team (IDT) Note, dated [DATE] at 10:22 AM, entered by the former Director of Nursing (DON), revealed the IDT met and discussed Resident #138's recent falls. Per review, staff reported Resident #138 felt like he/she had to use the bathroom and attempted to self-transfer, and then sustained another fall when trying to self-transfer in his/her room. Further review revealed the IDT determined the root cause of Resident #138's falls was being in a new environment, having a new supra-pubic catheter, and attempting to self-transfer. In addition, review of the IDT Note revealed Resident #138's care plan was updated. Review of Progress Note, dated [DATE] at 4:05 PM, revealed Resident #138 had sustained a fall while trying to self-transfer from his/her wheelchair. Per review, Resident #138 fell on to his/her bottom when he/she self-transferred from the wheelchair unassisted. Further review revealed no injury was noted, Resident #138 had no complaints of pain. Review of the Nurse's Note, dated [DATE] at 9:57 AM, revealed the IDT met and discussed Resident #138's recent fall. Continued review revealed the IDT determined the root cause of Resident #138's fall as his/her new environment and self determination to transfer self with poor safety awareness. Further review revealed Resident #138's care plan was updated to include interventions for staff to encourage the resident to call for assistance and to encourage him/her to lock his/her wheelchair. Review of the Nurse's Note, dated [DATE] at 9:52 AM, revealed an order had been received to stop Resident #138's Haldol, as needed, in fourteen (14) days and for psychiatry to see the resident. Review of Resident #138's CCP, dated [DATE], revealed interventions were added to encourage the resident to lock his/her wheelchair brakes prior to transfers and to encourage him/her to ask for assistance prior to self- transfers. However, record review revealed the facility assessed the resident to be disoriented to person, time and place and was cognitively impaired. Review of the Progress Note, dated [DATE] at 4:08 PM, revealed Resident #138 had sustained two (2) falls while self-transferring, unassisted out of his/her wheelchair. Continued review of the Note revealed Resident #138 denied hitting his/her head, had no injuries and no complaints of pain. Further review revealed Resident #138 was placed closer to the nurse's station for closer observation and the Medical Director was notified of the fall. Review of the Progress Note, dated [DATE] at 10:07 AM, revealed the IDT met and discussed Resident #138's recent falls. Continued review of the Note revealed staff reported they were having a difficult time redirecting or distracting Resident #138 and became easily agitated. Per review, staff also reported Resident #138 would purposefully continue unsafe actions while they were attempting to redirect him/her. Further review revealed Resident #138 also often attempted to stand and ambulate by himself/herself and became resistive when redirected by staff. Review further revealed the IDT determined the root cause of Resident #138's falls as his/her determination to do things without assistance and resistance to redirection or cues for safety. In addition, record review revealed Resident #138's care plan was updated to include an intervention for staff to assist the resident to ambulate when he/she attempted to stand up or was restless. Review of CCP revealed on [DATE], the care plan was updated with the intervention to assist Resident #138 to ambulate when he/she attempted to stand up or was restless as he/she would allow. Review of Resident #138's Change in Condition (CIC) Note, dated [DATE] at 2:52 PM, revealed staff observed the resident lying on the floor face down in the hallway near the dining area. Continued review revealed Resident #138 reported he/she did not know how he/she had fallen. Review further revealed neurological checks were initiated, and the Medical Director was contacted. Review of Resident #138's Progress Note dated [DATE] at 10:13 AM, revealed the IDT met and discussed the resident's recent fall. Per review of the Note, staff observed Resident #138 lying face down on the floor and had a bruise observed to his/her face near the left eye. Continued review revealed Resident #138 had been participating in therapy using a rolling walker and contact guard assist. Further review revealed the IDT determined the root cause was Resident #138's poor safety awareness, UTI and attempts to self -ambulate. Additional review of the Note revealed Resident #138's care plan was updated to include dropping the back of the resident's wheelchair seat. Review of the Change in Condition (CIC) Note, dated [DATE] at 9:15 AM, revealed staff observed Resident #138 lying face down on the floor in front of his/her wheelchair in a puddle of blood. The resident was noted with a deep, jagged laceration observed to his/her forehead above his/her left eye. Further review revealed Resident #138 had no loss of consciousness, and the Medical Director was notified of the resident's fall at [DATE] at 8:20 AM. Continued review of Resident #138's closed medical record revealed documentation, dated [DATE], noted the resident sustained a fall on that date which resulted in a laceration to his/her forehead that required sutures. Review of the Progress Note, dated [DATE] at 9:30 AM, revealed the Emergency Medical Technicians (EMs) arrived and transported Resident #138 to the hospital Emergency Department (ED) for further evaluation at approximately 9:00 AM, due to the deep, jagged laceration on the resident's forehead above the left eye. Review of the Progress Note, dated [DATE] at 1:30 PM, revealed Resident #138 returned to the facility from the ED at approximately 1:00 PM by ambulance. Continued review revealed Resident #138's forehead laceration was closed with approximately eleven (11) sutures. Further review revealed the computerized tomography (CT) scan of Resident #138's cervical spine was normal. Review of the Progress Note, dated [DATE] at 9:30 AM, revealed Resident #138 sustained a fall, and was found by staff face down on the floor in a puddle of blood in front of his/her wheelchair in the same position as he/she had been found the day before. Per review of the Note, Resident #138 experienced no loss of consciousness, had no complaints of pain, and had good range of motion (ROM) in all extremities. Continued review revealed Resident #138 had a history of unassisted, self-transfers and impulsivity. Review further revealed the Medical Director was notified on [DATE], at 9:22 AM, and a new intervention to be implemented for enhanced supervision of the resident. Review of the Progress Note, dated [DATE] at 10:17 AM, revealed the IDT met and discussed Resident #138's recent falls. Per review of the Note, Resident #138 was observed laying on the floor in the common area and had a laceration to the left eye area. Continued review revealed Resident #138 was sent to the ED and returned with eleven (11) sutures to the lacerated left eye area. Further review revealed Resident #138 again sustained a fall and was observed lying on the floor with blood noted coming from the nostril and sutured laceration areas. Review of Resident #138's CCP revealed it was updated on [DATE], with interventions which included: offer one on one (1:1) conversation or diversions when restlessness was noted; offer snacks and tactile cat and therapy to review the resident's positioning in the wheelchair to determine if wheelchair modifications were needed. Review of the CCP revealed an update, dated [DATE], for psychiatric (psych) services to do a medication review for Resident #138. Review of the CCP updated on [DATE] revealed additional interventions: to lay the resident down after meals; and place Dycem (sticky, non-slip rubber used for stabilization) to his/her wheelchair for positioning and safety. Review of the Change in Condition (CIC) Note dated [DATE] at 3:45 PM, revealed Resident #138 was observed lying on floor on his/her side beside his/her wheelchair with no injuries or complaints of pain, and good ROM (range of motion) to all extremities. Continued review revealed Resident #138 had a history of unassisted, self-transfers, falls and he/she had an impulsive nature. Review of the IDT Clinical Note, dated [DATE] at 9:49 AM, revealed the IDT met and discussed Resident #138's fall when he/she was found by staff lying on the floor in his/her room. Further review revealed Resident #138's CCP was updated to have his/her anti-roll backs checked to ensure they were in functioning order. In addition, review of the CCP revealed an intervention to lay Resident #138 down after meals as the resident would allow and continue to monitor. Review of the Nurse's Note, dated [DATE] at 3:54 PM, revealed Resident #138 was noted as sliding down in his/her w/c multiple times during the shift and required staff to assist the resident back to a seated position each time. Review further revealed an order was received for Dycem to the resident's w/c to prevent sliding and possible injury. Review of the Nurse's Note, dated [DATE] at 9:30 PM, revealed Resident #138 slid out of the chair, falling forward on the floor and landing on the left side of his/her face where the existing stitches were. Further review revealed no new injuries were noted, neurological (neuro) checks were initiated. Review of the Nurse's Note, dated [DATE] at 10:45 AM, revealed Resident #138 again sustained a fall out of his/her chair while in the hallway. Continued review revealed Resident #138 had significant bleeding to the sutured left facial laceration area. Further review revealed Resident #138's vital signs were obtained and the resident was being sent out to the hospital ED (Emergency Department) for further evaluation. Review of Hospital Discharge Summary dated [DATE], revealed upon entering hospital ED, the CT scan showed bilateral subdural hematomas with diagnoses that included multi-focal traumatic subdural hematomas, intraventricular hemorrhage, and falls at nursing home. Review of the Hospital Admission Note, dated [DATE] at 7:26 PM, revealed Resident #138 returned to the facility from the hospital at approximately 5:00 PM. Per review, Resident #138 had multiple bruises all over his/her body in various stages of healing, scabbed areas on his/her knees, and greenish/purplish bruising to his/her left hip. Further review revealed Resident #138 had also been attempting to put himself/herself on to the floor and 1:1 supervision had to be provided to ensure the resident's safety. Record review revealed Resident #138's code status was changed to Do Not Resuscitate (DNR) and palliative care was consulted for the resident. Review of the Nurse's Note dated [DATE] at 10:31 PM, revealed Resident #138 had sustained a fall from his/her wheelchair landing on previous injuries to the resident's left forehead which was bleeding. Per review of the Note, pressure was applied to the bleeding area and that area was cleansed. Review further revealed the Medical Director was notified and orders received to increase the resident's Ativan and monitor the resident closely. Review of the CCP revealed a revision, dated [DATE], with interventions which included to transfer Resident #138 to a stationary recliner in the common area when the resident appeared restless. Further review revealed additional interventions to offer to take Resident #138 for a stroll off the unit or outside when he/she was restless as the resident would allow, offer diversional activities and provide 1:1 conversation with him/her when restless. Review of the Progress Note, dated [DATE] at 10:08 AM, revealed the facility's IDT met and discussed Resident #138's recent falls. Review of the Note revealed Resident #138 had returned from the hospital on [DATE] with new orders. Continued review revealed Resident #138 had recently experienced a general decline and was now a DNR. Record review revealed a Hospice consult was made for Resident #138. Review of the Change in Condition Note, dated [DATE] at 1:27 PM, revealed Resident #138 had vomited a large amount of coffee ground liquid. Continued review revealed Hospice was to come and assess Resident #138, and Phenergan (anti-nausea medication) 12.5 milligram (mg) was administered. Review of the Progress Note, dated [DATE] at 5:44 PM, entered by LPN #17, revealed she went to check on Resident #138 and found the resident to have no signs of life. Record review revealed Registered Nurse (RN) #9 arrived and pronounced Resident #138 as expired at 4:27 PM. In addition, review of the Note revealed Hospice, the DON, and the Medical Director were notified of Resident #138's death. (b). Review of Resident #131's closed record revealed the facility admitted the resident on [DATE], with diagnoses that included Unspecified Dementia, difficulty walking, and Bipolar Disorder. Review of Resident #131's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status' (BIMS) score of ninety-nine (99), which indicated the resident was severely cognitively impaired and unable to be interviewed. Review of Resident #131's Progress Note, dated [DATE] at 1:18 PM, revealed Resident #131 nodded off to sleep while sitting up and slid out of the chair onto the floor. Continued review revealed Resident #131 had no apparent injuries. Review of the IDT Note, dated [DATE] at 10:18 AM, revealed the IDT met and discussed Resident #131's recent fall. Per review, staff witnessed Resident #131 slide off the edge of the chair when he/she started to fall asleep. Further review revealed a root cause analysis determined the resident's tiredness and sitting in the chair when sleepy was the cause. Review of the care plan revealed it was updated to include assist the resident to bed when he/she appeared sleepy. Review of Resident #131's Progress Note, dated [DATE] at 8:58 AM, revealed the resident sustained a fall in the hallway when walking to breakfast. Per review of the Note, Resident #131 had on another resident's shoes at the time of the fall, and he/she was not very responsive right after the fall. Continued interview revealed Resident #131 slowly began to respond more; however, he/she was not able to move his/her extremities very well. Review further revealed the facility transferred Resident #131 to the emergency room (ER). Review of Resident #131's Progress Note, dated [DATE] at 1:03 PM, revealed the ER Nurse stated the resident would be returning to the facility with no significant injuries noted. Further review of the Note revealed Resident #131's care plan was updated for staff to ensure the resident wore proper fitting footwear. Review of Resident #131's Progress Note, dated [DATE] at 6:30 PM, revealed the resident sustained an unwitnessed fall in his/her room which resulted in a scalp contusion with moderate bleeding. Review further revealed Resident #131 was sent back to the ER. Review of Resident #131's Progress Noted, dated [DATE] at 12:22 AM, entered by LPN #33, revealed the resident arrived back at the facility with no new orders. Continued review revealed Resident #131 had no verbal or facial expressions of pain, neurological (neuro) checks and range of motion (ROM) were within normal limits (WNL. Review of the Note revealed staff were to continue to monitor the resident for: any changes in neuro checks; ROM; complaints of pain; and signs and symptoms (s/s) of distress. Review of the IDT Note, dated [DATE] at 10:25 AM, revealed the IDT met and discussed Resident #131's recent falls. Review of the Note revealed the IDT determined the root cause for the first fall was the resident was not wearing inappropriate shoes, and the root cause for the second fall was the resident's general weakness from the first fall. Review of the Note revealed Resident #131's Care Plan was updated with interventions to ensure the resident had proper shoes on and for staff to pad the furniture in the resident's room. Review of the Change in Condition Note, dated [DATE] at 11:45 AM revealed staff had found Resident #131 lying on his/her back on the floor beside his/her bed. Continued review revealed Resident #131 stated he/she hit his/her head; however, he/she did not know how he/she came to be lying on the floor. Further review revealed Resident #131 was wearing gripper socks at the time of the fall, was assessed and sent out to the ER. Review of the IDT Note, dated [DATE] at 4:07 PM, revealed the IDT met and discussed Resident #131's fall. Continued review revealed staff reported entering Resident #131's room they observed the resident lying on the floor in front of his/her bed, with gripper socks on, which [TRUNCATED]

Based on observation, interview, record review, and review of the facility's assessment and policies, it was determined the facility failed to have an effective system in place to ensure sufficient nursing staff were available at all times Based on observation, interview, record review, and review of the facility's assessment and policies, it was determined the facility failed to have an effective system in place to ensure sufficient nursing staff were available at all times to ensure resident care needs were met for forty-two (42) of ninety-three (93) sampled residents. (Residents #5, #17, #19, #35, #36, #47, #48, #49, #56, #57, #59, #61, #67, #69, #73, #74, #76, #80, #81, #86, #88, #89, #91, #92, #93, #95, #96, #97, #101, #102, #106, #110, #112, #128, #131, #132, #134, #138, #144, #146, #371 and #821) The facility failed to ensure residents' environment was as free of accident hazards as possible and failed to provide the necessary supervision to avert accidents for fourteen (14) residents. (Residents #5, #61, #73, #74, #80, #96, #97, #106, #128, #131, #134, #138, #371 and #821). Resident #93 exited the facility, without staff's knowledge on 01/17/2023 at approximately 4:20 PM. The facility did not locate Resident #93, until 01/18/2023 at 1:10 AM, three (3) miles away. The facility failed to ensure residents were protected from physical abuse, including resident to resident abuse, for thirty-one (31) residents (Residents #17, #19, #35, #36, #47, #48, #49, #56, #57, #59, #67, #69, #74, #76, #80, #81, #86, #88, #89, #91, #92, #93, #101, #102, #110, #112, #131, #132, #138, #140, and #144) Resident #80 suffered significant injury as a result of abuse. Interviews with residents and residents' family members revealed the facility was short staffed and residents had long wait times, for staff to respond to their care needs. Interviews with staff revealed due to lack of staffing they were not able to meet all resident care needs related to fall and pressure prevention, wandering or elopement supervision. Staff stated due to not enough staff it was difficult to toilet residents routinely or change incontinent residents frequently, nor could staff provide supervision to prevent residents with a history of physical aggression, from injuring other residents. The facility's failure to have sufficient staffing to provide the residents with their assessed care and service needs has caused or was likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy (IJ) was identified on 02/21/2023 at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on 01/17/2023 and is ongoing. The facility was notified of the Immediate Jeopardy on 02/21/2023. Additionally, IJ was identified on 03/05/2023 at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a L; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a K and was determined to exist on 04/30/2022 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/05/2023. Additionally, IJ was identified on 03/07/2023 at 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a L and was determined to exist on 02/14/2023 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/07/2023. In addition, IJ was identified on 03/08/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600) at the highest S/S of a K, and 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on 12/16/2022 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/08/2023. Additionally, IJ was identified on 03/09/2023 at 42 CFR 483.35 Nursing Services (F725) at the highest S/S of a L and was determined to exist on 04/30/2022 and is ongoing. In addition, IJ was identified on 03/11/2023 at 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686) at the highest S/S of a J and was determined to exist on 10/05/2022 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/11/2023. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600); 42 CFR 483.25 Quality of Care (F684); 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686); and 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). (Refer to F-600, F-656, F-684, F-686, and F-689) The findings include: Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022, revealed staffing numbers and the skill requirements of direct care staff was determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment. Further review of the policy revealed factors considered in determining appropriate staffing ratios and skills included an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. Review of the Census and Condition form (Form completed by the facility and represented the current condition of resident needs) received from facility, on 02/14/2023, indicated the facility had a census of one hundred and twenty-two (122). The form indicated sixty-two (62) residents needed one (1) to two (2) direct care staff to assist them with bathing, and sixty (60) residents were totally dependent on staff for bathing. One-hundred six (106) residents needed assistance of one (1) to two (2) staff for dressing and ten (10) residents were totally dependent upon direct care staff for dressing. Forty-four (44) residents needed one (1) to two (2) staff to assist with transfers and twenty-one (21) residents depended totally upon staff to transfer them between surfaces, such as the resident's bed and his/her wheelchair. Thirty-four (34) residents needed the assistance of one (1) to two (2) staff to toilet and fifty-five (55) residents depended totally upon the facility's direct care staff for all their toileting needs. Sixty-four (64) residents were on a scheduled program for urinary toileting, and sixty-three (63) residents were on a scheduled program for bowel toileting. Review of the Facility Assessment (FA), dated 02/09/2023, revealed the purpose of the assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The FA was used, to make decisions about resident's direct care staff needs, as well the facility's capabilities to provide services to the residents in the facility. The FA stated the facility was to use a competency-based approach, that focused on ensuring each resident was provided care that allowed the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Continued review revealed the facility's average daily census was one-hundred and twelve (112) and the maximum was one-hundred and twenty-two (122). The FA stated twenty-one (21) Certified Nursing Assistants (CNAs), and twelve (12) licensed nursing staff were needed to provide direct care to residents. Review of the Staffing Daily Staffing Schedules, dated 02/01/2023 through 02/15/2023, revealed the facility had an Acute Care Unit (ACU) that was secured. In addition, had an East Unit, which included a B hall, C hall, and a D hall. The schedule also indicated the facility had a [NAME] Unit. Observations made during survey revealed the ACU was a unit where male and female residents resided. The female residents on the ACU were separated by a locked door from the male resident side of the ACU. Record review of the Facility Matrix, printed 02/14/2023, revealed the ACU male secured unit had a census of fifteen residents and the ACU female secure unit had nineteen residents, for a total of thirty-four (34) residents. The East Unit had seventy-five (75) residents and thirteen (13) residents resided on the [NAME] Unit. Further review of the staffing schedules revealed one nurse was scheduled to care for the thirty-four (34) residents on the ACU each day, from 7:00 AM to 7:00 PM and from 7:00 PM to 7:00 AM. In addition, the ACU had one certified medication technician (CMT) scheduled from 7:00 AM to 11:00 AM. The staffing schedule revealed, three certified nursing assistants, were assigned to care for the thirty-four (34) residents on the ACU, each day from 7:00 AM to 7:00PM and 7:00 PM to 7:00 AM. Continued review of the staffing schedules revealed the East Unit had three (3) nurses scheduled to care for the seventy-five (75) residents. One nurse for B Hall, one nurse for C Hall, and one nurse for the D Hall, for both the day and night shifts. The schedule revealed four (4) to five (5) aides were assigned to the East Unit for both day and night shifts. In addition, during night shift, the [NAME] Hall did not have a night nurse assigned. The form indicated the only staff assigned to the [NAME] Hall from 7:00 PM until 7:00 AM, was CMT. Interview with Resident #30, on 02/15/2023 at 3:35 PM, revealed he/she could only get showered late at night, due to short staffing. The resident reported he/she had laid in stool for as much as eight (8) hours, and some days there was only one aide for his/her unit. Interview with CNA #17, on 03/06/2023 at 3:30 PM, revealed there were usually two (2) nurse aides on the male and female secured units. She said memory care staffing was concerned because residents could get hurt without enough staff. She said only four (4) of the nineteen (19) residents on the women's side, could toilet themselves and the others required staff to assist with incontinence care. Interview with CNA #43, on 02/23/2023 at 8:52 PM, revealed the facility did not have enough staff to get everybody up every day. She stated they would have two (2) aides for sixty (60) residents on any given day. Further interview revealed the facility did not have enough staff to shower all the residents, and it was all staff could do to get residents fed, medicated, and some briefs changed. CNA #43 stated a resident got pressure sores on his/her bottom, and while she was not sure if the resident had the pressure sores when he/she was admitted , those pressure sores did not get better from that resident sitting in wetness. She stated staff could not change all the residents frequently, especially if two (2) staff were required for resident transfer. Interview with Registered Nurse (RN) #4, on 02/28/2023 at 2:22 PM, revealed there was never enough staff to answer call lights timely. She stated residents would get so upset when no staff came to assist them. She stated there were times when she was the only nurse on the whole unit and the Director of Nursing (DON) nor the Executive Director (ED), who was a nurse, would help. Continued interview revealed night shift had inadequate staffing numbers and one of the resident's complained to her every morning that he/she had to wait for help. Observation, on 02/19/2023 at 3:20 PM, revealed no staff were present on the [NAME] Wing, however five (5) residents were present in the common area. At 3:32 PM, twelve (12) minutes later, LPN #4 returned to the [NAME] Wing after having left the residents unsupervised. Observation on 03/07/2023 at 9:58 AM, revealed the call light was audible from the entrance of the East Wing. CNA #41, RN #19, the Interim Director of Nursing and housekeeping staff all walked past the room where the call light was activated, but the ringing did not cease. After the call light rang for twelve (12) minutes, the State Survey Agency (SSA) Surveyor approached the East Wing nurses' station where CNA #1 and RN #19 were seated. Interview at time of observation with RN #19 revealed she heard the call light ringing and it was part of her job to answer call lights. RN #19 then stood up and went to assist the resident in the room where the call light was ringing. 1. Record review revealed on 01/17/2023, Resident #93, with a history of elopement, and four (4) other residents were left in the smoking courtyard, without direct supervision by staff. The gate to exit the courtyard was unlocked. Resident #93 walked off grounds at approximately 4:20 PM and staff did not determine the resident was missing until approximately 5:20 PM. Resident #93 was not located until 01/18/2023 1:10 AM, approximately three (3) miles from the facility. (Refer to F689) Interview with Resident #40, on 02/14/2023 at 12:00 PM, revealed he/she was present out in the smoking area on 01/17/2023, when Resident #93 eloped from the facility. Resident #40 stated the gate was open to the courtyard, and it had been left open for a couple of days. Resident #40 also, stated it was not Resident #93's fault, if the facility staff could not keep the facility secured, it was their fault the resident left. Interview with Resident #38 on 02/14/2023 at 12:15 PM, revealed he/she was out in the smoking area on 01/17/2023 when Resident #93 eloped from the facility. Resident #38 stated the staff member who allowed them out to smoke, did not enter the courtyard with them, only lit their cigarettes and watched them from behind the closed door/window. Resident #38 stated the residents knew the gate in the courtyard was not secured, as they had witnessed it open for a few days in a row. 2. Review of the facility's Falls Report revealed from 02/18/2022 through 02/15/2023 there had been thirty-five (35) witnessed falls with injury, and twenty-four (24) unwitnessed falls with injury The facility failed to ensure a system was in place to ensure adequate supervision and monitoring to prevent accidents/falls for multiple residents. a) Record review revealed the facility admitted Resident #138, on 04/08/2022. The facility assessed the resident to require the assistance for ambulation and the resident used a wheelchair and a walker. The facility assessed the resident as a high-risk falls risk. Resident #138 had eleven (11) falls from 04/09/2022 to 05/14/2022. On 04/30/2022, staff found Resident #138 face down on the floor. The resident had a large, jagged laceration on his/her forehead above the left eye. Resident #138 received eleven (11) sutures. On 05/01/2022, Resident #138 was found face down on the floor in a puddle of blood in front of his/her wheelchair. From 04/30/2022 to 05/07/2022, Resident #138 had four (4) more falls. On 05/07/2022, Resident #138 was hospitalized due to a fall with injury and diagnosed with bilateral Subdural Hematomas. Review of Hospital records dated 05/07/2022-05/13/2022 revealed diagnoses that included: Multi-focal Bilateral Subdural hematomas and Intraventricular hemorrhage. Resident #138 was placed on Hospice upon discharge. On 05/14/2022, Resident #138 fell from the wheelchair to the floor, with bleeding noted to the previous laceration/sutured area to the left forehead. On 05/22/2022 at 5:44 PM, Resident #138 was found in bed, by facility staff, with no signs of life. b) Record review revealed the facility admitted Resident #96, on 08/06/2021, with diagnoses that included muscle weakness, dementia, and cognitive communication deficit. Further record review revealed Resident #96 sustained two (2) falls between 11/08/2022 and 02/11/2023. Review of the Risk Management Note, dated 02/11/2023, revealed at approximately 10:48 PM, the resident was found lying on the floor. Review of the radiology report, dated 02/12/2023, revealed the resident had a left trochanter hip fracture. c) Record review revealed the facility admitted Resident #5 on 05/10/2021 with diagnoses of Unspecified Dementia, Psychotic Disturbance, and Anxiety. Record review revealed Resident #5 had sixteen (16) falls in the past twelve (12) months. Resident #5 had a fall on 01/11/2023. Review of the Computerized Tomography dated 01/11/2023 at 10:44 PM revealed the resident had a nasal fracture and scalp laceration of the forehead. d) The facility admitted Resident #73, on 01/16/2023 with diagnoses Alzheimer's Disease late onset, Muscle Weakness, Dysphagia, difficulty walking and Cognitive Communication Deficit. Record review revealed Resident #73 had experienced two falls from 01/16/2023 to 02/24/2023. Resident #73 fell while walking with walker which resulted in chipping both front teeth and a lip laceration. e) The facility admitted Resident #821, on 12/21/2022, with diagnoses of Dementia with mood disturbance, Urinary Retention with a catheter and history of anticoagulants and anxiety. Record review revealed the facility assessed the resident with a BIMS' score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of the Risk Management report for Resident #821, dated 03/03/2023, revealed a fall from the bed. The nurse noted bruises from the previous falls. The resident complained of shoulder pain, with no evidence of any testing ordered. Record review revealed Resident #821 experienced six (6) falls in one (1) month. (f). Resident #131 sustained multiple falls from 04/21/2022 through 05/30/2022. On 05/30/2022, Resident #131 sustained a fall that resulted in a Sub-[NAME] Hematoma (collection of blood within the brain) with brain compression, and a midline shift (brain is pushed off center). (g). Review of Resident #134's Progress Note, dated 05/05/2022 at 7:21 AM, revealed the resident became combative with staff and he/she fell and hit his/her face on the bedframe. The nurse assessed the resident, who had complaints of pain and swelling to the left cheekbone below his/her eye and a laceration. Emergency Medical Services (EMS) was called to transport the resident to the emergency room (ER). (h). Resident #80 fell on [DATE] and sustained a laceration approximately four (4) centimeter (cm) to his/her lateral right eyebrow. The resident was sent to the ER and returned on 01/07/2023 with sutures to the lacerated area. Resident #80 sustained a fall again on 02/02/2023 at 2:00 AM, and per x-ray was noted to have a fracture of his/her right femur and was sent to the hospital for hip repair. (i). Review of Resident #97's Progress Notes revealed the resident sustained a fall on 07/20/2022 and was found lying on the floor. Further review revealed Resident #97 forgot to lock the brakes on his/her wheelchair. Review of the Progress Notes revealed on 07/25/2022, Resident #97 was found lying on the floor and was observed to have an abrasion to his/her hip. Review of the Progress Note dated 10/21/2022, revealed Resident #97 was found lying on the floor, and had attempted to self-transfer with regular socks on. Review of the Progress Note, dated 11/04/2022, revealed Resident #97 was found lying on the floor next to the toilet and reported to staff he/she attempted to go to the bathroom. Further review of the Progress Notes revealed on 01/17/2023, Resident #97 was found lying on the floor. Continued review of the Progress Notes revealed on 01/26/2023, Resident #97 was found lying on the floor. (j). Review of Resident #106's Fall investigation, dated 01/14/2023 revealed at he/she was asleep in his/her wheelchair (W/C) in the common area and fell from the W/C. The fall was witnessed by staff who was unable to stop the fall. (k). Resident #371 was admitted for rehabilitation services after frequent falls related to Lewy Body dementia. During the fifty (50) days Resident #371 was in the facility, he/she fell at least seven (7) times, with three (3) of those resulting in head lacerations requiring staples, sutures or surgical glue. (l). Review of the Facility's Self-Reported incident revealed Resident #61 had fallen out of bed on 11/07/2021, and the nurse did not complete an assessment or report the incident. Continued review of the clinical record revealed he/she had forty-three (43) documented falls from 06/12/2021 to 02/03/2023, and one fall on 11/07/2021, that was not documented, for a total of forty-four (44) falls. (m). Record review revealed Resident #128 sustained five (5) falls between 02/06/2022 and 07/18/2022. On 07/17/2022 Resident #128 sustained a fall resulting in a laceration to the back left side of the head and was sent to the hospital and returned. Then on 07/18/2022 the resident sustained another fall resulting in a laceration to the right side of the head, a fracture to the frontal sinuses that went through the cranial vault (skull fracture), was sent to the hospital and did not return to the facility. Resident #128 passed away at the hospital on 07/25/2022. (n). Record review revealed Resident #74 sustained a total of eight (8) falls between 12/29/2022 and 02/21/2023. On 12/29/2022 the resident was noted to have a large hematoma on the right side of the forehead. Interview, on 02/15/2023 at 2:36 PM, with Family Member (FM) #1, revealed Resident #114 had called on a Saturday night at about 11:45 PM and said his/her roommate, Resident #96, had fallen. FM #1 could hear Resident #96 yelling in pain. The facility had given residents a teeny tiny bell to ring. Continued interview revealed the call light response time was extremely slow. FM #1 stated that showed the facility was overwhelmed with understaffing. She further stated Resident #114 called another night to ask her to call the facility and ask them to come change Resident #114 since he/she had been ringing the bell for one (1) hour and five (5) minutes. FM #1 was not sure which day it was or who was working. Additional interview revealed FM #1 had visited four (4) days a week for the past six (6) weeks, and it looked to her like the facility did not have enough staff. Interview with CNA #51, on 03/09/2023 at 10:40 AM, revealed the facility was very short staffed, stating there was not enough staff to care for the residents, that they started the shift short. Sometimes people would leave in the middle of a shift so the facility would become even more short. She stated they could not keep up with all the residents' needs to prevent them from getting up and falling or from pressure wounds worsening, and/or from wandering into other residents' rooms. She stated there were just not enough staff to get appropriate care completed in a shift. Interview with RN #1, on 02/27/2023 at 1:35 PM, revealed she was the Unit Manager (UM) for both facility's memory care units. She did not think there was enough staff for both memory care units because residents on that unit were high fall risks and there were frequent falls 3. The facility failed to provide adequate supervision to ensure Resident #80 was protected from abuse by Resident #48, on 12/16/2022. Resident #48, who had a history of physical and verbal abuse towards other residents, punched Resident #80 in the face, causing the resident to fall. Review of Resident #80's hospital record, dated 12/17/2023, revealed the resident was admitted and required a surgical procedure for a right hip replacement. Additionally, thrity-one (31) other resident to resident abuse deficiencies were cited related to decreased supervision for residents assessed to exhibit behaviors causing an unsafe enviorment for residents. (Refer to F600) (a). Record review revealed on 12/16/2022, at 6:43 PM Resident #48, hit Resident #80 in the face causing him/her to fall to the floor. X-ray results revealed Resident #80 had sustained a fractured right hip, which required Resident #80 to have a surgical intervention to repair the fractured hip. (b). Record review revealed on 11/16/2021, Resident #81 touched Resident #80 resulting in Resident #80 reaching out and making contact with Resident #81's facial area. (c). Per the record on 11/22/2021, Resident #47 and Resident #80 were found on a bed together. Resident #80 was lying on his/her back with his/her knees bent and did not have clothes on from the waist down. Resident #47 was observed fully clothed, on his/her knees at the foot of the bed, with his/her face in Resident #80's crotch area. (d). Record review revealed on 12/02/2021, Resident #81 struck Resident #35 and then struck Resident #47. (e). Review of the record revealed on 04/24/2022, Resident #138 hit Resident #102 on the arm three (3) times. (f). Record review revealed on 04/27/2022, Resident #131 pushed resident #86 onto the bed and placed one (1) hand on Resident #86's blouse and the other hand around Resident #86's throat. (g). Review of the Incident Report revealed on 07/02/2022, Resident #80 slapped Resident #76 and then slapped Resident #132 in the face. (h). Record review revealed on 07/04/2022, Resident #91 got up and brushed the back of Resident #92. Resident #92 grabbed Resident #91 by the shoulder and punched him/her in the chest. (i). Record review revealed on 10/12/2022, Resident #144 slapped Resident #67 and then later slapped Resident #74 on the left side the face. (j). Review of the Incident Report, revealed on 12/27/2022, Resident #92 hit Resident #88 in the mouth. (k). Record review revealed on 02/25/2023, Resident #74 hit Resident #57 on the right forearm. (l). Review of the Incident Report dated 04/06/2022, revealed Resident #132 struck Resident #101 with a right open hand on the left side of the face. (m). Review of the Incident Report dated, 05/05/2022, revealed Resident #89 made contact to the left side of Resident #59's cheek with an open hand. (n). Review of the Incident Report, revealed on 05/08/2022, Resident #89 made contact to Resident #59's face three times with a closed fist. (o). Review of the record revealed, on 08/08/2022, Resident #59 slapped Resident #140 with an open hand to prevent her/him from taking the water cup which resulted in a scratch approximately two (2) inches long. (p). Per the Incident Report dated, 12/23/2022, Resident #110 became upset because Resident #140 had his/her belongings and hit Resident #140 on the forehead. (q). Review of the Incident Report and facility investigation revealed on 06/19/2022, Resident #35 attempted to take Resident #101's bag. Resident #35 hit Resident #101 with an open hand on the right side of her/his check. Resident #101 returned the hit making Resident #35 stumble and fall. Resident #35 suffered a small contusion to the bridge of the nose and was sent to the ER for evaluation and treatment. (r). Review of the Incident Report dated, 10/16/2022, revealed Resident #144 walked up to Resident #67 and made physical contact with the left side of Resident #67's face, and while staff was separating Resident #67 from Resident #144, Resident #144 then turned and made physical contact with Resident #74's left side of the face causing a mark. (s). Record review revealed on 02/25/2023 Resident #74 bit Resident #57 on the right forearm causing a discolored area (bruise). (t). Review of the Incident Report dated 10/11/2022, revealed Resident #36 started to yell at Resident #69 which initiated a verbal altercation. Resident #69, with his/her fist clinched, approached Resident #36 and kicked him/her. (u). Review of the incident Report revealed on 10/10/2022 Resident #56 talked to and pointed a finger in the face of Resident #69's then stepped on the resident's toes. Resident #69 pushed Resident #56 back hard enough for the resident to fall to the ground. (v). Record review revealed, on 11/30/2022 Resident #112 used his/her walker to hit Resident #17. Resident #112 then proceeded to hit Resident #17 in the shoulder. Resident #17 then hit #112 back. (w). Record review revealed on 03/08/2022 Resident #17 attempted to enter Resident #93's room and was stopped by the previous DON. Then Resident #17 walked up to Resident #93, who was standing in front of the common area television and grabbed Resident #93 by the back of the jacket and moved the resident out of the way. (x). Record review revealed, on 03/12/2022, Resident #19 leaned forward in the wheelchair and struck Resident #49 on the left side of his/her face with an open palm. Interview with CNA #21, on 03/06/2023 at 3:45 PM, revealed when she worked on the [NAME] Unit, she was the only aide for fifteen (15) residents. She stated she had to stop her medication pass to separate residents when they were arguing. She stated that situation was not safe for the residents or her. She stated she was all alone on the [NAME] Unit and nowhere in the facility should one (1) staff be assigned to fifteen (15) residents by themselves. Interview with CNA #7, on 03/13/2023 at 2:00 PM, revealed there was usually only one (1) aide on each of the Memory Care Units (MCUs) and a Certified Medication Technician (CMT). The other CMTs did not help in any way, with aide work, and she was often not able to take breaks, because they did not have any relief. CNA #7 stated not having enough aides scheduled to work was very dangerous for the residents and did not provide them with the care they needed and deserved. Interview with CNA #33, on 03/13/2023 at 9:45 AM, revealed the facility had staffing issues for some time. She stated it would be her and one other aide working to care for the residents. She stated she worked when there was critical staffing shortages in the building and management staff would just sit in their office and not come and help. Interview with Licensed Practical Nurse (LPN) #19, on 03/09/2023 at 10:30 AM, revealed she worked two (2) days a week and there was not sufficient staff to provide resident care during her shifts. Interview with the Human Resources (HR) person responsible for staff scheduling, on 03/02/2023 at 2:52 PM, revealed she made out the schedule based on the number of residents on the units. Interview with the Interim Director of Nursing (IDON), on 03/08/2023 at 1:15 PM, revealed the interdisciplinary team met daily to review resident care needs. The IDON stated there was also weekly meetings to discuss resident care issues, in addition to monthly quality assurance meetings. She stated the team had not identified issues with staffing. The IDON stated the facility used a tool to determine staffing needs. She stated the number of residents in the facility was used in the tool and that number provided them with how many hours they needed to dedicate care to each resident. The DON stated if staffing needed to be increased management could assist. Interview with the Executive Director (ED), on 03/08/2023 at 1:15 PM, revealed the facility had reviewed the facility assessment in January and did not determine revision was needed. She stated they had a staffing tool they used, in which the number of residents in the building could be put into determine how many staff were needed to provide care. Also, many of the facility's leadership staff had CNA certification and could come into work if there were call-ins or could work on the unit providing resident care even though they had other jobs to do. Interview with [NAME] President of Operations (VPO), on 03/16/2023 at 11:48 AM, revealed the facility assessment was a tool that had the facility staffing numbers and the facility's leadership was responsible for determining resident needs. The VPO stated leadership looked at the condition of the residents and the changes that could occur to determine acuity. The facility assessment which indicated twelve (12) licensed nurses, twenty-one (21) CNAs, and seven (7) nurse managers were needed per day, was a guideline. Typically nurse managers and nursing administration would assist if needed. He stated the facility had budgets and guidelines and leadership should have adjusted staffing according to needs. He stated he was not aware of any signification resident issues but was aware of problems with resident falls and abuse. He stated he would have adjusted staffing if there were significant issues. He stated it was a challenge to resolve the staffing challenge, and the facility was doing their best to staff to meet residents' needs. <b [TRUNCATED]

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents were protected from physical abuse, including resident to resident abuse, for thirty (30) of ninety-four (94) sampled residents (Residents #17, #19, #35, #36, #47, #48, #49, #56, #57, #59, #67, #69, #74, #76, #80, #81, #86, #88, #89, #91, #92, #93, #102, #110, #112, #131, #132, #138, #140, and #144) Resident #80 suffered significant injury as a result of abuse. The facility failed to provide adequate supervision to ensure Resident #80 was protected from abuse by Resident #48 on [DATE]. Resident #48, who had a history of physical and verbal abuse towards other residents' Resident #48 punched Resident #80, in the face, on [DATE] at 6:43 PM, causing Resident #80 to fall. Resident #80 was tearful upon assessment stating his/her hip was hurting. There was no documented evidence the facility performed a thorough assessment of Resident #80. Even though the Nurse Practitioner gave an order for an x-ray on [DATE] at 7:42 PM, the facility failed to obtain an x-ray until over twelve (12) hours later. Resident #80 was admitted to the hospital on [DATE] for a fracture to the right femoral neck with lateral displacement requiring surgery. (a). On [DATE], at 6:43 PM, Resident #48 hit Resident #80 in the face causing him/her to fall to the floor. However, an x-ray was not obtained until [DATE] at 8:06 AM. The x-ray results revealed Resident #80 had sustained a fractured right hip, which required surgical intervention to repair the fractured hip. (b). On [DATE], Resident #81 made contact with Resident #80's area, resulting in Resident #80 reaching out and making contact with Resident #81's facial area. (c). On [DATE], Resident #47 and Resident #80 were found on a bed together. Resident #80 was lying on his/her back with his/her knees bent and did not have clothes on from the waist down. Resident #47 was observed fully clothed, on his/her knees at the foot of the bed, with his/her face in Resident #80's crotch area. (d). On [DATE], Resident #81 struck Resident #35 and Resident #47. (e). On [DATE], Resident #138 hit Resident #102 on the arm three (3) times. (f). On [DATE], Resident #131 pushed Resident #86 onto the bed and placed one hand on Resident #86's blouse and the other hand around Resident #86's throat. (g). On [DATE], Resident #80 slapped Resident #76 and Resident #132 in the face. (h). On [DATE], Resident #91 got up and brushed the back of Resident #92. Resident #92 grabbed Resident #91 by the shoulder and punched him/her in the chest. (i). On [DATE], Resident #144 slapped Resident #67 and Resident # 74 on the left side of the face. (j). On [DATE], Resident #92 hit Resident #88 in the mouth. (k). On [DATE], Resident #74 hit Resident #57 on the right forearm. (l). On [DATE], Resident #132 struck Resident #101 with a right open hand on the left side of the face. (m). On [DATE], Resident #89 made contact to the left side of Resident #59's cheek with an open hand. (n). On [DATE], Resident #89 made contact to Resident #59's face three (3) times with a closed fist (o). On [DATE], Resident #59 slapped Resident #140 with an open hand to prevent her/him from taking the water cup which resulted in an approximately two (2) inch scratch. (p). On [DATE], Resident #110 became upset because Resident #140 had his/her belongings and hit Resident #140 on the forehead. (q). On [DATE], Resident #35 attempted to take Resident #101's bag. Resident #35 hit Resident #101 with an open hand on the right side of his/her check. Resident #101 returned the hit making Resident #35 stumble and fall. Resident #35 suffered a small contusion to the bridge of the nose and was sent to the emergency room for evaluation and treatment. (r). On [DATE], Resident #144 walked up to Resident # 67 and made physical contact with the left side of Resident #67's face, and while staff were attending to and separating Resident #67 from Resident #144, Resident #144 then turned and made physical contact with Resident #74's left side of the face causing a mark. (s). On [DATE], Resident #74 bit Resident # 57 on the right forearm causing a discolored area (bruise). (t). On [DATE], Resident #36 started to yell at Resident #69 and the two (2) started a verbal altercation. Resident #69 left the room, with his/her fist clinched and approached Resident #36, at which time Resident #69 kicked Resident #36. (u). On [DATE], Resident #56 got in Resident #69's face and talked, pointed, and stepped on the resident's toes. Resident #69 pushed Resident #56 back, hard enough the resident fell to the ground and landed on his/her bottom. (v). On [DATE], Resident #112 ambulated through the common area with his/her walker and used the walker to hit Resident #17. Resident #112 then proceeded to hit Resident #17 in the shoulder. Resident #17 then hit #112 back. (w). On [DATE], Resident #17 and Resident #93 had a physical altercation. First Resident #17 attempted to enter #93's room and was stopped by the previous DON. Then Resident #17 walked up to Resident #93, who was standing in front of the common area television. Resident #17 was upset about that, so he/she grabbed Resident #93 by the back of the jacket and moved the resident out of the way. (x). On [DATE], Resident #19 leaned forward in the wheelchair and struck Resident #49 on the left side of his/her face with an open palm. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at the highest S/S of a J, and 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on [DATE] and is ongoing. SQC was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect Policy, dated [DATE], revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy defined willful, as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's staff would conduct an investigation of any alleged or suspected abuse, neglect, exploitation of residents or misappropriation of property, and would provide notification of information to the proper authorities according to state and federal regulations. Prevention of abuse included staffing levels assessed on a continuing basis. Adjustments to staffing levels were to be based on the census and the individual needs of the residents. 1). Review of Resident #48's Admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included Dementia, Anxiety, Schizoaffective Disorder Bipolar type, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #48 with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), which indicated the resident was severely cognitively impaired. Further review revealed Resident #48 exhibited verbal and physical behaviors towards others including hitting, kicking, pushing, scratching, grabbing, screaming at others, or cursing and wandering. Review of Resident #48's Comprehensive Care Plan (CCP), initiated on [DATE], revealed the resident had been care planned for a Focus of Altered Psychosocial Needs related to schizoaffective disorder, dementia with behavior disturbance, anxiety, and adjustment disorder with depression and history of physical aggression toward staff. The goals included that the resident would be free from psychosocial instability. Interventions included arrange for psych consult as needed, and follow up as indicated, medications as ordered, provide non-pharmacological interventions such as redirect with activities, offer food, fluids, and reassurance and conversation; allow time to comprehend and accept task to be completed by staff initiated on [DATE]; one to one (1:1) staff observation initiated on [DATE]. Review of Resident #48's Nurse Practitioner note, dated [DATE], revealed 1:1 supervision was discontinued due to no further behaviors noted and was considered an isolated incident. Record review revealed Resident #48 had a history of physical and verbal altercations and the resident had been placed on 1:1 supervision, on [DATE] -[DATE]. Review of Resident #48's Progress Note, dated [DATE] at 6:49 PM, revealed Resident #48 had been placed on one on one (1:1) supervision, due to physical contact against another resident. Both residents were separated and 1:1 was initiated. Resident #48 had punched Resident #80 in the face. Review of the Facility Investigation/Initial Report, dated [DATE], revealed CNA #22 reported to LPN #3 that Resident #48 punched Resident #80 in the face and he/she fell to the right side and complained of pain. Review of the Social Service Progress Note, dated [DATE] at 4:15 PM, revealed Resident #48 showed signs of frustration and agitation. Resident #48 was difficult to redirect. Continued review revealed an order was received to send Resident #48 to a Behavioral Health facility for an evaluation and Resident #48 was admitted . Review of Resident #80's CCP, initiated on [DATE], revealed the resident had been care planned for Altered Psychosocial Needs related to Dementia and Anxiety, with a goal to maintain the highest level of independence with safety. Continued review revealed interventions included: administer medications as ordered; monitor for behaviors every shift and document; monitor for side effects of psychotropic medications as ordered; and arrange for psych consult, as needed. Interview, on [DATE] at 2:05 PM, with the Director of Nursing (DON), revealed Resident #48 had been placed on one on one (1:1) monitoring after the incident with Resident #80. She stated, generally residents were put on 1:1 supervision after aggressive incidents. The DON stated she expected residents to be watched and staff to follow the facility's policy related to abuse. Interview, on [DATE] at 1:14 PM with CNA #22, who witnessed the incident, revealed Resident #80 called Resident #48 a name and Resident #48 stood up and punched Resident #80 in the face. She stated Resident #80 fell to the floor on his/her right side. CNA #22 stated she separated Resident #80 and Resident #48 and notified LPN#3. Interview, on [DATE] at 3:45 PM with CNA #9, revealed Resident #80 was walking around the couch and talking in the common area. Resident #80 was overheard calling Resident #48 a bitch. Resident #48 stood up and punched Resident #80 in the face causing Resident #80 to fall. Continued interview with CNA #9 revealed, she and CNA#22 separated Resident #80 and Resident #48 immediately and notified the nurse. CNA #9 stated the incident happened so fast, they could not get there fast enough to separate the residents before Resident #48 hit Resident #80 causing him/her to fall and hit the floor. Interview, on [DATE] at 2:36 PM with LPN #3, revealed she did not witness the incident between Resident #80 and Resident #48, but had been notified by a CNA. LPN #3 stated she assessed Resident #80 after the incident occurred. LPN #3 stated Resident #80 was tearful and stated he/she was hurt. Resident #80 and Resident #48 were separated, and staff initiated enhanced supervision for Resident #48 after the incident occurred. 2. Review of Resident #80's Admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included Dementia, Cognitive Communication Disorder, Insomnia, Muscle weakness, and Osteoarthritis. Review of Resident #80's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #80 with a BIMS' score of four (4) out of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #80's CCP, initiated on [DATE], revealed the resident had been care planned for Altered Psychosocial Needs related to Dementia and Anxiety, with a goal to maintain the highest level of independence with safety. Continued review revealed interventions that included: administer medications as ordered; monitor for behaviors every shift and document; monitor for side effects of psychotropic medications as ordered; arrange for psych consult, as needed. Further review revealed a Focus of Sexual Behaviors that included: self-pleasure; intimate touching; and expression of sexual interest in others, initiated on [DATE] with goals to include: the resident would not engage in inappropriate sexual behaviors, with an intervention to provide privacy to masturbate. Additional review revealed a Focus of has a history of seeking companionship with other residents, with a goal to include resident would refrain from seeking out companionship with other residents. Interventions included allow resident to express feelings of sexual desires as needed. Review of the facility's Investigation Report, dated [DATE], revealed Resident #80 and Resident #47 were found on a bed together. Resident #80 was lying on his/her back with his/her knees bent and he/she did not have clothes on from the waist down. Continued review revealed Resident #47 was observed fully clothed, on his/her knees, at the foot of the bed, with his/her face in Resident #80's crotch area. Further review revealed Certified Nurse Assistant (CNA) #37 reported Resident #80 was lying in bed with no pants on, with his/her knees bent, and Resident #47 was at the foot of the bed leaning up with his/her head between Resident #80's legs. CNA #37 separated Resident #80 and Resident #47 and notified the nurse. Additional review revealed CNA #37 stated she did not see any specific sexual activities. Review of Resident #80's Social Service Progress Note, dated [DATE] at 10:39 AM, entered by the former Social Service Director (SSD) revealed Resident #80 stated, (Resident #47) helps me out a lot. Last night (Resident #47) helped me change my pajamas. Review of Resident #47's Admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included Alzheimer's Disease, Dementia, and Major Depressive Disorder. Review of Resident #47's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #47 with a BIMS' score of three (3) out of fifteen (15), which indicated the resident was severely cognitively impaired. Continued review revealed Resident #47 had not exhibited verbal and physical behaviors towards others including hitting, kicking, pushing, scratching, grabbing, screaming at others, or cursing and wandering. Review of Resident #47's CCP, initiated on [DATE], revealed the facility care planned the resident for Sexual Behaviors that included self-pleasure, intimate touching, and sexual expressive behaviors with other residents, with a goal to include the resident would not engage in inappropriate sexual behaviors. Continued review revealed interventions that included provide privacy to masturbate, allow to vent feelings about sexual desires as needed, contact state guardian if resident exhibits any inappropriate sexual behaviors, refer to psych as needed, resident to sleep with a body pillow, staff will continue to redirect resident as needed. Review of Resident #47's Social Service Progress Note, dated [DATE] at 12:21 PM, revealed Resident #47 had been asked about his/her sexual preferences. Resident #47 stated I like men and women, always have. When asked about the resident (Resident #80) he/she was reported to have been expressing sexual behaviors towards, Resident #47 stated, I always help (him/her) out. I helped (him/her) last night. Whatever (he/she) needed help with. I love (him/her). Interview, on [DATE] at 10:07 PM with CNA #37, revealed Resident #80 had a habit of taking his/her clothes off. Per interview, Resident #80 and Resident #47 had been observed in the room together. CNA #37 stated Resident #47 appeared to be between Resident #80's legs. Resident #80 did not have on bottom clothes. Further interview revealed Resident #80 was removed from the situation, and taken to his/her bed, and the nurse was notified. Interview, on [DATE] at 2:38 PM, with the Former Director of Nursing (DON), revealed CNA #37 had notified her of an incident involving Resident #80 and Resident #47. The DON stated CNA #37 reported that Resident #80 and Resident #47 had been observed in bed together, but she could not confirm they were touching each other. Interview revealed Resident #80 and Resident #47 were separated and an investigation was conducted. The former DON stated Resident #80 and Resident #47 were always together and helped each other do things such as get the other one's clothes. 3). Review of the Facility Investigation/Initial Report, dated [DATE], revealed Resident #80 had been observed by staff to make contact to the right side of Resident #132's face with an open hand. Continued review revealed, as staff approached to intervene, Resident #80 made contact to the right side of Resident #76's face with an open hand. Review of Resident #76's Admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included Alzheimer's Disease, Dementia with Behavior Disturbances, Major Depressive Disorder, and Muscle weakness. Review of Resident #76's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #76 with a BIMS score of three (3) of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #76's SSD Note, dated [DATE] at 6:01 PM, revealed Resident #76 had been involved in a physically aggressive incident with Resident #80. Review of Resident #132's Admission Record revealed the facility admitted the resident, on [DATE], with diagnoses that included Dementia, Unknown Psychosis not due to a substance or known Physiological Condition, and Cognitive Communication Deficit. Review of Resident #132's MDS Assessment, dated [DATE], revealed the facility assessed Resident #132 with a BIMS score of ninety-nine (99) which indicated the resident was severely cognitively impaired. Review of Resident #132's SSD Note, dated [DATE] at 5:57 PM, entered by SSD, revealed Resident #132 had been involved in a physically aggressive incident received by Resident #80. Interview, on [DATE] at 11:38 AM with CNA #9, revealed Resident #80 was beside Resident #132 and smacked him/her in the face. Continued interview revealed Resident #80 was moved away from Resident #132 and seated next to Resident #76. Resident #80 immediately smacked Resident #76 in the face. CNA #9 further stated, she had another staff member stay with the residents while she went to get the nurse. 4). Review of Resident #81's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included Altered Mental Status and Bipolar Disorder, and Acute Kidney Failure. A diagnosis of Cognitive Communication Deficit was added on [DATE]. Review of Resident #81's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of eleven (11) of fifteen (15), indicating moderate cognitive impairment. Continued review revealed Resident #81 was noted to have rejection of care one (1) to three (3) days during the seven-day look back period. Review of the Facility Investigation, dated [DATE], revealed Resident #81 made contact with Resident #80's area resulting in Resident #80 reaching out and making contact with Resident #81's face. Continued review revealed there were no witness statements to determine who was present or what occurred. The SSA requested additional information regarding the investigation from the Executive Director (ED) on [DATE], and again on [DATE], but the information was never received. Review of the Facility Investigation, dated [DATE], revealed Resident #81 was observed by a nurse striking Resident #35 on the back. LPN #11 intervened, separating the residents, and placing Resident #81 beside the med cart where LPN #11 was working. Continued review revealed Resident #47 walked towards the med cart, and before LPN #11 could intervene, Resident #81 stood up and struck Resident #47. Continued review revealed no injuries. Resident #81 was sent to the ER and treated for a Urinary Tract Infection (UTI). Interview with Resident #81, on [DATE] at 3:27 PM, revealed Resident #81 did not have any recollection of any altercations with other residents. Resident #81 stated another resident liked to swat at people, but stated that resident had died , and he/she had never been injured. Interview, on [DATE] at 9:23 AM, with the current Social Services Director (SSD), revealed since she had been at the facility ([DATE]) there had not been any resident-to-resident altercations involving Resident #81. She stated it was a surprise to her when she reviewed Resident #81's care plan regarding resident conflicts and behaviors as she had not observed those since she has been employed by the facility. Interview, on [DATE] at 1:48 PM, with the former SSD, revealed Resident #81 used to be located on a memory care unit. She stated her recollection of specific incidents from so long ago was limited, but she described Resident #81 as intrusive into other resident's personal space, describing Resident #81 as going up to others and patting them on the cheek as a way of showing love, which other residents did not always react well to. She further stated, other residents may have reacted to Resident #81's intrusiveness as a threat and just reacted. Continued interview revealed there were a lot of one-on-one (1:1)'s (supervision) on the unit, as a lot of residents had escalated behaviors, which she felt helped with residents requiring supervision. Interview, on [DATE] at 1:24 PM, with (former) LPN #11, revealed limited recollection of incidents involving Resident #81. She stated she did recall Resident #81 hitting Resident #35 on [DATE]. The LPN stated Resident #35 was not injured, but was upset at that moment. LPN #11 further stated, Resident #81 would have behaviors, acting out and being bossy towards other residents at times, although physical aggression was rare. Interview with the ED, on [DATE] at 2:40 PM, revealed she was not working at the facility at the time of the reported incidents involving Resident #81, and there had been a lot of changeovers of staff. The ED expressed frustration at not being able to find investigations for incidents. The ED stated her expectation was that residents should be protected from abuse, and the facility should respond to any allegation quickly and investigate them thoroughly. She further stated, a thorough investigation included witness statements, and interviews with both residents and staff, so that anyone reviewing would know what happened, who was involved, and how the facility responded. 5). Review of Resident #92's Admission Record revealed the facility admitted the resident, on [DATE], with diagnoses that included Alzheimer's Disease, Cognitive Communication Deficit, Agitation and Anxiety Disorder. Review of Resident #92's Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of six (6) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #88's Admission Record revealed the facility admitted the resident, on [DATE], with diagnoses that included Cognitive Communication Deficit, Dementia and Anxiety. Review of Resident #88's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of three (3) out of fifteen indicating the resident was severely cognitively impaired. Review of the facility's investigation, for [DATE], revealed Resident #88 was sitting in the common area on the sofa and Resident #92 hit Resident #88 in the mouth. The two (2) residents were separated immediately, and the Director of Nursing (DON) was contacted. Resident #88 was assessed and had no injuries. Interview with CNA #6, on [DATE] at 4:49 PM, revealed Resident #92 hit Resident #88, who was sitting down, in the face for no reason. Per interview, she separated the residents and notified the Director of Nursing (DON) and Administrator, who both came to the unit. Interview with Social Services #2 on [DATE] at 8:50 AM, revealed Resident #92 had been hallucinating and thought someone had stolen his/her clothes. She stated Resident #92 thought (he/she) was in (his/her) twenty's and was in a bar fight. Social Services #2 stated she provided information for behavioral health referral for Resident #92 and notified the resident's Partner. Continued interview revealed Social Service #1 followed up with Resident #88 the next day and showed no apparent distress. 6). Review of Resident #91's Admission Record revealed the facility admitted the resident, on [DATE] with diagnoses to include Dementia with Behavioral Disturbance, and Mood Disorder. Review of Resident #91's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of five (5) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of the Progress Note, dated [DATE] at 3:33 PM, entered by LPN #12, revealed staff had witnessed a resident-to-resident altercation between Resident #91 and Resident #92. Resident #92 was identified as the aggressor. Continued review revealed the residents were separated and placed on 1:1 supervision. Resident #91 was assessed with no injuries noted at the time of the incident. Review of the Facility Investigation dated [DATE], revealed a Resident-to-Resident abuse had occurred between Resident #92 and Resident #91. Both residents were seated in the common area of the unit, when Resident #91 got up and brushed the back of Resident #92. Resident #92 grabbed Resident #91 by the shoulder and punch him/her in the chest. Staff separated the residents and placed Resident #92 on 1:1 supervision. Resident #92 was referred for psychiatric evaluation. Resident #91 was assessed with no injuries. Review of Resident #92's Admission Record revealed the facility admitted the resident, on [DATE], with diagnoses to include Alzheimer's Disease, Cognitive Communication Deficit, Agitation and Anxiety Disorder. Review of Resident #92's Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of six (6) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #92's Progress Note, dated [DATE] at 3:33 PM, entered by Licensed Practical Nurse #12, revealed staff witnessed resident to resident altercation with Resident #92. Resident #92 was separated from other residents and placed on 1:1 supervision. Resident #91 was assessed with no injuries noted at this time. Interview, with Social Services #2, on [DATE] at 02:49 PM, revealed Resident #92 had a history of combination of dementia and domestic violence. Social Services stated she tried to redirect Resident #92 with leaving the office door open to visit to give a sense of purpose as the resident thinks he/she was an employee. Interview, with Interim DON #2, on [DATE] at 1:37 PM, revealed Resident #92 has had agitation and behaviors. Per interview, the resident appeared to have different triggers with each event. Resident #92 had been placed on 1:1 supervision, and staff had been instructed to redirect the resident and make a referral to Psychiatric services for medication adjustment. Interview with ED, on [DATE] at 3:30 PM, revealed Resident #92 had behaviors and would get agitated. Social Services #2 had been working with the resident and offering to talk with his/her partner more often by phone. Per interview, staff were to try to redirect Resident #92. The ED stated, investigations should include the resident's cognitive status and referrals should be made to psychiatric behavioral services. Resident #92 was placed on 1:1 supervision after his/her behaviors and his/her medications had been changed. The ED further stated Resident #92's behaviors possibly were due to the need for medication adjustments periodically. 7). Review of Resident #144's Admission Record, dated [DATE], revealed the facility admitted the resident with diagnoses to include dementia, anxiety disorder and urinary tract infection (UTI). Review of Resident #144's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident with the BIMS' score of two (2) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of the CCP, dated [DATE], revealed Resident #144 had a focus for the safety of residing on a secured unit with dementia. The goal was to maintain safety while residing there. Interventions placed on [DATE] were to re-direct as needed. Review of the CCP revealed Resident #144 had a urinary tract infection (UTI) and interventions placed on [DATE], was to monitor for altered mental status and behavioral changes. Review of the Facility's Investigation Report, dated [DATE], revealed Resident #144 had walked up to Resident #67 and made physical contact with the left side of Resident #67's face, with no injury noted. Continued review revealed staff immediately intervened and separated Residents #144 and #67. While attending to and separating Resident #67 from Resident #144, he/she turned and made physical contact with Resident #74's left side of the face causing a mark. Resident #144 was immediately placed on one to one (1:1) supervision and transported to local Emergency Department (ED) for psychiatric evaluation. Review of the Facility Investigation revealed a witness statement given by CNA #10, dated [DATE], time not noted, stated Resident #144 slapped the left side of Resident #67's face. Review of the Facility Investigation revealed a witness statement given by CNA # 10, dated [DATE], no time given, stating Resident #144 threw a walker at Resident #74 and slammed the door shut. Review of a written interview, dated [DATE], for Resident #67 and Resident #74 completed by the Director of the Memory Care/Social Worker Assistant # 2 revealed neither resident was able to recall, and both had severe cognitive impairment. Review of the Hospital emergency room note, dated [DATE], revealed the lab and computerized tomography (CT) of the head was unremarkable. Continued review revealed the resident's behavior was consistent with chronic dementia and acting out was due to confusion. Record review revealed Resident #144 had become combative and uncooperative when attempting the CT scan and was treated with 2.5 milligrams of Haldol intramuscular (IM) to obtain the CT of the head. Review of the Discharge Note from the previous Long-Term Care (LTC) Facility, dated [DATE], revealed 1:1 supervision was being provided due to Resident #144's behaviors of wandering, poor safety awareness and not easily directed due to advanced dementia. 8. Review of Resident #74's Admission Record, dated [DATE], revealed the facility admitted the resident with diagnoses to include dementia with agitation and traumatic brain injury. Review of Resident #74's Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident with a BIMS score of zero (0) out of fifteen (15), indicating the resident was s [TRUNCATED]

Based on interview, review of the medical records, and review of the facility's admission packet, it was determined the facility failed to assist residents to formulate an Advanced Directive upon admission for three (3) of ninety-four (94) sampled residents, (Residents #32, #90, and #91). The findings include: Review of the facility's admission packet titled, Resident Handbook and Admission Information not dated, revealed information under Health Care Advance Directives to make your wishes known. The Advance Directive was defined as a document written before a disabling illness. The Advance Directive stated it was a resident's choice about treatment and may name someone to make choices if the resident cannot. With Advance Directives, residents could legally decide about their future medical treatment. 1. Review of the medical record revealed the facility admitted Resident #32 on 10/28/2022 with diagnoses including Alcohol Dependence with Alcohol-Induced Persisting Dementia, Diabetes Mellitus Type 2, Anxiety and Major Depression. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated Resident #32 was severely cognitively impaired. Review of the admission paperwork checklist not dated, revealed there was no check in the area that covered Advance Directive. Interview, with Resident of #32's son, on 02/20/2023 at 5:00 PM, revealed the facility did not speak to him about formulating an Advance Directive. He stated he signed a lot of papers and did not remember anything about formulating an Advanced Directive, or the facility informing him of formulating an Advanced Directive for Resident #32. 2. Record review revealed the facility admitted Resident #90, on 09/14/2022, with diagnoses that included Alzheimer's Disease, Cognitive Communication Deficit, and Anxiety. Review of the Admission MDS, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated Resident #90 was severely cognitively impaired. Continued review of the medical record revealed no documented evidence of an Advance Directive for Resident #90. Interview, with Resident #90's son, on 02/20/2023 at 5:13 PM, revealed he did not remember the facility asking him about formulating an Advance Directive, upon admission. 3. Record review revealed the facility admitted Resident #91, on 05/04/2021 with diagnoses which included Dementia with Behavioral Disturbances, Anxiety, Alcohol Dependence, and Mood Disorder. Review of the Admission MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of six (6) of fifteen (15), which indicated Resident #91 was severely cognitively impaired. Review of the medical record revealed no documented evidence of an Advance Directive or Living Will. Interview, with Resident #91's sister/Power of Attorney (POA), on 02/20/2023 at 5:18 PM, revealed she thought Resident #91 had a Living Will prior to admission on 05/04/2021. She stated she was not aware the facility did not have a copy and she did not remember being asked by the facility about the Living Will or Advance Directive. Interview, with Business Officer Manager, on 02/21/2023 at 12:45 PM, revealed the admission personal liaison was responsible for the admission process to assess the residents for admission to the facility. She stated, she was responsible for the financial and questions concerning financial. Further interview revealed that usually, the POA or guardian supplied the paperwork for Advance Directives and Living Will. She stated she thought it was Social Services' responsibility to address code status and to assist residents and the residents' representatives with Living Wills and Advance Directives. Interview, with Social Services #2, on 02/21/2023 at 1:02 PM, revealed the Admissions Director was responsible for the Advance Directives. Interview, with the Admissions Concierge, on 02/23/2023 at 10:20 AM, revealed she was responsible for meeting with the Power of Attorney (POA) or Resident, (if own self) to go over admission paperwork, sign paperwork and provide them with the handbook. Interview, with Interim Director of Nursing (DON), on 02/21/2023 at 1:26 PM and on 02/23/2023 at 10:22 AM, revealed they followed up with the Advance Directive information. She stated the Admissions or Social Services was responsible for the recorded code status in the medical record. Interview, with the Executive Director, on 02/23/2023 at 10:23 AM, revealed they should follow up with the Advance Directive information and the information should be documented. The ED stated the Advance Directive was more than the code status and they should provide further information related to resident care.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to review and revise care plans for nine (9) of ninety-four (94) sampled residents, (Resident #17, #19, #69, #80, #95, #96, #98, #106, and #371). 1. Resident #96 had history of a fall related to cerebral infarction with residual weakness and motor ability as well as cognitive impairment. On [DATE], Resident #96 attempted to ambulate unassisted and fell , resulting in a fractured hip and surgery. The care plan was not revised to address future fall prevention. 2. Resident #371 was admitted after experiencing frequent falls related to Parkinson's Disease and Lewy Body Dementia. He/she fell on at least seven (7) documented occasions during approximately fifty (50) days of residence in the facility. The resident sustained lacerations from three (3) falls requiring a hospital visit with laceration repair. The care plan was not revised to address one-to-one (1) supervision. 3. Resident #95 went to the hospital after sustaining a cerebral infarction and returned with a pressure wound to the right ischium. The wound was healed, but then recurred within eight (8) days. In addition, more wounds emerged to the resident's sacrum and bilateral heels. The care plan was not revised timely to address wound healing and prevention. 4. Resident #17 had increased psychotic behaviors noted on [DATE], and on [DATE], the resident grabbed Resident #93 by the back of his/her coat and moved him/her out of the way of a television set, with no injuries. The care plan was not revised to address these increased behavior after [DATE] or [DATE]. 5. Resident #69 was involved in two (2) physical altercations on [DATE] (kicked Resident #36) and [DATE] (had physical contact with Resident #56). However, the care plan was not revised with new interventions after the [DATE] incident. 6. Resident #19 sustained a fall with injury on [DATE] with no new interventions added to the care plan. 7. Resident #98 sustained a fall with injury on [DATE] with no new interventions added to the care plan. 8. Resident #80 was assessed to exhibit verbal and physical behaviors toward others, and the resident cursed at another resident on [DATE]. However, there was no documented evidence the resident's care plan had been updated or revised to reflect these behaviors. 9. Resident #106 sustained a fall on [DATE] and had a new intervention identified at that time to be added to the care plan: Dycem (a non-slip material) to the wheelchair. However, this intervention was not added to the care plan until after the resident's [DATE] fall from the wheelchair. The findings include: Review of the facility's policy titled, Comprehensive Care Plan (CCP), dated [DATE], revealed the Minimum Data Set (MDS) Coordinators or designee were responsible to update the residents care plan. Policy review also revealed the CCP would describe the services to be furnished to attain or maintain highest practicable well being, and any services otherwise that would be required but not provided due to the resident's exercise of right to refuse treatment. Additional review revealed the Interdisciplinary Team (IDT) was responsible for review and updating of care plans when there had been a significant change in condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly. Review of the facility's policy titled, Fall Management, updated [DATE], revealed a root cause analysis would be done to determine an intervention based on the root cause to prevent further falls. The intervention was to be implemented immediately after the fall, and the care plan updated with the new intervention. 1. Review of Resident #96's electronic medical record (EMR) revealed the facility initially admitted the resident on [DATE] with most recent readmission on [DATE]. The resident's diagnoses included Age-Related Physical Debility, Muscle Weakness, Cognitive Communication Deficit, and Dementia. The Minimum Data Set (MDS) Significant Change Assessment, dated [DATE], revealed he/she was totally dependent for Activities of Daily Living (ADL) including bed mobility, transfers, and locomotion, requiring assistance from two (2) staff. Further review of the MDS assessment revealed his/her Brief Interview for Mental Status (BIMS) score was ninety-nine (99), unable to be assessed due to severe cognitive impairment. Review of Resident #96's EMR notes revealed the resident had sustained a fall subsequent to an arteriovenous malformation rupture in the cerebellum on [DATE], was hospitalized , and returned to the facility on [DATE] with related changes in mobility. Further review of Resident #96's EMR fall evaluation note, dated [DATE] at 12:28 AM, revealed he/she attempted to get up and stand when he/she fell and landed on his/her side. Per the note, the resident then complained of severe pain in the left hip, but would not allow for a full evaluation of the leg. Further review of the note revealed Resident #96 was at risk for falls due to dementia and loss of balance. The resident was diagnosed with a fractured hip and sent to the hospital for repair of the fracture. Review of the IDT note revealed Resident #96's fall on [DATE] was discussed on [DATE], and the root cause analysis showed Resident #96 was restless and fell out of bed. Further review revealed upon his/her return from the hospital, staff would assist Resident #96 up to the wheelchair when restless and that the care plan was updated. Review of Resident #96's care plan revealed a focus for risk of falls, initiated on [DATE]. Interventions included keep frequently used items within reach; conduct fall risk assessments on admission and at least quarterly; provide/monitor use of assistive devices; refer to therapies as needed; educate and remind resident of safety awareness such as locking brakes on wheelchair, asking for assistance before transferring, and call device use as the resident had history of attempts to self-transfer. Further review of the (CCP) revealed a revision on [DATE] to wear a soft helmet when out of bed, and on [DATE], to wear a soft helmet when out of bed as well as to keep call device within reach. After the [DATE] fall, the interventions added were a high back wheelchair and assist up to the wheelchair when restless. There was no intervention addressing the mobility rail on the bed, bed in low position, or the use of fall mats. Observation, on [DATE] at 2:27 PM, revealed Resident #96's room was at the end of the A hallway and not located close to the nurses' station. In addition, the mobility rail on his/her bed was at the lower end of the bed and flush against the wall. There were no fall mats in place. Resident #96 was resting in bed, and when asked, he/she could not recall or verbalize any recollection of his/her fall with injury. Interview with Certified Nursing Assistant (CNA) #18 on [DATE] at 8:28 PM, revealed she was not familiar with Resident #96's fall but stated the aides knew that for the residents with fall risks, the bed should be in low position with a mobility rail and fall mats. 2. Review of Resident #371's EMR revealed the facility admitted the resident on [DATE] with diagnoses including Parkinson's Disease, Lewy Body Disease with Dementia, Muscle Weakness, and Repeated Falls. Review of Resident # 371's Admission Minimum Data Set (MDS) Assessment, dated [DATE], (for falls) revealed he/she had history of Parkinson's and Dementia. Further review revealed Resident #371 had a history of frequent falls and was at risk for falls related to impaired cognition, unsteady gait, and poor safety awareness. Review also revealed he/she had sustained one non injury fall since readmission. Continued review of the admission MDS assessments revealed while Resident #371 was independent with bed mobility, he/she was totally dependent for transfers, toileting, and hygiene activities of daily living. The assessments also demonstrated unsteadiness with transitions and walking and used a wheelchair for locomotion. Additional review of the Admission MDS Assessment revealed a BIMS score of ninety-nine (99), indicating the resident was unable to participate with staff using the BIMS tool. Review of Resident #371's progress notes in the EMR revealed he/she had sustained multiple falls during his/her admission to the facility. By the day after admission, notes revealed a habit of placing self on hands and knees and crawling about on the floor. Further review revealed, on [DATE], Resident #371 was found on the floor of the room after falling at about 8:25 AM, sustaining a 2.3 centimeter (cm) by 0.3 cm laceration with subcutaneous tissue noted. He/she was transported to the hospital at 9:45 AM, returning that night at 9:05 PM with sutures closing the laceration. Continued review of the progress notes revealed Resident #371 was found on the floor after a fall again, on [DATE] at 6:39 AM, with a bloody laceration measuring 2.0 cm long by 0.1 cm deep, located just above the previous one, and standing blood pressure measuring ,d+[DATE]. Resident #371 was transported to the hospital and admitted for further workup, returning on [DATE]. Additional review of the progress notes revealed Resident #371 was found prone in the floor on elbows and forearms with legs extended the following day, [DATE] at 1:23 AM. He/she was tangled in a gown, anxious and tearful with standing, and his/her blood pressure measured at ,d+[DATE]. Further review revealed progress notes reflected there was supervision on a one-to-one (1:1) basis during the night shift of [DATE] to [DATE] and while the resident was awake on [DATE]. Continued review of the progress notes revealed Resident #371 stood from the wheel chair on [DATE] at approximately 8:10 AM, and fell resulting in a laceration to the right eyebrow and a standing blood pressure of ,d+[DATE]. Resident #371 was transported to the hospital where the laceration was approximated with glue and steri strips, a type of narrow bandage; the resident returned the same afternoon at 4:42 PM. Additional review revealed Resident #371 was found on the floor at 5:00 PM on [DATE] without injury, then slid out of the wheelchair to the floor on [DATE], after having been moved to a room in view of the nurses' station the day before. Further review revealed Resident #371 placed self in floor the morning of [DATE] then rolled self out of bed that afternoon. Additional review revealed he/she slid out of the wheelchair during the dinner meal on [DATE]. There was a note stating one-to-one (1:1) supervision for safety was begun on [DATE]. No further falls were noted throughout the resident's stay in the facility. One-to-one (1:1) supervision was reflected in the progress notes on [DATE], [DATE], [DATE], [DATE], and [DATE]; but, on [DATE], a note revealed one-to-one (1:1) supervision was expected but not in place due to short staffing. The note stated nursing staff made checks every thirty (30) minutes for fall prevention on [DATE]. Final review of the progress notes revealed this was a total of seven (7) falls in thirty (30) days in the facility. Review of Resident #371's CCP, initiated on [DATE], revealed a care plan focus for falls initiated the same date and revised on [DATE], [DATE], and [DATE]. Initial interventions, dated [DATE], included to keep frequently used items within reach, keep the call light in reach, provide and monitor use of assistive devices, and educate/encourage use of the call light, ask for assistance before transfers, and conduct fall risk assessments on admission and at least quarterly. Review further showed added interventions on [DATE] of assisting to crawling position as desired by resident to reduce risk of injury. A low bed with fall mats was added on [DATE], with enhanced supervision added on [DATE] and a pressure alarm in the wheelchair on [DATE]. However, the one-to-one (1:1) supervision that the progress note stated was begun on [DATE] was not in the care plan. In addition, the note stated after the one-to-one (1:1) supervision was added, the resident had no further falls. Interview with the Director of Nursing (DON) on [DATE] at 3:37 PM, revealed enhanced precautions or increased supervision meant, if a staff member was not assisting another resident, then that staff member should be beside the resident and/or they should watch that resident closer. She stated enhanced precautions or supervision was different from every fifteen (15) minute checks or one-to-one (1:1) supervision. The DON stated she would expect the care plan to be updated to reflect the MDS assessment and with any change in condition. Interview with Licensed Practical Nurse (LPN) #9 on [DATE] at 3:30 PM, revealed Resident #371 did fall a lot and hallucinated, which manifested itself when the resident was asleep, opened his/her eyes, got up, and started running, attempting to jump over the chairs. Further interview revealed if staff approached, the resident would swing fists at them. Continued interview revealed interventions were in place, but the LPN did not recall the specifics of when fall mats or one-to-one (1:1) supervision were put in place. Interview with Registered Nurse (RN) #18 on [DATE] at 8:25 PM, revealed Resident #371 had a lot of falls, and his/her condition declined pretty quickly. She stated she could not say for certain but there was a time he/she had one-to-one (1:1) supervision because he/she was always trying to get up and staff could not get to him/her quickly enough to keep him/her from falling. Interview with LPN #31 on [DATE] at 9:10 PM, revealed she only vaguely remembered Resident #371 and little of the resident's specific care but did report trying to keep somebody with him/her, either assigning an aide to sit with the resident, or placing the resident by the nurses' station to try to prevent falls. Continued interview revealed she did remember that Resident #371 had frequent falls, impulsive actions, and he/she became less able to communicate and declined rapidly. Interview with the Executive Director (ED) on [DATE] at 10:41 AM, revealed rounding was key to prevent falls and nurses were expected to update care plans in real time, especially with something like a fall. Further interview revealed for resident with frequent falls, if they fell multiple times in a short time, that would be a flag to add one-to-one (1:1) supervision. 3. Review of Resident #95's EMR revealed the facility admitted the resident, on [DATE], with diagnoses of Encephalopathy, Cerebral Infarction, Type II Diabetes Mellitus, and Dementia. Review of Resident #95's Electronic Medical Record (EMR) progress notes revealed the Stage III pressure wound to the right ischium was identified on [DATE] after readmission from a hospital stay. The resident was referred to a wound specialist care at that time and was seen by the physician on [DATE], who ordered Santyl and Calcium Alginate to treat it. Further review revealed the wound was evaluated as resolved by the wound care physician and he signed off on Resident #95's care on [DATE]. Continued review revealed a change in condition note on [DATE] at 5:03 PM, specifically the Nurse Practitioner (NP) diagnosed a Stage III pressure wound to the coccyx and referred for return to wound care, eight (8) days after prior wound resolution. Still further review revealed a dietary note on [DATE] demonstrating four open pressure areas in total, bilateral heels, sacrum and reopened area to ischium. Review of Resident #95's wound care notes confirmed recurrence of right ischium pressure wound diagnosed on [DATE], as well as new presence of deep tissue injury to bilateral heels, and a stage IV wound to the sacrum. Review of Resident #95's Comprehensive Care Plan revealed Focus for Risk of Skin Impairment, initiated [DATE], with interventions added as of the same date of turn and reposition to maintain skin integrity, pressure reducing mattress, and skin checks weekly. Further review revealed the first interventions added or revised after those at admission, even after the resident returned with a Stage III pressure wound on [DATE], were not documented until [DATE] and included moon boots to bilateral heels, wound MD to evaluate and treat, and turn and reposition to promote healing of current areas, without a frequency specified Continued review revealed the addition of interventions on [DATE] to include turn side to side in bed every one (1) to two (2) hours if able and to offload wounds. Observation of Resident #95 on [DATE] from 1:16 PM to 3:37 PM, revealed, even though CNA #18 entered the resident's room at 3:04 PM, the resident had not gotten up nor was the resident changed during this two (2) hour and twenty-one (21) minute time frame. Interview with CNA #18 on [DATE] at 8:28 PM, revealed staff should be repositioning residents every two (2)hours with pillows to protect skin or prevent contractures, and she only went in the room to weigh the resident with a Hoyer (mechanical) lift, not to reposition. Interview with CNA #15 on [DATE] at 3:20 PM, revealed there were two (2) different ways to know a resident's care needs: walking shift change report or look at the resident's care plan/Kardex. Continued interview revealed repositioning was expected every two (2) hours. Additional interview revealed turning and repositioning was important to protect residents' skin. Interview with CNA #48 on [DATE] at 8:33 PM, revealed she learned care needs with shift report from off going aides and from the Kardex. Further interview revealed check and change was supposed to be every two (2) hours. She stated keeping residents dry was important for hygiene, to be comfortable, and for protecting residents' skin from breakdown. Additional interview revealed Resident #95 should be turned every two (2) hours. Interview with LPN #31 on [DATE] at 9:10 PM, stated wound prevention relied on turning, repositioning, and offloading wounds. Telephone interview with the Wound Care Physician on [DATE] at 4:50 PM, revealed residents needed to be moved every two (2) hours and staff should be changing briefs then, if they were soiled or wet. He stated not doing so would clearly cause skin problems. 4. Review of Resident #17's clinical record revealed the facility admitted the resident on [DATE] with diagnoses of Schizoaffective Disorder and Post Traumatic Seizures. Review of Resident #17's Quarterly MDS Assessment, dated [DATE] revealed the facility assessed the resident with a BIMS score of fourteen (14) of fifteen (15), indicating intact cognition. Further review revealed Resident #17 had an altercation with Resident #93, on [DATE]. Resident #17 pulled Resident #93 by the back of his/her coat and moved him/her from in front of the television in the common room. No injuries were identified. Review of Resident #17's Psychiatric progress note dated [DATE], revealed the resident had increased psychotic symptoms, and he/she would be continued on the same medication, with no new orders recommended. The Psychiatric progress note for [DATE] revealed the resident had improved behaviors; however, on [DATE], after the resident was involved in an altercation with another resident, he/she was initially placed on one to one (1:1) supervision. The Psychiatric Nurse Practitioner (PNP) was informed by staff that the one to one (1:1) supervision only agitated the resident more, so she removed the extra supervision. Review of Resident #17's Comprehensive Care Plan (CCP) dated [DATE], revealed the resident was noted to have the potential for physical aggression towards peers related to anger and poor impulse control, and on [DATE] the care plan added for an intervention that staff was to help the resident to determine what worked to deescalate him/her when he/she became angry. On [DATE], interventions were added for staff to give the resident positive cues and feedback to alleviate anxiety and encourage the resident to seek out staff when he/she was agitated and discuss his/her feelings. However, no new interventions were put in place for the resident's increased psychotic symptoms or his/her [DATE] behaviors. Interview with Certified Nursing Assistant (CNA) #33 on [DATE] at 9:45 AM, revealed the incident on [DATE] might have been prevented if other interventions were tried in February because it was noted the resident had increased behaviors then. She said Resident #93 was very paranoid and talked to the television to his/her deceased nephew who the resident thought was going to come out of the TV. She stated Resident #17 thought Resident #93 was talking about him/her and that upset the resident. She said Resident #17 stood straight up, and he/she was very tall. She said before staff could intervene, Resident had grabbed Resident #93. She recalled Resident #17 stated, I am going to beat your ass. CNA #33 stated one-to-one (1:1) supervision was removed the same day because it increased the resident's agitation. Interview with the Executive Director (ED) on [DATE] at 11:00 AM, revealed care plans should be reviewed and revised in accordance with the facility policy. She stated it was important for them to be revised because interventions that worked before might not necessarily work anymore. However, she stated she was not sure if a new intervention would have made a difference in the incident between Resident #17 and Resident #93 on [DATE], based on the information provided. 5. Review of Resident #69's clinical record revealed the facility admitted the resident on [DATE] with diagnoses of Schizophrenia and Anxiety Disorder. Review of Resident #69's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident with a BIMS score of fourteen (14) of fifteen (15) indicating he/she was cognitively intact. Further review of the assessment, did not reveal the resident had behaviors. Review of Resident #69's Discharge MDS Assessment, dated [DATE], revealed the resident's BIMS was not assessed, and the resident was noted to have physical and verbal behaviors present toward others for one (1) to three (3) days during the review period. Review of the resident's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident with a BIMS score of fourteen (14) of fifteen (15) indicating he/she was cognitively intact. The resident was assessed as delusional and verbally aggressive towards other and had additional behaviors but were not directed towards others for one (1) to three (3) days during the review period. Review of Resident #69's progress notes, revealed he/she was involved in two (2) physical altercations on [DATE] (kicked Resident #36) and [DATE] (had physical contact with Resident #56). However, no new interventions were developed by the facility after the [DATE] incident. Resident #69 was already care planned for staff to anticipate and meet his/her needs, also for staff redirection ([DATE]). Staff were also to remove the resident from the situation that might trigger the resident's behaviors ([DATE]). 6. Review of Resident #19's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Displaced Intertrochanteric Fracture of the Left Femur, Closed Fracture and Abnormal Posture. Review of Resident #19's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident's BIMS assessment was unable to be completed due to the fact that the resident was rarely/never understood and was severely cognitively impaired. Review of Resident #19 Change of Condition note, dated [DATE] at 12:23 AM, revealed the resident had an unwitnessed fall from a wheelchair, was found lying on his/her right side in the common area next to his/her wheelchair with a laceration to the right side of his/her head. The resident was sent to the Emergency Department (ED) for evaluation and treatment. Review of Resident #19's CCP for falls, last revised [DATE], revealed interventions of add Dycem to the wheelchair to promote safety; anticipate and meet resident's needs; be sure resident's call light was within reach and encourage the resident to use it for assistance as needed; the resident needed prompt response to all requests for assistance; bed in low position unless providing direct care as tolerated by the resident; bilateral enabler bars to the head of the bed to help with transfer and positioning; and resident used a standard wheelchair and cushion and scoop mattress. However, further review revealed no new interventions had been put in place for the resident's fall dated [DATE]. 7. Review of Resident #98's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease and Hypertension. Review of Resident #98's Quarterly MDS Assessment, dated [DATE], revealed the resident's BIMS score was zero (0) of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #98's progress notes, dated [DATE] at 8:51 AM, revealed the resident was sitting in the common area in his/her wheelchair, fell asleep, leaned forward, and fell to the floor, receiving a laceration to his/her forehead. Review of Resident #98 CCP for falls, created on [DATE], revealed interventions included add Dycem to wheelchair and a fall mat to the left side of the bed to promote safety; keep the call light within reach; standard wheelchair with a roho cushion (used to decrease the amount of pressure on the sitting area); keep frequently used items within reach; fall risk assessment upon admission and at least quarterly; ensure appropriate footwear when out of bed; and refer to PT/OT/ST (physical therapy/occupational therapy/speech therapy) as needed. However, further review revealed, as of [DATE], no new interventions had been put in place to address the resident's fall on [DATE]. 8. Review of Resident #80's Admission Record revealed the facility admitted the Resident on [DATE], with diagnoses to include Dementia with Behavioral Disturbance, Cognitive Communication Disorder, and Muscle Weakness. Review of Resident 80's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #80 with a BIMS score of five (5) of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed Resident #80 exhibited verbal and physical behaviors toward others including hitting, kicking, pushing, scratching, grabbing, screaming at others or cursing and wandering. Review of Resident #80's CCP, initiated on [DATE], revealed a focus area of exhibiting adjustment issues as evidenced by yelling, attempting to hit, kick, bite, throw items, and be verbally aggressive toward staff with a goal to include that the resident would be successfully redirected with minimal cues from staff with no aggressive type behaviors. Interventions included encourage ongoing family involvement and give the opportunity for resident to communicate her/his feelings. Continued review revealed, on [DATE], an added intervention to assist the resident to promptly move away from the dining table after meals. On [DATE], an added intervention that staff could initiate was a one-to-one (1:1) observation as a proactive intervention when increased agitation was observed. Review of Resident #80's CCP, initiated on [DATE], revealed a focus area of altered psychosocial needs related to Dementia and Anxiety, with a goal to maintain highest level of independence with safety. Interventions included administer medications as ordered, monitor for behaviors every shift and document, monitor for side effects of psychotropic medications as ordered, arrange for psychiatric consult as needed. Continued review of the CCP revealed a new focus initiated on [DATE], for use of psychotropic medications (antipsychotic), related to Dementia and Anxiety with interventions which included administer medications as ordered, consult with Pharmacy, enhanced supervision as needed, monitor/document/report any adverse reactions of Psychotropic medications, and monitor/record occurrence of target behavior symptoms such as inappropriate response to verbal communication and violence/aggression toward staff and/or others. However, there was no documented evidence to support Resident #80's CCP had been updated or revised to reflect the behaviors assessed in the Quarterly MDS assessment dated [DATE] to include verbal and physical behaviors toward others. These behaviors included cursing at others, such as what occurred with the incident on [DATE] when Resident #80 cursed at another resident. Review of Resident #80 Behavior Progress Note dated [DATE], entered by the Social Worker, revealed Resident #80 displayed physical aggression toward others, and one-to-one (1:1) supervision was initiated. Review of Resident #80's Nursing Progress Note dated [DATE], entered by LPN #3 revealed she was informed Resident #48 hit Resident #80 in the face because Resident #80 called him/her a whore. Interview with CNA #9, on [DATE] at 8:50 AM, revealed she was sitting in the corner of the common area with several residents when Resident #80 got upset at another resident and started cursing. Resident #80 got up from the chair and was walking in front of the couch where Resident #48 was sitting, all the while cursing at no person in particular. CNA #9 reported she was trying to get Resident #80's attention to calm him/her, when Resident #48 got up from the couch and punched Resident #80, knocking him/her to the floor. CNA #9 stated, it happened so fast I couldn't get to them quick enough. CNA #9 revealed she immediately separated the residents. Per the interview, CNA #9 stated that Resident #80 was always cursing. Interview with the Director of Nursing (DON) on [DATE] at 3:37 PM, revealed enhanced precautions or increased supervision meant, if a staff member was not assisting another resident, then that staff member should be beside the resident and/or they should watch that resident closer. She stated enhanced precautions or supervision was different from every fifteen (15) minute checks or one-to-one (1:1) supervision. The DON stated she would expect the care plan to be updated to reflect the MDS assessment and with any change in condition. 9. Review of Resident #106's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses of Alzheimer's Disease, Difficulty with Walking, Unsteadiness of Feet, and History of Repeated Falls. Review of the Admission Minimum Data Set Assessment, dated [DATE], revealed a BIMS score of ninety-nine (99), indicating the resident could not participate with using the tool because of severe cognitive impairment. Review of the facility's Fall investigation for Resident #106 on [DATE] at 12:37 PM, revealed the resident was witnessed scooting self out of the wheelchair onto the floor in the day area. The root cause analysis showed the resident slid out of the wheelchair, with no injury. An added intervention was to add Dycem to the wheelchair. Review of facility's Fall investigation for Resident #106 on [DATE] at 12:00 PM, revealed the resident was asleep in the wheelchair in the common area and fell from the wheelchair, with no injury. The root cause analysis showed the resident fell asleep in the wheelchair and fell forward. There was no Dycem in the wheelchair. Review of Resident #106's CCP, initiated on [DATE], revealed there was a focus for risk of falls b [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, that would meet the residents physical, mental and psychosocial needs for one (1) of ninety-four (94) sampled residents (Resident #80). On 12/16/2022, Resident #48 punched Resident #80 in the face, which resulted in Resident #80 falling to the ground. On 12/16/2022 at 6:43 PM and 7:42 PM, Licensed Practical Nurse (LPN) #3, noted the fall, the resident's complaint of hip pain and verbal order received for an X-Ray. However, the facility did not obtain the X-Ray for Resident #80 until the following morning, on 12/17/2022 at 8:00 AM. Resident #80 entered the emergency room , at 3:57 PM on 12/17/2022, and received a total hip replacement for a displaced right hip fracture. The facility's failure to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious injury, serious harm, or death to residents in the facility. Immediate Jeopardy (IJ) was identified on 03/08/2023 at 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on 12/16/2022 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/08/2023. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684). The findings include: Review of the facility's policy titled, Fall Management- Response to a Resident's Fall, dated 09/01/2022, revealed the facility would evaluate and monitor the resident for 72 hours post fall; a neurological assessment would be completed on any unwitnessed fall or witnessed fall hitting the head; assess airway, breathing and circulation; summon help, as needed; assess level of consciousness, vital signs, and range of motion; look for lacerations, abrasions, and obvious deformities; initiate first aid if minor injury. Continued review revealed, if it was an emergency situation, initiate the Emergency Medical System (EMS) response, contact the provider and family, and remain with the resident until EMS arrives. Review of Resident #80's Admission Record revealed the facility admitted the resident, on 07/27/2021, with diagnoses that included Dementia, Cognitive Communication Disorder, Insomnia, Muscle weakness, and Osteoarthritis. Review of Resident #80's Quarterly Minimum Data Set (MDS) Assessment, dated 12/06/2022, revealed the facility assessed Resident #80 with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated the resident was moderately cognitively impaired. Continued review revealed Resident #80 exhibited verbal and physical behaviors towards others which included: hitting, kicking, pushing, scratching, grabbing, screaming at others, or cursing and wandering. Review of Resident #80's Nursing Progress Note, dated 12/16/2022 at 6:43 PM, entered by Licensed Practical Nurse (LPN) #3, revealed she had been informed by Certified Nursing Assistant (CNA) #22 that a resident had been punched in the face by another resident. Continued review revealed Resident #48 stated he/she hit Resident #80 in the face because he/she called him/her a whore. Further review revealed Resident #80 complained of pain in his/her right hip and had a small skin tear to the left side of his/her face. The Progress Note revealed LPN #3 continued to monitor Resident #80, and Resident #48 was placed on one on one (1:1) supervision immediately. Review of Resident #80's Nursing Progress Note, dated 12/16/2022 at 7:42 PM, revealed Nurse Practitioner (NP) #2 was contacted and gave a verbal order for an x-ray of the resident's right hip and pelvis. Review of a Triage Note, dated 12/16/2022 at 7:42 PM, entered by NP #2, revealed Resident #80 had been punched by another resident and fell on his/her right side, which resulted in right hip pain and a small skin tear to the left side of his/her face. Continued review revealed new orders were given to obtain an x-ray of the right hip/pelvis, and cleanse the skin tear, keep clean and dry, and to notify the provider of acute concerns. Review of Resident #80's Medication Administration Record (MAR), dated 12/16/2022, revealed Tylenol (pain medication) 500 milligram (mg) extended-release tablets, two (2) tabs had been administered by Certified Medication Technician (CMT) #13 at 9:00 PM. Review of the Radiology Report, dated 12/17/2022, at 8:06 AM revealed Resident #80 sustained a displaced fracture of the right femoral neck. Review of Resident #80's Hospital Discharge Summary, dated 12/23/2022, revealed the initial report from the facility had been called to the hospital on 12/17/2022 at 3:51 PM. Continued review revealed the resident had an acute displaced fracture through the sub-capital portion of the right femoral neck and an orthopedic surgical consultation was warranted. Interview on 02/23/2023 at 1:14 PM, with Certified Nursing Assistant (CNA) #22, who witnessed the incident, revealed Resident #80 called Resident #48 a name and Resident #48 stood up and punched Resident #80 in the face. Per interview, Resident #80 fell to the floor on his/her right side. CNA #22 stated she separated Resident #80 and Resident #48 and notified LPN #3. Interview on 02/23/2023 at 3:45 PM, with CNA #9, revealed Resident #80 was walking around the couch and talking in the common area. Resident #80 was overheard calling Resident #48 a bitch. Resident #48 stood up and punched Resident #80 in the face causing him/her to fall. Continued interview with CNA #9 revealed she and CNA #22 separated Resident #80 and Resident #48 immediately and notified the nurse. The CNA further stated the incident happened so fast, they could not get there fast enough to separate the residents before Resident #48 hit Resident #80, causing him/her to fall and hit the floor. Interview on 02/24/2023 at 2:36 PM, with Licensed Practical Nurse (LPN) #3, revealed Resident 80 was on the floor when she went to the resident. She stated Resident #80 was tearful and stated his/her hip hurt. LPN #3 stated she assessed Resident #80, and assisted the resident to a chair, and then assisted the resident to bed. Interview on 03/08/2023 at 1:56 PM, with NP #2, revealed she hardly recalled the call she received on 12/16/2022 regarding Resident #80. She stated she did give the order to get an x-ray due to the resident's complaints of hip pain. Per interview, it was her expectation that an order for an x-ray would be done the same day the order was given, and it would typically not be done the next day. Continued interview revealed a delay in treatment and services could cause continued pain and other complications with the hip due to the fracture. Interview, on 03/18/2023 at 11:34 AM, with the x-ray company's receptionist, revealed an order for a routine x-ray had been placed by phone on 12/16/2022 at 7:43 PM. Continued interview revealed a routine x-ray should be completed between eight to twenty-four (8-24) hours of receipt. However, a stat x-ray should be done within four to six (4-6) hours of receiving the order. Interview, on 03/08/2023 at 11:40 AM with the Medical Director (MD), revealed he did not specifically remember a call on 12/16/2022 regarding Resident #80. However, he did recall Resident #80 had altercations with other residents. The Medical Director stated the facility was to call him Monday through Friday 8:00 AM -5:00 PM, and to call the On-Call Physician Services Group after 5:00 PM, and on weekend for any concerns. Per interview, it was his expectation for staff to ensure safety of residents, assess the resident(s) involved, and he expected neurological tests to be initiated, assess for pain at specific area, and assess for any deformities. Further, he stated in specific situations, obtain a stat x-ray, if needed. The Medical Director stated it would concern him if x-rays were not completed timely for a suspected fracture, because of the pain level the resident might be experiencing. Interview on 02/22/2023 at 2:05 PM, with the Director of Nursing (DON), revealed she would expect residents to be watched and staff to follow the facility's policy. Interview on 03/16/2023 at 10:00 AM, with Executive Director (ED), revealed when a fall occurred, she expected the nursing to assess the resident, and if necessary, send the resident to the emergency room (ER). She stated if it was not emergent, she would expect an in-house x-ray to be obtained. The ED stated she expected the nurse to contact the DON immediately with any falls and hospital transfers.

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 residents received adequate care and assistance to prevent pressure injury for residents at risk or to prevent new injury from developing for two (2) of ninety-four (94) sampled residents (Resident #89 and #95). The facility admitted Resident #89, on 04/22/2022 and assessed the resident to be ambulatory and a low risk for pressure ulcers (injury to the skin and underlying tissue due to prolonged pressure on the skin). However, the facility assessed the resident to have a Stage III pressure ulcer to the sacrum (full thickness tissue loss with subcutaneous fat likely visible), on 10/05/2022. The resident was seen by the wound care specialist. The specialist recommended for staff to turn and reposition the resident every one (1) to two (2) hours. However, there was no documentation to support the resident was turned and repositioned nor was the resident's care plan developed to include turning and repositioning the resident. On 10/26/2022, the facility assessed the resident's pressure ulcer had worsened to a Stage IV (the last stage and bone, muscles, and tendons could be visible). Resident #89 was admitted to the hospital on 11/02/2022 for sepsis and surgical wound debridement. Observations on 02/23/2023, revealed the resident was not turned or repositioned for two (2) hours and forty-five (45) minutes. Additional observation, later that day, revealed the resident was not turned for a total of three (3) hours and forty (40) minutes. Interview with Licensed Practical Nurse (LPN) #31 and Certified Nursing Assistant (CNA) #42 revealed they often were not able to turn and reposition the residents every two (2) hours. Immediate Jeopardy (IJ) was identified on 03/11/2023 at 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686) at the highest S/S of a J and was determined to exist on 10/05/2022 and is ongoing. The facility was notified of the Immediate Jeopardy on 03/11/2023. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care/Prevention of Pressure Sores (F686). In addition, Resident #95 had sustained multiple ischemic events and was no longer independent with bed mobility or transfers. He/she returned from a hospital admission on 01/30/2023 with a Stage III pressure injury to the ischium that was healed but recurred in eight (8) days. Then, Resident #95 developed a Stage IV pressure injury to the sacrum. The findings include: Review of the facility's policy, Pressure Prevention, revised April 2020, revealed residents' skin should be assessed upon admission for existing pressure injury risk factors, then repeat the risk assessment weekly and upon any changes in condition. Further review revealed the facility would use a standardized pressure injury screening tool to determine and document risk factors as well as supplemental use of a risk assessment tool with assessment of additional risk factors. Review of the facility's policy titled, Prevention of Pressure Injuries Policy, dated 2001, revised April 2020, revealed the purpose was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The policy stated to review the resident's care plan and identify the risk factors as well as interventions designed to reduce or eliminate those considered modifiable. Per the policy, the skin was not to be rubbed or otherwise cause friction on skin that was at risk of pressure injuries. The policy also stated to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (IDT). The policy stated to choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Per the policy, potential changes in the skin must be evaluated, reported, and documented. The policy directed to review the interventions and strategies for effectiveness on an ongoing basis. 1. Review of Resident #89's medical record revealed the facility admitted the resident, on 04/22/2022 with diagnoses that included Schizophrenia, Personal History of Traumatic Brain Injury, and Dementia. Per the record, Resident #89 was ambulatory on admission. In addition, the admission skin assessment revealed Resident #89 was free of skin lesions. Further review of Resident #89's medical record revealed his/her condition declined, and the resident was admitted to the hospital from 09/04/2022 to 09/09/2022. Resident #89's condition further declined, and he/she was again admitted to the hospital from 09/14/2022 to 09/22/2022. Per the record, Resident #89 returned with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to provide liquid nutritional support). Further review revealed Resident #89 returned with two (2) pressure ulcers: a Stage II pressure wound (partial thickness loss of the dermis presenting as a shallow open ulcer) on the left medial thigh and a Stage III pressure wound on the right buttock. Review of Resident #89's medical record revealed, on 10/05/2022, the resident developed a Stage III pressure wound on the sacrum while in the facility. Per the record, the thigh and right buttock wounds were documented as healed on 10/12/2022. Further review revealed, on 10/26/2022, the sacrum wound deteriorated to a Stage IV pressure ulcer. Per the record, from 10/19/2022 to 02/20/2023, recommendations from the Wound Physician were to turn the resident from side to side and front to back in bed every one (1) to two (2) hours if able. Review of Resident #89's Wound Physician's Note, dated 11/02/2022, revealed a recommendation to send the resident to the emergency department (ED) due to a change in behavior and pallor of the skin. Review of Resident #89's hospital record revealed the resident was sent to the hospital ED on 11/02/2022. Per the record, in the ED the resident was found to have tachycardia (heart rate greater than 100 beats/minute) and tachypnea (breathing rate greater than 20 per minute). Further review revealed Resident #89 was administered intravenous (IV) Vancomycin and Zosyn (antibiotics to fight infection) in the ED. The hospital admitted the resident for further management. Per the record, upon admission, the resident was given IV fluids as the resident was diagnosed with Sepsis (a life threatening complication of an infection) and was dehydrated. Additional IV antibiotics were started as well. Continued record review revealed Resident #89 received an x-ray of the sacrum and coccyx on 11/03/2022 for possible osteomyelitis (an infection of the bone). The findings found decubitus ulceration in the region of the coccyx, and the distal coccygeal segments were eroded, compatible with osteomyelitis. The record stated Resident #89 underwent surgical wound debridement (removal of necrotic tissue) on the Stage IV pressure ulcer on the sacrum/coccyx on 11/04/2022 with no complications. Resident #89 was discharged back to the facility on [DATE]. Review of Resident #89's care plan, revised 10/25/2022, revealed it did not include interventions to off-load the sacral wound and turn every two (2) hours. Further review revealed the care plan did not have any documentation related to pressure ulcer care or prevention, even though the pressure ulcers were first identified when the resident returned to the facility, on 09/22/2022, from a hospital admission. Interview, with Minimum Data Set (MDS) Nurse #1, on 02/21/2023 at 5:40 PM, revealed she did not think the care plans needed to be more specific about prevention of pressure ulcers. Review of Resident #89's Treatment Administration Record (TAR) revealed there was no documentation that the resident was turned and repositioned at least every two (2) hours until 11/12/2022. Further review of the treatment record revealed Resident #89 was not turned every two (2) hours on eighteen (18) of the nineteen (19) days left in November 2022. Review of the Dietary Progress Note, dated 09/26/2022 at 1:14 PM, revealed Resident #89 returned from the hospital, on 09/22/2022, with enteral nutrition of Isosource 1.5 at 50 milliliters (ml)/hour continuous. Per the note, the enteral nutrition was changed to Osmolite 1.2 at 75 ml/hour continuous for twenty-two (22) hours, and off for Activities of Daily Living (ADLs) 8:00 AM to 10:00 AM. Interview with the Dietitian, on 02/26/2023 at 10:00 AM, revealed the tube (PEG) feeding was changed to the facility's formula. The Dietician stated this formula provided enough calories and protein to meet Resident #89's nutritional needs. Observation, on 02/15/2023 at 4:00 PM, of Resident #89's wound care by the Wound Doctor of Osteopathic Medicine (DOM) revealed the resident was found to have a Stage III pressure wound on the right lower medial shin; a left knee Stage III pressure wound; and a Stage IV pressure wound on the sacrum. Observation revealed the DOM used a scalpel to remove a small piece of necrotic tissue on the left knee Stage III pressure wound, and no pain behaviors were present. Further observation revealed a scar on the right buttock. The DOM sprayed a numbing solution on the area and used a [NAME] to remove necrotic tissue from the wound. Resident #89 did not exhibit any signs of pain. Observation, on 02/23/2023, revealed Resident #89 was lying on his/her right side for two (2) hours and forty-five (45) minutes, from 9:10 AM to 10:55 AM. Further observation, on the afternoon of 02/23/2023, revealed Resident #89 was lying on his/her back for three (3) hours and forty (40) minutes, from 12:10 PM to 3:50 PM. Observation, on 02/24/2023 every hour from 9:00 AM to 3:00 PM, revealed Resident #89 remained on her/his back the entire time. Interview, with Certified Nursing Assistant (CNA) #20, on 02/24/2023 at 3:10 PM, revealed, (Resident #89) has to be on the back, we have pillows where the wound is. When we turn her/him, (the resident) starts moaning. Observation, on 02/26/2023 at 2:45 PM, of Registered Nurse (RN) #7 changing the dressing on Resident #89s coccyx and lower extremities revealed CNA #32 assisted in turning Resident #89. Further, Resident #89 did not show any pain behaviors during dressing changes. Interview with CNA #42, on 03/09/2023 at 3:33 PM, revealed when specifically asked if she knew Resident #89 needed to be turned every two (2) hours, replied she did not know because she did not have time to look at the care plan. Interview, with the Associate Director of Nursing (ADON), on 02/23/2023 at 9:50 AM, revealed she had been doing rounds with the WP since 01/30/2023. She stated she thought the wounds on Resident #89 occurred due to the resident being contracted. The ADON stated she ensured staff followed the treatment listed in the chart by monitoring staff. She stated, if she found the treatment had not been followed, she educated the staff. Interview with the DOM, on 02/23/2023 at 10:19 AM, revealed he thought the wound on Resident #89's sacrum/coccyx was from pressure. Further he stated the resident was contracted, and the pressure wounds on the lower extremities could be caused by the contractures of the legs. He stated Resident #89's fairly young age should assist with the wound healing, and the wounds were less likely to occur. Interview with the Executive Director (ED), on 03/16/2023 at 10:36 AM, revealed she assured the Director of Nursing (DON) carried out the Physician's Orders by talking about them in the daily clinical meeting. She stated she could not say why the pressure ulcer was not documented or shown as worsening on the form used to show the resident's conditions. She stated it was also her understanding that the DON was knowledgeable about the worsening pressure ulcer. 44396 2. Review of Resident #95's electronic medical record (EMR) revealed the facility admitted the resident, on 10/14/2022, with diagnoses of Encephalopathy, Type II Diabetes Mellitus, and Dementia. Review of Resident #95's admission Skin Observation Tool, dated 10/17/2022, revealed no skin issues. Review of subsequent Skin Observation Tools revealed no skin disruption until 02/03/2023, when a Stage III pressure wound was identified to the right ischium after returning from a hospital stay following a cerebral infarction. Review of Resident #95's Braden Scale Evaluation, dated 01/30/2023, revealed he/she was at risk for pressure wounds with a score of sixteen (16). Review of Resident #95's MDS Significant Change Assessment, post cerebral infarction, dated 02/06/2023, revealed a Brief Interview of Mental Status (BIMS) score of ninety-nine (99), which indicated the resident could not participate, using this assessment tool. Review of Resident #95's EMR progress notes revealed the Stage III pressure wound to the right ischium was identified on 01/31/2023 after readmission from a hospital stay. The facility referred the resident for wound specialist care at that time. The resident was seen by the wound physician on 02/02/2023, who ordered Santyl (removed dead tissue from a wound to promote healing) and Calcium Alginate (created a dry wound by removing fluid to promote healing) to treat it. Further review revealed the wound was evaluated as resolved by the wound care physician, and he signed off on Resident #95's care on 02/15/2023. Continued record review revealed a change in condition note, dated 02/23/2023 at 5:03 PM. The note stated the Nurse Practitioner (NP) diagnosed a Stage III pressure wound to the coccyx and referred the resident back to wound care, eight (8) days after after the wound was noted to be resolved. Further review revealed a dietary note, dated 03/01/2023, which stated there were four (4) open pressure areas in total: bilateral heels, sacrum, and a reopened area to the ischium. Review of Resident #95's wound care note, dated 02/27/2023, confirmed the recurrence of the right ischium pressure wound, as well as the new presence of deep tissue injuries to the bilateral heels and a Stage IV wound to the sacrum. Review of Resident #95's Treatment Administration Record for February revealed treatments were documented as completed as ordered through 02/15/2023; and noted that the wound had healed. However, review of the point of care documentation for the month did not reflect consistent documentation for turning and repositioning or for offloading of the wounds. Review of Resident #95's Comprehensive Care Plan revealed a Focus for Risk of Skin Impairment, initiated 10/17/2022, with interventions added on the same date. The interventions were to turn and reposition to maintain skin integrity (it did not give the frequency), pressure reducing mattress, and skin checks weekly. Further review revealed the first interventions added or revised after those at admission were documented on 02/24/2023 and included moon boots (an orthotic device to offload weight) to bilateral heels, wound physician to evaluate and treat, and turn and reposition to promote healing of current areas (no frequency mentioned). Continued review revealed the addition of interventions on 03/15/2023 to include turn side to side in bed every one (1) to two (2) hours if able, to offload wound and wound care physician rounds at facility per schedule. Observation of Resident #95, on 03/07/2023 at 1:16 PM, revealed Resident #95 resting in bed on his/her back, his/her heels were not on an offload pillow, and his/her right hip was offloaded with a pillow. The resident was located in a corner room with the bed not visible to the hallway. Continued observation at 2:18 PM revealed Certified Occupational Therapy Assistant (COTA) #1 donned (put on) Personal Protective Equipment (PPE) and entered Resident #95's room then exited the room at 2:24 PM. Interview at that time revealed COTA #1 had removed the splint from Resident #95's right arm and placed a pillow under it. Observation at 2:29 PM revealed Resident #95's right hip was still offloaded with a pillow; his/her heels were not on offloaded on a pillow. The only change made was the resident's right arm was now offloaded with a pillow. Continued observation at 3:04 PM revealed CNA #18 entered Resident #95's room with a Hoyer (name brand mechanical) lift, then exited the room and returned down the hall. CNA #18 returned at 3:23 PM alone, obtained gloves from the cart and entered the room, closing the door. Additional observation at 3:37 PM revealed Physical Therapy Assistant (PTA) #1 entered the room to see Resident #95, and CNA #18 exited. Interview with CNA #18 revealed she was using the lift to weigh Resident #95, and she had not gotten him/her up nor had she changed him/her. Observation of Resident #95, after CNA #18's exit, revealed the resident was with the Speech Therapist (ST) and with the right hip still offloaded and his/her heels were not on an offload pillow. Observation with the Wound Care Physician and Resident #95, on 03/09/2023 at 4:15 PM, revealed the resident was diagnosed , on 02/27/2023, with a Stage III full thickness pressure wound to the right ischium, a Stage IV full thickness pressure wound to the sacrum, and bilateral Deep Tissue Injury (DTI) to his/her bilateral heels. This observation revealed the resident's right heel DTI had resolved, and the other three (3) wounds were healing. Interview, with the Wound Care Physician, on 03/09/2023 at 4:15 PM, revealed the key to wound care beyond the treatments was consistency. Further interview revealed that consistency with keeping residents dry and keeping the wounds offloaded was important to healing. He stated a wound was always multifactorial in causes and that a wound that had been treated consistently for three (3) weeks and was healing could be disrupted with a day of not providing that care. Telephone interview with the Wound Care Physician, on 02/27/2023 at 4:50 PM, revealed his expectation of staff to do dressing changes routinely as ordered was key and that the wound care nurse had to play a role through the week to spot check for compliance with orders being carried out. He stated, specifically when rounding, the nursing staff should always check to see what was being put on the wound. Continued interview revealed so much depended on the quality of aides on a particular floor because residents needed to be moved and wet or soiled briefs changed every two (2) hours. He stated not doing that would clearly cause problems. The wound care physician stated he enjoyed having aides come help them when they were rounding on the units because it was an opportunity for education on what poor hygiene caused as far as wound care. He also stated, in the end, the aides were the ones who had to respond to the lights and do the work. The physician stated central to wound healing was how well the resident was eating, and the aides were the ones with the best observance of that. He stated aides should clean, turn, and apply creams, lotions, and powders as ordered. Interview, with CNA #15, on 03/01/2023 at 3:20 PM, revealed there were two (2) different ways to know a resident's care needs, walking shift change report or review the care plan/Kardex. Further interview revealed she usually had ten (10) to twelve (12) residents, maximum of fifteen (15). She stated she had worked on all units except one (1), so she knew a lot of residents already, but otherwise she would ask a full time staff member or the nurse for guidance. Continued interview revealed repositioning was expected every two (2) hours even when the resident was in a chair. She stated turning and repositioning was important to protect residents' skin. Interview, with CNA #48, on 03/01/2023 at 8:33 PM, revealed she learned care needs with shift report from off going aides and from the Kardex or asked the nurse for guidance. She stated check and change the residents was supposed to be every two (2) hours, but it depended if the resident had diarrhea or was a heavy wetter. She stated keeping residents dry was important for hygiene, for comfort, and to protect skin from breakdown. Continued interview revealed she knew it was also important for residents' skin to reposition with pillows on the side or put pillows under the back, under the arm, or between the knees. She stated Resident #95 should be turned every two (2) hours and also the head of his/her bed should be up because of tube feedings. Interview with CNA #18, on 03/02/2023 at 8:28 PM, revealed he/she thought the facility needed a paper report sheet because there was so much agency staff and new people in the building. She stated that way they would more easily know things like who needed to be turned every two (2) hours. Further interview revealed staff should be repositioning residents every two (2) hours with pillows to protect skin and prevent contractures. Interview with Registered Nurse (RN) #4, on 03/09/2023 at 3:50 PM, revealed she often did not have the treatment supplies she needed to complete wound care. However, she stated she used the supplies she had. Interview, with CNA #42, on 03/09/2023 at 3:33 PM, revealed she often did not have the time to turn residents every two (2) hours. Interview, with Licensed Practical Nurse (LPN) #31, on 03/15/2023 at 9:10 PM, revealed often times the facility was short staffed, and staff members did the best they could at the time to give the care to prevent wounds. LPN #31 stated wound prevention relied on turning and repositioning and offloading wounds. Interview, with the Assistant Director of Nursing (ADON), on 03/01/2023 at 3:43 PM, revealed her expectation for staff to provide turning and repositioning and offloading wounds, both to protect skin from developing wounds or to help existing wounds heal. She also stated she expected staff to conduct rounding every two (2) hours. Interview, with the Executive Director (ED), on 03/11/2023 at 11:01 AM, revealed she relied on the DON to ensure the Wound Care Physician's orders were carried out by the nursing staff. She stated there was a weekly clinical meeting that the DON attended where staff discussed the residents' wounds. She stated the DON would review the recommendations from the meeting and ensure these recommendations were put on the residents' care plans and implemented. Interview with the previous DON (Interim DON #3), on 03/08/2023 at 1:15 PM, revealed the floor staff were responsible to assure the residents were turned every two (2) hours. She further stated it was important to turn residents every two (2) hours to reduce pressure because if residents were not turned it could lead to skin impairment. Interview with the Immediate Past DON, on 03/16/2023 at 11:40 AM, revealed she had only vacated the DON position five (5) days earlier. Further interview revealed her expectation was for nurses to follow physician's orders for wound treatment. She stated the aides must follow standards of practice, such as offloading pressure areas, as even micro movement could make a difference. Continued interview revealed it was important that the staff took credit for what they did, by documenting it. She stated it was important to keep residents clean, dry, and to conduct perineal care during rounds. Interview, with RN #10 (former DON), on 03/11/2023 at 11:15 AM, revealed the process to assure care plans and the Kardex were followed was for nurses to report to the nurse aides each day after the morning huddle meetings. She stated the primary nurse or anyone in the morning huddle meeting was to physically go to the unit and verbally tell each nurse and nurse aide of any change in the care plan interventions. Further interview revealed the nurse aides would perform their rounds with the next shift and report any new changes. RN #10 added it was the primary nurse's responsibility to assure the residents were being repositioned as ordered. She stated the only time a turn should not take place would be if the resident refused or had pain. However, if pain was occurring, it should be reported to the nurse for pain medication prior to turning. She stated the Braden Scale was performed on new admits; skin assessments were performed upon admission; within the next twenty-four (24) hours, and then weekly. She added the Wound Care Physician performed treatments and measurements; but, if the measurements were not taken, it was ultimately the responsibility of the primary nurse to perform the task. She stated pressure relieving devices and offloading should be added to the care plan and performed. She stated monitoring of wounds was performed by either the Wound Care Physician or nurse weekly. Additional interview with the ED, on 03/16/2023 at 10:41 AM, revealed her expectation was that CNAs should keep residents turned, repositioned, clean, and dry to prevent pressure wounds. She stated immediate incontinence care and getting residents out of bed if tolerated would also help to prevent pressure wounds.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents were treated with dignity and respect for two (2) of ninety-four (94) sampled residents (Residents #14 and #821). Resident #14's toilet was non-functional and had been non-functional frequently for the past year. Resident #821 was observed with a catheter bag hanging from a wheelchair without a dignity bag. The findings include: Review of the facility's policy titled, Resident Rights, dated 02/2021, revealed federal and state laws guaranteed certain basic rights to all residents of the facility. Those rights included a dignified existence, and to be treated with respect, kindness, and dignity. 1. Review of an untitled document revealed it was reported, on 03/08/2022, that the toilet adjacent to Resident #14's room was stopped up and backed up. Further review revealed a handwritten note that stated, Closed 03/12/2022. Interview with Resident #71, on 02/19/2023 at 2:25 PM, who shared the toilet with Resident #14, revealed he/she told staff not to flush the toilet because it would overflow. He/she stated a plumber had snaked it a while ago, but it had been broken for several weeks. Observation, on 02/19/2023 at 2:30 PM, revealed the toilet, between Resident #14's and Resident #71's room, was not flushed and was filled with urine and feces. After a plunger was located and brought to Resident #71's room, the Human Resources (HR) staff member repeatedly plunged and flushed the toilet, but it did not flush enough to allow the toilet bowl to fill with clear water. The HR staff member lifted the lid off the toilet to reveal the toilet tank was not filled with water completely after being flushed. Interview, with the HR staff member, on 02/19/2023 at 3:00 PM, revealed it seemed to her there was not enough water pressure to fill the toilet for it to flush. She stated the toilet was out of order and requested staff put an Out of Order sign on the door of the bathroom between Resident #14's and Resident #71's room. Interview, with Family Member #2, on 02/22/2023 at 2:01 PM, revealed her relative's toilet had recently been stopped up and was stopped up sometime last summer. Interview, with Maintenance Technician #1, on 02/20/2023 at 4:14 PM, revealed he began working on the toilet in room [ROOM NUMBER] on this date after he received notification the toilet was broken. He stated he snaked the toiled, then used the shop vacuum, and it was now in working order. Interview, with Resident #14, on 02/21/2023 at 10:10 AM, revealed he/she had lived in his/her current room for about two (2) years. The resident stated that he/she used the toilet, but it had been broken for several months. Resident #14 stated some of the aides had flushed wipes down the toilet, which caused it to get stopped up. He/she stated the only reason the toilet was fixed the previous day was because the State Survey Agency Surveyors were in the building. Resident #14 stated when the toilet was broken, he/she had to use the toilet in the shower room, which made him/her feel like they don't care. Interview, with the Executive Director (ED), on 03/16/2023 at 11:34 AM, revealed the risks for residents associated with a broken toilet could be incontinence and skin breakdown. 2. Review of Resident #821's clinical record face sheet revealed the facility admitted the resident on 12/21/2022 with diagnoses of Unspecified Dementia with Mood Disorders, Retention of Urine, and Malnutrition. Review of the hospital discharge papers, dated 12/21/2022, revealed the resident was sent to the facility with a catheter for long term use. Observation, on 03/04/2023 at 9:18 AM revealed Resident #821 wheeling himself/herself around. Observation revealed a catheter bag attached to the resident's wheelchair without a dignity bag. Interview, with Certified Nurse Aide (CNA) #34, on 03/04/2023 at 9:18 AM, revealed the night aide had put the dignity bags some place and she could not find them. She also stated the resident's catheter bag was broken at the clip and it could not hang like it was supposed to, so staff just hung it on the wheelchair between the resident's legs. Interview with the ED, on 03/16/2023 at 11:00 AM, revealed all people wanted to be treated with respect and dignity. She stated dignity was treating people kind, and it meant being compassionate and treating people the right way. She further stated maybe it was the way people talked to each other or how staff talked to the residents, and if one person thought it was disrespectful, that could impact their dignity. Continued interview revealed some things that show the residents dignity were knocking on the door, pulling their curtain closed, or making sure their catheter was covered with a dignity bag. The resident may not want everyone to know they had a catheter in. She further stated it was the responsibility of the aides to ensure the resident had a dignity cover over the catheter bag, and if a nurse noticed a resident did not have one, they would also be responsible to ensure the resident had one.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report immediately, but no later than two (2) hours allegations of abuse for one (1) out of nineteen (19) sampled residents (Resident #66). Registered Nurse (RN) #11 reported to the Director of Nursing (DON) on 06/22/2023 that she overheard staff state Resident #66 was dragged to the shower, sprayed off, and thrown in his/her bed. Further, she noted the resident had a reddened area to his/her face. Additionally, observations by the State Survey Agency (SSA) surveyor revealed a light brownish discolored area approximately one (1) inch long, and 1/2 inch wide on the resident's left upper arm, which the resident stated occurred during the transfer to the shower. However, the allegations were not reported to the SSA until 06/24/2023, approximately two (2) days after the incident occurred. In an interview with the resident's roommate (Resident #1) he/she stated the resident was crying and kept him/her up all night. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, not dated, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed willful, as used in this definition of abuse, meant the individual acted deliberately, not that the individual intended to inflict injury or harm. Further review revealed that all allegations of abuse would be 1.) reported to the Executive Director (ED) immediately. 2.) The facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required. Further review revealed the timing of reporting events that caused the suspicion of abuse that resulted in serious bodily injury was to be reported immediately, but not later than two (2) hours after forming the suspicion; and if the event did not result in serious bodily injury, the individual was to report the suspicion not later than twenty-four hours after forming the suspicion. Review of Resident #66's Admission Record revealed the facility admitted the resident on 12/06/2019 with diagnoses to include: Schizoaffective Disorder, Bipolar, Anxiety Disorder, Major Depressive Disorder, Dementia, and Bladder Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of MDS section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed the resident was assessed to reject his/her care one (1) to three (3) days in the past fourteen (14) days. Review of the facility's initial investigation dated 06/24/2023 completed by the [NAME] President of Operations (VPO), revealed an allegation of physical abuse was received on 06/24/2023, which alleged that upon providing incontinent care to Resident #66, the resident was transferred with a blanket cradle to the shower room versus traditional shower chair. Continued review of the investigation revealed Certified Nurse Aides (CNAs) #120, #104, #84, and Licensed Practical Nurse (LPN) #37 completed the transfer. A skin assessment had been completed with mild redness noted on the resident's right side of his/her face. Further review revealed that all staff who were involved in the transfer had been suspended pending investigation. Review of the Facility's 5-day investigation, that was incorrectly dated for 07/21/2023 (as this date had not yet occurred) revealed a shower sheet was completed post shower that showed red areas of irritation. In an interview with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated she completed the shower sheet for Resident #66, the morning of 06/22/2023, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders. Review of the facility's witness statements attached with the facility's investigation were signed with completion dates of 06/23/2023. Review of the email confirmation provided by the facility revealed the state agency was notified, on 06/24/2023 at 2:38 PM, of alleged physical abuse. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, 1/2 inch wide on his/her left upper arm. Interview on 06/29/2023 at 10:05 AM with Resident #1, he/she stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 further stated he/she did not want them to take him/her to the shower, so they slid him/her across the floor. Resident #1 stated, I couldn't sleep for them (staff) cleaning and him/her (Resident #66) crying. Interview on 06/28/2023 at 2:35 PM with Certified Nurse Aide (CNA) #104 revealed sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she smelled a urine odor around the C-wing Hall. CNA #104 stated she had looked in on Resident #66 but had not checked to see if the resident needed incontinent care. CNA #104 further stated she did not receive a report from the off-going staff at shift change at 7:00 PM. According to the CNA, Resident #66 would get up around two (2) AM and come out of his/her room holding onto the top of his/her pants/brief. She stated she would assist with changing the resident at that time. Further, CNA #104 stated on the morning of 06/22/2023, Resident #66 did not get up so sometime between 1:00-2:00 AM, she went into Resident #66's room to check on him/her and when she turned on the lights, she immediately saw soaked sheets. She stated the resident was curled in the fetal position, had on a shirt, pants, and a brief, and his/her head was at the foot of his/her bed. Certified Nurse Aide (CNA) #104 stated, on 06/28/2023 at 2:35 PM, Resident #66's brief was swelled up and she/he was wet from head to toe, and the floor was wet. CNA #104 further stated she tried to assist Resident #66 to get up so she could change him/her but Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked for assistance. She stated she and CNA #120 could not encourage Resident #66 to go to the shower. CNA#104 stated they wanted to get Resident #66 into a wheelchair, but the Resident stayed curled in a fetal position. CNA #104 further stated she, along with, CNA #120, and CNA #84 tried coaxing, tried promising him/her a soft drink and could not get him/her to get up. CNA #104 stated she tried to assist Resident #66 to get up and Resident #66 tried to kick at them, and the Resident kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. After numerous attempts to get Resident #66 cleaned up, she stated they decided to carry Resident #66 in his/her blankets to the shower room. During the interview, the CNA stated she and CNA #120 picked the resident up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from Resident #66's room. CNA #104 stated they carried the resident to the shower room and sat the resident on the floor on his/her bottom. She stated staff got on each side of the resident and lifted him/her to the shower chair and completed the resident's shower. During an interview on 06/28/2023 at 1:21 PM with Certified Nurse Aide (CNA) #120, she stated she assisted CNA #104 with carrying Resident #66 into the shower in a blanket cradle, in the early morning hours of 06/22/2023. She stated Resident #66 refused to get out of bed to be cleaned. CNA #120 further stated she felt that was the safest way they could transport the resident due to him/her kicking at them and refusing to stand. CNA #120 stated that while she and CNA #104 transported Resident #66 to the shower, CNA #84 was mopping and cleaning the resident's room. CNA #120 stated there was urine on the floor, under the bed, in the bed, dripping from the mattress, and Resident #66 was completely saturated. She further stated the Resident was stating I can't touch the floor, I will die. The CNA #84 stated there was so much urine on the floor, they were afraid of being shocked as the bed was plugged into the electrical outlet. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused and transferring the resident by a blanket cradle was the only choice they had at the time. CNA #120 stated the [NAME] President of Operations (VPO) contacted her by phone on Thursday night, 06/22/2023, on the next shift she worked, and questioned her about the incident. She further stated the VPO contacted her again by phone on Friday, on 06/23/2023 at 8:56 PM, and she was notified that she had been suspended. Interview on 06/29/2023 at 8:21 AM, with Certified Nurse Aide (CNA) #84, she stated when CNA #120, and CNA #104 went into Resident #66's room, he/she was curled in a fetal position and would not get out of bed. CNA #84 stated Resident #66 was saturated in urine, including his/her clothes and shoes. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed by CNA #104 to go get another CNA on the other hall to assist and by the time CNA #84 got back to Resident #66's room, CNA #120 and CNA #104 had already had Resident #66 in a blanket, and they were carrying him/her out of the resident's room to the shower room. CNA #84 stated Resident #66 was not resisting or fighting but was stating, I am not alive, I am dead. CNA #84 stated she went into the shower room with them and assisted with getting Resident #66 into the shower chair and added, it was difficult to maneuver the resident into the shower chair. CNA #84 stated that she then went to Resident #66's room and began cleaning the room. She stated there was urine everywhere, and that urine appeared to be coming from inside of the mattress. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats in the room. CNA #84 further stated that when she took the mattress out of the room there was a wet trail down the hall, and she also had to mop that area. CNA #84 stated, no matter anyone's mental capacity, they should stay clean, and the resident needed out of that room. CNA #84 stated it would have been negligent if the staff had left Resident #66 in the condition, he/she was found in and therefore was not abuse. During an interview with Licensed Practical Nurse (LPN) #37, on 06/27/2023 at 5:12 PM, she stated she had assisted CNA #120, CNA #104, and CNA #84 with Resident #66. LPN #37 stated that Resident #66 was refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with them. Per the interview, LPN #37 stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, adding, they did not drag him/her. Further, LPN #37 stated she held the door open as CNA #104 and CNA #120 brought the resident to the shower room. In an interview on 06/29/2023 at 9:51 AM with Registered Nurse (RN) #11, she stated that on 06/22/2023 around 6:50 PM, she overheard CNAs (unknown) discussing Resident #66 being dragged to the shower room, sprayed off, then thrown into bed by staff. RN #11 stated she immediately contacted the Director of Nursing (DON) and made her aware. She stated she was instructed by the DON to complete a head-to-toe assessment of Resident #66 and to report her findings to the DON. RN #11 further stated that the only area she noted was a reddened area to the resident's face. Further, she stated Resident #66's roommate (Resident #1) and Resident #66 both corroborated the same scenario that Resident #66 was dragged. RN #11 further stated that Resident #1 stated that Resident #66 kept him/her up all night crying. Interview on 06/28/2023 at 4:00 PM, with the Director of Nursing (DON), she stated she was contacted by RN #11 on 06/22/2023 with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed RN #11 to complete a skin assessment on Resident #66. She stated RN #11contacted her after the skin assessment and reported only a small, reddened area on the side of Resident #66's face. She further stated that although this was not the conventional way to transport residents, she felt this was the safest way staff could transfer the resident to the shower. The DON stated that the staff should have reached out to the nurse or thought the incident out further. She further stated that she did not feel this was deficient practice but taking everything into consideration she felt staff did the best they could at the time. The DON stated she was more bothered that the resident and his/her bed were wet. In an interview with the Executive Director, on 06/28/2023 at 11:28 AM, she stated she was unaware of the alleged allegations of abuse until she was notified on 06/23/2023. Per the interview, the Executive Director stated she was on vacation at the time the incident occurred. In an interview on 06/29/2023 at 10:40 AM with the [NAME] President of Operations (VPO), he stated he had been contacted on the evening of 06/22/2023 around 7:00-7:30 PM by the [NAME] President of Clinical Services (VPCO), who had just been notified by the DON. Per the interview, he stated that at that time the incident was presented, it was communicated as one staff overhearing a conversation between two other staff. The VPO stated he interviewed Resident #66 on 06/23/2023 and the resident had no recollection of the shower incident. The VPO stated he emailed the State Survey Agency (SSA) on 06/24/2023, to report the allegations of alleged abuse. He further stated that his delay in reporting was because the allegation was reported to him as hearsay. However, review of the facility's policy revealed, the timing of reporting events that caused the suspicion of abuse was to be reported immediately, but no later than two (2) hours after forming the suspicion.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report immediately, but no later than two (2) hours allegations of abuse for one (1) out of nineteen (19) sampled residents (Resident #66). Registered Nurse (RN) #11 reported to the Director of Nursing (DON) on 06/22/2023 that she overheard staff state Resident #66 was dragged to the shower, sprayed off, and thrown in his/her bed. Further, she noted the resident had a reddened area to his/her face. Additionally, observations by the State Survey Agency (SSA) surveyor revealed a light brownish discolored area approximately one (1) inch long, and ½ inch wide on the resident's left upper arm, which the resident stated occurred during the transfer to the shower. However, the allegations were not reported to the SSA until 06/24/2023, approximately two (2) days after the incident occurred. In an interview with the resident's roommate (Resident #1) he/she stated the resident was crying and kept him/her up all night. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect, not dated, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed willful, as used in this definition of abuse, meant the individual acted deliberately, not that the individual intended to inflict injury or harm. Further review revealed that all allegations of abuse would be 1.) reported to the Executive Director (ED) immediately. 2.) The facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required. Further review revealed the timing of reporting events that caused the suspicion of abuse that resulted in serious bodily injury was to be reported immediately, but not later than two (2) hours after forming the suspicion; and if the event did not result in serious bodily injury, the individual was to report the suspicion not later than twenty-four hours after forming the suspicion. Review of Resident #66's admission Record revealed the facility admitted the resident on 12/06/2019 with diagnoses to include: Schizoaffective Disorder, Bipolar, Anxiety Disorder, Major Depressive Disorder, Dementia, and Bladder Disorder. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of MDS section E titled Behaviors, revealed Resident #66 had no indicators of Psychosis, no exhibited behavioral symptoms directed toward others and no behaviors exhibited not directed toward others. Further review revealed the resident was assessed to reject his/her care one (1) to three (3) days in the past fourteen (14) days. Review of the facility's initial investigation dated 06/24/2023 completed by the [NAME] President of Operations (VPO), revealed an allegation of physical abuse was received on 06/24/2023, which alleged that upon providing incontinent care to Resident #66, the resident was transferred with a blanket cradle to the shower room versus traditional shower chair. Continued review of the investigation revealed Certified Nurse Aides (CNAs) #120, #104, #84, and Licensed Practical Nurse (LPN) #37 completed the transfer. A skin assessment had been completed with mild redness noted on the resident's right side of his/her face. Further review revealed that all staff who were involved in the transfer had been suspended pending investigation. Review of the Facility's 5-day investigation, that was incorrectly dated for 07/21/2023 (as this date had not yet occurred) revealed a shower sheet was completed post shower that showed red areas of irritation. In an interview with Certified Nurse Aide (CNA) #104, on 06/28/2023 at 2:35 PM, she stated she completed the shower sheet for Resident #66, the morning of 06/22/2023, and circled all the reddened areas on the resident's trunk which appeared to be scalded, bright red raised areas on his/her thighs, groin, stomach and shoulders. Review of the facility's witness statements attached with the facility's investigation were signed with completion dates of 06/23/2023. Review of the email confirmation provided by the facility revealed the state agency was notified, on 06/24/2023 at 2:38 PM, of alleged physical abuse. In an interview on 06/29/2023 at 10:15 AM, Resident #66 stated the other night two (2) people carried him/her in blankets to the shower room, sat him/her on the floor, then put him/her in the chair. Resident #66 stated his/her arm was hurt when the people did that. During the interview the State Survey Agency (SSA) Surveyor asked Resident #66, if he/she had been hurt when the CNAs transferred him/her to the shower room, and the resident nodded his/her head up and down indicating Yes. Resident #66 then proceeded to show the SSA Surveyor a light brownish discolored area approximately one (1) inch long, ½ inch wide on his/her left upper arm. Interview on 06/29/2023 at 10:05 AM with Resident #1, he/she stated the other night his/her roommate (Resident #66) had pissed and shit everywhere. Resident #1 further stated he/she did not want them to take him/her to the shower, so they slid him/her across the floor. Resident #1 stated, I couldn't sleep for them (staff) cleaning and him/her (Resident #66) crying. Interview on 06/28/2023 at 2:35 PM with Certified Nurse Aide (CNA) #104 revealed sometime after midnight on 06/21/2023 (which would have been the morning hours of 06/22/2023), she smelled a urine odor around the C-wing Hall. CNA #104 stated she had looked in on Resident #66 but had not checked to see if the resident needed incontinent care. CNA #104 further stated she did not receive a report from the off-going staff at shift change at 7:00 PM. According to the CNA, Resident #66 would get up around two (2) AM and come out of his/her room holding onto the top of his/her pants/brief. She stated she would assist with changing the resident at that time. Further, CNA #104 stated on the morning of 06/22/2023, Resident #66 did not get up so sometime between 1:00-2:00 AM, she went into Resident #66's room to check on him/her and when she turned on the lights, she immediately saw soaked sheets. She stated the resident was curled in the fetal position, had on a shirt, pants, and a brief, and his/her head was at the foot of his/her bed. Certified Nurse Aide (CNA) #104 stated, on 06/28/2023 at 2:35 PM, Resident #66's brief was swelled up and she/he was wet from head to toe, and the floor was wet. CNA #104 further stated she tried to assist Resident #66 to get up so she could change him/her but Resident #66 kept saying things like I am dead, this isn't real. CNA #104 stated she went to Licensed Practical Nurse (LPN) #37, CNA #120, and CNA #84 and asked for assistance. She stated she and CNA #120 could not encourage Resident #66 to go to the shower. CNA#104 stated they wanted to get Resident #66 into a wheelchair, but the Resident stayed curled in a fetal position. CNA #104 further stated she, along with, CNA #120, and CNA #84 tried coaxing, tried promising him/her a soft drink and could not get him/her to get up. CNA #104 stated she tried to assist Resident #66 to get up and Resident #66 tried to kick at them, and the Resident kept saying things like If I put my feet on the floor I will die, I am dead, this isn't real. After numerous attempts to get Resident #66 cleaned up, she stated they decided to carry Resident #66 in his/her blankets to the shower room. During the interview, the CNA stated she and CNA #120 picked the resident up in the blankets and carried him/her to the shower room which was approximately forty (40) feet from Resident #66's room. CNA #104 stated they carried the resident to the shower room and sat the resident on the floor on his/her bottom. She stated staff got on each side of the resident and lifted him/her to the shower chair and completed the resident's shower. During an interview on 06/28/2023 at 1:21 PM with Certified Nurse Aide (CNA) #120, she stated she assisted CNA #104 with carrying Resident #66 into the shower in a blanket cradle, in the early morning hours of 06/22/2023. She stated Resident #66 refused to get out of bed to be cleaned. CNA #120 further stated she felt that was the safest way they could transport the resident due to him/her kicking at them and refusing to stand. CNA #120 stated that while she and CNA #104 transported Resident #66 to the shower, CNA #84 was mopping and cleaning the resident's room. CNA #120 stated there was urine on the floor, under the bed, in the bed, dripping from the mattress, and Resident #66 was completely saturated. She further stated the Resident was stating I can't touch the floor, I will die. The CNA #84 stated there was so much urine on the floor, they were afraid of being shocked as the bed was plugged into the electrical outlet. CNA #120 stated she did not see an extra wheelchair anywhere and the extra ones were locked in the Therapy Department at night. She stated she did not feel Resident #66 had been abused and transferring the resident by a blanket cradle was the only choice they had at the time. CNA #120 stated the [NAME] President of Operations (VPO) contacted her by phone on Thursday night, 06/22/2023, on the next shift she worked, and questioned her about the incident. She further stated the VPO contacted her again by phone on Friday, on 06/23/2023 at 8:56 PM, and she was notified that she had been suspended. Interview on 06/29/2023 at 8:21 AM, with Certified Nurse Aide (CNA) #84, she stated when CNA #120, and CNA #104 went into Resident #66's room, he/she was curled in a fetal position and would not get out of bed. CNA #84 stated Resident #66 was saturated in urine, including his/her clothes and shoes. CNA #84 stated, I was shocked when I saw the room. CNA #84 stated she was instructed by CNA #104 to go get another CNA on the other hall to assist and by the time CNA #84 got back to Resident #66's room, CNA #120 and CNA #104 had already had Resident #66 in a blanket, and they were carrying him/her out of the resident's room to the shower room. CNA #84 stated Resident #66 was not resisting or fighting but was stating, I am not alive, I am dead. CNA #84 stated she went into the shower room with them and assisted with getting Resident #66 into the shower chair and added, it was difficult to maneuver the resident into the shower chair. CNA #84 stated that she then went to Resident #66's room and began cleaning the room. She stated there was urine everywhere, and that urine appeared to be coming from inside of the mattress. She stated the urine under the bed was brown in color and the odor reeked, and there were gnats in the room. CNA #84 further stated that when she took the mattress out of the room there was a wet trail down the hall, and she also had to mop that area. CNA #84 stated, no matter anyone's mental capacity, they should stay clean, and the resident needed out of that room. CNA #84 stated it would have been negligent if the staff had left Resident #66 in the condition, he/she was found in and therefore was not abuse. During an interview with Licensed Practical Nurse (LPN) #37, on 06/27/2023 at 5:12 PM, she stated she had assisted CNA #120, CNA #104, and CNA #84 with Resident #66. LPN #37 stated that Resident #66 was refusing to shower and was saying, I would rather die than shower. The LPN stated Resident #66 refused to shower and attempted to kick and fight with them. Per the interview, LPN #37 stated CNA #120 and CNA #104 carried Resident #66 in a blanket to the shower room, adding, they did not drag him/her. Further, LPN #37 stated she held the door open as CNA #104 and CNA #120 brought the resident to the shower room. In an interview on 06/29/2023 at 9:51 AM with Registered Nurse (RN) #11, she stated that on 06/22/2023 around 6:50 PM, she overheard CNAs (unknown) discussing Resident #66 being dragged to the shower room, sprayed off, then thrown into bed by staff. RN #11 stated she immediately contacted the Director of Nursing (DON) and made her aware. She stated she was instructed by the DON to complete a head-to-toe assessment of Resident #66 and to report her findings to the DON. RN #11 further stated that the only area she noted was a reddened area to the resident's face. Further, she stated Resident #66's roommate (Resident #1) and Resident #66 both corroborated the same scenario that Resident #66 was dragged. RN #11 further stated that Resident #1 stated that Resident #66 kept him/her up all night crying. Interview on 06/28/2023 at 4:00 PM, with the Director of Nursing (DON), she stated she was contacted by RN #11 on 06/22/2023 with the report of overhearing CNAs talking about a resident being dragged to the shower. The DON stated she instructed RN #11 to complete a skin assessment on Resident #66. She stated RN #11contacted her after the skin assessment and reported only a small, reddened area on the side of Resident #66's face. She further stated that although this was not the conventional way to transport residents, she felt this was the safest way staff could transfer the resident to the shower. The DON stated that the staff should have reached out to the nurse or thought the incident out further. She further stated that she did not feel this was deficient practice but taking everything into consideration she felt staff did the best they could at the time. The DON stated she was more bothered that the resident and his/her bed were wet. In an interview with the Executive Director, on 06/28/2023 at 11:28 AM, she stated she was unaware of the alleged allegations of abuse until she was notified on 06/23/2023. Per the interview, the Executive Director stated she was on vacation at the time the incident occurred. In an interview on 06/29/2023 at 10:40 AM with the [NAME] President of Operations (VPO), he stated he had been contacted on the evening of 06/22/2023 around 7:00-7:30 PM by the [NAME] President of Clinical Services (VPCO), who had just been notified by the DON. Per the interview, he stated that at that time the incident was presented, it was communicated as one staff overhearing a conversation between two other staff. The VPO stated he interviewed Resident #66 on 06/23/2023 and the resident had no recollection of the shower incident. The VPO stated he emailed the State Survey Agency (SSA) on 06/24/2023, to report the allegations of alleged abuse. He further stated that his delay in reporting was because the allegation was reported to him as hearsay. However, review of the facility's policy revealed, the timing of reporting events that caused the suspicion of abuse was to be reported immediately, but no later than two (2) hours after forming the suspicion.

Based on interview, record review, and facility policy review it was determined the facility failed to develop the care plan to manage behaviors for one (1) of four (4) sampled residents, Resident #1. On 05/25/2020, the facility admitted Resident #1 to a secure same gender unit and readmitted Resident #1 to a general rehabilitation unit on 06/11/2020. Nursing noted on 06/12/2020 and 06/22/2020 Resident #1 exhibited sexually inappropriate behaviors towards staff. On 07/05/2020, staff discovered Resident #1 seated next to Resident #2 with Resident #1's hand on a breast of Resident #2. Review of Resident #1's comprehensive care plan revealed no plan of care was developed to manage the resident's behaviors until 07/05/2020. The facility's failure to implement comprehensive care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/14/2020 and was determined to exist on 06/12/2020. The facility was notified of the IJ on 08/14/2020. The facility provided an acceptable Allegation of Compliance (AoC) on 08/20/2020, which alleged removal of the Immediate Jeopardy on 08/18/2020. The State Survey Agency verified the IJ was removed on 08/18/2020, prior to exit on 08/27/2020. The Scope and Severity was lowered to a D while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: Review of the policy Baseline Care Plans, revised December 2016, revealed to assure that the resident's immediate care needs were met and maintained, a baseline care plan would be developed within forty-eight (48) hours of the resident's admission. The policy revealed the Interdisciplinary Team (IDT) would review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the policy Comprehensive Person-Centered Care Plans, revised December 2016, revealed the IDT, in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive care plan for each resident. The policy revealed care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Further review revealed the comprehensive, person-centered care plan would include measurable objectives and timeframes; Describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Describe services that would otherwise be provided for the above, but were not provided due to the resident exercising his/her rights, including the right to refuse treatment; Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; Incorporate identified problems areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables and objectives in measurable outcomes; Identify the professional services that were responsible for each element of care; Aid in preventing or reducing decline in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions. The policy revealed a comprehensive, person-centered care plan was developed within seven (7) days of the completion of the required comprehensive assessment (Minimum Data Set - MDS). The policy revealed once behaviors were assessed, the next step was to develop a resident-specific care plan based directly on the conclusion/underlying cause. If behaviors placed the resident or other at risk for harm, immediate action was required to prevent any harm. Further review revealed the focus of the care plan should be to address the underlying cause or causes, reversing the daily display of troubling behaviors, and preventing any harm from occurring. Review of the clinical record revealed the facility admitted Resident #1 on 05/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed Physician Orders, dated 05/25/2020, for [MEDICATION(S)] 125 mg once a day and 250mg at bedtime for Impulsive Control/Sexual Behaviors. Review of the Nursing Progress Notes, dated 06/12/2020, revealed the facility readmitted Resident #1 on 06/11/2020. Review of the nursing progress notes, dated 06/12/2020, revealed Resident #1 exhibited inappropriate sexual behaviors toward staff. Review of the Psychiatric Assessment, dated 06/15/2020, revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Notes, dated 06/22/2020, exhibited sexually inappropriate behaviors. Review of the facility investigation, dated 07/05/2020, revealed a staff member observed Resident #1 with his/her hand on Resident #2's shirt, fondling his/her breast. Review of the Change in Condition note, dated 07/05/2020, Resident #1's family reported he/she had a long history of sexually inappropriate behaviors. Review of the Resident #1's Care Plan, initiated 07/05/2020, revealed a goal the resident would have no evidence of sexually inappropriate behaviors. Further review revealed the behavior care plan was revised on 07/09/2020 with an intervention to assure personal items were in the room and preferences were accounted for; however, there were no further interventions to manage the resident's verbally and physically aggressive behaviors until 07/16/2020 when he/she hit another resident. Interview with Licensed Practical Nurse (LPN) #1, on 08/12/2020 at 2:46 PM, revealed care plans focused on a certain problems and included interventions to manage the problem. She stated a behavior care plan would include nursing interventions to prevent potential behaviors. LPN #1 stated she was unaware if the care plan for Resident #1 included interventions to implement regarding behaviors or to prevent abuse. Interview with Registered Nurse (RN) #1, on 08/13/2020 at 8:57 AM, revealed care plans were individualized and guided care to meet the needs of each resident. The RN revealed behaviors should be included in the care plan to ensure staff could monitor for potential issues. According to RN #1, the Inter-Disciplinary Team (IDT) developed the baseline care plan during the daily clinical meeting. Additionally, RN #1 could not verbalize why she did not develop a baseline care plan for Resident #1 upon admission. Interview with RN #3, on 08/13/2020 at 1:54 PM, revealed she reviewed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the care plan was individualized and included interventions to guide resident care. The RN revealed she usually initiated a baseline care plan during the admission process; however, the facility admitted about sixteen (16) residents on 05/25/2020. She revealed there was an assembly line to process the admissions and stated she entered physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated the facility should include behaviors in the resident's care plan to alert staff on what to observe for, and the interventions to implement. Interview with the Unit Manager (UM) for East Hall, on 08/13/2020 at 4:19 PM, revealed the IDT reviewed admissions, physician orders, care plans, medications, and discharge summaries to ensure the clinical record was complete. She stated behaviors should be care planned so staff were aware to monitor for potential behaviors. Additionally, the East Hall UM revealed behaviors were not included when the facility developed the care plan for Resident #1. She stated she audited care plans monthly for the East Hall; however, Resident #1 was hospitalized when she audited for June. Interview with the West Hall UM, on 08/13/2020 at 5:25 PM, revealed the facility should develop a baseline care plan within 48 hours of admission. The UM revealed the IDT reviewed progress notes, assessments, physician orders, and care plans daily to ensure the clinical record was accurate. She stated it would be important to care plan behaviors so staff knew how to care for the resident. Interview with the Social Services Director (SSD), on 08/13/2020 at 10:20 AM, revealed the baseline care plan should be developed upon admission and stated the Minimum Data Set (MDS) Coordinator or SDC was responsible for revising the care plan as needed. The SSD revealed she was not aware of Resident #1's history of sexual behaviors until he/she violated Resident #2. The SSD stated a resident care plan should include information on sexual behaviors. Interview with the Assistant Director of Nursing (ADON), on 08/13/2020 at 11:00 AM, revealed the purpose of the care plan was to identify care needs and communicate how to treat the resident. She stated the admitting nurse was responsible for initiating the baseline care plan, which should be incorporated in the comprehensive care plan. The ADON revealed the IDT reviewed new admissions, care plans, physician orders, behavior notes, changes in condition, and significant change notes daily to ensure the clinical record was accurate. Additionally, the ADON could not verbalize why Resident #1's care plan was not developed for sexual behaviors nor if the IDT reviewed the resident's care plan. Interview with the DON, on 08/14/2020 at 9:00 AM, revealed the facility discovered Resident #1's history of behaviors during the course of the investigation and stated once the facility had knowledge of them they addressed the issues. Further interview with the DON revealed the MDS Coordinator was responsible for the developing the baseline care plan. The DON revealed the facility admitted fifteen (15) residents on 05/25/2020 and the MDS Coordinator assured her she would initiate the care plans. However, the DON stated she did not review to ensure the care plans were developed. Additionally, the DON stated the investigation did not reveal the base line care plan was not developed nor interventions developed after the staff became aware of Resident #1's behaviors. Interview with the Executive Director (ED), on 08/14/2020 at 9:52 AM, revealed the facility reviewed care plans to address clinical issues and ensure they were personalized. The ED stated he could not recall any major issues with care plans and was comfortable with the thoroughness of the facility's investigation. He revealed a goal of the facility was to provide a safe environment for residents and staff.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of four (4) sampled residents was protected from sexual abuse, Resident #2. On 05/25/2020, the facility admitted Resident #1 to a secure same gender unit. After a brief hospital stay, the facility readmitted Resident #1 to a general rehabilitation unit. Nursing documented the resident displayed sexually inappropriate behaviors towards staff, after readmission; however, the facility failed to increase supervision of Resident #1. On 07/05/2020, staff discovered Resident #1 seated close to Resident #2 with his/her hand on the resident's breast. The facility's failure to protect a resident from sexual abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/14/2020 and was determined to exist on 06/12/2020. The facility was notified of the IJ on 08/14/2020. The facility provided an acceptable Allegation of Compliance (AoC) on 08/20/2020, which alleged removal of the Immediate Jeopardy on 08/18/2020. The State Survey Agency verified the IJ was removed on 08/18/2020, prior to exit on 08/27/2020. The Scope and Severity was lowered to a D while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: Review of the policy Freedom from Abuse and Neglect, effective 10/30/19, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy revealed sexual abuse was the non-consensual sexual contact of any type with a resident. Review of the policy Resident Rights, revised December 2016, revealed federal and state laws guaranteed certain basic rights to all residents of the facility. Those rights included the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the policy Behavior Assessment and Management, effective 06/25/17, revealed behavioral health encompassed the resident's whole being and included but was not limited to types of abuse. If behaviors placed the resident or other at risk for harm, immediate action was required. Review of the clinical record revealed the facility admitted Resident #1 on 05/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of twelve (12) and determined he/she was interviewable. The facility did not provide a copy of Resident #1's transfer records for the admission on 05/25/2020, to include a History & Physical (H&P). Further review of the clinical record revealed Physician Orders, dated 05/25/2020, for [MEDICATION(S)] 125 mg once a day and 250mg at bedtime for Impulsive Control/Sexual Behaviors. Review of the Nursing Progress Notes, dated 06/12/2020, revealed the facility readmitted Resident #1 on 06/11/2020. Review of the Nursing Progress Notes, dated 06/12/2020, revealed Resident #1 exhibited inappropriate sexual behaviors toward staff and verbal redirection was non-effective. Review of the Psychiatric Assessment, dated 06/15/2020, revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Notes, dated 06/16/2020, revealed Resident #1 was non-compliant with isolation on 06/22/2020, and exhibited sexually inappropriate behaviors. However, record review revealed the facility failed to increase supervision to prevent sexually inappropriate behaviors. Review of the Psychiatric Therapy Note, dated 06/26/2020, revealed staff should monitor mood and behaviors and report concerns to the physician. Review of the Change in Condition note, dated 07/05/2020, Resident #1 touched another resident inappropriately and included an intervention to continue to monitor for behaviors. According to the note, the resident's family reported he/she had a long history of touching other females inappropriately sexually. Review of the facility investigation, dated 07/05/2020, revealed a staff member observed Resident #1 with his/her hand on Resident #2's shirt, fondling his/her breast. According to the investigation, staff immediately intervened and transferred Resident #1 to a same gender Alzheimer's Care Unit (ACU). Further review of the facility investigation revealed the facility did not investigate any other resident allegations of abuse. Review of nursing progress notes revealed on 07/16/2020, staff observed Resident #1 grab another resident aggressively by the arm and hit him/her with the other hand knocking a toy out of the resident's hand. Observation, on 08/11/2020 at 5:32 PM, revealed Resident #1 lying in bed with a Patient Care Attendant (PCA) in the room providing 1:1 supervision. Interview with the resident revealed he/she denied touching and/or fondling another resident's breast. Review of Resident #2's clinical record revealed the facility admitted the resident on 03/17/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of six (6) and determined he/she was cognitively impaired. Further review of the MDS revealed the resident required extensive assistance for mobility in a wheelchair. Observation, on 08/11/2020 at 5:06 PM, revealed Resident #2 lying in a low bed covered with a sheet. Interview during observation revealed the resident could not recall if someone touched or fondled his/her breast. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's clinical record revealed the facility admitted the resident on 02/10/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) and determined he/she was interviewable. Observation, on 08/11/2020 at 5:20 PM, revealed Resident #3 seated at the edge of the bed eating supper. Interview during observation revealed another resident had asked him/her to play with your boobs. According to the resident, he/she reported the incident to staff. Interview with Certified Nursing Assistant (CNA) #1, on 08/13/2020 at 8:34 AM, revealed she was sitting at the East Hall nurses station when she overheard CNA #3 tell Resident #1 to stop. CNA #1 revealed when she looked up she observed Resident #1 sitting in the common area with his/her hand on Resident #2's shoulder. She stated CNA #3 removed Resident #2 from the area and she escorted Resident #1 to his/her assigned nurse. The CNA revealed she was aware of Resident #1's behaviors, but was not aware they were as bad as they were. According to the CNA, Resident #1 made sexually inappropriate comments to staff but she just figured it was a man thing. CNA #1 revealed she monitored residents every two (2) hours during rounds and periodically checked on them between rounds in an effort to prevent residents from sexual behaviors toward other residents. She stated there was no increased supervision of Resident #1 and staff kind of kept an eye on him/her like the other residents. Interview with CNA #3, on 08/13/2020 at 2:29 PM, revealed she was looking for Resident #1 when she observed him/her seated next to Resident #2 in the common area. The CNA stated when she approached the two (2) residents she observed Resident #1's hand cupped around Resident #2's breast. She stated she and CNA #1 separated the residents and notified the nurse. CNA #3 revealed she referred to the care plan to determine if a resident had behaviors. CNA #3 stated she believed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #3 revealed it would be important to be aware of behaviors to address the resident's needs and prevent potential abuse of others. Further interview with CNA #3 revealed Resident #1 made sexually inappropriate comments to women all of the time, including comments about body parts and descriptions of oral sex. She stated she reported Resident #1's behaviors to the nurse; however, she stated the nurses would just tell Resident #1 to not speak to people in that manner; and CNA #3 was not aware of an increase in supervision. She stated most of the time residents were on 1:1 supervision when they exhibited behaviors. Interview with CNA #2, on 08/13/2020 at 1:26 PM, revealed Resident #1 yelled out of his/her room and made sexually inappropriate jokes and comments to staff. She stated she reported the behavior to the DON when the resident made a remark to her about oral sex. CNA #2 was not able to specify when she reported Resident #1's comments about oral sex, but stated the DON instructed her to not engage with the resident and to keep the resident's door closed so it wouldn't be too loud. Additionally, CNA #2 stated Resident #1 asked another female resident if he/she could touch them and made inappropriate comments to another resident while outside smoking. Interview with Licensed Practical Nurse (LPN) #1, on 08/12/2020 at 2:46 PM, revealed she was Resident #1's assigned nurse on the day of the incident and stated the resident moved around the unit independently. The nurse revealed she was not aware of the resident's history of sexual behavior(s). In addition, she did not know if the facility care planned Resident #1 for sexual behaviors. LPN #1 stated it was her first weekend working at the facility and another nurse handled the incident involving Resident #1. Interview with RN #2, on 08/13/2020 at 9:46 AM, revealed she assisted with the investigation of the incident. She revealed she was not familiar with Resident #1, but was aware of his/her sexually inappropriate comments to staff. She further revealed it would be important to increase supervision of a resident that exhibited behaviors to prevent potential abuse of other resident(s); however, she was not aware of an increase in supervision for Resident #1. Interview with RN #3, on 08/13/2020 at 1:54 PM, revealed Resident #1 made sexually inappropriate comments to staff and she spoke with the resident to redirect him/her. She stated she did not know the resident that well and thought he/she was being dumb with the Aides. According to RN #3, transferring the resident back to the same gender unit or increasing his/her supervision would have solved the problem. Interview with the Unit Manager (UM) for East Hall, on 08/11/2020 at 5:02 PM, revealed CNA's supervised residents every two (2) hours during rounds and she rounded in between. The UM further revealed 15-minute checks or 1:1 supervision could be implemented if increased supervision was needed for a resident with behaviors. The UM stated that while she assisted with admissions she was not aware of Resident #1 exhibiting sexual behaviors prior to or since admission. Further interview with the UM, on 08/13/2020 at 4:19 PM, revealed the Inter-Disciplinary Team (IDT) reviewed the physician orders, care plan, medications, and discharge summary when a resident was readmitted to ensure the clinical record was accurate. The UM stated all the previous day's resident notes are reviewed during the IDT meeting and she could not recall any notes of behaviors. She stated she was aware Resident #1 made inappropriate comments, but was not aware of other sexually inappropriate behaviors. According to the UM, the resident did not return to the same gender unit after quarantine because the facility was trying to see if he/she was a good fit on the East Hall. Interview with LPN #4, on 08/27/2020 at 9:59 AM, revealed Resident #1 exhibited behaviors, including sexual behaviors. She stated the resident made sexually inappropriate comments and displayed aggressive behaviors towards other residents. LPN #4 revealed Resident #1 was placed on 1:1 supervision, on 07/17/2020, after he/she hit another resident. She stated she was not aware if the resident was on 1:1 supervision prior to altercation; however, an increase in supervision would be documented in the clinical record. The LPN revealed Resident #1 was alert and oriented and redirection was an appropriate intervention to manage his/her behaviors. According to the LPN, she notified the UM and DON of the resident's behaviors. Interview with the West/ACU UM, on 08/13/2020 at 5:25 PM, revealed the IDT reviewed progress notes, assessments, physician orders, discharge summary, and care plan for new/readmissions to ensure the clinical record was accurate. She further revealed she audited clinical records daily to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Social Services Director (SSD), on 08/13/2020 at 10:20 AM, revealed the interdisciplinary team (IDT) reviewed progress notes, behaviors, and hospitalization s during the morning meeting. She stated the IDT included the SSD, Director of Nursing (DON), Unit Managers (UM), Staff Development Coordinator (SDC), Therapy Director, and Executive Director (ED). The SSD revealed she could not recall discussing notes of Resident #1's sexual behaviors or acting out during the IDT meeting. According to the SSD, it would be important to be aware of sexual behaviors to ensure resident safety and prevent abuse. Interview with the Assistant Director of Nursing (ADON), on 08/13/2020 at 11:00 AM, revealed she was unaware of any increased supervision for Resident #1 and when her staff immediately notified her of the incident involving Resident #1, she initiated an investigation, and the resident was immediately transferred to the same gender ACU. The ADON revealed the IDT reviewed new admissions, care plans, physician orders, behavior notes, changes in condition, and significant changes during the daily clinical meeting; however, she was not aware of Resident #1's sexually inappropriate behaviors. Interview with the DON, on 08/14/2020 at 9:00 AM, revealed she assisted with the investigation of the incident and stated she had not identified any concerns. The DON revealed she was not aware of the Resident #1's behaviors prior to the resident's hospitalization . She stated she had a conversation with Resident #1 on one occasion after a CNA reported the resident made an inappropriate sexual comment; however, she was not aware of any further incidents after that. The DON revealed the facility did not transfer the resident back to the same gender unit after quarantine because he had not exhibited behaviors. According to the DON, the IDT decided to keep the resident on the East Hall with residents of the same activity level and the facility could open up beds for those residents that needed to be on a secure dementia unit. Further interview with the DON revealed the facility did not increase supervision of Resident #1 while he/she resided on the East unit. The DON further revealed the facility tried to do visual observation of the resident at one point. However, it was not until after Resident #1 acted sexually inappropriate with a resident, moved to the secure unit, and then was in an altercation with another resident, did the facilty initiate 1:1 supervision, to protect the residents from abuse. Interview with the Executive Director (ED), on 08/14/2020 at 9:52 AM, revealed during the investigation the facility identified a couple of instances where residents disclosed Resident #1 made comments to them. He stated the residents shut him/her down, there was no contact made, and the residents were okay with how the facility handled everything. The ED revealed he was comfortable with the thoroughness of the investigation and stated the facility substantiated the allegation of sexual abuse. The ED revealed the goal of the facility was to provide a safe environment for residents and staff. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1 to a secure same gender unit on 07/05/2020. The Medical Director assessed the resident and adjusted medications to manage behaviors. The Assistant Director of Nursing (ADON) assessed Resident #2 on 07/05/2020 with no negative findings. The Medical Director assessed the resident on 07/06/2020 with no negative findings. 2. The Licensed Nurse Manager and Memory Care Program Director interviewed sixty-nine (69) residents, on 07/05/2020, with a Brief Interview for Mental Status (BIMS) score greater than six (6) regarding concerns related to sexual advances or sexual abuse with no concerns identified. The ADON and Licensed Nurse Manager interviewed eighteen (18) staff working on 07/05/2020 regarding concerns of sexual advances or sexual abuse with no identified concerns. The Licensed Nurse, ADON, Director of Nursing (DON), and Unit Managers completed 113 skin assessments on 07/05/2020 and 07/06/2020 to observe for any signs of abuse with no negative findings. Skin assessments were completed for four (4) residents by 07/11/2020 with no negative findings. One (1) resident was hospitalized at the time of the incident. The Vice President (VP) of Clinical Services, VP of Operations, DON, and Unit Managers reviewed progress notes on 08/17/2020 for 112 residents. The review included a lookback of the previous sixty (60) days to identify documentation related to behaviors that were sexual in nature. The DON and ADON reviewed care plans on 08/17/2020 for any resident identified with sexual behaviors to ensure the care plan reflected the behaviors and included interventions to address the behaviors. 3. The facility educated all facility and agency staff regarding the Abuse and Neglect Policy, Comprehensive Care Plan Policy, and Behavior Management on 08/17/2020. The Staff Development Coordinator (SDC) and/or the Executive Director (ED) conducted the education. The education included a post-test derived from the facility's policy and procedures. The facility educated 110 staff and six (6) agency staff. Ten (10) staff members that worked as needed schedules remained untrained on 08/27/2020. The facility will train staff prior to the beginning of their next scheduled shift and prior to providing direct resident care. The Staff SDC added the education material to the orientation agenda. 4. The Administrator conducted an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the entire care team on 08/14/2020 to review the alleged cited deficiencies, policies for Abuse and Neglect, Comprehensive Care Plans, and management of sexual behaviors. Members of the Committee include the Medical Director, Social Services, SDC/Infection Preventionist, and UM's. The QAPI committee approved the facility's action plan. The DON and ADON conducted daily audits of residents beginning 08/15/2020 to observe for changes in baseline psychosocial status that could indicate abuse. The audits included review of progress notes and care plan review/updates for any identified areas of concern. The facility conducted daily audits of 100% of residents until immediacy was removed; then audits would decrease to 25% of residents five (5) times a week for two (2) weeks, then decrease to three (3) times a week for two (2) weeks, then decrease to weekly for four (4) weeks, then decrease to monthly thereafter. The DON presented the results of the audits to the QAPI Committee to ensure ongoing compliance. The QAPI Committee met weekly until immediacy was removed, then monthly thereafter. The SSA validated the facility implemented the following actions: 1. Record review on 08/12/2020 revealed the facility transferred Resident #1 to a secure same gender unit on 07/05/2020. Notifications were made according to policy. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation, on 08/25/2020 at 1:15 PM, revealed Resident #1 was supervised 1:1 in his/her room on the secure same gender Alzheimer Care Unit (ACU). Record review on 08/12/2020 revealed the ADON assessed Resident #2's skin, pain, and psychosocial status on 07/05/2020 with no negative findings. Further review revealed the Medical Director assessed the resident on 07/06/2020 with no new orders. The Progress Note revealed the resident was calm and had no complaints. Interview with the Medical Director, on 08/27/2020 at 10:55 AM, revealed he assessed Resident #2 on 07/06/2020. He stated he had not identified any clinical changes in the resident since the incident on 07/05/2020. Observation, on 08/25/2020 at 4:27 PM, revealed Resident #2 resting quietly in his/her room on the East Hall. 2. Record review on 08/25/2020 revealed the Licensed Nurse Manager and Memory Care Program Director conducted interviews on 07/05/2020 for sixty-nine (69) residents with a Brief Interview for Mental Status (BIMS) score greater than six (6) regarding concerns related to sexual advances or sexual abuse. Residents voiced no concerns. Interview with the Licensed Nurse Manager, on 08/26/2020 at 11:45 AM, revealed she interviewed residents on the East Hall regarding concerns related to sexual abuse and sexually inappropriate touch. The Nurse Manager revealed no concerns were identified. Interview with the Memory Care Program Director, on 08/27/2020 at 12:32 revealed he interviewed residents on the West Hall on 07/06/2020. He stated he interviewed residents with a BIMS score of eight (8) or above on 07/06/2020 regarding concerns related to sexual abuse. The Director revealed no concerns were identified. Record review on 08/25/2020 revealed the ADON and Licensed Nurse Manager interviewed eighteen (18) staff working on 07/05/2020 regarding concerns of sexual advances or sexual abuse with no identified concerns. Interview with the ADON and Licensed Nurse Manager revealed they interviewed staff working on 07/05/2020 regarding concerns of sexual advances or sexual abuse. No concerns were reported by staff. Record review on 08/25/2020 revealed the Licensed Nurse, ADON, DON, and UM conducted skin assessments on 07/05/2020 and 07/06/2020 for 113 residents to observe for signs of abuse with no negative findings. Skin assessments for four (4) residents were completed by 07/11/2020 with no negative findings. One (1) resident was hospitalized . Interview with the Licensed Nurse, ADON, DON, and UM revealed they performed skin assessments of all residents on 07/05/2020 and 07/06/2020 with no identified concerns. Record review on 08/26/2020 revealed the facility revised five (5) resident care plans for behaviors on 08/17/2020. Review of Resident #5's clinical record revealed the behavior care plan was revised on 08/17/2020 and 08/18/2020. Review of Resident #6's clinical record revealed the behavior care plan was revised on 08/25/2020 and the [CONDITION(S)] medication/behavior care plan was revised on 08/15/2020. Interview with the West Hall/ACU UM, on 08/26/2020 at 2:35 PM, revealed she reviewed progress notes on 08/17/2020 for sexual behaviors. She stated no new sexual behaviors were identified. Interview with the ADON, on 08/27/2020 at 9:21 AM, revealed she reviewed progress notes for increased behaviors, refusals of care, anything related to abuse, and sexual behaviors. She stated the IDT reviewed and updated care plans with any identified behaviors and notified the physician as needed. Interview with the DON, on 08/27/2020 at 10:15 PM, revealed she and the ADON, VP of Clinical Services, VP of Operations, and the UM's reviewed all resident progress notes on 08/17/2020 for the previous 60 days to identify any behaviors, sexual, verbal, aggression, or physical to ensure all behaviors were included in the care plan. She stated care plans were updated as needed when behaviors were identified. The DON revealed no sexual behaviors were identified that she could recall. Interview with the VP of Clinical Services and the VP of Operations revealed they and the IDT reviewed progress notes of all residents on 08/17/2020 to identify any behaviors within the previous sixty (60) days. Interviews revealed no new sexual behaviors were identified. 3. Record review on 08/25/2020 of the Employee Inservice Education, dated 08/17/2020, revealed the SDC and/or the ED educated 110 staff and six (6) agency staff regarding the facility's Abuse and Neglect Policy, Comprehensive Care Plan Policy, and Behavior Management on 08/17/2020. Ten (10) staff members that worked as needed schedules remained untrained on 08/27/2020. The facility will train staff prior to the beginning of their next scheduled shift and prior to providing direct resident care. The Staff SDC added the education material to the orientation agenda. Interview with the SDC, on 08/25/2020 at 11:52 AM, revealed she educated staff on the facility's Abuse/Neglect Policy and Behavior Management utilizing a staff roster to ensure all staff were educated. She stated she reviewed incorrect answers on the post-test as needed to ensure understanding of the content. Further interview revealed the SDC reviewed the staffing schedule with the IDT during the daily clinical meeting to ensure all agency and facility staff were educated before their scheduled shift. She further revealed the education was included in the New Hire Orientation Agenda. Review of the New Hire Orientation Agenda and Orientation Checklist on 08/25/2020 revealed the Abuse Policy, Resident Rights, and Behavior Management was included in the education material. Interview with the ED, on 08/27/2020 at 11:55 AM, revealed the SDC led the education and he assisted as needed. The ED revealed all staff were educated on 08/17/2020, including the leadership team, and were required to score 100% on the post-test. He stated any incorrect answers were reviewed and addressed individually to ensure understanding of the content. Further interview with the ED revealed the SDC met with staff at the beginning of their scheduled shift as needed to ensure no one worked until they were educated. 4. Record review of the Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 08/14/2020, revealed the entire care team attended the meeting, to include the ED, Medical Director, VP of Clinical Services, DON, ADON, SSD, and Memory Care Program Director. Interview with the Executive Director, on 08/27/2020 at 11:55 AM, revealed he conducted an Ad Hoc QAPI meeting on 08/14/2020 and formed an allegation of compliance and action plan. He stated the QAPI committee met weekly and made changes to the process as needed to improve and meet resident needs. Interview with the Medical Director, on 08/27/2020 at 10:55 AM, revealed he participated by phone in the Ad Hoc QAPI meeting on 08/14/2020. The Medical Director further revealed the QAPI Committee discussed the incident of sexual abuse and the facility's action plan. The ED stated he provided guidance and recommendations to the committee as needed. Interview with the VP of Clinical Services, on 08/26/2020 at 4:53 PM, revealed she participated in the Ad Hoc QAPI meeting on 08/14/2020 with facility department leaders. She stated the committee reviewed information included in the IJ citation and the facility's action plan, including the audit process and staff education. The VP of Clinical Services further revealed the committee approved the action plan. She stated the facility conducted weekly QAPI meetings until immediacy was removed. Record review of the Psychosocial/Behavior Monitoring Audit Tool revealed the DON and ADON conducted daily audits of residents beginning 08/15/2020 to observe for changes in baseline psychosocial status that could indicate abuse. The tool included observing for tearfulness, signs of fear, resistance to certain staff, decrease in activity participation, flat affect, and changes in sleep patterns.) The audits included daily review of progress notes and care plan reviews/updates for any identified areas of concern. The facility conducted daily audits of 100% of residents until immediacy was removed. No psychosocial changes were observed during the daily audits. Interview with the ADON, on 08/27/2020 at 9:21 PM, revealed performed daily audits to observe residents for behavioral changes. The ADON revealed she talked with resident during rounds and stated any identified behavior changes were investigate further to identify a trigger or root cause. The ADON revealed the IDT reviewed progress notes daily for all resident to identify any new behaviors and revised the care plan as needed. She further revealed the facility reported the findings of the audits, including any identified concerns to the QAPI Committee. She stated she had not identified any concerns as a result of the psychosocial audits. Interview with the DON, on 08/27/2020 at 10:15 AM, revealed the IDT made walking rounds daily and observed the changes in resident behaviors. She stated the IDT (ED, ADON, SSD, and UM's) discussed their observations and any pertinent findings twice a day during daily meetings. The DON revealed she and the ADON completed the audit sheets with the findings. Further interview with the DON revealed she reported any audit findings weekly to the QAPI Committee. She stated the entire IDT attended the meeting to include the Medical Director, ED, ADON, UM's, Housekeeping Director, Dietary Director, and Therapy Director. Interview with the Medical Director, on 08/27/2020 at 10:55 AM, revealed the facility conducted weekly QAPI meetings since the incident on 07/05/2020. He stated the next weekly QAPI meeting was scheduled for 08/21/2020.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received necessary care and services to attain the highest practicable physical well-being for one (1) of eleven (11) sampled residents, Resident #1. The facility failed to ensure the resident's Mediport (medical appliance installed under the skin and connected to a vein) dressing changes were completed per order, failed to assess the resident per the care plan, and failed to administer the resident's medication as ordered for an infection. Record review and interview revealed the facility failed to ensure Resident #1's Mediport dressing changes were completed per order, dated 10/07/17. The facility had orders to change the Mediport dressing on admission, weekly, and as needed; however, there was no evidence staff had changed the dressing. During the resident's hospitalization on [DATE], the hospital determined the resident's Mediport was infected and was removed. In addition, on 10/23/17, Resident #1 had a large green emesis and a large, very distended and firm abdomen. According to Resident #1's care plan, the resident was at risk for constipation with interventions to assess for firm/distended abdomen, nausea, and diminished bowel sounds. There was no evidence staff assessed the resident's bowl sounds or notified the physician of the resident's change in condition. The resident was transferred to the hospital, on 10/24/17, and a Computed Tomography (CT) revealed evidence of stool impaction in the rectum. The facility also failed to administer Resident #1's medication for an infection per the physician's orders [REDACTED]. The findings include: 1. Review of the facility's Implanted Vascular Access Device Policy, dated 06/01/99, revealed to change non-coring needle and dressing weekly if accessed. Review of Resident #1's closed clinical record revealed the facility originally admitted the resident on 11/10/00, with [DIAGNOSES REDACTED]. Further review of Resident #1's closed clinical record revealed the resident was transferred to the hospital on [DATE] and re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Order Review Report revealed an order written [REDACTED].#1 having a Mediport, right chest). However, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the dressing change order was not transcribed on either record. Review of the MAR, dated 10/01/17 through 10/31/17, revealed Resident #1's Mediport was accessed from 10/07/17 through 10/24/17, as evidenced by staff flushing the port. Further review of the clinical record revealed no documented evidence that staff completed dressing changes to the resident's Mediport per the physician's orders [REDACTED].>Interview with Director of Nursing (DON) #2, on 03/26/18 at 4:00 PM, revealed when a resident readmitted to the facility, chart checks were completed by a supervisor or charge nurse to ensure orders were taken off correctly. She stated the orders and hospital discharge summary were reviewed in the morning meetings to ensure the orders were transcribed correctly. The DON stated the computer orders should automatically carry over to the MARs and TARs. She stated it was possible the nurse put the dressing change order in as an FYI (information only); which would not have carried over to the MAR and TAR. She stated that would not have been acceptable. Per interview and review of the order, it could not be determined who wrote the order for the dressing changes. The facility employed Agency nurses at that time; however, the facility no longer uses Agency nurses. There were no nurses currently in the facility that knew about the situation. Review of the Progress Notes, dated 10/24/17 at 9:01 AM, revealed Resident #1 was very lethargic with a temperature of 99.8 degrees F. The Progress Notes at 12:05 PM revealed a temperature of 100.2 F with rapid breathing and general malaise. Resident #1 was transferred to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Continued interview with DON #2, on 03/26/18 at 4:00 PM, revealed she was the DON as of 02/26/18. She stated the order for Mediport dressing changes should have been included on the TAR to ensure nurses had instructions for assessment with documentation of completion, per physician's orders [REDACTED].#1 would be at risk for infection. Interview with Medical Doctor (MD) #2, on 01/24/18 at 12:15 PM and 03/27/18 at 8:15 AM, revealed he expected the facility to follow their policy related to Mediport dressing changes/care. He revealed if staff was not monitoring the site and changing the dressing, it could cause infection. 2. Review of Resident #1's Care Plan, undated, revealed the resident was at risk for Constipation with interventions to assess for signs/symptoms of constipation such as firm/distended abdomen, diminished bowel sounds, nausea, or abdominal discomfort. Review of Resident #1's Progress Notes, dated 10/23/17 at 10:15 PM, revealed Resident #1 had a large dark green emesis. The resident's abdomen was large, very distended, and firm; however, there was no evidence staff assessed bowel sounds or notified the physician. Resident #1 was transferred to the hospital on [DATE] where a Computed Tomography (CT) scan impression showed evidence of stool impaction in the rectum. The resident returned to the facility on [DATE]. Interview with Agency Licensed Practical Nurse (LPN) #3 via telephone, on 01/23/18 at 3:30 PM, revealed she worked on 10/23/17 and was assigned to care for Resident #1; however, she refused to answer any questions regarding the assessment of the resident's condition. Interview with the DON #1, on 01/25/18 at 2:20 PM, revealed Resident #1 should have been sent to the hospital on [DATE], when the nurse noted the green emesis and distended abdomen. Further interview with MD #2, on 01/24/18 at 12:15 PM and 03/27/18 at 8:15 AM, revealed he was very concerned with the care given to Resident #1. 3. Review of the facility's Preparation and General Guidelines policy, dated 12/18/12, revealed medications would be administered in accordance with written orders of the attending physician. If two (2) consecutive doses of a vital medication was withheld or refused, the physician would be notified. Review of Resident #1's Progress Notes, dated 09/20/17 at 6:41 AM, revealed Resident #1's supra-pubic catheter was unable to be irrigated. There was dark yellow urine noted with a foul odor and a moderate amount of sedimentation. The facility notified the physician and transferred Resident #1 to the hospital on [DATE]. Resident #1 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MAR, dated (MONTH) (YEAR), revealed a physician order [REDACTED]. The MAR revealed the medication was not given as ordered on [DATE] at 12:00 AM, 8:00 AM, and 4:00 PM. Review of Resident #1's Progress Notes, dated 09/29/17, revealed [MEDICATION NAME] was not given (for all three (3) doses) because it was not available in the facility. Interview with LPN #2, on 01/23/18 at 11:20 AM, revealed she did not give Resident #1 the dose of [MEDICATION NAME] on 09/29/17 at 12:00 AM because it was not available. She revealed it should have been in the emergency box; however, she did not recall the specific instance. LPN #2 stated if it were not available, she would have passed that information on to the next shift, as she would not call the physician in the middle of the night. She revealed missing doses of [MEDICATION NAME] could cause the infection to worsen. Interview with Agency LPN #4 via telephone, on 01/23/18 at 2:17 PM, revealed she did not give Resident #1's dose of [MEDICATION NAME] on 09/29/17 at 8:00 AM because it was not available. She stated an infection could get worse if all medication doses were not given as scheduled. Interview with Agency LPN #1 via telephone, on 01/23/18 at 10:30 AM, revealed she did not give Resident #1's dose of [MEDICATION NAME] on 09/29/17 at 4:00 PM because it was not available. She stated there was no way for her to know the resident missed two (2) prior doses because only the current dose of medication due was visible on the electronic MAR. Interview with the Pharmacy Consultant, on 01/24/18 at 10:20 AM and 12:55 PM, revealed [MEDICATION NAME] was available for use in the emergency box at the facility. He stated if the facility was missing a medication, they should notify the pharmacy. He stated there was no record of calls regarding Resident #1's [MEDICATION NAME] on 09/29/17. Per interview, the facility should have had enough doses to last until the next delivery on the evening of 09/29/17. Interview with DON #1, on 01/25/18 at 12:20 PM, revealed the nurse should check the emergency box for missing medications, as there were six (6) in the facility. She revealed if it was not available, the nurse should notify the pharmacy. Per interview, she did not know why the medication was not available on 09/29/17 to be administered at 12:00 AM, 8:00 AM, and 4:00 PM. Interview with MD #2, on 01/24/18 at 12:15 PM and 03/27/18 at 8:15 AM, revealed [MEDICATION NAME] was ordered for the resident's [DIAGNOSES REDACTED].

Based on interview, record review, review of the facility's policy, and review of the Center for Medicare/Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to revise the care plan for two (2) of eleven (11) sampled residents, Resident #1 and #2. Record review and interview revealed the facility failed to ensure Resident #1's Mediport dressing changes were completed per order. The facility had orders to change the Mediport dressing on admission, weekly, and as needed; however, the resident's care plan had not been revised to note the dressing changes. During the resident's hospitalization on [DATE], the hospital determined the resident's Mediport was infected and was removed. In addition, Resident #2's care plan was not revised after a decline in the resident's cognition to reflect the appropriateness of an intimate relationship. The findings include: Review of the facility's Care Planning policy, undated, revealed the care plan was based on the resident's comprehensive assessment. Review of the CMS RAI 3.0 User's Manual, dated (MONTH) (YEAR), Chapter 4, revealed the comprehensive care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Continued review of the CMS RAI 3.0 User's Manual, Chapter 3, revealed a Brief Interview for Mental Status (BIMS) aided in detecting cognitive impairment. The BIMS assessments scores were distributed as a score of thirteen (13) to fifteen (15) as cognitively intact, a score of eight (8) to twelve (12) as moderately impaired, and a score of zero (0) to seven (7) as severe impairment. 1. Review of Resident #1's closed clinical record revealed the facility readmitted the resident on 10/06/17, with a [DIAGNOSES REDACTED]. Review of the Order Review Report, dated 09/14/17 through 10/31/17, revealed an order written [REDACTED].#1 having a Mediport, right chest). There was no documented evidence in the resident's clinical record of completed dressing changes. Resident #1 was transferred to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, undated, revealed the resident was at risk for infection due to a Mediport; however, the care plan did not address the ordered dressing changes on 10/17/17. Review of the Progress Notes, dated 10/24/17 at 9:01 AM, revealed Resident #1 was very lethargic with a temperature of 99.8 degrees F. The Progress Notes at 12:05 PM revealed a temperature of 100.2 F with rapid breathing and general malaise. The facility transferred the resident to the hospital on [DATE]. Resident #1 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Interview with Director of Nursing (DON) #1, on 01/29/18 at 9:30 AM, revealed care plans were monitored and updated quarterly with the MDS assessment and as needed with changes. She stated any nurse could update care plans. Interview with DON #2, on 03/26/18 at 4:00 PM, revealed she was the DON as of 02/26/18, and stated the order for Mediport dressing changes should have been included on the care plan to ensure nurses had instructions for assessment with documentation of completion. Interview revealed Agency nurses were employed at that time and there was no way to know who failed to update the resident's care plan. 2. Review of Resident #2's clinical record revealed the facility originally admitted the resident on 02/22/02, with a [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan, dated 04/03/14, revealed the resident had formed a relationship with another resident to include spending time alone in his/her room. The Care Plan was updated on 05/01/15, to include an intervention to maintain privacy for intimate touching. Review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 with a BIMS and determined the resident was cognitively intact. Review of a MDS, dated [DATE], revealed the facility assessed Resident #2 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15). The MDS, dated [DATE], revealed further decline in cognition with a BIMS score of nine (9) out of fifteen (15). The current MDS, dated [DATE], revealed severe impairment with a BIMS score of six (6) out of fifteen (15); however, there was no evidence the facility re-assessed Resident #2 for the appropriateness of his/her relationship with another resident after the noted cognitive decline. Review of the facility's Self-Reported Incident, dated 12/02/17, revealed on 12/02/17, a Certified Nursing Assistant (CNA) found Resident #2 in his/her room, the resident's shirt was pulled up, and another resident was touching Resident #2's breasts. Review of a BIMS assessment, dated 12/03/17, revealed the facility assessed Resident #2 as moderately cognitively impaired with a BIMS score of ten (10) out of fifteen (15). Interview with the Social Services Specialist, on 01/29/18 at 8:50 AM, revealed he completed Resident #2's BIMS assessment on 11/22/17. He revealed he should have re-assessed the resident for appropriateness of having an intimate relationship and updated the care plan at that time; however, he stated he missed it. Interview with DON #1, on 01/29/18 at 9:30 AM, revealed the facility monitored and updated care plans quarterly with the MDS, and as needed. She revealed the cognition change from moderately impaired to severely impaired should have warranted further assessment to determine if Resident #2 had a significant change and the resident's care plan should have been updated to reflect the change in cognition.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to follow the care plan for one (1) of eleven (11) sampled residents, Resident #1, related to the assessment of constipation. On 10/23/17, Resident #1 had a large green emesis and a large, very distended and firm abdomen. According to Resident #1's care plan, the resident was at risk for constipation with interventions to assess for firm/distended abdomen, nausea, and diminished bowel sounds. There was no evidence staff assessed the resident's bowl sounds or notified the physician of the resident's change in condition. The resident was transferred to the hospital, on 10/24/17, and a Computed Tomography (CT) revealed evidence of stool impaction in the rectum. The findings include: Review of the Care Planning policy, undated, revealed the care plan was based on the resident's comprehensive assessment and was developed by a Care Planning/Interdisciplinary Team, which included the Charge Nurse responsible for resident care. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 11/10/00, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as required extensive assistance with bed mobility, transfer, hygiene, and bathing. The MDS revealed the facility assessed Resident #1 as always incontinent of bowel and had a supra-pubic catheter. Review of Resident #1's care plan, undated, revealed the resident was at risk for Constipation with interventions to assess for signs/symptoms of constipation such as firm/distended abdomen, diminished bowel sounds, nausea, or abdominal discomfort. Review of Resident #1's Progress Notes, dated 10/23/17 at 10:15 PM, revealed Resident #1 had a large dark green emesis. The note stated the resident's abdomen was large, and very distended and firm; however, there was no evidence staff assessed the resident's bowel sounds per the plan of care. Review of the Progress Notes, dated 10/24/17 at 9:01 AM, revealed Resident #1 was very lethargic with a temperature of 99.8 degrees Fahrenheit (F). The Progress Notes at 12:05 PM revealed a temperature of 100.2 F with rapid breathing and general malaise. Resident #1 was transferred to the hospital on [DATE] and a Computed Tomography (CT) scan impression showed evidence of stool impaction in the rectum. Interview, on 01/23/18 at 3:30 PM with Agency Licensed Practical Nurse (LPN) #3 assigned to care for Resident #1, via telephone revealed she worked on 10/23/17; however, she refused to answer any questions about assessing the resident per the plan of care. Interviews with current staff revealed inconsistencies regarding residents' care plans. Interview with Agency LPN #1 via telephone, on 01/23/18 at 10:30 AM and with Agency LPN #4 via telephone, on 01/23/18 at 2:17 PM, revealed they did not have access to resident care plans to know what needed to be implemented. LPN #4 further stated she did not know where the care plans were located. Interview with LPN #2, on 01/23/18 at 11:20 AM, revealed she reviewed resident care plans as time allowed. Interview with Director of Nursing (DON) #1, on 01/29/18 at 9:30 AM, revealed care plans were monitored quarterly and as needed. There was no process to ensure interventions were implemented. She stated agency nurses who were not familiar with the facility's computer system used for resident records, which housed the resident care plans, were trained on the system if they came in early for their shift, or they could review the manual at the nurses' station on how to access the system. She stated facility nurses who followed agency nurses would let her know if there were any issues that needed addressed. Post survey interview with DON #3 via telephone, on 04/13/18 at 3:00 PM, revealed she worked at the facility as the MDS Coordinator during the time Resident #1 was in the facility. She stated the DON and Assistant DON, at that time, were responsible to monitor nursing staff to ensure care plan interventions were implemented.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the physician of a change in condition and unavailable medication for one (1) of eleven (11) sampled residents, Resident #1. Record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICATION NAME] was ordered to be given three (3) times a day for the Proctitis; however, record review revealed the facility did not administer the three (3) doses of medication on 09/29/17, due to unavailability, and did not notify the physician. On 10/23/17, Resident #1 had a large dark green emesis and his/her abdomen was assessed as large, very distended, and firm. There was no documented evidence the physician was notified. The next day, 10/24/17, the resident was transferred to the hospital after assessed with [REDACTED]. A Computed Tomography (CT) revealed evidence of stool impaction in the rectum. The findings include: 1. Review of the facility's Preparation and General Guidelines policy, dated 12/18/12, revealed medications would be administered in accordance with written orders of the attending physician. If two (2) consecutive doses of a vital medication was withheld or refused, the physician would be notified. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 11/10/00, with [DIAGNOSES REDACTED]. Review of Resident #1's Progress Notes, dated 09/20/17 at 6:41 AM, revealed Resident #1's supra-pubic catheter was unable to be irrigated. There was dark yellow urine noted with a foul odor and a moderate amount of sedimentation. The facility notified the physician and transferred Resident #1 to the hospital on [DATE]. Resident #1 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #1's Progress Notes, dated 09/29/17, revealed [MEDICATION NAME] was not given (for all three (3) doses) because it was not available in the facility; however, there was no evidence of physician notification. Interview with License Practical Nurse (LPN) #2, on 01/23/18 at 11:20 AM, revealed she did not give Resident #1 the dose of [MEDICATION NAME] on 09/29/17 at 12:00 AM. LPN #2 stated if it were not available, she would have passed that information on to the next shift, as she would not call the physician in the middle of the night. Interview with Agency LPN #4 via telephone, on 01/23/18 at 2:17 PM, revealed she did not give Resident #1's dose of [MEDICATION NAME] on 09/29/17 at 8:00 AM. She revealed it was not her practice to notify the physician of missed medication doses for all medications. Interview with Agency LPN #1 via telephone, on 01/23/18 at 10:30 AM, revealed she did not give Resident #1's dose of [MEDICATION NAME] on 09/29/17 at 4:00 PM. She revealed pharmacy delivered medication every day; therefore, there was no need to notify the physician of missing medication. Interview with Medical Doctor (MD) #2, on 01/24/18 at 12:15 PM and 03/27/18 at 8:15 AM, revealed [MEDICATION NAME] was ordered for the resident's [DIAGNOSES REDACTED]. He would have expected the facility to notify him if the resident's [MEDICATION NAME] was not available. Interview with Director of Nursing (DON) #1, on 01/25/18 at 12:20 PM, revealed the nurse should notify the physician if a dose of medication was missed. 2. Review of the facility's Change in a Resident's Condition or Status policy, revised (MONTH) (YEAR), revealed the facility would promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. The policy stated the Nurse Supervisor/Charge Nurse would notify the resident's Attending Physician or On-Call Physician when there had been a need to alter the resident's medical treatment significantly. Further review of Resident #1's Progress Notes, dated 10/23/17 at 10:15 PM, revealed Resident #1 had a large dark green emesis. The resident's abdomen was large, very distended, and firm; however, there was no evidence of physician notification. Review of the Progress Notes, dated 10/24/17 at 9:01 AM, revealed Resident #1 was very lethargic with a temperature of 99.8 degrees F. The Progress Notes at 12:05 PM revealed a temperature of 100.2 F with rapid breathing and general malaise. The resident was transferred to the hospital on [DATE] where a Computed Tomography (CT) scan impression showed evidence of stool impaction in the rectum. The resident returned to the facility on [DATE]. Interview with Agency LPN #3 via telephone, on 01/23/18 at 3:30 PM, revealed she worked on 10/23/17, and cared for Resident #1. However, she refused to answer any further questions regarding the resident's condition or the need to notify the physician. Interview with MD #2, on 01/24/18 at 12:15 PM and 03/27/18 at 8:15 AM, revealed staff should always notify him of changes in condition in an effort to avoid going out to the hospital. Interview with DON #1, on 01/25/18 at 12:20 PM, revealed she expected nurses to notify the physician of any significant change in condition.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI), User Manual Version 3.0, it was determined the facility failed to have an effective system to ensure staff accurately assessed one (1) of nine (9) sampled residents (Resident #1) for exit seeking behavior. Resident #1 exhibited wandering and verbalized wanting to go home between 09/29/17 and 10/03/17 with a Code Alert device ordered on [DATE]. However, these behaviors were not reflected on the resident's admission MDS Assessment, dated 10/06/17, and therefore a plan of care was not triggered for the comprehensive assessment. On 11/13/17, Resident #1 exited the facility around 2:30 PM without staff knowledge. Around 2:50 PM staff discovered Resident #1 walking alone down the driveway at the front of the building toward the street. Interviews with staff revealed they had not observed the resident exit the building. Further interviews revealed staff had not heard the door alarm when the resident exited the facility or when a Certified Nursing Assistant escorted him/her back inside. The facility's failure to accurately assess residents at risk of elopement placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 12/07/17 and was determined to exist on 11/13/17. The facility provided and Acceptable Allegation of Compliance (A[NAME]) on 12/15/17, which alleged removal of the IJ on 12/13/17. The State Survey Agency verified the IJ was removed on 12/13/17, prior to exit on 12/20/17. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the RAI 3.0 Manual, section E0900: Wandering - Presence and Frequency, revealed to enter code 3 if the resident exhibited the behavior daily. Review of section E1000: Wandering - Impact revealed to enter code 1 if the wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Review of section P0100: Alarms, revealed to enter code 2 if a wander/elopement alarm was used daily. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 09/29/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Physician Order, dated 10/03/17, revealed Resident #1 had a Code Alert device. Review of Resident #1's admission MDS assessment, dated 10/06/17, revealed the facility coded the resident's wander/elopement alarm 0: not used, and wandering presence and frequency were coded 0: behavior not exhibited. The MDS assessment was electronically signed on 10/05/17, by the Social Services Assistant for Section E, and on 10/10/17, by the MDS Coordinator as completing Section P. The MDS assessment was signed by the MDS Coordinator as completed on 10/10/17. Review of Resident #1's quarterly MDS assessment, dated 11/08/17, revealed the facility coded the resident's wander/elopement alarm 0: not used, and wandering presence and frequency 0: behavior not exhibited. The MDS assessment was electronically signed on 11/14/17, by the MDS Coordinator as completing Section P, and signed on 11/09/17, by the Social Services Director for Section E. The MDS assessment was signed by the MDS Coordinator as completed on 11/14/17. Interview with the Social Services Director (SSD), on 12/06/17 at 8:58 AM, revealed she was responsible for MDS Section E. According to the Social Services Director, Resident #1 wandered up and down the B Hall. The Social Services Director stated she wanted to move the resident to the ACU because the resident frequently sat in a chair at the back door on B Hall. She stated she knew from admission, the family had previously discussed moving the resident to the ACU. The SSD revealed she was responsible for ensuring Resident #1's wandering behaviors were documented on the MDS. The Director revealed she only used the documentation entered in the clinical record and if a behavior was not documented, then she would not know about it. She revealed the purpose of the MDS assessment was to guide resident care. Interview with the MDS Coordinator, on 12/06/17 at 3:41 PM, revealed she compiled data from the nurses' notes, the Activities of Daily Living (ADL) flowsheet report, and the 24-hour order report, for the MDS assessment. She revealed Resident #1's admission and quarterly MDS did not reflect his/her code alert device and was inaccurate. The MDS Coordinator revealed the missing code alert data was an oversight. Interview with the Director of Nursing, on 12/07/17 at 5:15 PM, revealed she had not had time to review MDS assessments for accuracy. She revealed it was important to ensure the MDS was accurate because it was a reflection of the resident's needs. Interview with the Administrator, on 12/07/17 at 7:10 PM, revealed he was not aware of any concerns regarding accuracy of MDS assessments. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1, after the elopement, to the secure Alzheimer's Care Unit (ACU) on 11/13/17, and fitted Resident #1 with a Code Alert device. Notifications were made according to policy. The Nurse Scheduler reassessed the resident on 12/08/17 for elopement risk. The care plan and physician orders [REDACTED]. The DON modified Resident #1's MDS on 12/08/17, to reflect the resident's code alert device and revised the care plan to reflect the code alert device and the resident's history of removing the device. 2. The SSD began validating all MDS assessments on 12/07/17, for coding of wandering behavior. The SSD would validate five (5) MDS assessments weekly times twelve (12) weeks and report the findings of those audits to the QA Committee. 3. The QA Committee, including the Medical Director, met on 12/07/17, to discuss the event as set forth in the notification of Immediate Jeopardy and the action plan. The Administrator held an Ad Hoc QA meeting on 12/08/17, with the entire team to discuss progress with the plan including initial audit results and progress of staff education. The team also discussed weekend coverage to complete the plan. 4. The Regional Nurse re-educated the MDS nurse on 12/08/17, regarding accuracy of coding the code alert device on the MDS. 5. The facility reassessed one hundred and fifteen (115) current residents residing in the facility for elopement risk on 12/08/17. Care plans for fourteen (14) residents at risk for elopement were reviewed and revised as needed by the Nurse Scheduler, DON, ADON, or DCE. 6. The facility's DON and MDS Nurse audited the MDS assessments of thirteen (13) residents identified as elopement risk, on 12/08/17 and 12/12/17, and modified the MDS as needed. 7. The Regional VP of Clinical Services conducted train the trainer education on 12/08/17, with the Interim Administrator, DON, ADON, and SSD regarding education to be given to staff. A post-test was given to determine understanding of key points. The DON then conducted train the trainer education with the Dietary Manager, Director of Rehab, MDS, DCE, Admissions, Social Services Assistant, and the Nurse Scheduler. A post-test was given to determine understanding of key points. Train the trainer education included: elopement risk assessments; revision of the care plan; placement of the code alert device; notification for changes in behaviors; following physician orders; and monitoring and documentation of the code alert device. Licensed nursing staff were re-educated on 12/08/17, and were required to take a competency test to determine understanding of the topics on 12/08/17. 8. The DCE, DON, ADON, MDS nurse, and the Nurse Scheduler educated Certified Nursing Assistants (CNA) on 12/08/17, regarding monitoring of residents at risk for elopement, responding to door alarms, and reporting missing code alert devices. The Nurse Scheduler would educate Agency staff prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during the orientation period by the DON/ADON/DCE/Administrator. One (1) employee on Family Medical Leave (FMLA) would be educated prior to returning to work. The facility completed education for ninety-five (95) current staff by 12/11/17. 9. On 12/08/17, the Regional Director of Operations trained Department Heads, including the DON, the ADON, Interim Administrator, SSD, the Social Services Assistant, MDS, Admission, DCE, and the Nurse Scheduler on conducting a thorough investigation. 10. The facility posted signs at the time clock and on each door on 12/08/17, to alert staff of the required education to be completed prior to clocking in for work. To ensure that no staff worked prior to education, a department head waited at the time clock on 12/08/17. 11. On 12/08/17, the Maintenance Director educated Department Heads, who performed as Managers on duty, (consisting of the DON, ADON, MDS, Dietary Manager, Activities Director, Nurse Scheduler, Admissions, Interim Administrator, Assistant Business Office Manager, SSD, and the Social Services Assistant) on how to check the door alarm function and document the checks. 12. The IDT would review new and readmission resident charts Monday thru Friday during morning meeting to ensure elopement risk assessments had been completed, beginning 12/09/17. If a resident had been identified as an elopement risk, the IDT would review the care plan to ensure it accurately reflected the resident's needs, ensure physician orders [REDACTED]. For any new or readmissions that occurred on the weekend, the Manager on duty would follow-up with the Charge Nurse to confirm that the elopement assessment was completed, and if identified at risk, a code alert device was in place. If needed, the nurse on call would be notified and would come to the facility to follow-up on the issue. The resident's chart, including the care plan, would be reviewed with the Charge Nurse by the nurse on call (consisting of the DON, ADON, DCE, MDS, and Nurse Scheduler) within that shift. 13. The SSD or DON would be responsible for updating the six (6) elopement binders (Hiker's Handbook) as needed. 14. A member of the IDT would perform daily visual rounds Monday thru Friday beginning 12/09/17, to verify the code alert device was in place on residents who had been identified as needing the device. The Manager on duty would validate code alert placement on weekends and holidays for the next twelve (12) weeks. Nurses would visualize and check function of the code alert device three (3) times a day (or once a shift). 15. The Administrator would perform an audit of the door alarm check documentation weekly for twelve (12) weeks, beginning 12/10/17, and would report the findings to the Quality Assurance (QA) Committee. 16. The IDT team would begin weekly audits of documentation for code alert device placement and function for five (5) residents with a code alert device times twelve (12) weeks beginning 12/10/17. 17. The facility would audit five (5) elopement risk/exit seeking care plans weekly times twelve (12) weeks beginning 12/10/17, to ensure the care plan was accurate. The DON would report the audit findings to the QA committee. 18. The facility would audit the physician orders [REDACTED]. The DON would report the findings of the audits to the QA Committee. 19. A Regional Team member would review current investigations, consisting of reportable concerns or significant events in the facility, with the Administrator and/or DON weekly times twelve (12) weeks. The Regional Team member would report any concerns to the QA Committee. 20. The facility would hold weekly QA meetings times (8) weeks, then monthly times one (1) month, beginning the week of 12/10/17. A Regional Team member (consisting of the Regional Director of Operations, Regional Vice President of Clinical Services, and the Regional Reimbursement Director/Chief Operating Officer) would attend the weekly meeting times four (4) weeks. 21. The Maintenance Director or Administrator would check the function of the two (2) doors with code alert alarms with a gauge instrument daily Monday thru Friday, beginning 12/12/17. The Manager on duty would perform the door checks on weekends and holidays and document on the Door Code Alert Daily Checklist kept in the main office. Any concerns with the door alarms would be immediately addressed by maintenance and the Administrator would be notified. The SSA validated the facility implemented the following actions: 1. Observation of Resident #1, on 12/18/17 at 10:30 AM, revealed the resident on the ACU with a code alert to his/her right ankle. Review of Resident #1's clinical record revealed he/she was re-assessed for elopement risk on 12/08/17. There was a physician order [REDACTED]. Review of the MDS revealed the DON modified the assessment on 12/08/17, to accurately reflect Resident #1's wandering behavior and code alert device. Interview with Licensed Practical Nurse (LPN) #9 revealed Resident #1 was transferred to the ACU after he/she was returned from exiting the building unsupervised. Interview with the DON revealed Resident #1's MDS and Care Plan were updated for the resident's wandering behavior and code alert device. 2. Record review revealed MDS's for residents assessed as an elopement risk were reviewed by the DON and MDS Nurse for accuracy on 12/08/17. Review of audits revealed a weekly audit of five (5) resident MDS's were reviewed by the Social Services Director on 12/13/17, for coding accuracy of wandering behaviors. Interview with the MDS Coordinator, on 12/20/17 at 9:50 AM, revealed MARs, TARs, Physician Orders, and Progress Notes, along with assessing the resident, were reviewed to code wandering behaviors on the MDS. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 3. Review of the In-service Attendance Records revealed a QA meeting for IJ notification was held on 12/08/17 at 1:00 PM, and an Ad Hoc QA was held on 12/08/17 at 7:00 PM to review Plan progress related to the IJ, audits completed, assessments completed, and progress of staff education. Interview with the Medical Director, on 12/20/17 at 3:06 PM, revealed he participated in the facility's QA meetings related to the IJ. The Director revealed he advised and consulted with the facility regarding correction of the IJ. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed the facility had an immediate QA meeting with the Medical Director and IDT for the initial plan of correction. The Administrator revealed the IDT identified each area of failure based upon the citation and conducted an Ad Hoc QA meeting on 12/08/17. He revealed the facility made changes to processes as a result of the IJ. 4. Interview with the MDS nurse, on 12/20/17 at 9:50 AM, revealed the Regional MDS nurse trained her on 12/08/17, regarding Section P0200 Alarms coding on the MDS assessment. 5. Record review revealed one-hundred fifteen (115) residents were assessed for elopement risk on 12/08/17 and fourteen (14) care plans were revised to include the code alert device and/or resident behaviors. Review of three (3) new admission records and one (1) re-admission record revealed all four (4) residents were assessed for elopement risk upon admission to the facility. Interview with the DON, on 12/18/17 at 4:09 PM, she completed elopement risk assessments on one-hundred fifteen (115) resident and validated the Care Plans, MDS, Physician Orders. She stated changes to the Care Plans were made as needed. 6. Interview with the MDS Coordinator, on 12/20/17 at 9:50 AM, revealed she reviewed MDS assessments for residents identified as elopement risk. Record review revealed the MDS assessments for resident at risk for elopement were reviewed and eight (8) of thirteen (13) residents at risk for elopement were modified to accurately reflect the code alert and/or behaviors. Review of the clinical record for Residents #7, #8, and #9 revealed the care plans and MDS assessments reflected the residents' code alert device and behaviors. 7. Review of the In-service Attendance Record, dated 12/08/17, revealed the Regional VP of Clinical Services conducted a train the trainer education to the Interim Administrator, DON, ADON, and SSD with completion of post-tests. Review of the In-service Attendance Record, dated 12/08/17, revealed the DON conducted train the trainer education to the Dietary Manager, Director of Rehabilitation, MDS, DCE, Admissions, the Social Services Assistant, and the Nurse Scheduler with completion of post-tests. Interview with LPN #11, on 12/18/17 at 9:45 AM, revealed she had been trained on the facility's Elopement Policy and Procedure and completed a post-test after the training on 12/08/17. The LPN stated she verified placement and function of code alerts every shift and documented on the TAR immediately after the check. The LPN revealed residents at risk for elopement were listed in the Hikers Handbooks located at the nurses' station on each unit and CNAs were responsible for checking the handbook at the beginning of each shift. The LPN was knowledgeable regarding the facility's Elopement Policy and Procedure. Interview with the MDS nurse, on 12/20/17 at 9:50 AM, revealed the DON trained her regarding resident elopement risk assessment. Interview with the Nurse Scheduler, on 12/20/17 at 11:25 AM, revealed she had been trained regarding the facility's Elopement Policy and Procedure. Interview with the DON, on 12/20/17 at 11:58 AM, revealed the Regional VP trained her on the elopement policy and procedure of what to do when a resident eloped. The training covered care plan updates, code alert placement and daily checks, elopement assessments on admission, readmission, and change in behavior, and when and to whom to notify resident change in behavior and/or when a resident eloped. 8. Review of the In-service Attendance Record, dated 12/08/17, revealed CNAs were trained on the wandering residents, door alarms, and reporting missing code alert devices with post-test completed. Further review of post-tests revealed all staff was educated by 12/11/17. Interview with the Housekeeper, on 12/18/17 at 10:00 AM, revealed he was trained on elopement procedures and not giving out door codes to anyone. Interview with the Dietary Aide, on 12/18/17 at 10:50 AM, revealed she was trained on elopements, door alarms, and what to do if she saw a resident without a code alert device. Interview with the Activity Director, on 12/19/17 at 3:19 PM, revealed she received training regarding elopements, and code alerts and alarm doors. Interview with CNA #3, on 12/18/17 at 1:45 PM, revealed she had been trained on the facility's Elopement Policy and Procedure. The CNA stated resident behaviors should be documented in the clinical record and reported immediately to the nurse. The CNA revealed the Hikers Handbook on each unit had the names and pictures of residents who were at risk for elopement. CNA #3 was knowledgeable regarding the facility's elopement procedure. Interview with CNA #17 (agency staff), on 12/18/17 at 10:32 AM, revealed the facility trained her on the Elopement Policy and Procedure, Resident Behaviors and Safety, and she completed a post-test prior to starting work on her assigned shift. 9. Review of the In-service Attendance Record, dated 12/08/17, revealed the Regional Director of Operations educated Department Managers regarding the facility policies on Wandering, Unsafe Residents, Elopements, and Conducting a Thorough Investigation. Further review revealed staff completed a post-test to demonstrate understanding of the education. Interview with the ADON, on 12/20/17 at 10:26 AM, revealed she had been trained on the facility's Elopement Risk Policy and Conducting a Thorough Investigation. Interview with the DON, on 12/20/17 at 11:58 AM, revealed the Regional Director of Operations educated Department Managers on 12/08/17 regarding Elopements and Investigations. The DON revealed Investigations included beginning a twenty-four (24) timeline of resident behaviors, obtaining written and signed statements from witnesses, audit of the investigation and clinical record for completion, and IDT review to determine any staff education that was needed. The DON revealed all investigations were taken to QA for further review. 10. Observation of a sign posted at the time clock, on 12/18/17 at 1:10 PM, revealed it stated no staff, including agency, were authorized to work until educated on the current elopement policy and procedure information. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed a sign was posted by the time clock and the Nurse Scheduler ensured agency staff was trained prior to scheduling them to work. 11. Interview with the Maintenance Director, on 12/18/17 at 11:14 AM, revealed he trained Department Managers on the procedure for checking the door alarms and observed return demonstration to determine competency. Interview with the Dietary Manager, on 12/18/17 a 10:55 AM, revealed she had been trained regarding the facility's Elopement Policy and the procedure for checking function of the door code alert alarm. The Manager stated alarm checks were documented in a binder kept in the front office. The Manager revealed she would notify the Maintenance Director immediately and post a staff member at the door if the alarm was not operable. Interview with the Nurse Scheduler, on 12/20/17 at 11:25 AM, revealed the Maintenance Director had trained her on the procedure for checking the door code alert alarms. 12. Interview with the ADON, on 12/20/17 at 10:26 AM, revealed the IDT reviewed the elopement risk assessment and revised care plans of residents with new behaviors during the morning meeting and reviewed the clinical records of new or readmitted residents for accuracy during the daily meeting, including the elopement risk assessment. Interview with the MDS nurse, on 12/20/17 at 9:50 AM, revealed the IDT reviewed elopement risk assessments during the daily morning meeting. She stated the risk assessment and other factors, such as wandering or exit-seeking behaviors, were taken in to consideration in the determination of elopement risk. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed the nursing team monitored elopement assessments during morning meetings and used the A[NAME] as a guide to ensure all steps were reviewed and verified. 13. Observation revealed there were six (6) Hikers Handbooks located at each nurses' station. Review of the binders contents revealed there was a current list of residents, including demographics and photos; copies of the Wandering, Unsafe Resident and Elopement Policies; and Missing Person Report Forms. The resident list was dated 12/08/17. Interview with the DON, on 12/19/17 at 11:00 AM, revealed the IDT reassessed elopement risk when a resident exhibited exit-seeking behaviors. She revealed if the IDT determined the resident was an elopement risk, his/her name would be added to the Hikers Handbook and the Care Plan would be updated. She stated staff reviewed the Handbook to see what residents were elopement risks. The DON stated the Handbook was updated 12/08/17. 14. Observations of Residents #7, #8, and #9, on 12/19/17, revealed the residents had code alert devices in place. Review of Resident #7, #8, and #9 TAR's revealed the code alert device checks for function and placement were documented. Review of the audits verifying placement of code alert devices revealed audits began on 12/08/17, and conducted daily by a member of the IDT. Interview with LPN #7, on 12/18/17 at 10:12 AM, revealed she checked the placement and function of the code alert devices at the beginning of each shift. If the device did not work, it was replaced. The checks were documented on the TAR. 15. Review of the weekly audit for Door Alarm Check Documentation revealed the Administrator had completed an audit on 12/11/17. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed door codes were changed monthly and as needed. The Administrator revealed he monitored door alarm checks and spot-checked alarmed doors during daily rounds of the facility. 16. Review of the audits verifying placement and documentation of code alert devices revealed audits began on 12/08/17, and conducted daily by a member of the IDT. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed code alert audits were completed by members of the IDT. 17. Review of audits revealed five (5) care plans were reviewed by the DON on 12/12/17, to ensure accuracy of elopement care plans. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 18. Review of audits revealed Physician orders [REDACTED]. Interview with the DON, on 12/20/17 at 11:58 AM, revealed physician orders [REDACTED]. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 19. Review of audits revealed the Regional VP of Clinical Services reviewed investigations beginning 12/12/17. Interview with the DON, on 12/20/17 at 11:58 AM, revealed audits of investigations were performed to ensure they were completed correctly. Interview with the Administrator, on 12/18/17 at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 20. Review of QA meeting attendance records revealed meetings were held on 12/12/17, 12/13/17, 12/15/17, and 12/18/17 regarding audit findings. Interview with the Medical Director, on 12/20/17 at 3:06 PM, revealed he participated in the facility's QA meetings. The Director revealed he advised and consulted with the facility regarding correction of the IJ. 21. Review of the Daily Code Alert Checklist revealed the two (2) code alert alarmed doors located on the East and West units were checked and documented daily beginning 12/01/17. Interview with the Maintenance Director, on 12/18/17 at 11:14 AM, revealed the function of the two (2) door code alert alarms were verified daily. The Director revealed he checked the door alarms Monday thru Friday and the assigned Manager on Duty was responsible for the weekend alarm checks.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure residents at risk for elopement received adequate supervision to prevent elopement from the facility for one (1) of nine (9) sampled residents (Resident #1). On [DATE], Resident #1, whom the facility assessed as an elopement risk with a Code Alert device applied, exited the facility around 2:30 PM without staff knowledge. Around 2:50 PM staff discovered Resident #1 walking alone down the driveway in front of the building towards the street. Interviews with staff revealed they had not observed the resident exit the building. Further interviews revealed staff had not heard the door alarm when the resident exited the facility or when the Certified Nursing Assistant (CNA) escorted him/her back inside. The facility did not complete a thorough investigation to determine how the resident was able to exit the building or the reason staff did not hear the Code Alert door alarm sound. Review of the AccuWeather forecast for the Louisville area on [DATE] revealed the high temperature for the day was 48° Fahrenheit (F) and the low temperature was 41° F. The facility's failure to supervise residents at risk of elopement and investigate incidents involving elopement placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility provided and acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy Wandering, Unsafe Resident, revised (MONTH) 2014, revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement. Staff were to identify those residents at risk for harm because of unsafe wandering (including elopement) and assess for potentially correctable risk factors. According to the policy, when a resident was returned to the facility, the Director of Nursing (DON) or Charge Nurse should examine the resident for injuries, contact the physician to report the findings and condition of the resident, notify the resident's legal representative, complete an incident report, and document relevant information in the resident's medical record. Review of the facility's policy Elopements, revised (MONTH) 2007, revealed staff should investigate and report all cases of missing residents. The policy further revealed staff should report any resident who tried to leave the premises to the Charge Nurse or Director of Nursing. When a resident was returned to the facility, the Director of Nursing or the Charge Nurse should examine the resident for injuries, notify the physician and resident's legal representative, complete a Report of Incident/Accident, and document the event in the resident's clinical record. Review of the facility's policy Accidents and Incidents - Investigating and Reporting, revised (MONTH) 2014, revealed all accidents or incidents involving residents occurring on facility premises were to be investigated and reported to the Administrator. In addition, the policy revealed the Nurse Supervisor/Charge Nurse and/or the department director or supervisor would promptly initiate and document investigation of the accident or incident. The following data, as applicable, should include the date and time the accident or incident took place, the circumstances surrounding the incident, where the incident took place, names of witnesses and their accounts of the incident, the time the physician was notified and the time the physician responded with instructions, the date and time the family was notified, the resident's condition which included his/her vital signs, disposition (i.e. transferred to hospital, put to bed .etc.), any corrective action and follow-up information, other pertinent data as necessary or required, and the signature and title of the person completing the report. The facility did not provide a policy for Code Alert devices. Review of the clinical record for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Admission Assessment, for [DATE], revealed the Risk for Elopement had not been completed. Review of the pre-admission History & Physical (H&P), dated [DATE], revealed the resident had [DIAGNOSES REDACTED]. Review of the twenty-four (24) - seventy-two (72) Hour Admission Checklist for Resident #1, undated, revealed the elopement section was not completed. Interview with Licensed Practical Nurse (LPN) #13, on [DATE] at 12:20 PM revealed she was assigned to care for Resident #1 on the day the resident was admitted and stated the resident appeared very confused. The LPN stated she made a progress note but did not complete the admission assessment because the Nurse Supervisor was responsible for doing the assessment. However, interview on [DATE] at 10:10 AM with LPN #2, revealed the admitting nurse was responsible to ensure the Admission Assessment, including the Elopement Risk Assessment, was completed at the time of admission. Review of a physician/nurse practitioner progress note, dated [DATE], revealed the resident was a new resident and had a [DIAGNOSES REDACTED]. The resident was alert and oriented to himself/herself and the year; however the resident was not oriented to his/her situation or who was the President. Review of the Physician order [REDACTED].#1's right ankle for proper functioning, and replace when expired, every shift for elopement. Review of a Nurse's Note, dated [DATE] at 7:51 PM, revealed a Certified Nursing Assistant (CNA) accidentally let the resident out the door because the CNA did not know he/she was a resident. Per the Nurse's Note, the resident previously refused to have the Code Alert placed; however, when the family arrive the resident agreed to have the Code Alert put on by the nurse. A Nurse's Note, dated [DATE] at 10:46 PM, revealed the resident agreed to wear the Code Alert and the bracelet was placed on his/her right ankle. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) of a nine (9) out of fifteen (15), indicating the resident was moderately cognitively impaired. The MDS noted the resident did not wander and was able to ambulate independently with supervision. The MDS also revealed the resident was assessed not to exhibit any wandering and the use of a wander/elopement alarm was not noted. Review of Resident #1's CNA care sheet, not dated, revealed the Code Alert device and the resident's exit seeking behavior were not listed. Interview with CNA #9, on [DATE] at 4:00 PM, revealed Resident #1 wandered a lot and asked when he/she was going home, however also stated the resident did not have behaviors. According to the CNA, the resident would sit in a chair at the B Hall exit door all day long. The CNA revealed she was responsible for ensuring resident behaviors were documented in the resident Activities of Daily Living (ADL) record and the nurse had been notified of behaviors. The CNA further revealed resident elopement risk was not listed on the CNA care plan. Review of a Progress Note for Resident #1, dated [DATE] at 7:50 AM, revealed the resident walked up and down the halls and asked when he/she was going home. Review of an elopement assessment, dated [DATE], for Resident #1 revealed the facility determined the resident was at high risk for elopement. On [DATE] at 8:58 AM, interview with the Social Services Director (SSD) revealed the facility did not conduct an elopement assessment for Resident #1 prior to [DATE]. The SSD revealed if a resident was admitted to the facility with a [DIAGNOSES REDACTED]. However, record review revealed the resident had a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident with a BIMS score of five (5) out of fifteen (15) indicating the resident was cognitively impaired. However, review of the MDS revealed the resident did not wander and did not use a wander/elopement alarm, even though the behavior was documented in the resident's clinical record. Review of a Nurse's Note, dated [DATE] at 2:35 PM, completed by the Director of Nursing (DON) revealed a nurse stated Resident #1 was sitting at the end of the hall as usual at approximately 2:35 PM. The note further revealed the resident chose to enjoy the outside patio and staff quickly escorted the resident back into the facility as the resident was not properly dressed with a coat for the cold weather. The responsible party was notified. However, interview, on [DATE] at 1:30 PM, with LPN #9 revealed Resident #1 exited the building unknown to staff on [DATE]. She was assigned to care for the resident that day and also on previous days and revealed he/she appeared really confused. In addition, she stated the resident often sat by the door at the end of B Hall where the resident phone was located. She revealed, on [DATE] before she went to lunch, she recorded in the resident's Treatment Administration Record (TAR) that she had checked for placement and function of the Code Alert bracelet and then went to lunch, without actually checking the resident for the device. She stated she intended to check for it after lunch and before the end of her shift; however, failed to do so when she returned from lunch. The LPN stated when she returned from lunch she observed Resident #1 sitting by the back door at the end of B Hall. The LPN revealed she did not see Resident #1 exit the building and did not hear a door alarm sound. She stated ten (10) to fifteen (15) minutes later CNA #10 escorted Resident #1 to the East unit and informed her that the resident had been discovered outside near the front of the building. She stated she notified the DON who then stated the resident would be moved to the Alzheimer's Care Unit (ACU) and instructed her (LPN #9) to notify the resident's family. Interview with CNA #10, on [DATE] at 1:40 PM, revealed on [DATE] at about 2:50 PM he was outside the facility near his car which was parked in front of the building. He stated when he walked to the back of his car he noticed a person walking alone down the driveway and around the corner of the building. He stated a man driving from the back parking lot stopped and told the CNA that the person walking was a resident and to get him/her. The CNA stated he then looked closer at the person walking, recognized he/she was a resident, and asked the resident to accompany him back inside. The CNA stated he accompanied the resident back inside the building through the locked (keypad) front entry door. He revealed he escorted the resident past the receptionist office, down the enclosed ramp (through two (2) locked, key padded doors), and into the East unit. The CNA stated he took the resident to LPN #9 and reported finding the resident outside the building. Interview with the Maintenance Assistant, on [DATE] at 2:10 PM, revealed he worked at the facility on [DATE] and left around 2:30 PM. The Maintenance Assistant revealed he exited the facility to the parking lot through the B Hall door. The Maintenance Assistant stated he did not see anyone outside the B Hall door on the patio or in the parking lot. According to the Maintenance Assistant, he walked to his vehicle, drove up the driveway, and observed Resident #1 walking down the driveway towards the street. He stated the resident was dressed in blue jeans, long sleeved shirt, and shoes and was not wearing a jacket. He stated he told a CNA in the visitor parking lot to take the resident back in to the building and he parked his car. The Maintenance Assistant stated the CNA walked Resident #1 back in to the front entrance of the building and he entered the building approximately four (4) to five (5) feet behind the CNA and resident. Per interview, no alarm sounded as the resident entered the building. The Maintenance Assistant stated he immediately reported the incident to the DON, but never provided a written statement of the account. He revealed the codes to the exit doors were changed the following day ([DATE]). Interview, on [DATE] at 12:17 PM, with the Assistant Director of Nursing (ADON) revealed Resident #1 exited the B Hall door of the East Unit on [DATE]. The ADON revealed she heard the B Hall door open, but did not hear the door alarm. She stated she looked through the windows and observed Resident #1 outside, standing alone on the patio. The nurse revealed she observed other people in the cars parked in the parking lot. In addition, the ADON stated she observed a male, whom she identified as a housekeeper, walk up from the parking lot and began talking to the resident. According to the ADON, the housekeeper walked with the resident to talk with a man in a truck located in the parking area and then walked the resident up the driveway and back in the front door near the receptionist desk. The ADON walked through the building to the receptionist area where she saw the housekeeper walk through the front door with the resident. The ADON stated she accompanied the resident through the building and back onto the East unit. She stated no alarm sounded when she heard the B Hall door open or when Resident #1 re-entered the building through the front door. She revealed both doors had a Code Alert system and would have alarmed if the resident was wearing a Code Alert device. Interview with the DON, on [DATE] at 5:15 PM, revealed she initiated an investigation when Resident #1 exited the building. The DON revealed CNA #10 brought Resident #1 back in the building from the parking lot. She stated CNA #10 had been alerted by a maintenance man, who was driving near the visitor parking area, that a resident was walking up the drive. She stated the CNA accompanied the resident back into the building to the East unit. According to the DON, she approached the resident and talked to him/her for a minute. The DON stated when the resident walked into the building he/she did not appear to be upset, had no visible bleeding, and was fully dressed and smiling. The DON stated she did not know if the resident was wearing the code alert device when he/she re-entered the building. She stated she had assumed someone had let the resident out of the building accidentally, but did not know who. Continued interview with the ADON , on [DATE] at 12:17 PM, revealed Resident #1's Code Alert device had been replaced three (3) or four (4) times due to the resident getting the device off. According to the ADON, Resident #1 had a soft file that included her written statement from [DATE]. The ADON stated she did not participate in the elopement investigation and did not know how Resident #1 exited the facility. Review of the facility's file of the incident revealed the [DATE] QAPI Plan- Elopement System Review document revealed a (unnamed) resident exited the facility. Actions included the resident returned immediately and assessed- placed on one to one supervision, notification of DON and investigation initiated, immediate check of the doors, door code changed, other elopement risk residents checked and included assessments of wanderguards (Code Alert)-checked for expiration and placement, elopement books checked, all other residents reviewed to ensure an elopement evaluation in the last quarter and was accurate, and monitoring that included daily door checks were completed and Code Alert checked every shift. Each item listed had a target date of [DATE] and a checkmark was next to each target date, except for the monitoring. Additionally, the file included an elopement risk assessment, dated [DATE], which revealed the facility determined Resident #1 was at high risk for elopement. The only statement included was from the ADON, dated [DATE], which revealed she saw the resident walking around the the East wing by the door and she looked away. The ADON statement further revealed when she turned back around, the resident was outside on the patio and staff brought the resident in the front door. Additionally, an untitled documented list of fourteen (14) residents, not dated, revealed Resident #1 was assessed for risk of elopement on [DATE], however did not have a care plan in place and needed one. Additionally, the Code Alert for Resident #1 should be in place at all times. The facility file did not include additional staff and witness interviews or statements, any information to determine the root cause of the incident, or if the resident was, or was not, wearing the Code Alert device. Observation of Resident #1 in the ACU, on [DATE] at 4:23 PM, on [DATE] at 11:50 AM, and on [DATE] at 5:25 PM revealed the resident had no Code Alert device on any extremity. However, per the facility's investigation, Resident #1's Code Alert should be in place at all times. Interview with LPN #10, during the observation on [DATE] at 11:50 AM, revealed Resident #1 was not wearing a Code Alert device. The LPN stated the resident had a physician's orders [REDACTED]. Interview with Registered Nurse (RN) #3, on [DATE] at 4:40 PM, revealed she observed Resident #1 without a code alert two (2) times and had replaced them on both occasions. The RN revealed she informed the resident's assigned nurse and expected that the nurse would make a progress note regarding her observations and actions. However, review of the Progress Notes for Resident #1, dated [DATE] through [DATE], revealed there were no entries regarding the resident's missing code alert device or replacement of the device. Review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed monitor code alert to right ankle every shift for proper functioning and replace when expires every shift for elopement. Further review revealed Code Alert monitoring was not documented eighteen (18) shifts on the TAR for (MONTH) (YEAR), dated [DATE] - [DATE]. Interview with LPN #2, on [DATE] at 10:10 AM, revealed nurses were responsible for monitoring and documenting the code alert checks on the TAR. The nurse stated it was important to monitor the code alert device to prevent the risk of elopement and ensure resident safety. Interview with the DON, on [DATE] at 5:15 PM, revealed nurses were responsible for monitoring the code alert devices every shift and signing off the TAR when the check was completed. The DON stated there was a risk for elopement if the resident was not wearing the code alert or it was not functioning properly. Interview with the Medical Director, on [DATE] at 4:57 PM, revealed he expected staff to monitor the Code Alert device as ordered. He further revealed there was an increased risk of elopement and potential harm to a resident if the Code Alert device was not monitored. Interview, on [DATE] at 7:15 PM, with the Interim Administrator revealed it was the responsibility of the DON, ADON, and nursing staff to ensure admission assessments, and TARs were completed, and physician's orders [REDACTED]. Interview with Resident #1's Power of Attorney (POA), on [DATE] at 5:05 PM, revealed he had asked the facility to admit the resident to the locked, secured unit (ACU); however, the facility admitted the resident to a private room on the East unit. The POA stated he was not sure the reason Resident #1 was not admitted to the secured unit but the resident was moved to the secured unit after getting out of the facility. Interview with the Admissions Director, on [DATE] at 4:10 PM, revealed Resident #1 was admitted from home accompanied by the Power of Attorney (POA). The Admissions Director stated she did not recall if the POA had requested Resident #1 be placed on the secure ACU. According to the Director, room assignments were discussed during morning Interdisciplinary Team (IDT) meeting and consideration was taken regarding compatibility of a potential roommate. She revealed any special needs that were identified were communicated to the DON and/or SSD. The Admissions Director stated she would have notified the DON of a specific request for the ACU. Continued interview, on [DATE] at 8:58 AM, with the SSD revealed she knew from admission, the family had discussed moving the resident to the ACU. She stated she wanted to move Resident #1 to another room as she was concerned with the location of the resident's room. She further stated the resident wandered up and down the hall and would sit in a chair at the back door on the B Hall. The SSD revealed she notified the IDT during morning meeting and discussed with the DON, and everyone was in agreement. She further revealed she left a message for the family on [DATE] and documented the call in the progress notes. Review of a Social Services Note, dated [DATE], revealed the SSD left a message for the resident's family regarding a potential room move. Review of a Social Service Note, dated [DATE], by the SSD revealed a message was left for the family on [DATE] at 3:00 PM regarding a room change. The note also revealed the family had previously discussed moving the resident to the ACU and was understanding a potential room move. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1, after the elopement, to the secure Alzheimer's Care Unit (ACU) on [DATE], and fitted Resident #1 with a Code Alert device. Notifications were made according to policy. The Nurse Scheduler reassessed the resident on [DATE] for elopement risk. The care plan and physician orders [REDACTED]. The DON modified Resident #1's MDS on [DATE], to reflect the resident's code alert device and revised the care plan to reflect the code alert device and the resident's history of removing the device. 2. The SSD began validating all MDS assessments on [DATE], for coding of wandering behavior. The SSD would validate five (5) MDS assessments weekly times twelve (12) weeks and report the findings of those audits to the QA Committee. 3. The QA Committee, including the Medical Director, met on [DATE], to discuss the event as set forth in the notification of Immediate Jeopardy and the action plan. The Administrator held an Ad Hoc QA meeting on [DATE], with the entire team to discuss progress with the plan including initial audit results and progress of staff education. The team also discussed weekend coverage to complete the plan. 4. The Regional Nurse re-educated the MDS nurse on [DATE], regarding accuracy of coding the code alert device on the MDS. 5. The facility reassessed one hundred and fifteen (115) current residents residing in the facility for elopement risk on [DATE]. Care plans for fourteen (14) residents at risk for elopement were reviewed and revised as needed by the Nurse Scheduler, DON, ADON, or DCE. 6. The facility's DON and MDS Nurse audited the MDS assessments of thirteen (13) residents identified as elopement risk, on [DATE] and [DATE], and modified the MDS as needed. 7. The Regional VP of Clinical Services conducted train the trainer education on [DATE], with the Interim Administrator, DON, ADON, and SSD regarding education to be given to staff. A post-test was given to determine understanding of key points. The DON then conducted train the trainer education with the Dietary Manager, Director of Rehab, MDS, DCE, Admissions, Social Services Assistant, and the Nurse Scheduler. A post-test was given to determine understanding of key points. Train the trainer education included: elopement risk assessments; revision of the care plan; placement of the code alert device; notification for changes in behaviors; following physician orders; and monitoring and documentation of the code alert device. Licensed nursing staff were re-educated on [DATE], and were required to take a competency test to determine understanding of the topics on [DATE]. 8. The DCE, DON, ADON, MDS nurse, and the Nurse Scheduler educated Certified Nursing Assistants (CNA) on [DATE], regarding monitoring of residents at risk for elopement, responding to door alarms, and reporting missing code alert devices. The Nurse Scheduler would educate Agency staff prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during the orientation period by the DON/ADON/DCE/Administrator. One (1) employee on Family Medical Leave (FMLA) would be educated prior to returning to work. The facility completed education for ninety-five (95) current staff by [DATE]. 9. On [DATE], the Regional Director of Operations trained Department Heads, including the DON, the ADON, Interim Administrator, SSD, the Social Services Assistant, MDS, Admission, DCE, and the Nurse Scheduler on conducting a thorough investigation. 10. The facility posted signs at the time clock and on each door on [DATE], to alert staff of the required education to be completed prior to clocking in for work. To ensure that no staff worked prior to education, a department head waited at the time clock on [DATE]. 11. On [DATE], the Maintenance Director educated Department Heads, who performed as Managers on duty, (consisting of the DON, ADON, MDS, Dietary Manager, Activities Director, Nurse Scheduler, Admissions, Interim Administrator, Assistant Business Office Manager, SSD, and the Social Services Assistant) on how to check the door alarm function and document the checks. 12. The IDT would review new and readmission resident charts Monday thru Friday during morning meeting to ensure elopement risk assessments had been completed, beginning [DATE]. If a resident had been identified as an elopement risk, the IDT would review the care plan to ensure it accurately reflected the resident's needs, ensure physician orders [REDACTED]. For any new or readmissions that occurred on the weekend, the Manager on duty would follow-up with the Charge Nurse to confirm that the elopement assessment was completed, and if identified at risk, a code alert device was in place. If needed, the nurse on call would be notified and would come to the facility to follow-up on the issue. The resident's chart, including the care plan, would be reviewed with the Charge Nurse by the nurse on call (consisting of the DON, ADON, DCE, MDS, and Nurse Scheduler) within that shift. 13. The SSD or DON would be responsible for updating the six (6) elopement binders (Hiker's Handbook) as needed. 14. A member of the IDT would perform daily visual rounds Monday thru Friday beginning [DATE], to verify the code alert device was in place on residents who had been identified as needing the device. The Manager on duty would validate code alert placement on weekends and holidays for the next twelve (12) weeks. Nurses would visualize and check function of the code alert device three (3) times a day (or once a shift). 15. The Administrator would perform an audit of the door alarm check documentation weekly for twelve (12) weeks, beginning [DATE], and would report the findings to the Quality Assurance (QA) Committee. 16. The IDT team would begin weekly audits of documentation for code alert device placement and function for five (5) residents with a code alert device times twelve (12) weeks beginning [DATE]. 17. The facility would audit five (5) elopement risk/exit seeking care plans weekly times twelve (12) weeks beginning [DATE], to ensure the care plan was accurate. The DON would report the audit findings to the QA committee. 18. The facility would audit the physician orders [REDACTED]. The DON would report the findings of the audits to the QA Committee. 19. A Regional Team member would review current investigations, consisting of reportable concerns or significant events in the facility, with the Administrator and/or DON weekly times twelve (12) weeks. The Regional Team member would report any concerns to the QA Committee. 20. The facility would hold weekly QA meetings times (8) weeks, then monthly times one (1) month, beginning the week of [DATE]. A Regional Team member (consisting of the Regional Director of Operations, Regional Vice President of Clinical Services, and the Regional Reimbursement Director/Chief Operating Officer) would attend the weekly meeting times four (4) weeks. 21. The Maintenance Director or Administrator would check the function of the two (2) doors with code alert alarms with a gauge instrument daily Monday thru Friday, beginning [DATE]. The Manager on duty would perform the door checks on weekends and holidays and document on the Door Code Alert Daily Checklist kept in the main office. Any concerns with the door alarms would be immediately addressed by maintenance and the Administrator would be notified. The SSA validated the facility implemented the following actions: 1. Observation of Resident #1, on [DATE] at 10:30 AM, revealed the resident on the ACU with a code alert to his/her right ankle. Review of Resident #1's clinical record revealed he/she was re-assessed for elopement risk on [DATE]. There was a physician order [REDACTED]. Review of the MDS revealed the DON modified the assessment on [DATE], to accurately reflect Resident #1's wandering behavior and code alert device. Interview with Licensed Practical Nurse (LPN) #9 revealed Resident #1 was transferred to the ACU after he/she was returned from exiting the building unsupervised. Interview with the DON revealed Resident #1's MDS and Care Plan were updated for the resident's wandering behavior and code alert device. 2. Record review revealed MDS's for residents assessed as an elopement risk were reviewed by the DON and MDS Nurse for accuracy on [DATE]. Review of audits revealed a weekly audit of five (5) resident MDS's were reviewed by the Social Services Director on [DATE], for coding accuracy of wandering behaviors. Interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed MARs, TARs, Physician Orders, and Progress Notes, along with assessing the resident, were reviewed to code wandering behaviors on the MDS. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 3. Review of the In-service Attenda (TRUNCATED)

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete for monitoring of the code alert device for three (3) of nine (9) sampled residents, Residents #1, #5, and #6. In addition, review of Resident #1's Admission Assessment revealed the facility failed to complete the elopement, skin, pressure sore, and nutritional risk assessments upon admission to the facility. Review of Resident #1's clinical record also revealed Resident #1's behaviors of wandering were not consistently documented. Also, the clinical record failed to accurately detail the incident of Resident #1's elopement from the facility. Record review revealed Resident #1 had exit seeking behaviors and was to wear a code alert device and staff was to monitor the code alert device every shift for proper functioning. Review of the record revealed missing entries documenting staff had monitored the code alert every shift for proper functioning and staff failed to document the resident's exit seeking behavior. On [DATE], Resident #1 eloped from the facility without staff knowledge. Further review of Resident #1's clinical record revealed this incident was not detailed in the Nurse's Notes. The facility's failure to have an effective system in place to ensure clinical records were accurate and complete placed residents in a situation that has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency verified Immediate Jeopardy was removed on [DATE], as alleged, prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. In addition, staff failed to document pain medication administration for three (3) of four (4) unsampled residents, Unsampled Residents B, C, and D. The findings include: 1. Review of the facility's policy, Admission Assessment and Follow Up: Role of the Nurse, revised (MONTH) 2012, revealed the purpose of the procedure was to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the Minimum Data Set (MDS). Documentation recorded in the resident's medical record should include all relevant assessment data obtained during the procedure, orders obtained from the physician, and the signature and title of the person recording the data. Review of the clinical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Assessment, dated [DATE], revealed the Elopement, Skin, Pressure Sore, and Nutritional Risk assessments were not completed and the form was not signed by a nurse. Interview with Licensed Practical Nurse (LPN) #13, on [DATE] at 12:20 PM, revealed she was assigned to care for Resident #1 when he/she was admitted on [DATE]. The LPN stated she entered a progress note regarding the admission, but did not complete the admission assessment. The LPN revealed the Nurse Supervisor usually performed the assessment for new admissions. However, interview with LPN #2, on [DATE] at 10:10 AM, revealed the admitting nurse was responsible for ensuring the resident Admission Assessment, including the Elopement Risk Assessment, was completed at the time of admission. Interview with the Director of Nursing (DON), on [DATE] at 5:15 PM, revealed the resident's assigned nurse was responsible for ensuring the admission assessment, including the elopement assessment, was completed. The DON further revealed the assessment should be completed within twenty-four (24) hours of the resident admission to the facility. The DON revealed she did not conduct audits of clinical record to ensure accuracy. The Director stated Resident #1's admission assessment was not complete and the elopement risk assessment was not done. 2. The facility did not provide a policy regarding documenting on the Treatment Administration Record (TAR). Review of the clinical record for Resident #1 revealed a physician progress notes [REDACTED].#1 was admitted to the facility for progression of Dementia and was exit seeking at times. Further review revealed a Physician Order, dated [DATE], to monitor the code alert device on the right ankle every shift for proper functioning and replace when expired. However, review of Resident #1's Treatment Administration Record (TAR), dated [DATE] to [DATE], revealed there were fourteen (14) missing entries documenting the code alert had been monitored every shift for proper function and expiration date for elopement. Review of the TAR, dated [DATE] to [DATE], revealed there were eighteen (18) missing entries documenting the code alert had been monitored for function and expiration date. Record review revealed issues with the documentation of monitoring of the Code Alert devices for two (2) other residents. Review of Resident #5's clinical record revealed a TAR, for (MONTH) (YEAR), with a physician order [REDACTED]. The order's start date was [DATE]. Further review revealed eight (8) missing entries for monitoring the code alert for working order. Review of the TAR, for (MONTH) (YEAR), revealed there were five (5) missing entries for monitoring of the code alert for proper working order. Review of Resident #6's clinical record revealed a TAR, for (MONTH) (YEAR), with a physician order [REDACTED]. The order's start date was [DATE]. Further review revealed ten (10) missing entries for monitoring the code alert for placement and function. Review of the TAR, for (MONTH) (YEAR), revealed there were fifteen (15) missing entries for monitoring of the code alert for placement and function. Interview with LPN #2, on [DATE] at 10:10 AM, revealed nurses were responsible for ensuring the code alert checks were monitored and documented on the TAR. The nurse stated it was important to monitor the code alert device to prevent the risk of elopement and ensure resident safety. Interview with LPN #9, on [DATE] at 1:30 PM, revealed she signed off all TARs, including the code alert checks, during the less busy time of the shift. The LPN revealed there was a risk of an error if all TARs were signed off at the same time. She stated the code alert device was monitored each shift to ensure it was functioning properly. The LPN revealed there was a risk a resident could elope and be harmed if the code alerts were not in place or not functioning. Interview with the DON, on [DATE] at 5:15 PM, revealed nurses were responsible for ensuring the code alert devices were monitored every shift. She revealed the code alert was monitored by checking for placement, expiration date, and testing for function. The DON revealed it was important to document resident behaviors in the clinical record to identify new or worsening behaviors, and so the physician could address those behaviors. The Director revealed she had not identified any concerns with nursing documentation on the TARs. Interview with the Medical Director, on [DATE] at 4:57 PM, revealed he expected staff to monitor the code alert device as ordered. He further revealed there was an increased risk of elopement and potential harm to a resident if the code alert device was not monitored. 3. Review of the CNA Activity of Daily Living (ADL) Report for Resident #1, for (MONTH) (YEAR), revealed there were forty-one (41) missing entries related to Behavior Monitoring. Further review of the ADL Report for (MONTH) (YEAR), revealed there were twenty-one (21) missing entries related to Behavior Monitoring. Interview with CNA #11, on [DATE] at 11:00 AM, revealed CNAs were responsible for ensuring resident behaviors were documented in the ADL record. The CNA revealed resident behaviors could not be identified if they were not documented. Interview with CNA #9, on [DATE] at 4:00 PM, revealed she was responsible for ensuring resident behaviors were documented in the resident ADL record and notifying the nurse of behaviors. She revealed Resident #1 wandered a lot and asked when he/she was going home; however, these were not documented as behaviors on the ADL record. Interview with LPN #2, on [DATE] at 10:10 AM, revealed CNAs were responsible for documenting behaviors on the resident ADL record. Continued interview with the DON, on [DATE] at 5:15 PM, revealed she had identified areas for improvement in CNA documentation; however, there was no documented evidence any action had been taken. 4. Review of the facility's policy Elopements, revised (MONTH) 2007, revealed when a resident was returned to the facility, the Director of Nursing or the Charge Nurse should document the event in the resident's clinical record. Review of Resident #1's clinical record revealed a Nurse's Note dated [DATE] at 2:35 PM and completed by the DON. Review of the note revealed the resident chose to enjoy the outside patio and staff quickly escorted the resident back into the facility as the resident was not properly dressed with a coat for the cold weather. The responsible party was notified. However, interview revealed the resident exited the facility without staff knowledge and was found walking down the driveway towards the street by staff leaving the facility. Interview, on [DATE] at 1:30 PM, with LPN #9 who was assigned to care for Resident #1 on [DATE] when the resident exited the building unknown to staff, revealed she spoke to the DON and asked the process for documentation. The LPN revealed the DON then entered a progress note regarding the incident. LPN #9 stated the professional standard was to document everything that happened in the clinical record. The LPN further stated that documentation served as communication to other staff members about the resident and should contain all significant events, including behaviors. 5. Review of the facility's policy, Administering Medications, revised (MONTH) 2012, revealed the individual administering the medication must initial the resident's Medication Administration Record [REDACTED]. Further review revealed the individual administering the medication would record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug. Review of the facility's policy, Documentation of Medication Administration, revised (MONTH) 2007, revealed administration of medication must be documented immediately after it was given. Documentation must include reason(s) why a medication was withheld, not administered, or refused (as applicable), signature and title of the person administering the medication, and resident response to the medication, if applicable. Review of the clinical record for Unsampled Resident B revealed an Admission MDS dated [DATE], and the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of the pain assessment portion of the MDS revealed Unsampled Resident B had not experienced any pain during the look back period. Interview with Unsampled Resident B, on [DATE] at 11:00 AM, revealed he/she received pain medication when he/she asked. Review of Unsampled Resident B's MAR, for (MONTH) (YEAR), revealed a physician order [REDACTED]. Review of the Controlled Drug Record (Narcotic Sheet) for Unsampled Resident B revealed [MEDICATION NAME] ,[DATE] mg had been signed out on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; however review of the resident's MAR indicated [REDACTED]. Review of the Progress Notes for Unsampled Resident B revealed no documentation the [MEDICATION NAME] was administered on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with LPN #3 on [DATE] at 3:30 PM revealed she had not signed the MAR indicated [REDACTED]. Review of Unsampled Resident C's clinical record revealed a Quarterly MDS dated [DATE], and the facility assessed the resident with a BIMS score of a fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of the Pain section of the MDS revealed the resident had not experienced any pain during the look back period. Interview with Unsampled Resident C, on [DATE] at 11:20 AM, revealed he/she received pain medication for back pain when he/she asked for it and had not requested pain medication for a couple of weeks. Review of Physician Orders, signed [DATE], for Unsampled Resident C, revealed an order for [REDACTED]. Review of Unsampled Resident C's Controlled Drug Record for (MONTH) (YEAR), revealed staff signed out [MEDICATION NAME] 7XXX,[DATE] mg twenty-five (25) times from [DATE] through [DATE]; however, review of the resident's MAR for (MONTH) (YEAR), revealed documentation the medication was administered to the resident only seven (7) times, on ,[DATE],/17, [DATE], twice on [DATE], [DATE], [DATE], and [DATE]. Interview with LPN #4, on [DATE] at 10:20 AM, revealed Unsampled Resident C usually was administered a pain medication before he/she went out to [MEDICAL TREATMENT]. LPN #4 stated sometimes staff would forget to click on the as needed [MEDICATION NAME] when administering and that was why it did not show up on the MAR indicated [REDACTED]. Interview with LPN #3 on [DATE] at 3:30 PM revealed she had not signed the MAR, but did sign the narcotic book, on [DATE], [DATE], [DATE], [DATE] for Unsampled Resident C. LPN #3 revealed she had gotten busy and by not signing the MAR indicated [REDACTED]. Review of Unsampled Resident D's clinical record revealed the facility assessed the resident, on [DATE], with a BIMS score of thirteen (13) out of fifteen (15) and determined the resident interviewable. Further review revealed a physician order, dated [DATE], for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) ,[DATE] mg every six (6) hours as needed for pain. The resident was at [MEDICAL TREATMENT] and unavailable for interview. Review of Unsampled Resident D's Controlled Drug Record, for (MONTH) (YEAR), revealed staff signed out [MEDICATION NAME] on [DATE] at 9:00 AM, [DATE] at 8:00 AM, [DATE] at 1:30 AM, [DATE] at 6:35 PM, [DATE] at 8:00 PM, [DATE] at 1:45 AM, [DATE] at 10:22 AM and 6:15 PM, [DATE] at 9:00 AM, and on [DATE] at 8:30 PM. However, review of the resident's MAR, for (MONTH) (YEAR), revealed no documentation staff administered [MEDICATION NAME] to the resident on those dates and times. Interview with LPN #7, on [DATE] at 10:10 AM, revealed the procedure for administration of narcotics included rating the resident's pain, signing out the narcotic on the drug count record, and then administering the medication. She stated after the medication had been administered, the nurse was responsible for documenting on the MAR indicated [REDACTED]. The nurse revealed it was important to document on the MAR indicated [REDACTED]. Interview with LPN #3, on [DATE] at 3:44 PM, revealed she was responsible for assessing a resident for pain, signing out the pain medication on the narcotic count record, and documenting on the MAR indicated [REDACTED]. The LPN stated sometimes she got busy and would follow the directions from the pharmacy label instead of using the resident's MAR. The LPN revealed there was a risk a resident could get the wrong medication if the MAR indicated [REDACTED]. LPN #3 stated it was important to document the pain medication on the MAR indicated [REDACTED]. The nurse revealed Unsampled Resident D's MAR indicated [REDACTED]. Interview with the DON, on [DATE] at 1:40 PM, revealed nurses were responsible for documentation of the pain assessment and medication administration on the MAR. The Director revealed there was no acceptable reason as needed pain medication would not be entered on the MAR. The DON revealed she did not routinely monitor the MARs or the Controlled Drug Record count sheets. The DON stated it was important to monitor the Controlled Drug Record count sheets and the MARs to ensure staff administered the medications properly and to ensure resident pain was managed. The DON revealed she had not identified any concerns regarding nursing documentation on the MARs. Interview with the Administrator, on [DATE] at 7:10 PM, revealed the DON and Assistant DON were responsible for ensuring the MARs and TARs were complete and accurate. He revealed he was not aware of any concerns with clinical records. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1, after the elopement, to the secure Alzheimer's Care Unit (ACU) on [DATE], and fitted Resident #1 with a Code Alert device. Notifications were made according to policy. The Nurse Scheduler reassessed the resident on [DATE] for elopement risk. The care plan and physician orders [REDACTED]. The DON modified Resident #1's MDS on [DATE], to reflect the resident's code alert device and revised the care plan to reflect the code alert device and the resident's history of removing the device. 2. The SSD began validating all MDS assessments on [DATE], for coding of wandering behavior. The SSD would validate five (5) MDS assessments weekly times twelve (12) weeks and report the findings of those audits to the QA Committee. 3. The QA Committee, including the Medical Director, met on [DATE], to discuss the event as set forth in the notification of Immediate Jeopardy and the action plan. The Administrator held an Ad Hoc QA meeting on [DATE], with the entire team to discuss progress with the plan including initial audit results and progress of staff education. The team also discussed weekend coverage to complete the plan. 4. The Regional Nurse re-educated the MDS nurse on [DATE], regarding accuracy of coding the code alert device on the MDS. 5. The facility reassessed one hundred and fifteen (115) current residents residing in the facility for elopement risk on [DATE]. Care plans for fourteen (14) residents at risk for elopement were reviewed and revised as needed by the Nurse Scheduler, DON, ADON, or DCE. 6. The facility's DON and MDS Nurse audited the MDS assessments of thirteen (13) residents identified as elopement risk, on [DATE] and [DATE], and modified the MDS as needed. 7. The Regional VP of Clinical Services conducted train the trainer education on [DATE], with the Interim Administrator, DON, ADON, and SSD regarding education to be given to staff. A post-test was given to determine understanding of key points. The DON then conducted train the trainer education with the Dietary Manager, Director of Rehab, MDS, DCE, Admissions, Social Services Assistant, and the Nurse Scheduler. A post-test was given to determine understanding of key points. Train the trainer education included: elopement risk assessments; revision of the care plan; placement of the code alert device; notification for changes in behaviors; following physician orders; and monitoring and documentation of the code alert device. Licensed nursing staff were re-educated on [DATE], and were required to take a competency test to determine understanding of the topics on [DATE]. 8. The DCE, DON, ADON, MDS nurse, and the Nurse Scheduler educated Certified Nursing Assistants (CNA) on [DATE], regarding monitoring of residents at risk for elopement, responding to door alarms, and reporting missing code alert devices. The Nurse Scheduler would educate Agency staff prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during the orientation period by the DON/ADON/DCE/Administrator. One (1) employee on Family Medical Leave (FMLA) would be educated prior to returning to work. The facility completed education for ninety-five (95) current staff by [DATE]. 9. On [DATE], the Regional Director of Operations trained Department Heads, including the DON, the ADON, Interim Administrator, SSD, the Social Services Assistant, MDS, Admission, DCE, and the Nurse Scheduler on conducting a thorough investigation. 10. The facility posted signs at the time clock and on each door on [DATE], to alert staff of the required education to be completed prior to clocking in for work. To ensure that no staff worked prior to education, a department head waited at the time clock on [DATE]. 11. On [DATE], the Maintenance Director educated Department Heads, who performed as Managers on duty, (consisting of the DON, ADON, MDS, Dietary Manager, Activities Director, Nurse Scheduler, Admissions, Interim Administrator, Assistant Business Office Manager, SSD, and the Social Services Assistant) on how to check the door alarm function and document the checks. 12. The IDT would review new and readmission resident charts Monday thru Friday during morning meeting to ensure elopement risk assessments had been completed, beginning [DATE]. If a resident had been identified as an elopement risk, the IDT would review the care plan to ensure it accurately reflected the resident's needs, ensure physician orders [REDACTED]. For any new or readmissions that occurred on the weekend, the Manager on duty would follow-up with the Charge Nurse to confirm that the elopement assessment was completed, and if identified at risk, a code alert device was in place. If needed, the nurse on call would be notified and would come to the facility to follow-up on the issue. The resident's chart, including the care plan, would be reviewed with the Charge Nurse by the nurse on call (consisting of the DON, ADON, DCE, MDS, and Nurse Scheduler) within that shift. 13. The SSD or DON would be responsible for updating the six (6) elopement binders (Hiker's Handbook) as needed. 14. A member of the IDT would perform daily visual rounds Monday thru Friday beginning [DATE], to verify the code alert device was in place on residents who had been identified as needing the device. The Manager on duty would validate code alert placement on weekends and holidays for the next twelve (12) weeks. Nurses would visualize and check function of the code alert device three (3) times a day (or once a shift). 15. The Administrator would perform an audit of the door alarm check documentation weekly for twelve (12) weeks, beginning [DATE], and would report the findings to the Quality Assurance (QA) Committee. 16. The IDT team would begin weekly audits of documentation for code alert device placement and function for five (5) residents with a code alert device times twelve (12) weeks beginning [DATE]. 17. The facility would audit five (5) elopement risk/exit seeking care plans weekly times twelve (12) weeks beginning [DATE], to ensure the care plan was accurate. The DON would report the audit findings to the QA committee. 18. The facility would audit the physician orders [REDACTED]. The DON would report the findings of the audits to the QA Committee. 19. A Regional Team member would review current investigations, consisting of reportable concerns or significant events in the facility, with the Administrator and/or DON weekly times twelve (12) weeks. The Regional Team member would report any concerns to the QA Committee. 20. The facility would hold weekly QA meetings times (8) weeks, then monthly times one (1) month, beginning the week of [DATE]. A Regional Team member (consisting of the Regional Director of Operations, Regional Vice President of Clinical Services, and the Regional Reimbursement Director/Chief Operating Officer) would attend the weekly meeting times four (4) weeks. 21. The Maintenance Director or Administrator would check the function of the two (2) doors with code alert alarms with a gauge instrument daily Monday thru Friday, beginning [DATE]. The Manager on duty would perform the door checks on weekends and holidays and document on the Door Code Alert Daily Checklist kept in the main office. Any concerns with the door alarms would be immediately addressed by maintenance and the Administrator would be notified. The SSA validated the facility implemented the following actions: 1. Observation of Resident #1, on [DATE] at 10:30 AM, revealed the resident on the ACU with a code alert to his/her right ankle. Review of Resident #1's clinical record revealed he/she was re-assessed for elopement risk on [DATE]. There was a physician order [REDACTED]. Review of the MDS revealed the DON modified the assessment on [DATE], to accurately reflect Resident #1's wandering behavior and code alert device. Interview with Licensed Practical Nurse (LPN) #9 revealed Resident #1 was transferred to the ACU after he/she was returned from exiting the building unsupervised. Interview with the DON revealed Resident #1's MDS and Care Plan were updated for the resident's wandering behavior and code alert device. 2. Record review revealed MDS's for residents assessed as an elopement risk were reviewed by the DON and MDS Nurse for accuracy on [DATE]. Review of audits revealed a weekly audit of five (5) resident MDS's were reviewed by the Social Services Director on [DATE], for coding accuracy of wandering behaviors. Interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed MARs, TARs, Physician Orders, and Progress Notes, along with assessing the resident, were reviewed to code wandering behaviors on the MDS. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 3. Review of the In-service Attendance Records revealed a QA meeting for IJ notification was held on [DATE] at 1:00 PM, and an Ad Hoc QA was held on [DATE] at 7:00 PM to review Plan progress related to the IJ, audits completed, assessments completed, and progress of staff education. Interview with the Medical Director, on [DATE] at 3:06 PM, revealed he participated in the facility's QA meetings related to the IJ. The Director revealed he advised and consulted with the facility regarding correction of the IJ. Interview with the Administrator, on [DATE] at 3:20 PM, revealed the facility had an immediate QA meeting with the Medical Director and IDT for the initial plan of correction. The Administrator revealed the IDT identified each area of failure based upon the citation and conducted an Ad Hoc QA meeting on [DATE]. He revealed the facility made changes to processes as a result of the IJ. 4. Interview with the MDS nurse, on [DATE] at 9:50 AM, revealed the Regional MDS nurse trained her on [DATE], regarding Section P0200 Alarms coding on the MDS assessment. 5. Record review revealed one-hundred fifteen (115) residents were assessed for elopement risk on [DATE] and fourteen (14) care plans were revised to include the code alert device and/or resident behaviors. Review of three (3) new admission records and one (1) re-admission record revealed all four (4) residents were assessed for elopement risk upon admission to the facility. Interview with the DON, on [DATE] at 4:09 PM, she completed elopement risk assessments on one-hundred fifteen (115) resident and validated the Care Plans, MDS, Physician Orders. She stated changes to the Care Plans were made as needed. 6. Interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed she reviewed MDS assessments for residents identified as elopement risk. Record review revealed the MDS assessments for resident at risk for elopement were reviewed and eight (8) of thirteen (13) residents at risk for elopement were modified to accurately reflect the code alert and/or behaviors. Review of the clinical record for Residents #7, #8, and #9 revealed the care plans and MDS assessments reflected the residents' code alert device and behaviors. 7. Review of the In-service Attendance Record, dated [DATE], revealed the Regional VP of Clinical Services conducted a train the trainer education to the Interim Administrator, DON, ADON, and SSD with completion of post-tests. Review of the In-service Attendance Record, dated [DATE], revealed the DON conducted train the trainer education to the Dietary Manager, Director of Rehabilitation, MDS, DCE, Admissions, the Social Services Assistant, and the Nurse Scheduler with completion of post-tests. Interview with LPN #11, on [DATE] at 9:45 AM, revealed she had been trained on the facility's Elopement Policy and Procedure and completed a post-test after the training on [DATE]. The LPN stated she verified placement and function of code alerts every shift and documented on the TAR immediately after the check. The LPN revealed residents at risk for elopement were listed in the Hikers Handbooks located at the nurses' station on each unit and CNAs were responsible for checking the handbook at the beginning of each shift. The LPN was knowledgeable regarding the facility's Elopement Policy and Procedure. Interview with the MDS nurse, on [DATE] at 9:50 AM, revealed the DON trained her regarding resident elopement risk assessment. Interview with the Nurse Scheduler, on [DATE] at 11:25 AM, revealed she had been trained regarding the facility's Elopement Policy and Procedure. Interview with the DON, on [DATE] at 11:58 AM, revealed the Regional VP trained her on the elopement policy and procedure of what to do when a resident eloped. The training covered care plan updates, code alert placement and daily checks, elopement assessments on admission, readmission, and change in behavior, and when and to whom to notify resident change in behavior and/or when a resident eloped. 8. Review of the In-service Atten (TRUNCATED)

Based on observation, interview, record review, Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, and facility policy review, it was determined the facility failed to revise resident care plans for one (1) of nine (9) sampled residents, Resident #1. Resident #1's care plan was not revised to reflect the resident's elopement risk or the application of a Code Alert device. On [DATE], Resident #1 exited the facility around 2:30 PM without staff knowledge. Around 2:50 PM staff discovered Resident #1 walking alone down the driveway at the front of the building toward the street. Interviews with staff revealed they had not observed the resident exit the building. Further interviews revealed staff had not heard the door alarm when the resident exited the facility or when a Certified Nursing Assistant (CNA) escorted him/her back inside. The facility's failure to revise the care plan for residents at risk of elopement placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility provided and Acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the CMS RAI 3.0 User's Manual, dated (MONTH) (YEAR), Chapter 4, revealed the comprehensive care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Review of the clinical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of a physician progress notes [REDACTED].#1 was admitted to the facility for progression of Dementia and was exit seeking at times. Review of a Physician Order, dated [DATE], for Resident #1 revealed an order to monitor the Code Alert device on the right ankle every shift for proper functioning and replace when expired. Review of Resident #1's CNA care sheet, not dated, revealed the Code Alert device was not listed. Review of Resident #1's 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) out of fifteen (15) and determined the resident was moderately cognitively impaired. The facility assessed the resident able to independently ambulate with supervision. Review of an elopement assessment for Resident #1, dated [DATE], revealed the facility assessed the resident was occasionally disoriented, ambulatory, independently mobile, and wandered throughout the facility. The facility determined the resident was at high risk for elopement. However, review of the resident's comprehensive plan of care revealed it had not been revised to include the resident's elopement risk. Review of Resident #1's CNA care sheet, not dated, revealed the resident's elopement risk was not listed. Review of a quarterly MDS, dated [DATE], revealed the facility assessed Resident #1 with a BIMS score of five (5) out of fifteen (15) and determined the resident cognitively impaired. The facility assessed the resident ambulated independently with supervision. However, there was no assessment of the resident's elopement risk, the application of the Code Alert device, and the plan of care was not revised. Review of the facility documentation related to Resident #1's elopement on [DATE] revealed Resident #1 was reviewed in relation to elopement assessment and care plan. The documentation revealed Resident #1 had an elopement assessment, dated [DATE], however there was no care plan, which needed to be fixed. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 10:10 AM, revealed she documented recommendations for care plan updates in the nursing progress notes. She further revealed changes in resident behaviors, including exit seeking, would be documented on the 24-hour report. The LPN revealed the Interdisciplinary Team (IDT) updated the care plans after the 24-hour report and resident progress notes were reviewed during the daily morning meetings. The nurse stated she was did not know who was responsible to update the care plan. Review of the 24-hour report, for [DATE], revealed there were no entries regarding Resident #1's behaviors or the elopement from the facility. Interview with the MDS Coordinator, on [DATE] at 3:41 PM, revealed care plans were revised with each resident's comprehensive and quarterly assessment. The Coordinator stated resident behaviors, including wandering and exit seeking, would need care plan revision and would be documented on the 24-hour report. She stated Resident #1 had been exit seeking. She further stated the IDT reviewed 24-hour reports, identified new/worse behaviors, and revised the care plan as needed during the daily morning meeting. According to the MDS Coordinator, if a behavior or incident was not documented on the 24-hour report, or on a physician order, she would not know to revise the care plan. She revealed care plans should be revised when new or changed behaviors were identified. The MDS Coordinator revealed nurses would not be aware of a resident's current care needs or concerns if the care plan were not revised. She further revealed social services was responsible for revising the care plan when a resident had exit seeking or wandering behaviors, and had a Code Alert. Interview with the Social Services Director (SSD), on [DATE] at 8:51 AM, revealed care plans were revised quarterly or with resident changes. The SSD revealed she was not responsible for revising the elopement/behavior care plan. Interview with the Director of Nursing (DON), on [DATE] at 5:15 PM, revealed the care plan should be revised as needed for new or changed resident behaviors. She revealed nurses could update the care plan, and the MDS Coordinator was responsible to update care plans. Additionally, social services was responsible for ensuring resident care plans were revised related to resident behaviors. Interview with the Administrator, on [DATE] at 7:10 PM, revealed the DON and Assistant DON were responsible for monitoring and ensuring the accuracy of clinical records. The Administrator revealed he was not aware of any concerns regarding clinical records. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1, after the elopement, to the secure Alzheimer's Care Unit (ACU) on [DATE], and fitted Resident #1 with a Code Alert device. Notifications were made according to policy. The Nurse Scheduler reassessed the resident on [DATE] for elopement risk. The care plan and physician orders [REDACTED]. The DON modified Resident #1's MDS on [DATE], to reflect the resident's code alert device and revised the care plan to reflect the code alert device and the resident's history of removing the device. 2. The SSD began validating all MDS assessments on [DATE], for coding of wandering behavior. The SSD would validate five (5) MDS assessments weekly times twelve (12) weeks and report the findings of those audits to the QA Committee. 3. The QA Committee, including the Medical Director, met on [DATE], to discuss the event as set forth in the notification of Immediate Jeopardy and the action plan. The Administrator held an Ad Hoc QA meeting on [DATE], with the entire team to discuss progress with the plan including initial audit results and progress of staff education. The team also discussed weekend coverage to complete the plan. 4. The Regional Nurse re-educated the MDS nurse on [DATE], regarding accuracy of coding the code alert device on the MDS. 5. The facility reassessed one hundred and fifteen (115) current residents residing in the facility for elopement risk on [DATE]. Care plans for fourteen (14) residents at risk for elopement were reviewed and revised as needed by the Nurse Scheduler, DON, ADON, or DCE. 6. The facility's DON and MDS Nurse audited the MDS assessments of thirteen (13) residents identified as elopement risk, on [DATE] and [DATE], and modified the MDS as needed. 7. The Regional VP of Clinical Services conducted train the trainer education on [DATE], with the Interim Administrator, DON, ADON, and SSD regarding education to be given to staff. A post-test was given to determine understanding of key points. The DON then conducted train the trainer education with the Dietary Manager, Director of Rehab, MDS, DCE, Admissions, Social Services Assistant, and the Nurse Scheduler. A post-test was given to determine understanding of key points. Train the trainer education included: elopement risk assessments; revision of the care plan; placement of the code alert device; notification for changes in behaviors; following physician orders; and monitoring and documentation of the code alert device. Licensed nursing staff were re-educated on [DATE], and were required to take a competency test to determine understanding of the topics on [DATE]. 8. The DCE, DON, ADON, MDS nurse, and the Nurse Scheduler educated Certified Nursing Assistants (CNA) on [DATE], regarding monitoring of residents at risk for elopement, responding to door alarms, and reporting missing code alert devices. The Nurse Scheduler would educate Agency staff prior to working in the facility. New hires in the nursing department and any new department leaders would be educated during the orientation period by the DON/ADON/DCE/Administrator. One (1) employee on Family Medical Leave (FMLA) would be educated prior to returning to work. The facility completed education for ninety-five (95) current staff by [DATE]. 9. On [DATE], the Regional Director of Operations trained Department Heads, including the DON, the ADON, Interim Administrator, SSD, the Social Services Assistant, MDS, Admission, DCE, and the Nurse Scheduler on conducting a thorough investigation. 10. The facility posted signs at the time clock and on each door on [DATE], to alert staff of the required education to be completed prior to clocking in for work. To ensure that no staff worked prior to education, a department head waited at the time clock on [DATE]. 11. On [DATE], the Maintenance Director educated Department Heads, who performed as Managers on duty, (consisting of the DON, ADON, MDS, Dietary Manager, Activities Director, Nurse Scheduler, Admissions, Interim Administrator, Assistant Business Office Manager, SSD, and the Social Services Assistant) on how to check the door alarm function and document the checks. 12. The IDT would review new and readmission resident charts Monday thru Friday during morning meeting to ensure elopement risk assessments had been completed, beginning [DATE]. If a resident had been identified as an elopement risk, the IDT would review the care plan to ensure it accurately reflected the resident's needs, ensure physician orders [REDACTED]. For any new or readmissions that occurred on the weekend, the Manager on duty would follow-up with the Charge Nurse to confirm that the elopement assessment was completed, and if identified at risk, a code alert device was in place. If needed, the nurse on call would be notified and would come to the facility to follow-up on the issue. The resident's chart, including the care plan, would be reviewed with the Charge Nurse by the nurse on call (consisting of the DON, ADON, DCE, MDS, and Nurse Scheduler) within that shift. 13. The SSD or DON would be responsible for updating the six (6) elopement binders (Hiker's Handbook) as needed. 14. A member of the IDT would perform daily visual rounds Monday thru Friday beginning [DATE], to verify the code alert device was in place on residents who had been identified as needing the device. The Manager on duty would validate code alert placement on weekends and holidays for the next twelve (12) weeks. Nurses would visualize and check function of the code alert device three (3) times a day (or once a shift). 15. The Administrator would perform an audit of the door alarm check documentation weekly for twelve (12) weeks, beginning [DATE], and would report the findings to the Quality Assurance (QA) Committee. 16. The IDT team would begin weekly audits of documentation for code alert device placement and function for five (5) residents with a code alert device times twelve (12) weeks beginning [DATE]. 17. The facility would audit five (5) elopement risk/exit seeking care plans weekly times twelve (12) weeks beginning [DATE], to ensure the care plan was accurate. The DON would report the audit findings to the QA committee. 18. The facility would audit the physician orders [REDACTED]. The DON would report the findings of the audits to the QA Committee. 19. A Regional Team member would review current investigations, consisting of reportable concerns or significant events in the facility, with the Administrator and/or DON weekly times twelve (12) weeks. The Regional Team member would report any concerns to the QA Committee. 20. The facility would hold weekly QA meetings times (8) weeks, then monthly times one (1) month, beginning the week of [DATE]. A Regional Team member (consisting of the Regional Director of Operations, Regional Vice President of Clinical Services, and the Regional Reimbursement Director/Chief Operating Officer) would attend the weekly meeting times four (4) weeks. 21. The Maintenance Director or Administrator would check the function of the two (2) doors with code alert alarms with a gauge instrument daily Monday thru Friday, beginning [DATE]. The Manager on duty would perform the door checks on weekends and holidays and document on the Door Code Alert Daily Checklist kept in the main office. Any concerns with the door alarms would be immediately addressed by maintenance and the Administrator would be notified. The SSA validated the facility implemented the following actions: 1. Observation of Resident #1, on [DATE] at 10:30 AM, revealed the resident on the ACU with a code alert to his/her right ankle. Review of Resident #1's clinical record revealed he/she was re-assessed for elopement risk on [DATE]. There was a physician order [REDACTED]. Review of the MDS revealed the DON modified the assessment on [DATE], to accurately reflect Resident #1's wandering behavior and code alert device. Interview with Licensed Practical Nurse (LPN) #9 revealed Resident #1 was transferred to the ACU after he/she was returned from exiting the building unsupervised. Interview with the DON revealed Resident #1's MDS and Care Plan were updated for the resident's wandering behavior and code alert device. 2. Record review revealed MDS's for residents assessed as an elopement risk were reviewed by the DON and MDS Nurse for accuracy on [DATE]. Review of audits revealed a weekly audit of five (5) resident MDS's were reviewed by the Social Services Director on [DATE], for coding accuracy of wandering behaviors. Interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed MARs, TARs, Physician Orders, and Progress Notes, along with assessing the resident, were reviewed to code wandering behaviors on the MDS. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 3. Review of the In-service Attendance Records revealed a QA meeting for IJ notification was held on [DATE] at 1:00 PM, and an Ad Hoc QA was held on [DATE] at 7:00 PM to review Plan progress related to the IJ, audits completed, assessments completed, and progress of staff education. Interview with the Medical Director, on [DATE] at 3:06 PM, revealed he participated in the facility's QA meetings related to the IJ. The Director revealed he advised and consulted with the facility regarding correction of the IJ. Interview with the Administrator, on [DATE] at 3:20 PM, revealed the facility had an immediate QA meeting with the Medical Director and IDT for the initial plan of correction. The Administrator revealed the IDT identified each area of failure based upon the citation and conducted an Ad Hoc QA meeting on [DATE]. He revealed the facility made changes to processes as a result of the IJ. 4. Interview with the MDS nurse, on [DATE] at 9:50 AM, revealed the Regional MDS nurse trained her on [DATE], regarding Section P0200 Alarms coding on the MDS assessment. 5. Record review revealed one-hundred fifteen (115) residents were assessed for elopement risk on [DATE] and fourteen (14) care plans were revised to include the code alert device and/or resident behaviors. Review of three (3) new admission records and one (1) re-admission record revealed all four (4) residents were assessed for elopement risk upon admission to the facility. Interview with the DON, on [DATE] at 4:09 PM, she completed elopement risk assessments on one-hundred fifteen (115) resident and validated the Care Plans, MDS, Physician Orders. She stated changes to the Care Plans were made as needed. 6. Interview with the MDS Coordinator, on [DATE] at 9:50 AM, revealed she reviewed MDS assessments for residents identified as elopement risk. Record review revealed the MDS assessments for resident at risk for elopement were reviewed and eight (8) of thirteen (13) residents at risk for elopement were modified to accurately reflect the code alert and/or behaviors. Review of the clinical record for Residents #7, #8, and #9 revealed the care plans and MDS assessments reflected the residents' code alert device and behaviors. 7. Review of the In-service Attendance Record, dated [DATE], revealed the Regional VP of Clinical Services conducted a train the trainer education to the Interim Administrator, DON, ADON, and SSD with completion of post-tests. Review of the In-service Attendance Record, dated [DATE], revealed the DON conducted train the trainer education to the Dietary Manager, Director of Rehabilitation, MDS, DCE, Admissions, the Social Services Assistant, and the Nurse Scheduler with completion of post-tests. Interview with LPN #11, on [DATE] at 9:45 AM, revealed she had been trained on the facility's Elopement Policy and Procedure and completed a post-test after the training on [DATE]. The LPN stated she verified placement and function of code alerts every shift and documented on the TAR immediately after the check. The LPN revealed residents at risk for elopement were listed in the Hikers Handbooks located at the nurses' station on each unit and CNAs were responsible for checking the handbook at the beginning of each shift. The LPN was knowledgeable regarding the facility's Elopement Policy and Procedure. Interview with the MDS nurse, on [DATE] at 9:50 AM, revealed the DON trained her regarding resident elopement risk assessment. Interview with the Nurse Scheduler, on [DATE] at 11:25 AM, revealed she had been trained regarding the facility's Elopement Policy and Procedure. Interview with the DON, on [DATE] at 11:58 AM, revealed the Regional VP trained her on the elopement policy and procedure of what to do when a resident eloped. The training covered care plan updates, code alert placement and daily checks, elopement assessments on admission, readmission, and change in behavior, and when and to whom to notify resident change in behavior and/or when a resident eloped. 8. Review of the In-service Attendance Record, dated [DATE], revealed CNAs were trained on the wandering residents, door alarms, and reporting missing code alert devices with post-test completed. Further review of post-tests revealed all staff was educated by [DATE]. Interview with the Housekeeper, on [DATE] at 10:00 AM, revealed he was trained on elopement procedures and not giving out door codes to anyone. Interview with the Dietary Aide, on [DATE] at 10:50 AM, revealed she was trained on elopements, door alarms, and what to do if she saw a resident without a code alert device. Interview with the Activity Director, on [DATE] at 3:19 PM, revealed she received training regarding elopements, and code alerts and alarm doors. Interview with CNA #3, on [DATE] at 1:45 PM, revealed she had been trained on the facility's Elopement Policy and Procedure. The CNA stated resident behaviors should be documented in the clinical record and reported immediately to the nurse. The CNA revealed the Hikers Handbook on each unit had the names and pictures of residents who were at risk for elopement. CNA #3 was knowledgeable regarding the facility's elopement procedure. Interview with CNA #17 (agency staff), on [DATE] at 10:32 AM, revealed the facility trained her on the Elopement Policy and Procedure, Resident Behaviors and Safety, and she completed a post-test prior to starting work on her assigned shift. 9. Review of the In-service Attendance Record, dated [DATE], revealed the Regional Director of Operations educated Department Managers regarding the facility policies on Wandering, Unsafe Residents, Elopements, and Conducting a Thorough Investigation. Further review revealed staff completed a post-test to demonstrate understanding of the education. Interview with the ADON, on [DATE] at 10:26 AM, revealed she had been trained on the facility's Elopement Risk Policy and Conducting a Thorough Investigation. Interview with the DON, on [DATE] at 11:58 AM, revealed the Regional Director of Operations educated Department Managers on [DATE] regarding Elopements and Investigations. The DON revealed Investigations included beginning a twenty-four (24) timeline of resident behaviors, obtaining written and signed statements from witnesses, audit of the investigation and clinical record for completion, and IDT review to determine any staff education that was needed. The DON revealed all investigations were taken to QA for further review. 10. Observation of a sign posted at the time clock, on [DATE] at 1:10 PM, revealed it stated no staff, including agency, were authorized to work until educated on the current elopement policy and procedure information. Interview with the Administrator, on [DATE] at 3:20 PM, revealed a sign was posted by the time clock and the Nurse Scheduler ensured agency staff was trained prior to scheduling them to work. 11. Interview with the Maintenance Director, on [DATE] at 11:14 AM, revealed he trained Department Managers on the procedure for checking the door alarms and observed return demonstration to determine competency. Interview with the Dietary Manager, on [DATE] a 10:55 AM, revealed she had been trained regarding the facility's Elopement Policy and the procedure for checking function of the door code alert alarm. The Manager stated alarm checks were documented in a binder kept in the front office. The Manager revealed she would notify the Maintenance Director immediately and post a staff member at the door if the alarm was not operable. Interview with the Nurse Scheduler, on [DATE] at 11:25 AM, revealed the Maintenance Director had trained her on the procedure for checking the door code alert alarms. 12. Interview with the ADON, on [DATE] at 10:26 AM, revealed the IDT reviewed the elopement risk assessment and revised care plans of residents with new behaviors during the morning meeting and reviewed the clinical records of new or readmitted residents for accuracy during the daily meeting, including the elopement risk assessment. Interview with the MDS nurse, on [DATE] at 9:50 AM, revealed the IDT reviewed elopement risk assessments during the daily morning meeting. She stated the risk assessment and other factors, such as wandering or exit-seeking behaviors, were taken in to consideration in the determination of elopement risk. Interview with the Administrator, on [DATE] at 3:20 PM, revealed the nursing team monitored elopement assessments during morning meetings and used the A[NAME] as a guide to ensure all steps were reviewed and verified. 13. Observation revealed there were six (6) Hikers Handbooks located at each nurses' station. Review of the binders contents revealed there was a current list of residents, including demographics and photos; copies of the Wandering, Unsafe Resident and Elopement Policies; and Missing Person Report Forms. The resident list was dated [DATE]. Interview with the DON, on [DATE] at 11:00 AM, revealed the IDT reassessed elopement risk when a resident exhibited exit-seeking behaviors. She revealed if the IDT determined the resident was an elopement risk, his/her name would be added to the Hikers Handbook and the Care Plan would be updated. She stated staff reviewed the Handbook to see what residents were elopement risks. The DON stated the Handbook was updated [DATE]. 14. Observations of Residents #7, #8, and #9, on [DATE], revealed the residents had code alert devices in place. Review of Resident #7, #8, and #9 TAR's revealed the code alert device checks for function and placement were documented. Review of the audits verifying placement of code alert devices revealed audits began on [DATE], and conducted daily by a member of the IDT. Interview with LPN #7, on [DATE] at 10:12 AM, revealed she checked the placement and function of the code alert devices at the beginning of each shift. If the device did not work, it was replaced. The checks were documented on the TAR. 15. Review of the weekly audit for Door Alarm Check Documentation revealed the Administrator had completed an audit on [DATE]. Interview with the Administrator, on [DATE] at 3:20 PM, revealed door codes were changed monthly and as needed. The Administrator revealed he monitored door alarm checks and spot-checked alarmed doors during daily rounds of the facility. 16. Review of the audits verifying placement and documentation of code alert devices revealed audits began on [DATE], and conducted daily by a member of the IDT. Interview with the Administrator, on [DATE] at 3:20 PM, revealed code alert audits were completed by members of the IDT. 17. Review of audits revealed five (5) care plans were reviewed by the DON on [DATE], to ensure accuracy of elopement care plans. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 18. Review of audits revealed Physician orders [REDACTED]. Interview with the DON, on [DATE] at 11:58 AM, revealed physician orders [REDACTED]. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 19. Review of audits revealed the Regional VP of Clinical Services reviewed investigations beginning [DATE]. Interview with the DON, on [DATE] at 11:58 AM, revealed audits of investigations were performed to ensure they were completed correctly. Interview with the Administrator, on [DATE] at 3:20 PM, revealed audits were reviewed during the IDT meeting and during QA. 20. Review of QA meeting attendance records revealed meetings were held on [DATE], [DATE], [DATE], and [DATE] regarding audit findings. Interview with the Medical Director, on [DATE] at 3:06 PM, revealed he participated in the facility's QA meetings. The Director revealed he advised and consulted with the facility regarding correction of the IJ. 21. Review of the Daily Code Alert Checklist revealed the two (2) code alert alarmed doors located on the East and West units were checked and documented daily beginning [DATE]. Interview with the Maintenance Director, on [DATE] at 11:14 AM, revealed the function of the two (2) door code alert alarms were verified daily. The Director revealed he checked the door alarms Monday thru Friday and the assigned Manager on Duty was responsible for the weekend alarm checks.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to follow resident care plan interventions to prevent falls by ensuring assistance with ambulation, a seat belt alarm was turned on at all times and assistance with toileting for three (3) of fifteen (15) sampled residents. (Residents #1, #8, and #10) Resident #1 had a history of [REDACTED]. The resident was care planned to need staff assistance with walking due to unsteady gait. On [DATE] at 12:14 PM, Physical Therapy assessed the resident to need the maximum assistance of two (2) persons for ambulation; however, this was not communicated to nursing. On [DATE] at 5:10 PM, Resident #1 fell while walking in the hallway without staff assistance. Resident #1 sustained bilateral subdural hematomas to the forehead and a skull fracture to the back of the head and expired sixteen (16) hours later at the hospital. In addition, on [DATE] at 9:00 AM, revealed Resident #8 had not received the restorative services that was care planned. Resident #8 experienced a fall on [DATE] trying to transfer to the toilet. Interview with the ADON revealed the staff had not implemented the toileting and restorative care plan interventions, as per their policy. She stated if the staff had provided toileting assistance to the resident the fall would have been prevented. The facility's failure to have an effective system in place, to ensure care plans were followed has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on [DATE]. An acceptable Allegation of Compliance was received on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated the removal of Immediate Jeopardy on [DATE] as alleged prior to exit on [DATE]. The scope and severity was lowered to a D while the facility monitors the systemic changes and the Quality Assurance monitors the effectiveness of the plan of correction. The findings include: Review of the facility's policy regarding Falls Management Guidelines, dated [DATE], revealed the interdisciplinary team would evaluate the fall prevention plan of care for residents at risk for falls. Appropriate interventions would be implemented and the care plan updated. Review of the POS [REDACTED]. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) exam was conducted and the facility assessed the resident with a score of ten (10) meaning the resident was interviewable. Review of the Comprehensive Care Plan for Resident #1 revealed a plan was developed on [DATE] with updated goals and a target date for [DATE]. The problem stated the resident was at risk for falls due to a history of falls at home and cognitive impairment related to the [DIAGNOSES REDACTED]. The approaches directed the staff to monitor for changes in functional status, environmental and situational hazards daily to ensure a safe environment was provided. Further review of the care plan revealed on [DATE], due to a fall that occurred on [DATE], the facility noted the resident was to be evaluated by Physical Therapy and staff was to assist with transfers and walking due to an unsteady gait. However on [DATE], nursing staff failed to follow the residents' plan of care to assist with ambulation due to an unsteady gait. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:25 AM, revealed Resident #1 was very lethargic on the morning of [DATE] and was pacing on the unit. She tried to keep the resident as close to her as possible while she completed her daily tasks and so did other staff. She stated later in the day she requested extra staff on the unit in order for Resident #1 to have one to one assistance and monitoring because the resident was at risk for falls; however, she was not provided a rationale for not sending additional staff. Instead she was provided a chair alarm to use. However, the care plan stated to use one staff for ambulation, not a chair alarm. LPN #1 stated a chair alarm was not an appropriate intervention for Resident #1 because the resident would not remain seated for any length of time. Around 5:00 PM she was in the hallway by the nursing station passing medications and Resident #1 was behind her. She stated she turned to give another resident some medications and heard a loud thud. When she turned around she observed Resident #1 laying on the floor on his/her back. Interview, on [DATE] at 5:00 PM, with LPN #5, revealed she worked as an aide on [DATE] when Resident #1 sustained the fall. The resident was very lethargic and was observed to walk with his/her eyes closed. LPN #5 stated Resident #1 was assessed as a fall risk. She requested extra staff for the unit in order for someone to stay one on one with Resident #1 to maintain his/her safety and prevent a fall. However, the request was not granted and instead a chair alarm was provided for use with Resident #1. She did the best she could to watch the resident while trying to take care of her other residents. She stated the chair alarm was not appropriate because the resident would not stay seated and would get up and pace around the unit. Interview with Certified Nursing Assistant (CNA) #4, on [DATE] at 8:00 AM, revealed Resident #1 would pace around the unit and at times would walk around with his/her eyes closed. She stated staff was told to keep a closer eye on the resident and assist as needed; however, if she had to tend to another resident she could not be there to provide that close attention. She stated she would put the resident in the chair that reclined in the common area and go tend to another resident. She stated she would come back and the resident would be up walking around without assistance. Interview with the Director of Nursing (DON), on [DATE] at 3:40 PM, revealed she was not the DON at the time of Resident #1's fall. She stated after assuming the role of DON and assessing the nursing staff skills related to the care planning process she stated she had concerns with the facility's ability to implement the care plan. She stated she was in the process of developing a plan to fix the issues and the identified concerns. She stated if resident care plans were not followed the appropriate interventions related to the fall, residents were at risk for falls and injuries. Attempted interview with the previous Director of Nursing, on duty at the time of Resident #1's fall, on [DATE] at 4:10 PM, [DATE] at 8:17 PM and 3:00 PM, revealed no contact was made and no return call was received. Interview with the Administrator, on [DATE] at 3:30 PM, revealed the nursing care plan for Resident #1 was not meaningful to ensure another fall would not occur. She stated the facility had recently recognized the nursing staff needed additional training in the care planning process and they were still in the process of improving the skills of their nursing staff. 2. Review of Resident #8's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) examination was conducted and the facility assessed the resident with a score of ninety-nine (99) meaning the resident was unable to complete the interview. The MDS assessment stated the resident was currently on a toileting program and occasionally incontinent of urine and always continent of bowel. On [DATE] at 11:25 AM, an interview with Licensed Practical Nurse (LPN) #9, revealed Resident #8 needed the assistance of two (2) to toilet. She stated the resident was able to make his/her needs known to staff and would yell out instead of using the call light for assistance to use the bathroom and staff would respond. She stated if staff was not within range they would not hear the resident yelling. Review of the POS [REDACTED]. Recommendations made from the interdisciplinary team review were to immediately reassess the resident; reassess the resident's toileting program needs; refer the resident to therapy for screening or evaluation; for restorative to see as ordered; monitor for changes for three (3) days; and, report to the physician any change in the resident's condition. Review of the Comprehensive Care Plan for Resident #8 revealed a plan was developed on [DATE], with updated goals and a target date for [DATE]. The problem stated the resident had functional incontinence related to the inability to recognize bladder cues secondary to poor mobility and dementia. The goal stated the resident would be accepting to toileting cues and staff would maintain dignity with odor/soiled free clothing. The approaches directed staff to monitor the resident's response with the toileting program; offer assistance to toilet before and after supper; at bedtime; every three (3) hours during the night; and, as necessary. Review of the POS [REDACTED]. Review of the resident's Restorative Program revealed the resident had only received twelve (12) of twenty-eight (28) sessions; and, from [DATE] to [DATE] the resident had only received two (2) fifteen (15) minute sessions. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 9:00 AM, revealed Resident #8 had not received the daily restorative care per the the resident's was care plan. Continued interview with the ADON, revealed Resident #8 experienced another fall on [DATE] trying to transfer to the toilet again. The ADON stated the staff had not implemented the toileting and restorative care plan interventions, as per their policy. She stated if the staff had provided toileting assistance to the resident the fall would have been prevented. Interview with the Director of Nursing, on [DATE] at 5:20 PM, revealed she did not remember speaking about Resident #8's falls or care plan interventions related to toileting or the restorative programs during the morning meetings. She stated care plans needed to be current and the facility needed to ensure care plan interventions were implemented by the staff to prevent another occurrence as per the facility's policy. Interview with the Administrator, on [DATE] at 5:50 PM, revealed she made rounds daily, had an open door policy and insisted staff call her when there were falls or other concerns. She stated she had identified the facility staff still needed additional education and supervision to ensure the resident's care plans were followed and the resident's needs were met. She stated the facility should have followed their care plan policy to ensure Resident #8 received the necessary toileting assistance and restorative services per his/her plan of care. 3. Review of Resident #10's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Annual Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) examination was conducted and the facility assessed the resident with a score of three (3) meaning the resident was not interviewable. Review of the Comprehensive Care Plan for Resident #10 revealed a plan was developed on [DATE], with updated goals and a target date for [DATE]. The problem stated the resident was at risk for falls due to a history of falls related to unsteady balance, attempts to get up unassisted and anxious behavior. The goal stated the resident would not receive any injuries from falls through the next review. The approaches directed staff to ensure the bed and seat belt alarm to wheelchair was in place at all times and offer diversional activities such as snacks, music or pictures and toilet as scheduled. Observation of Resident #10, on [DATE] at 2:00 PM, revealed the resident was in bed in the low position with eyes closed. Observation on [DATE] at 11:50 AM, revealed Resident #10 was in the common area seated in a wheelchair with a self releasing seat belt. Review of the POS [REDACTED]. Continued review of the document revealed each time the resident was found on the floor the seat belt alarm was not sounding and found to be in turned on the off position. Review of the recommended care plan interventions developed after each fall revealed they were the same on each document. Interventions included to immediately assess the resident and monitor for three (3) days; ensure the proper working order of the seat belt alarm; staff to make sure, each shift, the alarm was turned on; and, to provide supervision and offer diversional activities of the resident's choice. However, the facility was unable to provide documented evidence they were following the care plan intervention, per the facility policy, to ensure the seat belt alarm was checked each shift for proper working order. On [DATE] at 3:50 PM, an interview with the East Unit Nursing Supervisor, revealed nursing did not document that residents' alarms were checked daily or per shift for functionality. She stated there were no orders to do so for any resident with an alarm. However, it was the nursing staff's responsibility to ensure Resident #10's plan of care intervention regarding making sure his/her alarm was on and functioning properly was actually implemented as per the care plan policy. On [DATE] at 1:00 PM, an interview with the Director of Nursing, revealed the facility did not document if the residents' bed/chair/seat belt alarms were checked for functionality. That would have to be put in as a physician's orders [REDACTED]. The DON stated documenting those types of checks had not been a routine practice for the facility. She stated she had identified the staff was not providing the necessary supervision or diversional activities to prevent the resident from trying to get up from the wheelchair unassisted, as per their facility's care plan policy for implementing care plan interventions. On [DATE] at 1:45 PM, an interview with the Administrator, revealed the Director of Nursing and Assistant Director of Nursing brought it to her attention that the staff was not following the care plan policy related to the seat belt alarm intervention to ensure it was on while Resident #10 was in the wheelchair. She stated she was responsible for making sure the staff followed the care plan policy. The facility took the following actions to remove the Immediate Jeopardy on [DATE] as follows: 1. On [DATE] Resident #1 was assessed by RN #2 the Nursing Supervisor and immediately sent to the hospital. 2. On [DATE], the Director of Rehabilitation and Executive Director (ED) reviewed the Therapy Evaluation policy and agreed the policy was followed and that communication would be enhanced by updating to include Tell a Nurse for the evaluation process. This was also discussed on the phone with Kentucky Area Vice President of Golden Living on [DATE]. The previous policy did not include communication upon evaluation. This was completed on [DATE]. 3. On [DATE] the facility started training supervisors on one to one (1:1) supervision staffing by the Administrator and Director of Nursing (DNS); seventy-seven (77) staff had been trained. Training completed [DATE]. Any staff that had not been trained will not work until training had been completed. Starting on [DATE] Nurses and CNAs received training on the meaning of 1:1 by DNS. Seventy-seven (77) nurses and CNAs have received training as of [DATE]. Attendance is checked by DNS, ADNS and Nursing Supervisors. If a CNA or Nurse was on leave or vacation, they were scheduled to have the education prior to shift upon return. Golden Living Camelot does not utilize Agency staffing. 4. One on one competency audit interviews for the one on one (1:1) supervision training follow-up started [DATE] with Certified Nursing Assistant (CNA) and nursing staff, Registered Nurse (RN), and Licensed Practical Nurse (LPN). This was completed by Nursing Consultant, ED, and Nursing Supervisors. Forty-eight (48) interviews had been done. Going forward five (5) interviews would be done on varied shifts each day for two (2) weeks and then five (5) times per week for one month. Any deficits were retrained at the time of the interview with the CNA or Nurse. 5. Rehabilitation Manager identified residents that had been evaluated by therapy in the last three (3) months or on therapy caseload as of [DATE] without any issues noted. Thirty-seven (37) residents had been evaluated. Thirty-seven (37) care plans were revised by nursing and therapy to include gait and transfer information. Those care plans had been reviewed and revised as indicated. On [DATE] CNA care cards were revised to assure consistent language was used throughout the building for CNA care. 6. Training on Tell a Nurse program was done with ten (10) therapists starting [DATE] by the Director of Rehabilitation. Training with therapists was completed on [DATE]. Starting on [DATE], DNS trained forty-three (43) of forty-four (44) nurses on the Tell a Nurse program. Training for nurses was completed on [DATE]. The one remaining nurse would be trained prior to working a shift by the DNS, Assistant Director of Nursing Services (ADNS), or Nursing Supervisor. 7. Checked the Tell A Nurse binders on each nursing unit for communication sheet, check care plan and care sheet to assure any changes were added to the care plan and the CNA care sheet. Audits were completed on [DATE] through [DATE] by DNS, ADNS, ED, Nursing Supervisor or Nurse Consultant subsequent to Tell A Nurse form to observe service and confirm it was consistent with Tell A Nurse information. On [DATE] the Nurse Consultant completed an audit of the Tell a Nurse process. Each binder was reviewed to assure communication sheets were in place, and care plans and care sheets were reviewed to assure accuracy. Three (3) care plans were updated or changed by the Nurse Consultant. Follow up was completed with the nurse. The modifications included more specific information to a care plan regarding transfers, and supervision to licensed nurse to assure update of CNA care sheet. On the two other cases it was assured that the care plan and CNA care sheets matched and both were updated. 8. Starting [DATE] when a 1:1 was done, the Unit Manager brought the 1:1 supervision documentation to the clinical start up for a check of the documentation. The Administrator, DNS, or Nursing Supervisor would complete an audit of 1:1's at varied times daily to assure one to one supervision was being done according to protocol. 9. Starting on [DATE] the DNS, ADNS, or Nurse Supervisor continue to check that changes were made to the care plans from therapy evaluations at the daily clinical start up. The nurse brought the binder to clinical start up, when a Tell a Nurse form had been completed. Therapy, Nursing Consultant/ DNS or ADNS checked the Tell A Nurse form and assured care plan updates and care sheet updates were completed using the Tell A Nurse Audit Form. 10. An Ad Hoc Quality Assurance Process Improvement (QAPI) meeting was held on [DATE] to discuss and validate that the results of the therapy evaluations were updated to the care plans and the CNA care cards. This was conducted by the Administrator, DNS, ADNS, Social Worker, Therapist, and Medical Director and will continue weekly times four (4) weeks, then bi-weekly times four (4) weeks, then monthly thereafter. The monitoring and auditing of the Tell A Nurse program would be done by the DNS, ADNS, or Nurse Supervisor. Additional Ad Hoc QAPI held on [DATE] to update system of checks and validate current systems. Ad Hoc QAPI for entire system held on [DATE] including Competency Interview system. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] as follows: 1. Review of Resident #1 nurses note, dated [DATE], revealed Resident #1 was assessed by RN #2 the Nursing Supervisor and sent to emergency department post fall on [DATE] at 5:17 PM. 2. Review of Evaluation-Plan of Care policy, undated, and Tell A Nurse form, undated, on [DATE], revealed the Therapy Evaluation policy and procedure was reviewed and updated to include the Tell A Nurse form by the Director of Rehabilitation, ED, and the Kentucky Area Vice President of Golden Living. Interview with the Rehabilitation Director, on [DATE] at 11:00 AM, and Administrator, on [DATE] at 8:45 AM, revealed the policy was reviewed and procedure updated to include the Tell A Nurse communication form and completed on [DATE]. 3. Review of in-service records, dated [DATE], revealed seventy-seven (77) staff had been trained by the Administrator and Director of Nursing on one to one staffing. Training included the definition of 1:1 staffing, steps to provide 1:1 supervision, and the required documentation for 1:1 supervision. Interview with Nursing Supervisor #2, on [DATE] at 3:50 PM and Licensed Practical Charge Nurse #3 revealed they had received training on 1:1 resident care and could correctly define 1:1 and knew what to document regarding 1:1 supervision. 4. Review of one on one (1:1) Competency Interview audits and Daily Assignment Sheets, revealed forty eight (48) staff, including CNAs, RNs, and LPNs, on varied shifts had been interviewed regarding 1:1 supervision. Interviews began on [DATE] and were completed daily until [DATE] by Nursing Consultant, Administrator, and Nursing Supervisors. Interview with Administrator, on [DATE] at 8:45 AM, revealed she conducted 1:1 Competency interviews, and had done more than the required five each day during the first 2 weeks. She stated any staff person requiring retraining was done at the time of the interview. Intervew with Certified Nursing Assistant #10, on [DATE] at 3:10 PM, revealed she received training on 1:1 supervision and had been interviewed after training to determine if she could recite what she was required to do. Interview with Licensed Practical Nurse #7, on [DATE] at 1:55 PM, stated she had received training regarding 1:1 supervision and had been interviewed afterwards to check if she knew her responsibility regarding 1:1 supervision. She stated she was to ensure the CNA's documented their 1:1 observations and that staff could not leave the resident unless provided relief. Interview with Registered Nurse #2, on [DATE] at 11:00 AM, revealed she had received training on 1:1 supervision and had been interviewed after the training to determine her knowledge of the 1:1 process. She stated her responsibility was to ensure documentation was completed by the CNA and that staff was not to leave the resident unless another staff member relieved them. 5. Review of the facility's document titled Level of Assist from [DATE] to current, revealed thirty-seven (37) residents had been evaluated by therapy during that time. Record review of those thirty seven (37) resident care plans and CNA care cards, revealed gait and transfer information was included on the care plans and CNA care cards. Interview with Rehabilitation Manager, on [DATE] at 11:00 AM, revealed she identified 37 residents had been evaluated by therapy in the last 3 months, and resident care plans were updated to include gait and transfer information. Interview with Director of Nursing, on [DATE] at 10:40 AM, revealed CNA care cards were revised on [DATE] to assure consistent language was used throughout the building. 6. Review of in-service records, dated [DATE], revealed ten (10) therapists had been trained on Tell a Nurse program by the Director of Rehabilitation. Interview with the Director of Rehabilitation, on [DATE] at 11:00 AM, revealed she had trained 10 therapists on the Tell A Nurse program. Interview with the Occupational Therapist, on [DATE] at 11:10 AM, revealed she had received training by the Director of Rehabilitation regarding the Tell A Nurse program which included filling out the form and verbally providing a report to nursing staff of their assessment findings. Additional review of in-service record, dated [DATE], revealed forty-three (43) nurses had attended training on the Tell A Nurse program by the DNS. Interview with Licensed Practical Nurse #7, on [DATE] at 1:55 PM, revealed he/she had been trained on the Tell A Nurse program, including the location and purpose of the Tell a Nurse binder, and the process for updating care plans and CNA care sheet after therapy evaluation. 7. Review completed on [DATE], of the Tell A Nurse Binder communication sheets, resident care plans, and CNA care sheets, revealed changes and updates from the Tell A Nurse form were updated on the resident care plan and CNA care sheets. Interview with the Administrator, on [DATE] at 8:45 AM, and Director of Nursing, on [DATE] at 10:40 AM, revealed they had conducted audits of the Tell A Nurse communication sheet, resident care plans, and CNA care sheets to confirm that information was consistent on all documents. Interview with Nurse Consultant, on [DATE] at 10:45 AM, and Nursing Supervisor #2, on [DATE] at 3:50 PM, revealed they completed audits of the Tell A Nurse process on [DATE], including reviewing the Tell A Nurse binders to assure communication sheets were in place, and care plans and care sheets were reviewed for accuracy. In addition, they revealed three (3) care plans were updated to include more specific information regarding transfers, and supervision to licensed nurse to assure update of CNA care sheet. Review of the three care plans, revealed care plans and CNA care sheets were updated with therapy's recommendations for assistance with transfers and walking. 8. Observation of the clinical start up meeting, on [DATE] at 9:00 AM, revealed the Unit Manager of the Alzheimer's Care Unit (ACU) had one resident on 1:1 supervision. The 1:1 documentation was discussed and reviewed by the DON. Review of the 1:1 documentation for the resident, revealed 1:1 documentation was complete, and the ED, DNS, or Nursing Supervisor had completed a daily audit of the documentation. Review of Golden Living Center Camelot E.D. Stand-Up Meeting sheets from [DATE]-[DATE], revealed 1:1 documentation was reviewed daily during the clinical start up meeting. 9. Observation of the clinical start up meeting, on [DATE] at 9:00 AM, revealed the Tell A Nurse binders on each nursing unit were reviewed with no new Tell A Nurse forms completed the previous day. Review of the Tell A Nurse forms from [DATE], resident care plans, and CNA care sheets, revealed therapy evaluations from the Tell A Nurse form were updated on the resident care plan and CNA care sheets to reflect therapy recommendations. Interview with the DNS, on [DATE] at 5:20 PM, revealed she checked the Tell A Nurse form and assured care plans and CNA care sheets were updated using the Tell A Nurse Audit Form. 10. Review of the Ad Hoc Quality Assurance Process Improvement (QAPI) sign in sheets, and agendas dated [DATE] and [DATE], revealed the Adminstrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Therapist and Medical Director were in attendance. Interview with the Administrator, on [DATE] at 5:50 PM, revealed the QAPI team met weekly if not more frequently. In addition, the QAPI team discussed the results of therapy evaluations and ensured care plans and CNA care cards were updated. Interview with the Director of Nursing, on [DATE] at 5:20 PM, revealed she was responsible for the monitoring and auditing of the Tell A Nurse program. She stated she reviewed the Tell A Nurse communication sheet in the daily clinical start up meeting and completed audits to ensure care plans and CNA care sheets were updated as needed. Interview with the Medical Director, on [DATE] at 1:45 PM, revealed he met weekly with the facility QA committee members to discuss the information brought to the committee by its members. He stated the Tell A Nurse form and communication process was discussed and actions were developed at the meeting. He stated the 1:1 supervision process was also discussed along with audit findings. Review of the QAPI sign in sheets, revealed QAPI meetings were held on [DATE], [DATE], [DATE], and [DATE]. Review of the QAPI documentation, dated [DATE], revealed process and progress of audit systems were discussed.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents received supervision to prevent accidents. The facility's analysis of the potential causes of the incidents failed to determine the root cause. In addition, the interventions developed were not evaluated for relevancy or effectiveness in order to prevent recurrence for three (3) of fifteen (15) sampled residents. (Resident's #1, #8, and #10). Resident #1 had a history of [REDACTED]. The resident was assessed to need staff assistance with transfers and walking. On [DATE], at 12:14 PM Physical Therapy assessed the resident to need the maximum assistance of two (2) persons for ambulation. However, Therapy staff failed to communicate the resident's need for maximum assist to nursing staff. On [DATE], at 5:10 PM, Resident #1 fell while walking in the hallway without any assistance of staff. Resident #1 sustained bilateral subdural hematomas to the forehead and a skull fracture to the back of the head and expired sixteen (16) hours later at the hospital. In addition, Resident #8 had a history of [REDACTED]. The resident experienced another fall, on [DATE] at 10:00 AM, again at the time of the facility's smoking break. On [DATE] at 4:22 PM, [DATE] at 3:35 PM and [DATE] at 9:00 AM, Resident #10 experienced non-injury falls from the wheelchair on each of these dates. All three falls the resident was found on the floor in the common area by the nurses station, and the seat belt alarm was not sounding and was found to be turned off. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents to prevent accidents or incidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on [DATE]. An acceptable Allegation of Compliance was received on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated the removal of Immediate Jeopardy on [DATE] as alleged prior to exit on [DATE]. The scope and severity was lowered to an D while the facility monitors the systemic changes and the Quality Assurance monitors the effectiveness of the plan of correction. The findings include: Review of the facility's policy regarding Falls Management Guideline, dated [DATE] and reviewed [DATE], revealed the interdisciplinary team would evaluate the fall prevention plan of care for residents at risk for falls. Following a resident's fall the nurse would assess the resident for injuries and provide the necessary care and services, including neurological checks if indicated. Appropriate interventions would be implemented and the care plan updated. Per center practices licensed nurses would complete continued ongoing assessment and documentation. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) exam was conducted and the facility assessed the resident with a score of ten (10) meaning the resident was interviewable. Review of the Comprehensive Care Plan for Resident #1 revealed a plan was developed on [DATE] with updated goals and a target date for [DATE]. The problem stated the resident was at risk for falls due to a history of falls at home and cognitive impairment related to the [DIAGNOSES REDACTED]. The approaches directed the staff to monitor for changes in functional status, environmental and situational hazards daily to ensure a safe environment was provided. Review of Nursing note, dated [DATE] and timed 9:50 AM, revealed the staff witnessed Resident #1 stand without assistance in the dining room and then observed the resident to lose their balance and fall to his/her knees. Further review of the resident's care plan revealed on [DATE], due to a fall that occurred on [DATE], Resident #1's care plan approaches were revised, and the facility noted the resident was to be evaluated by Physical Therapy and staff was to assist with transfers and walking due to an unsteady gait. Review of the Therapy assessment, dated [DATE] at 12:14 PM, revealed the reason for referral was due to a fall. The therapist assessed the resident as moderate assistance of two (2) persons for ambulation, the resident required cues redirection on multiple occasions during the evaluation. The resident further scored a one (1) of five (5) on the standing balance and fell asleep twice when ambulating twenty (20) feet. Review of Nursing note, dated [DATE] and 5:10 PM, revealed the nurse was standing in the hallway with Resident #1 and turned her back to the resident to provide care to another resident. The nurse heard a loud noise from behind her and turned back toward to the resident to find the resident laying on the floor, flat on his/her back unresponsive. Interview, on [DATE] at 8:41 AM, with Physical Therapist #1, revealed she had completed an ordered Physical Therapy evaluation, with the help of the Occupational Therapist, on [DATE] at 12:14 PM. The evaluation was to determine Resident #1's gait, transferring and walking ability. The resident required the maximum assistance of two (2) to assist the resident out of a reclining chair, to walk twenty (20) feet and to return to a sitting position. The resident could only provide twenty-five percent of own effort in rising from the chair. While walking the resident would close his/her eyes and also fall asleep, but was easily cued to open the eyes. She did not provide a report to nursing, using the facility's Tell a Nurse form regarding her evaluation; however, she stated the nursing staff had access to the report in the medical record. She stated if she had made a report to the nursing staff she would have recommended Resident #1 be a maximum assistance of one (1) to two (2) at all times while walking. She added the problem was the resident had a history of [REDACTED]. Interview, on [DATE] at 5:00 PM, with Licensed Practical Nurse (LPN) #5, revealed she worked as an aide on [DATE] when Resident #1 sustained the fall. She stated the resident was very lethargic and was observed to walk with his/her eyes closed. LPN #5 stated Resident #1 was assessed as a fall risk. She spoke with the Director of Nursing and requested extra staff for the unit in order for someone to stay one on one with Resident #1 to maintain his/her safety and prevent a fall. However, the request was denied and instead a chair alarm was provided for use with Resident #1. She did the best she could to watch the resident while trying to take care of her other residents. The chair alarm was not appropriate because the resident would not stay seated and would get up and pace around the unit. She stated she did not know about the Therapy evaluation. She stated the staff knew the evaluation was in the computer; however, did not know the evaluation was completed. Phone calls to the previous Director of Nursing (DON), on duty at the time of Resident #1's fall, were attempted on [DATE] at 4:10 PM and on [DATE] at 8:17 AM and 3:00 PM, but were unsuccessful and no return calls were received by the DON. Interview, on [DATE] at 9:20 AM, with Licensed Practical Nurse (LPN) #1, revealed she had worked on [DATE] from 7:00 AM to 11:00 PM. Resident #1 appeared very tired all day and had been experiencing problems with sleeping and staying awake. The resident was unsteady on his/her feet and was a fall risk. Further the resident paced the unit and mumbled constantly about going somewhere. She continued to complete her daily nursing duties while keeping an eye on Resident #1 and trying to keep him/her close to her. She stated a Physical Therapist evaluated the resident on [DATE]; however, she did not receive a report regarding their evaluation and was not provided any recommendations related to the resident's assessed needs related to walking and she had not reviewed the chart for the evaluation. She was administering medications to another resident while standing in the hallway. She stated Resident #1 was a little ways behind her when she turned her back to Resident #1, in order to administer medication to a resident. She heard a loud thud behind her and when she turned around Resident #1 was on the floor, on his/her back and unresponsive. The resident was unresponsive for a few minutes and sustained swelling to the back of the head, breathing was difficult and pupils were sluggish. An ambulance was called to transport the resident to the hospital. She stated she learned later that the resident had passed away at the hospital from his/her injuries. Interview with the Rehab Director, on [DATE] at 8:41 AM, revealed it was not the rehab's policy to use a Tell A Nurse form, or their process to notify nursing of any evaluation results, as it is put in the computer and the nursing staff was aware they can retrieve the information at any time. If staff was aware of the resident's risk for falls and did not report it then the resident would remain at risk and if therapy did not communicate with nursing the resident would still be at risk for falls. Interview, on [DATE] at 5:30 PM, with the Administrator revealed she was not aware of the request for extra staffing in order to provide the one to one supervision for Resident #1. If she had known she would have approved the request. The facility could have done a better job at identifying the root cause of Resident #1's falls and in the development of relevant interventions to prevent reoccurrence. She stated the facility had identified educational needs in regards to the root cause analysis and care planning process. Further the facility was still in the process of providing additional education to correct these identified issues. Continued interview with the Administrator, revealed they had not identified an issue with communication between nursing and rehab and the root cause analysis, until after surveyor intervention. She further stated the process was to use the Tell A Nurse form; however, this was not a policy. Per interview, it was at the discretion of therapy whether to use the form or not after an evaluation was completed. 2. Review of Resident #8's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) exam was conducted and the facility assessed the resident with a score of ninety-nine (99) meaning the resident was unable to complete the interview. However, the resident was able to use a picture board, and answer yes and no with a nod of the head. The MDS assessment stated the resident was currently on a toileting program and occasionally incontinent of urine and always continent of bowel. Review of the Post Fall Analysis/Plan, dated [DATE], revealed Resident #8 had a history of [REDACTED]. The analysis stated the resident was found on the floor on his/her left side with the upper body in the adjoining resident's room. Recommendations made from the interdisciplinary team review were to immediately reassess resident, reassess resident's toileting program needs, refer to therapy for screen or evaluation, and for restorative to see as ordered, monitor for changes for three days and report to physician any change in condition. Interview with Restorative Nursing Assistant (RNA) #2, on [DATE] at 11:55 AM, revealed at times the restorative aides were pulled to work as a Certified Nursing Assistant (CNA). RNA #2 stated the facility was short CNA's on [DATE] and she was not able to complete the restorative program requirements for Resident #8. Interview with Assistant Director of Nursing (ADON), on [DATE] at 9:00 AM, revealed she worked remotely from home and completed the Post Analysis Fall form after Resident #8's fall on [DATE]. She had identified Resident #8 had not received the daily restorative care the resident should have and thought maybe the resident had experienced a decline in ability so she ordered; a therapy screen/evaluation, the resident's toileting program to be reevaluated and for restorative to provide services daily. Review of the Comprehensive Care Plan for Resident #8 revealed a plan was developed on [DATE], with updated goals and a target date for [DATE]. The problem stated the resident was at risk for falls due to a history of falls, balance problems during transfers due to an immobility syndrome related to Cerebral Vascular Accident with right sided hemiparesis. The goal stated the resident would safely transfer with staff assistance with no injuries through next review. The approaches directed physical therapy to perform an evaluation to determine a possible decline in transfer ability, staff to assist with toileting as resident would allow and keep environment well lit and free of clutter, restorative nursing as ordered for transfer training, sit to stand at hand rail or hemi-walker times three, assess for increased joint stiffness, decline in mobility or signs and symptoms of pain. Review of Certified Nursing Aide Care sheet, undated, revealed no mention of Resident #8's toileting program needs or schedule. The form noted the resident required assistance with transfers and extensive assistance with activities of daily living; however, not the assistance of how many. The only special precaution listed on the form was for the resident to have a mat to the bedside. Review of the resident's clinical record revealed no evidence a therapy screen was completed after the fall on [DATE]. Review of the Physical Therapy Screen Form, dated [DATE], revealed the resident was screened on [DATE] and therapy noted an evaluation was not indicated for Resident #8 and stated the resident had not experienced a decline. Review of Post Fall Analysis/Plan, dated [DATE], revealed Resident #8 experienced a fall on [DATE] at 10:00 AM again at the time of the facility's smoking break. The documentation stated the resident had recently been evaluated by therapy and required extensive assistance with transfers. A toileting program was implemented on [DATE] related to functional incontinence; however, the resident attempted to transfer self to the toilet. A Restorative Program was ordered; however, the resident had only received twelve (12) of twenty-eight (28) sessions and from [DATE] to [DATE] the resident had only received two (2) fifteen (15) minute sessions. The recommended interventions were to perform an immediate assessment to report changes to the physician, provide assistance with transfers and provide toileting program and restorative as ordered. These interventions were the same interventions listed on the [DATE] Post Fall Analysis form and no new interventions were added to the falls care plan to prevent another fall for Resident #8. Interview with LPN #12, on [DATE] at 8:35 AM, revealed the staff was busy assisting other residents when they heard Resident #8 hollering for assistance. The resident was found on the floor in the bathroom after trying to transfer to the toilet unassisted. LPN #12 stated she was not sure what the toileting program requirements were for Resident #8 or if restorative was helping with toileting. The facility had been using the restorative nursing staff as Certified Nursing Assistants when the aides called in and they needed staff to cover and believed they had done so on the day of Resident #8's fall on [DATE]. Interview with the Restorative Nurse on, [DATE] at 1:32 PM, revealed staff normally just left her a note or verbally requested she perform an evaluation for a resident. She had not received one for Resident #8 and had not completed a toileting program or restorative reassessment. On [DATE] at 10:40 AM, the Restorative Nurse stated she had revised Resident #8's plan of care related to Functional Incontinence and the resident would be offered toileting assistance before and after supper, at bedtime and every three (3) hours during the night and as necessary. Interview with the Restorative Nurse, on [DATE] at 9:05 AM, revealed there were ninety six (96) residents on the restorative program and four (4) staff to deliver the restorative program requirements. The restorative staff consisted of three (3) restorative aides and her to deliver the program requirements seven (7) days a week. She stated she worked the weekend on [DATE] in a supervisory role and was not aware Resident #8 had experienced another fall. Continued interview with the ADON, on [DATE] at 9:00 AM, revealed the resident experienced another fall on [DATE] trying to transfer to the toilet again. She again completed the Post Analysis Fall Form and put the same interventions from the [DATE] fall as recommendations. She stated if these interventions were implemented they would prevent another fall. She stated when staff provide the toileting program as scheduled the resident would be assisted to the toilet and falls would be prevented. Interview with the Rehabilitation Director, on [DATE] at 11:30 AM, revealed when Resident #8 fell on [DATE] she was not told of the request for the screen until [DATE] and it was done immediately after being requested. Normally she finds out about the request in the morning meeting the day after the fall; however, after reviewing her notes she stated the team did not request a therapy screen for Resident #8's fall during the morning meeting on [DATE] or any day after that. Interview with the Director of Nursing, on [DATE] at 5:20 PM, revealed she did not remember speaking about Resident #8's falls or care plan interventions related to toileting or restorative programs. Communication amongst the interdisciplinary team was an identified concern. She stated the facility needed to work on identifying the root cause after an incident or fall occurred in order to develop and implement relevant interventions to prevent another occurrence. Interview with the Administrator, on [DATE] at 5:50 PM, revealed after Resident #8's fall the facility should have ensured the resident received the required assistance for toileting and restorative that was care planned. The Administrator stated she made rounds daily, had an open door policy and insisted staff call her when there were falls or other concerns; however, there were issues she was still not aware of, like Resident #8's late therapy screen. She stated she had identified the facility staff still needed additional education and required supervision to ensure communication occurred and resident needs were met. She stated they were working on that presently. Observation, on [DATE] at 3:00 PM, of Resident #8 revealed the resident was outside in the courtyard smoking. Interview with Resident #8 at this time revealed the resident could answer yes and no questions by shaking his/her head and saying yes and no. The resident shook head up and down and said yes to remembering the falls that occurred on [DATE] and [DATE], where he/she attempted to transfer without assistance to the toilet and fell . Resident #8 responded yes and shook head up and down as to whether he/she asked for assistance by yelling or using call light. The resident was asked if anyone answered the yells for assistance and the resident shook his/her head back and forth and said no. The resident shook head up and down and said yes and began to cry regarding ever having incontinent episodes due to staff not assisting with toileting timely. Again the resident shook head up and down and said yes when asked if this was upsetting. 3. Review of Resident #10's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Annual Minimum Data Set (MDS) assessment, completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) exam was conducted and the facility assessed the resident with a score of three (3) meaning the resident was not interviewable. Review of the Comprehensive Care Plan for Resident #10 revealed a plan was developed on [DATE], with updated goals and a target date for [DATE]. The problem stated the resident was at risk for falls due to history of falls due to unsteady balance, attempts to get up unassisted and anxious behavior. The goal stated the resident would not receive any injuries from falls through the next review. The approaches directed the staff to ensure the bed and seat belt alarm to wheelchair was in place at all times and offer diversional activities such as snacks, music or pictures and toilet as scheduled. Review of the Post Fall Analysis/Plan forms, dated [DATE] at 4:22 PM, [DATE] at 3:35 PM and [DATE] at 9:00 AM (day shift falls), revealed Resident #10 experienced non-injury falls from the wheelchair on each of these dates. Continued review of the documentation revealed with all three falls the resident was found on the floor in the common area by the nurses station, and the seat belt alarm was not sounding and was found to be turned off. Review of interventions to be put in place after each fall revealed they were the same for all three falls. The interventions were to immediately assess the resident and monitor for three (3) days, ensure the proper working order of the seat belt alarm and to ensure it was turn on each shift, and to provide supervision and offer diversional activities of resident's choice. Review of the resident's clinical record revealed these checks could not be located and the facility was unable to provide evidence that the seat belt alarm was checked each shift for proper working order. Interview with East Unit Nursing Supervisor, on [DATE] at 3:50 PM, revealed she was working on [DATE] and had seen a resident fiddling with Resident #10's seat belt alarm box prior to the resident being found on the floor and thought maybe that resident might have turned it off. The nurse stated she was busy with the smoking residents and did not follow up regarding the wandering resident. Interview with the House Supervisor, on [DATE] at 3:40 PM, revealed the UM was busy on [DATE], she found out the staff was busy with other residents during the falls and she did not address the suspected resident who had been turning the alarms off. There was no system to check alarms and staff could not always meet Resident #10's needs and could not provide one on one supervision. Interview with CNA #10, on [DATE] at 3:10 PM, revealed when she worked she usually was assigned to take care of Resident #10. She was not sure if she worked on the days Resident #10 fell and just could not remember. She stated if she did work she was probably busy with other residents when Resident #10 fell . She stated she would check the resident's alarm to ensure it was on each time she put the resident in the wheelchair, but there was no required documentation for that check. She continued to state she had never seen Resident #10 turn off the alarm and did not think the resident would be able to do that. She stated she had seen other wandering residents fiddle with Resident #10's alarm and they had one resident that went around turning off alarms regularly. She stated when the resident needed to go to the bathroom or was bored was when the resident would attempt to get out of the wheelchair. She stated if you took care of those two needs the resident would not attempt to get up. Interview with East Unit Nursing Supervisor, on [DATE] at 3:50 PM, revealed nursing did not document the verification that resident alarms were checked daily or per shift for functionality. She stated there were no orders to do so for any resident with an alarm. The Nursing Supervisor also stated Resident #10 was provided items such as puzzles/coloring books and crayons for diversional activities. But usually did not attend the scheduled activities because the resident needed constant redirection by staff due to setting off the seat belt alarm. Interview with the Director of Nursing, on [DATE] at 1:00 PM, revealed the facility did not document if the residents' bed/chair/seat belt alarms were checked for functionality. She stated that would have to be put in as a physician's orders [REDACTED]. Documenting those types of checks had not been a routine practice for the facility. However, review of the falls analysis form revealed the staff were to check the alarm every shift. She had identified the staff was not providing the necessary supervision or diversional activities to prevent the resident from trying to get up from the wheelchair unassisted. The DON stated she was aware of the wandering resident who turned the alarms off; however, no interventions had been put in place. Interview with Administrator, on [DATE] at 1:45 PM, revealed the Director of Nursing and Assistant Director of Nursing brought it to her attention that the interdisciplinary team did not determine the interventions documented on the Post Falls Analysis form after each of Resident #10's falls were all the same and that each time the resident's alarm was found to be turned off. She stated all she could do was apologize the interventions were not effective in preventing another fall. The facility was still in the learning process when it came to determining the root cause of falls and developing care plan interventions after incidents. The facility took the following actions to remove the Immediate Jeopardy on [DATE] as follows: 1. On [DATE] Resident #1 was assessed by RN #2 the Nursing Supervisor and immediately sent to the hospital. 2. On [DATE], the Director of Rehabilitation and Executive Director (ED) reviewed the Therapy Evaluation policy and agreed the policy was followed and that communication would be enhanced by updating to include Tell a Nurse for the evaluation process. This was also discussed on the phone with Kentucky Area Vice President of Golden Living on [DATE]. The previous policy did not include communication upon evaluation. This was completed on [DATE]. 3. On [DATE] the facility started training supervisors on one to one (1:1) supervision staffing by the Administrator and Director of Nursing (DNS); seventy-seven (77) staff had been trained. Training completed [DATE]. Any staff that had not been trained will not work until training had been completed. Starting on [DATE] Nurses and CNAs received training on the meaning of 1:1 by DNS. Seventy-seven (77) nurses and CNAs have received training as of [DATE]. Attendance is checked by DNS, ADNS and Nursing Supervisors. If a CNA or Nurse was on leave or vacation, they were scheduled to have the education prior to shift upon return. Golden Living Camelot does not utilize Agency staffing. 4. One on one competency audit interviews for the one on one (1:1) supervision training follow-up started [DATE] with Certified Nursing Assistant (CNA) and nursing staff, Registered Nurse (RN), and Licensed Practical Nurse (LPN). This was completed by Nursing Consultant, ED, and Nursing Supervisors. Forty-eight (48) interviews had been done. Going forward five (5) interviews would be done on varied shifts each day for two (2) weeks and then five (5) times per week for one month. Any deficits were retrained at the time of the interview with the CNA or Nurse. 5. Rehabilitation Manager identified residents that had been evaluated by therapy in the last three (3) months or on therapy caseload as of [DATE] without any issues noted. Thirty-seven (37) residents had been evaluated. Thirty-seven (37) care plans were revised by nursing and therapy to include gait and transfer information. Those care plans had been reviewed and revised as indicated. On [DATE] CNA care cards were revised to assure consistent language was used throughout the building for CNA care. 6. Training on Tell a Nurse program was done with ten (10) therapists starting [DATE] by the Director of Rehabilitation. Training with therapists was completed on [DATE]. Starting on [DATE], DNS trained forty-three (43) of forty-four (44) nurses on the Tell a Nurse program. Training for nurses was completed on [DATE]. The one remaining nurse would be trained prior to working a shift by the DNS, Assistant Director of Nursing Services (ADNS), or Nursing Supervisor. 7. Checked the Tell A Nurse binders on each nursing unit for communication sheet, check care plan and care sheet to assure any changes were added to the care plan and the CNA care sheet. Audits were completed on [DATE] through [DATE] by DNS, ADNS, ED, Nursing Supervisor or Nurse Consultant subsequent to Tell A Nurse form to observe service and confirm it was consistent with Tell A Nurse information. On [DATE] the Nurse Consultant completed an audit of the Tell a Nurse process. Each binder was reviewed to assure communication sheets were in place, and care plans and care sheets were reviewed to assure accuracy. Three (3) care plans were updated or changed by the Nurse Consultant. Follow up was completed with the nurse. The modifications included more specific information to a care plan regarding transfers, and supervision to licensed nurse to assure update of CNA care sheet. On the two other cases it was assured that the care plan and CNA care sheets matched and both were updated. 8. Starting [DATE] when a 1:1 was done, the Unit Manager brought the 1:1 supervision documentation to the clinical start up for a check of the documentation. The Administrator, DNS, or Nursing Supervisor would complete an audit of 1:1's at varied times daily to assure one to one supervision was being done according to protocol. 9. Starting on [DATE] the DNS, ADNS, or Nurse Supervisor continue to check that changes were made to the care plans from therapy evaluations at the daily clinical start up. The nurse brought the binder to clinical start up, when a Tell a Nurse form had been completed. Therapy, Nursing Consultant/ DNS or ADNS checked the Tell A Nurse form and assured care plan updates and care sheet updates were completed using the Tell A Nurse Audit Form. 10. An Ad Hoc Quality Assurance Process Improvement (QAPI) meeting was held on [DATE] to discuss and validate that the results of the therapy evaluations were updated to the care plans and the CNA care cards. This was conducted by the Administrator, DNS, ADNS, Social Worker, Therapist, and Medical Director and will continue weekly times four (4) weeks, then bi-weekly times four (4) weeks, then monthly thereafter. The monitoring and auditing of the Tell A Nurse program would be done by the DNS, ADNS, or Nurse Supervisor. Additional Ad Hoc QAPI held on [DATE] to update system of checks and validate current systems. Ad Hoc QAPI for entire system held on [DATE] including Competency Interview system. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] as follows: 1. Review of Resident #1 nurses note, dated [DATE], revealed Resident #1 was assessed by RN #2 the Nursing Supervisor and sent to emergency department post fall on [DATE] at 5:

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure the staff provided adequate supervision to prevent Sexual Acting Out (SAO) behaviors; and, failed to have an effective system to evaluate and identify interventions to prevent injurious falls for five (5) of twenty-nine (29) sampled residents (Resident #10, #1, #6, #11, and #12). In addition, the facility failed to ensure safe storage of hazardous materials in three (3) of four (4) shower rooms. The facility failed to provide supervision to the residents on the Alzheimer's Care Unit. On 03/11/15 at 5:50 AM, facility staff observed Resident #10 sitting on a couch next to Resident #18 sucking on his/her right breast. The facility placed Resident #10 on 1:1 supervision and requested inpatient psychiatric hospitalization . Review of the intake assessment conducted by the hospital, on 03/11/15 at 1:00 PM, revealed the resident was exhibiting sexually acting out (SAO) behaviors. The hospital Intake Coordinator documented the SAO behaviors presented a threat of harm to other residents. The facility identified the resident had a history of [REDACTED]. The resident required hospitalized from [DATE] to 03/24/15. Review of the facility's staffing for 03/11/15 revealed one nurse and one nurse aide was scheduled to care for thirty-one residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, revealed there were two locked units, the Alzheimer's Care Unit (ACU) and the Advanced Alzheimer's Care Unit (AACU). She revealed she and the nurse aide was on the AACU together leaving the ACU with fifteen (15) residents unsupervised during the incident. The facility's failure to monitor Resident #10's SAO behaviors and provide adequate supervision resulted in an unsafe environment for other residents. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents who exhibited SAO behaviors was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 03/11/15. The facility was notified of the Immediate Jeopardy on 04/24/15. An acceptable Allegation of Compliance was received on 04/29/15 which alleged removal of the Immediate Jeopardy on 04/29/15. An extended survey was conducted on 05/05/15 through 05/07/15. The State Survey Agency determined the Immediate Jeopardy was not removed on 04/29/15 as alleged, but on 05/07/15, prior to exit of the survey. The Scope and Severity was lowered to a G level (actual harm) for 42 CFR 483.25 (323) while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. In addition, the facility failed to have an effective system in place to identify the root cause of falls in order to identify interventions to prevent further accidents for residents. Resident #12 was identified by the facility as at risk for falls with a history of falling at home. Resident #12 sustained a fall on 03/26/15 transferring from the toilet unassisted. The resident sustained [REDACTED]. On 04/11/15, Resident #12 experienced slurred speech and was transferred to the hospital. The resident was admitted to the hospital with [REDACTED]. Resident #6 was identified as being at risk for falls and sustained falls on 01/18/15 with no injuries. On 02/22/15, the resident sustained [REDACTED]. Resident #6 was sent to the hospital and admitted to the hospital with [REDACTED]. Resident #11 was identified at risk for falls and sustained a fall on 03/14/15. The resident sustained [REDACTED]. Resident #1 sustained falls on 01/02/15, 01/27/15 and, on 03/14/15 and the facility failed to identify the root cause of the falls. In addition, observation of the shower rooms on the Alzheimer's Care Unit, Advanced Alzheimer's Care Unit and the East Wing-Hall C, revealed chemicals stored in unlocked cabinets. The units had cognitively impaired residents who wandered the units. On 05/05/15, observation of the East Wing Shower Room revealed a utility cart with a utility knife, a bottle of glue, a box that contained screws and other sharp metals. The findings include: Interview with the Director of Nursing Services (DNS), on 05/06/15 at 3:15 PM, revealed the facility did not have a policy on supervision of residents or falls prevention. Review of the facility's policy regarding Behavior Management Guideline, dated 02/12/15, revealed the facility was to develop behavior plans and medication regimens to optimize the functional abilities of residents while monitoring for adverse side effects and improved behaviors. The facility was supposed to utilize the Antecedent Behavior Monitoring Log for residents with behaviors that negatively affect functioning or quality of life. The Behavior Committee members were to review the log to identify patterns and causative triggering events for the behaviors and to measure the effectiveness of interventions. Additionally, the policy stated when the facility used an antipsychotic medication to treat an enduring condition; the facility must clearly and specifically identify and document the target behaviors. The facility must have clear documented evidence in the medical record that the situation or condition continued or recurred over time and the behaviors negatively affected the resident's quality of life. Interview with the Administrator, on 05/06/15 at 10:53 AM, revealed the facility did not utilize the Antecedent Behavior Monitoring Log before the Immediate Jeopardy. He stated it was available in the Corporate policies on-line and he was to utilize the form; however, neither he or the DNS had implemented the form. Therefore, the Behavior Committee did not review residents' behaviors at the weekly meetings according to the Corporate policy. He stated he could not recall when the Behavior Management Guidelines went into effect and could not recall if he received an e-mail regarding the new policy as was the practice of the Corporation. Review of the Corporate guidelines for Communication and Documentation of an Event, dated 02/10/10, defined an event as an incident that resulted in, or had the potential to result in, physical or mental harm to a resident. Per the guidelines, an event included resident-to-resident altercations and demonstrated high-risk patient behaviors or situations. When an event occurred, the facility was always to complete a thorough and objective Verification of Investigation form. 1. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 04/08/12 with [DIAGNOSES REDACTED]. Review of the most recent physician's orders [REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment, completed on 12/23/14, revealed the facility completed a Brief Interview Mental Status (BIMS) examination with a score of eleven (11) out of fifteen (15), indicating the resident had moderate cognitive impairment. The MDS assessed the resident as not exhibiting any physical, verbal, or other behaviors directed at himself/herself or others during the seven (7) day look back period prior to completion of the MDS assessment. Review of Resident #10's Annual Minimum Data Set (MDS) assessment, completed on 04/13/15, revealed the facility assessed the resident requiring only supervision or limited assistance to complete Activities of Daily Living (ADL). The resident was able to transfer and walk in the corridor with supervision only. The facility did not assess the resident's BIMS for this MDS assessment. The MDS assessed the resident as not exhibiting any physical, verbal, or other behaviors directed at himself/herself or others during the seven (7) day look back period prior to completion of the MDS assessment. Review of the care plan for Resident #10, initiated on 08/13/14 with a print date of 01/27/15 and reviewed on 03/24/15, revealed the resident had sudden sexual impulses and touched staff in inappropriate manners. The interventions specifically specified the resident would redirect himself/herself when he/she felt an impulse coming on, and the facility would monitor the resident for increased emotional distress. The facility dated these interventions 08/13/14. On 03/24/15, the facility updated the resident's care plan pertaining to behaviors of shouting and rejecting care to assess for inappropriate sexual behaviors and aggression and report to MD. Review of the Progress Notes, dated 06/06/14 at 11:29 AM, revealed the ACU Manager documented the Psychiatrist had met with Resident #10 on 06/06/14 and discussed the resident's behaviors with the ACU Manager. The Note stated the resident had sexual behaviors toward staff including touching female staff in inappropriate places. The ACU Manager documented an unsuccessful intervention stating staff had not been able to redirect Resident #10. Review of the Psychiatric Consult/Follow-Up for Resident #10, dated 06/06/14, revealed the facility consulted with the Psychiatrist due to increased SAO behaviors. The document reported Resident #10 had touched females on the buttocks. The Psychiatrist increased the medication Premarin (to help decrease sexual urges) from 0.625 mg (milligrams) to 1.25 mg at the time of the consult. Review of the Interdisciplinary Progress Notes, dated 08/12/14 at 8:45 AM, revealed staff observed Resident #10 hugging a female resident. The Note indicated staff was able to redirect the resident and placed the resident on fifteen (15) minute checks. Further review of the Progress Notes revealed the fifteen (15) minute checks continued through 08/14/14. Review of the Psychiatric Consult/Follow-Up, dated 08/12/14, revealed the facility consulted with the Psychiatrist. Under reason for visit, the document stated the resident continued to inappropriately touch females' (staff and peers) buttocks and breasts. The Consult further stated the behaviors were impulsive and the resident was unable to remember any of these behaviors. Review of the Progress Notes, dated 08/16/14 at 2:10 PM, revealed nursing documented Resident #10 touched a nurse on the buttocks and staff redirected the resident. The Note did not include effectiveness of the intervention. On 08/16/14 at 10:14 PM, a different nurse documented Resident #10 had no behaviors; however, documented the resident was on fifteen (15) minute checks due to a history of touching others. The Progress Notes contained no other reference to the fifteen (15) minute checks or additional supervision required post incident. Interview with the ACU Manager, on 4/24/15 at 10:30 AM, revealed the facility monitored residents when they had SAO behaviors by placing the resident on the 24-hour report and placing the resident on fifteen (15) minute checks, usually for three (3) days. After Resident #10 returned from the hospital, the facility did not change or increase supervision on the unit. Review of the Progress Notes, dated 12/20/14 at 1:18 AM, revealed the facility documented they had placed Resident #10 on fifteen (15) minute checks due to sexual behaviors. The Progress Notes did not indicate what SAO behaviors the resident exhibited to warrant placing him/her on fifteen (15) minute checks. In addition, the Progress Notes did not indicate what interventions the facility used when the SAO behaviors occurred or what interventions the facility would use to prevent reoccurrence of the behavior. Continued review of the clinical record revealed the next documented instance of SAO behaviors occurred in a Progress Note written on 01/12/15 at 2:15 PM. At that time, nursing documented Resident #10 had touched a Certified Nursing Assistant (CNA) on the buttocks earlier in the morning. The nurse also documented she would continue to monitor for behaviors. The Note did not indicate what intervention nursing used or what monitoring the facility implemented. The facility did not document in the clinical record that any increased supervision was provided following that incident. Review of the Progress Notes, dated 01/30/15 at 2:40 PM, revealed nursing staff documented they had placed Resident #10 on fifteen (15) minute checks due to increased behaviors and needing redirection from female residents. The record did not indicate what behavior the resident exhibited or if any interventions were used with the resident. In addition, the record did not indicate how long the resident would remain on fifteen (15) minute supervision. The facility did not document any additional Progress Notes pertaining to the resident's behaviors or fifteen (15) minute supervision in the shifts that followed. Review of the Psychiatric Consult/Follow-Up, dated 02/06/15, revealed the facility consulted with the Psychiatrist due to Resident #10 becoming more inappropriate with touching other residents and staff. The Consult further revealed the resident had Dementia and Sexual Acting Out (SAO) behaviors and the facility had previously attempted a Gradual Dose Reduction (GDR) of Risperdal. Review of the Progress Notes for Resident #10, on 03/11/15 at 5:50 AM, revealed nursing staff made an entry in the Progress Notes under Behavior Charting. Staff noted Resident #10 was sitting in the common area sucking on the breast of Resident #18. The resident refused to leave the common area after the incident. Staff documented vital signs and reported the resident was calm within twenty (20) minutes of the incident. However, the Note does not include what staff did to ensure the safety of other residents. A Progress Note, dated 03/11/15 at 9:26 AM, revealed nursing notified the physician of the incident. At 10:20 AM, the nurse notified the Psychiatrist of Resident #10's behaviors. The Note further revealed the Psychiatrist ordered to send the resident out for further psychiatric evaluation. Review of the Verification of Investigation form for Resident #10, dated 03/11/15 at 5:50 AM, revealed staff observed Resident #10 sitting in the common area sucking on the breast of Resident #18, who was sitting next to him/her. The form stated the residents were immediately separated for their protection and staff placed Resident #10 on one-on-one (1:1) supervision until the resident left the facility to go to the hospital. The facility staff did not complete the portions of the Verification of Investigation form labeled Summary and Outcome of Investigative Findings. Review of the Verification of Investigation form for Resident #18, dated 03/11/15 at 5:50 AM, revealed staff observed Resident #18 sitting on the couch raising his/her pajama top. Resident #10 was sitting on the couch next to Resident #18 and was sucking on Resident #18's breast. Resident #18 had come out of his/her room and into the common area between 5:43 AM and 5:50 AM. At the time of the incident, staff separated the residents immediately and a completed an assessment. Staff placed Resident #18 on fifteen (15) minute checks. The facility staff did not complete the portions of the Verification of Investigation form labeled Summary and Outcome of Investigative Findings. Review of the MDS for Resident #18, on 03/17/15, revealed the facility assessed the resident to have a BIMS score of 9, indicating moderate cognitive impairment and non-interviewable. Review of the Integrated Level of Care Intake Assessment from the Psychiatric Hospital, dated 03/11/15, revealed the hospital staff documented the facility staff had reported Resident #10 was in the common area sucking on another resident's breast; and, had been touching staff and peers on the genitals and bottom. The evaluation further stated staff had found Resident #10 between multiple residents' legs in their bedrooms and had a resident bent over and was humping the resident from behind. Under the section for high risk factors, the assessment indicated Resident #10 was at risk of sexual perpetration due to SAO behaviors. The indicators included the resident touching and fondling females, putting resident's breast in his/her mouth, exposing himself/herself to others, and bending a resident over and humping the resident from behind. The section for The assessment for sexually acting out risk factors, stated the resident had pulled his/her and others' pants down; humped another resident; and, had touched other residents and staff on the breasts, genitals, and bottom. The intake assessment also documented Resident #10 was not oriented and did not remember acting out sexually. Interview with CNA #5, on 04/22/15 at 2:15 PM, revealed Resident #10 had a history of [REDACTED].#10. She also stated the resident had not experienced these behaviors since the last medication adjustment on 02/06/15. Interview with the ACU Manager, on 04/23/15 at 11:00 AM, revealed Resident #10 had a history of [REDACTED].#10 had a history of [REDACTED]. She stated the Psychiatrist was at the facility each Tuesday and Friday to discuss patients on the ACU and AACU. On 01/30/15, the ACU Manager documented she had placed Resident #10 on fifteen (15) minute checks due to increased SAO behaviors. The Unit Manager stated she failed to document what specific behaviors the resident was displaying at the time or for how long the resident was to stay on fifteen (15) minute checks. She stated she remembered she placed Resident #10 on the fifteen (15) minute checks after she found a resident of the opposite sex in Resident #10's room with him/her. The Unit Manager stated she did not observe any inappropriate touching on that occasion. Further interview with the ACU Manager on 04/23/15 at 11:00 AM, revealed in order to increase monitoring of the resident, the nursing staff would put Resident #10 on fifteen (15) minute checks anytime he/she had SAO behaviors. The Unit Manager also stated the Dose Reduction Committee, consisting of the Psychiatrist, the Unit Director, the DNS, and the Unit Nurse, decided on 02/26/15 to do a gradual dose reduction of psychiatric medications for Resident #10 to reduce sleepiness during the day. At the time of the GDR, initiated on 02/26/15, Resident #10 was not exhibiting SAO behaviors. The Unit Manager stated after initiating the GDR, Resident #10 had not had any increased behaviors. Continued interview with the ACU Manager, on 04/23/15 at 11:00 AM, revealed Resident #10 and Resident #18 became focused on each other. She stated Resident #18 also had SAO behaviors and had been flirtatious with Resident #10. The ACU Manager stated the staff redirected both of the residents many times; however, because of cognitive problems; the residents would quickly forget the redirection and start to focus on each other again. The ACU Manager stated nursing did not document these redirections in the Progress Notes. Additionally, the ACU Manager stated on 03/11/15 staff observed Resident #10 with his/her mouth on the breast of Resident #18. The Unit Manager stated the facility sent Resident #10 to the hospital on [DATE] due to increased SAO. The ACU Manager stated Resident #18 also had SAO and believed the incident was consensual between the two (2) residents. However, after consultation with the Psychiatrist and because the residents were not easily redirected and Resident #10 had a history of [REDACTED].#10 to the hospital for evaluation and medication adjustments. The ACU Manager revealed Resident #10 had multiple GDR attempts in the past that resulted in SAO behaviors. Interview with Registered Nurse (RN) #6, on 04/23/15 at 1:45 PM, revealed she was the nurse on duty the morning of 03/11/15. RN #6 stated she was working on the AACU side passing medications and the CNA was on the AACU side providing care to another resident. The RN stated when she returned to the nurses' station she observed Resident #10 with his/her mouth on the breast of Resident #18. The RN reported she escorted Resident #18 back to his/her room and returned to Resident #10. RN #6 asked Resident #10 to return to his/her room and he/she declined three (3) times. The resident did not talk or answer any questions the RN asked. The RN then called the supervisor and reported the incident. The Supervisor requested the RN write a statement and put Resident #10 on one-on-one supervision. At the time of the incident, no staff was present to supervise the residents on the ACU side. The RN stated on the night shift the facility only had one nurse and one CNA for the ACU and AACU units. RN #6 stated Resident #10 had a history of [REDACTED]. Review of the Daily Census, dated 03/11/15, revealed the ACU and AACU had thirty-one (31) residents on the units combined. Interview with the Administrator, on 04/22/15 at 4:00 PM, revealed an investigation of the event was started on the day of the incident (3/11/15) but stopped because after a discussion with the DNS, they did not consider it to be a reportable (sexual abuse) instead just behaviors. He stated Resident #10 was placed on 1:1 supervision until he/she was transferred to the hospital. He stated he had not reviewed the staffing for supervision and was not aware the residents had been left alone, unsupervised. He stated he had not been told of any problems with supervision. Since no investigation was completed, the incident was not discussed in a Quality Assurance (QA) meeting. Further interview with the Administrator, on 04/23/15 at 2:15 PM, revealed the Administrator did not report the incident because he did not believe that it was an abuse situation, but rather impulsive sexually acting out behaviors. The Administrator stated he knew Resident #10 was on psychiatric medications for behaviors, but he did not know for what specific behaviors. The Administrator also stated both residents were participating and he believed the act was consensual. The Administrator discussed the incident in the morning meeting with the DNS. They determined the situation was not reportable. At that point, the Administrator stopped investigating the incident. Interview with the ACU Manager, on 4/24/15 at 10:30 AM, revealed the facility was aware Resident #10 had inappropriate sexually acting out behaviors prior to 03/11/15. The ACU Manager stated Resident #10 would try to touch others inappropriately and would try to walk other residents into his/her room. Resident #10 had touched staff on the buttocks. She stated she had reported staff had observed Resident #10 in another resident's room standing over the other resident. The ACU Manager also stated Resident #10 touched staff a lot, and then started with Resident #18. Interview with the ACU Social Worker, on 04/24/15 at 10:30 AM, revealed she had not read the psychiatric hospital assessment completed on Resident #10. After reviewing the psychiatric hospital's assessment, the Social Worker stated she was unaware of Resident #10 exposing himself/herself to others. Interview with the DNS, on 04/24/15 at 10:30 AM, revealed she had not read the psychiatric hospital assessment completed on Resident #10. After reviewing the psychiatric hospital's assessment, the DNS stated she was unaware of the behaviors reported under the section titled Current Presenting Problems. The DNS further stated the night nursing staff print out any documentation typed into the computer and placed it in the charts each night. The DNS stated she and the Administrator discussed the behaviors of both Resident #10 and Resident #18 to make the determination that the incident on 03/11/15 was not a reportable abuse situation; therefore, did not conduct an investigation. The DNS stated she did not have the hospital's intake assessment at the time she and the Administrator determined it was just behaviors. The hospital sent the assessment when they discharged Resident #10 back to the facility on [DATE]. The DNS further stated the facility had not added staffing on the night shift after the incident on 03/11/15. She stated the facility continued to staff the ACU and AACU with one (1) nurse and one (1) CNA for both units. However, she had not interviewed the nurse and CNA that had worked the morning of the incident and did not know the residents had been left unsupervised. Interview with the Intake Evaluation Coordinator #2 from the hospital, on 04/24/15 at 11:15 AM, revealed she completed an evaluation for Resident #10 on 03/11/15 at the facility. The Intake Coordinator stated she gathered information for evaluations from the nursing home staff and the resident's chart. She also stated she gathers information from family members when possible. She stated if she had talked with Resident #10's family, she would have indicated that in the evaluation on page four (4). On the evaluation, the information placed under The Immediate Problem section of the document stated the reason the facility called the hospital for the evaluation, the presenting problem. The precipitant to that problem was any behaviors or issues that lead to the episode. The Intake Evaluation Coordinator revealed she had a lengthy conversation with the nurse at the facility. The nurse told the Evaluation Coordinator about the incident that happened that day. The Intake Evaluation Coordinator also revealed she looked through the entire chart to make her evaluation. From interview and record review, the Evaluation Coordinator documented Resident #10's current medications, conditions, and behaviors including sexually acting out (SAO) behaviors. Interview with Resident #10's Psychiatrist, on 04/24/15 at 2:05 PM, revealed Resident #10 had a [DIAGNOSES REDACTED]. Because of this, staff must redirect the resident many times. The Psychiatrist stated that due to the resident's size and history of SAO, the Psychiatrist placed Resident #10 on Premarin to help decrease sexual urges. Resident #10 would have periods of doing well and would then impulsively exhibit SAO behaviors. The Psychiatrist was aware of the incident on 03/11/15 and stated he thought it was impulsive behaviors instead of a perpetrator instinct because the resident was unable to plot or plan as a perpetrator. Unlike a perpetrator, the resident did not try to hide his/her actions or isolate a victim. Instead, Resident #10 acted in front of staff. Additionally, Resident #10 required redirection often because he/she could not remember. The facility sent the resident for inpatient treatment because the interventions in place were not working or because the environment was not safe due to his/her behaviors. The Psychiatrist further stated that a BIMS score of eleven (11) for Resident #10 was not a good indicator of cognition because a resident could have a reserve of knowledge and score well one day and not well on another day. However, functionally, the resident could not care for self and did not have the cognition to solve problems. Interview with the Administrator, on 05/05/15 at 8:40 AM, revealed the facility had a morning meeting, Monday through Friday, to discuss various issues including resident behaviors. On the weekends, the Charge Nurse conducted meetings with the supervisors. The Administrator stated the facility started using behavior logs to document resident behaviors. When a behavior happened, the Unit Manager would document that behavior in the progress notes or SBAR (Situation, Background, Assessment, and Recommendation). The SBAR triggered the incident report. The Social Worker would bring the behavior logs to the morning meetings any time after a behavior occurred. The Social Worker and the DNS audited the behavior logs and behavior monitoring. The facility held weekly Behavior Meetings to review behaviors in order to track the behaviors and prevent reoccurrence. Interview with CNA #13, on 05/05/15 at 3:55 PM, revealed the CNA was unable to see both the ACU and the AACU residents when working on one of the two units. The CNA stated she worked third (3rd) shift on the ACU and AACU. The facility staffed the two units with one (1) nurse and one (1) CNA. CNA #13 stated it was not policy to ensure that if the nurse is working on one hallway, that the CNA would be on the other hallway. The CNA stated the ACU and AACU contained residents who wander and who would get up early in the morning. Often a resident would wander into other resident's rooms. If a situation existed that required staff to provide one-on-one monitoring or other resident issues, such as working with a resident who had fallen or who was exhibiting behaviors, then the CNA would not have been able to monitor the rest of the unit. Additionally, CNA #13 revealed she could not supervise both the ACU and the AACU at the same time. The CNA stated it was impossible to view one hallway when on another. The CNA stated she tried to ensure she was on the opposite hallway when the nurse was working on one of the hallways, but that was not a facility policy. Interview with CNA #14, on 05/05/15 at 4:14 PM, revealed the CNA was not able to supervise both the ACU and the AACU at the same time with one nurse and one CNA working the unit at night. The CNA stated she could not visually see both units unless she was in the office, and then was not able to see the back portion of the ACU. The CNA stated residents would frequently get up in the night and many would wander into other resident's rooms. She stated that at times both the CNA and the nurse were required to work on the same hallway at the same time. When the CNA and the nurse worked on the same hallway at the same time, nobody was monitoring the other hallway. A telephone interview with CNA #12, on 05/05/15 at 9:40 PM, revealed third shift, when staffed with one (1) nurse and one (1) CNA, could not have adequately supervised the ACU and AACU. The CNA stated she was unable to see both units at the same time. CNA #12 revealed that from the nurses' station one could see down the AACU and could see about half of the rooms on the ACU hall. From the nurses' station, one would not be able to view down the back half of the ACU. The CNA stated many of the residents on the backside of the ACU wandered. Those residents wandered into each other's rooms frequently, including at night. CNA #12 revealed there were times when the nurse and the CNA would have to work on the same hallway, leaving the other hallway unsupervised. She stated when this happened there was no way to know what was happening on the other unit. Further, CNA #12 stated many of the residents on the unit had behaviors, including SAO's and fighting. Many residents were often up at all hours of the night. Further interview revealed CNA #12 discussed the morning of 3/11/15. The CNA stated she was working on the AACU giving care to a resident. The nurse was about to give nursing care to another resident on the AACU. After a few moments, the nurse went back to the nurses' station for a needed item pertaining to the care she was giving. When she entered th

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete to ensure documentation of sexual acting out behaviors and Physician order [REDACTED].#10 and #29). Record review and interviews revealed on 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch in the Alzheimer's Care Unit (ACU) next to Resident #18 sucking on his/her right breast. Interviews with nurses and Certificated Nursing Assistants (CNAs) revealed Resident #10 had history of sexually acting out behaviors (SAO). On 02/06/15, the facility had consulted with the Psychiatrist due to Resident #10 becoming more inappropriate with touching other residents and staff. However, the clinical record did not reflect this. In addition, the facility staff documented the resident was placed on every fifteen (15) minute checks, but did not document in the clinical record what behaviors the resident was exhibiting that warranted close supervision. After Resident #10's readmission to the facility on [DATE] from a psychiatric hospitalization , the facility failed to place the hospital discharge information into the clinical record for continuation of care. The facility failed to place telephone orders signed by the physician into the clinical record for Resident #29. The staff failed to obtain Resident #29's weights as ordered by the physician. The facility's failure to have an effective system in place to ensure clinical records were accurate and complete placed residents in a situation that has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on 04/24/15 and was determined to exist on 03/11/15. The facility provided an acceptable Allegation of Compliance (AOC) on 04/29/15 which alleged removal of the Immediate Jeopardy on 04/29/15. The State Survey Agency verified Immediate Jeopardy was not removed on 04/29/15 as alleged, but on 05/07/15 prior to exit. The Scope and Severity was lowered to a D while the facility monitors the implementation of the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy manual regarding Health Information Management Manual: Policies, Procedures, and Guidelines for Medical Records Maintenance, dated 10/07/13, revealed the facility would ensure the medical records contained sufficient information to demonstrate the resident's current condition and provide evidence the facility was providing care per the care plan. The policy stated the purpose of the medical record was to provide information for the evaluation of the quality and effectiveness of the care provided. The facility was to have chronologically documented the events surrounding resident care and should include observation and description of significant changes in condition, provision of care, and response to care. The policy went on to state the Nursing Progress Notes should contain a complete record of nursing care provided. The nursing documentation should occur often enough to tell the whole story. Nursing Progress Notes should include changes in behavior, incidents, or accidents involving the resident, and documentation of behavioral interventions. Nursing Progress Notes should also contain a record of the resident's response to care provided. Review of the facility's policy regarding Behavior Management Guideline, dated 02/12/15, revealed the facility would utilize the Antecedent Behavior Monitoring Log for residents with behaviors that negatively affect functioning or quality of life. The facility must have clearly documented evidence in the medical record that the situation or condition continued or recurred over time and the behaviors negatively affected the resident's quality of life. In order to monitor, the facility would establish a monitoring system for targeted behaviors, interventions, medication effectiveness, and side effects. Review of the Corporate Guidelines for Communication and documentation of an event, dated 02/10/10, defined an event as an incident that resulted in, or had the potential to result in physical or mental harm to a resident. Per the Guidelines, an event included resident-to-resident altercations and demonstrated high-risk patient behaviors or situations. When an event occurred, the facility was always to complete a thorough and objective Verification of Investigation. 1. Review of Resident #10's clinical revealed the facility admitted the resident on 04/08/12 with [DIAGNOSES REDACTED]. The resident was receiving anti-depressant medications, anti-psychotic medications, and hormone medications. Review of Resident #10's Annual Minimum Data Set (MDS) assessment, completed on 04/13/15, revealed the facility assessed the resident as requiring only supervision or limited assistance to complete Activities of Daily Living (ADL). The resident was able to transfer and walk in the corridor with supervision only. Continued review of Resident #10's clinical record of a Progress Note, dated 06/06/14 at 11:29 AM, revealed the ACU Manager documented the Psychiatrist met with Resident #10 on 06/06/14. The Psychiatrist's Note revealed the resident had sexually inappropriate behaviors toward staff including touching female staff in inappropriate places. However, the Nurse's Notes reviewed from 04/30/14 through 06/06/14 revealed no documentation of Resident #10 exhibiting SAO behaviors or interventions for the SAO behaviors, or that any interventions were implemented as directed by the facility's policy. Review of the Psychiatric Consult/Follow-Up, dated 08/12/14, revealed the facility consulted with the Psychiatrist. Under reason for the visit, the Psychiatrist documented the resident continued to inappropriately touch females' (staff and peers) buttocks and breasts. The Consult further stated the behaviors were impulsive and the resident was unable to remember any of these behaviors. However, the Nurse's Notes from 07/16/14 through 08/11/14 revealed no documentation of Resident #10 exhibiting SAO behaviors or of staff using interventions for SAO behaviors. A Nursing Note, on 08/12/14 at 8:45 AM, revealed staff observed Resident #10 hugging a female resident. Review of the Progress Notes, dated 12/20/14 at 1:18 AM, revealed the facility documented they had placed Resident #10 on fifteen (15) minute checks due to sexual behaviors. The Progress Note did not indicate what SAO behaviors the resident exhibited to warrant the facility placing him/her on every fifteen (15) minute checks. The Progress Notes did not indicate what interventions the facility used when the SAO behaviors occurred or what interventions the facility was using to prevent reoccurrence of the behavior. Review of the Progress Notes, dated 01/30/15 at 2:40 PM, revealed nursing staff documented they had placed Resident #10 on fifteen (15) minute checks due to increased behaviors and needing redirection from female residents. The record did not indicate what behavior the resident exhibited. The record did not indicate what interventions staff used with the resident. The record did not indicate how long the resident would remain on fifteen (15) minute supervision. The facility did not add additional progress notes pertaining to behaviors or fifteen (15) minute supervision in the shifts that followed. Review of the Psychiatric Consult/Follow-Up, dated 02/06/15, revealed the facility consulted with the Psychiatrist due to Resident #10 becoming more inappropriate with touching other residents and staff. The consult further revealed the resident had Dementia and Sexual Acting Out (SAO) behaviors. Review of the Progress Notes for Resident #10, on 03/11/15 at 5:50 AM, revealed Resident #10 was observed in the common area sucking on the breast of Resident #18. The clinical record revealed the resident was placed on 1:1 supervision until transferred to a Psychiatric Hospital. Continued review of the clinical record revealed the facility completed the Verification of Investigation form, dated 03/11/15 at 5:50 AM; however, the facility failed to complete the section for summary and outcome of investigative findings. Review of the Verification of Investigation form for Resident #18, dated 03/11/15 at 5:50 AM, revealed staff observed Resident #18 sitting on the couch raising his/her pajama top. Resident #10 was sitting on the couch next to Resident #18 and was sucking on Resident #18's breast. The resident was placed on every fifteen (15) minutes checks; however, the facility failed to complete the sections of the form titled Summary and Outcome of Investigative Findings. Interview with Certified Nursing Assistant (CNA) #5, on 04/22/15 at 2:15 PM, revealed Resident #10 had a history of [REDACTED]. The CNA stated she had to supervise the resident around other residents as he/she had a history of [REDACTED]. Interview with the Administrator, on 04/23/15 at 2:15 PM, revealed the facility did not complete an investigation of the incident of 03/11/15 where staff observed Resident #10 with his/her mouth on the breast of Resident #18. Interview with the ACU Manager, on 04/23/15 at 11:00 AM, revealed Resident #10 had a history of [REDACTED].#10 had a history of [REDACTED]. The Unit Manager stated in order to increase monitoring of the resident, the nursing staff would put Resident #10 on fifteen (15) minute checks anytime the resident exhibited SAO behaviors. The Unit Manager stated she failed to document in the clinical record what specific behaviors the resident was exhibiting on 01/30/15 that required closer supervision of the resident. The Unit Manager indicated nursing did not always document behaviors in the clinical record. Further interview with the ACU Manager, on 4/24/15 at 10:30 AM, revealed the facility staff was aware of Resident #10's inappropriate SAO behaviors prior to 03/11/15. The ACU Manager stated Resident #10 would try to touch others inappropriately and would try to walk other residents into his/her room. The resident also liked to touch staff's buttocks. She stated Resident #10 and #18 developed an interest in each other. She stated she was the person who talked with the Intake Evaluation Coordinator from the Psychiatric Hospital and provided information related the Resident #10's behaviors. She stated after the resident's return, the information from the hospital was not placed into the resident's clinical record. She stated that information had been left in the envelope from the hospital. She had not followed up with staff to inquire why they had not put the documents into the chart. Additional interview with the ACU Manager, on 05/06/15 at 4:00 PM, revealed she talked with the Psychiatrist when he came in to let him know what was going on with the residents on the unit. The ACU Manager stated on 02/06/15 she discussed Resident #10's inappropriate behaviors with the Psychiatrist, but did not document specifically what the behaviors were in the Nursing Notes. Interview with the Director of Nursing Services (DNS), on 04/24/15 at 10:30 AM, revealed the night shift nursing staff printed out any documentation typed into the computer and placed it in the charts each night. The DNS reviewed the clinical record and stated she could not find any documented evidence the staff had provided redirection to Resident #10 prior to the incident on 03/11/15. The DNS stated she had not read the Psychiatric Hospital assessment and was unaware of the behaviors reported under the section titled Current Presenting Problems. Further interview with the DNS, on 05/06/15 at 3:15 PM, revealed the nursing staff did not document on SAO behaviors for Resident #10 on 01/30/15. The DNS stated she was aware Resident #10 had been having problems with inappropriate touching of staff, but she was unable to find documentation on SAO behaviors for Resident #10 prior to 01/30/15. Interview with the Administrator, on 05/05/15 at 8:40 AM, revealed the facility did not use behavior logs to track and monitor resident behaviors prior to the incident on 03/11/15. When a behavior happened, the Unit Managers were to document that behavior in the progress notes or SBAR (Situation, Background, Assessment, and Recommendation) as the SBAR triggered the incident report. 2. Review of Resident #29's clinical record revealed the facility admitted the resident on 04/15/15, with a [DIAGNOSES REDACTED]. Review of Resident #29's Physician order [REDACTED].#29 was ordered to have daily weights at the same time in the morning (after he/she has emptied his/her bladder/voided). If the weight goes up more than three (3) pounds in a day, the nurse was to give an additional dose of [MEDICATION NAME] ([MEDICATION NAME]) forty (40) milligrams (mg) that day. Review of Resident #29's Medication Administration Record [REDACTED]. Review of Resident #29's Vital Signs and Weight Flow Sheet revealed no weights were obtained after 04/22/15. Review of Resident #29's Progress Notes from 04/22/15 through to current, revealed no Nurses' Note verifying the Physician Orders, dated 04/22/15. Interview with RN #2, on 05/05/15 at 1:30 PM, revealed after review of Resident #29's record, there was a mistake made in the transcription of orders. RN #2 explained; when a nurse places an order in the computer system, the nurse must choose a category to place the order to ensure implementation of physician orders. The daily weight order should have been placed under the routine Medication Administration Record [REDACTED]. Instead the order was placed under a one-time only order; therefore, the facility staff did not monitor the resident's weight to ensure the resident received the diuretic according to the physician parameters. Interview with RN #3, on 05/07/15 at 9:15 AM, revealed confirmation of the process of the nurse placing a daily weight order in the computer as stated earlier by RN #2. Interview with the Assistant Director of Nursing Services (ADNS), on 05/07/15 at approximately 10:00 AM, revealed the telephone orders for the Physician Orders, dated 04/22/15, had not been placed in the clinical record originally. She obtained them signed from her office. The facility took the following actions to remove the Immediate Jeopardy on 05/28/15 by implementing the following: 1. Resident #10 was separated from the female residents and placed in sight of staff until transferred to a behavior unit for treatment on 03/11/15. Resident #10's documentation was noted in the Caretracker and Point Click Care by the Unit Manager on 04/26/15. On 03/11/15 the Charge Nurse and Certified Nursing Assistant took immediate action to ensure the safety of other residents by closely monitoring Resident #10 until transfer to the behavior treatment unit at approximately 5:20 PM. No other behaviors occurred. 2. On 04/28/15, The Nursing Home Administrator and Director of Nursing Services discussed staffing patterns in the Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU) on the 11-7 shift. It was determined one Certified Nursing Assistant was added to the 11 PM-7 AM shift on the Alzheimer's Care Unit. 3. On 04/25/15 and 04/26/15 conference calls were conducted with the Administrator and Director of Nursing Services. The facility's Health Care Council guided the Administrator and the Director of Nursing Services through the location on the Policy Center and existence of behavior monitoring guidelines and log. The Area Vice-President and Field Services Clinical Director were present for both calls. On 04/27/15 the Field Services Clinical Director provided additional education to the Administrator, Director of Nursing Services, Assistant Director of Nursing, ACU/AACU Director, Director of Clinical Education, and Social Services Director on behavior management guidelines and monitoring. The Director of Nursing Services and Assistant Director of Nursing Services received education on the Behavioral Management Guideline Policy, on 03/26/15, during the quarterly clinical guideline training hosted by the Field Services Clinical Director. On 04/25/15, the Administrator received education related to the Behavior Guideline and Monitoring by the Health Care Council. The Administrator ensured the Director of Nursing Services began education and no employee would work unless they received the education. The Administrator monitored progress at least daily in the Clinical Start-Up meeting at least daily. On 04/27/15, the Files Services Clinical Director provided additional education to the Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Education, ACU/AACU Director, and Social Services Director on behavioral management guidelines and behavior monitoring and charting. On 04/27/15, the Administrator consulted with the Field Services Clinical Director for investigations and incidents that may result as a reportable. There were two (2) incidents reported in April and eight (8) incidents reported in May. 4. An Ad Hoc Quality Assurance Process Improvement meeting, consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Clinical Director of Education and the Medical Director by phone was held on 04/27/15 to discuss the event of 03/11/15 and to develop a plan to prevent reoccurrence. The behavioral management guidelines and monitoring plan that the facility had implemented was discussed with the Medical Director via phone. A Quality Assurance Process Improvement Committee meeting will be held weekly x 4 weeks, then monthly thereafter. The committee will review results of the care plan and behavior log audits, behavior monitoring, and any investigations or [MEDICATION NAME]. The Behavior Monitoring Log is utilized for residents who are exhibiting behaviors. The audit identifies patterns and positive or triggering events and effectiveness of interventions. The audits will be completed weekly by the Social Worker and Director of Nursing Services and/or Assistant Director of Nursing Services. The Administrator held Quality Assurance Process Improvement meetings to review behavior care plan logs, audits, [MEDICATION NAME], and investigations on 05/04/15, 05/14/15, 05/21/15. The State Survey Agency validated the removal of Immediate Jeopardy on 06/03/15 prior to exit as follows: 1. Interview with Licensed Practical Nurse #13, on 06/01/15 at 2:55 PM, revealed until Resident #10 was transferred to a local behavioral unit he/she was kept in staff view. Review of Caretracker and Point Click Care revealed the resident was placed on 1:1 supervision until transferred on 03/11/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed Resident #10 was placed on observations for the safety of ACU/AACU residents. Review of the Discharge Summary from the behavior unit on 06/02/15 revealed, Resident #10 was admitted for evaluation on 03/11/15 and discharged on [DATE] back to the facility. Interview with Licensed Practical Nurse #7, on 06/02/15 at 6:25 AM, revealed on the morning of 03/11/15 she separated the residents without difficulty and reported the incident to the House Supervisor. She stayed with the female resident and the male resident was taken to his room. Resident #10 was then monitored. 2. Interview with the Director of Nursing on 06/03/15 at 8:30 AM, revealed the staffing schedule was revised to include two (2) Certified Nursing Assistants were now scheduled on the 11:00 PM to 7:00 AM shift daily for the ACU/AACU unit. She was to be notified of any scheduling difficulty and a staff member would be mandated to meet the ACU/ACCU staffing schedule. Interviews with the Licensed Practical Nurse (LPN) #7 on 06/02/15 at 9:40 AM, LPN #11, at 9:45 AM, CNA #18 at 9:46 PM, CNA #1 at 2:10 PM, validated there were now two (2) CNAs scheduled for the ACU/AACU on the 11 PM to 7 AM shift. Review of the staffing guidelines, received 06/02/15, revealed one nurse and two CNAs are scheduled for the ACU/AACU for the 11 PM-7 AM shift. Review of the daily staffing sheet from 04/28/15 to 06/02/15 revealed there were one nurse and two CNAs scheduled for the units on the 11 PM-7 AM shift except for 05/03/15. 3. Interview with the Area Vice-President on 06/02/15 at 3:35 PM, revealed she was present at the 04/25/15, the 04/26/15, and the 04/27/15 conference calls for the education of the Behavioral Guidelines and Monitoring log and could validate the Administrator and the Director of Nursing Services was in attendance. Interview with the Field Service Clinical Director on 06/03/15 at 1:35 PM, validated she was the moderator for the education on the Behavior Policy and Guideline Log, on the conference calls, and she attended the Ad Hoc and all Quality Assurance Process Improvement meetings. In addition, she revealed education of the Behavioral Management Guideline Policy was provided to the Director of Nursing Services and Assistant Director of Nursing Services during the quarterly clinical training on 03/26/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the Assistant Director of Nursing Services, on 06/03/15 at 3:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the ACU/ACCU Manager/Director on 06/03/15 at 1:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Telephone interview with the former Administrator, on 05/22/15 at 4:35 PM, revealed he had received training on the Behavior Policy and Log on 04/25/15 from the Field Service Director. In addition, he stated the Director of Nursing Services was assigned to begin education and no employee was allowed to work until they were trained. Record review of the Human Resource employee roster on 06/03/15 revealed, all staff were trained except for: two (2) staff not on schedule, two (2) new hired that began their employment 06/01/15 and were in orientation. Training for behaviors and the behavior log was now part of orientation. Three (3) staff were on Family Medical Leave and one (1) PRN staff had not worked. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed training on the Behavior Policy and log was completed on 04/27/15. Staff that were off received training before their shift. Staff not trained were notified they would not be scheduled to work, until they were trained. In the morning meetings the behavior logs were reviewed. To date one resident on the ACU unit had to be placed on a 1:1 for behaviors. Any resident on [MEDICAL CONDITION] medications or that exhibited behaviors was placed on the behavior log. They are placed in the medication administration binder. Review of the quarterly Clinical Guideline training sign in sheet, dated 03/26/15, revealed the Director of Nursing Services and the Assistant Director of Nursing were trained on the policies by the Field Services Clinical Director. Interview with the Field Services Clinical Director on 06/03/15 at 2:35 PM, revealed the Administrator reports all incidents and [MEDICATION NAME] to her. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed she reports to the Field Services Clinical Director. Review of reportable incidents, on 06/03/15, revealed from 04/23/15 to 05/31/15 the Administrator reported twelve (12) incidents to the Field Services Clinical Director and State Agencies. 4. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed Quality Assurance Improvement Process meetings would be held weekly for four (4) weeks, bi-weekly for four (4) weeks, and then monthly thereafter. At the meetings care plans, behavior log audits, behavior monitoring, investigations, and [MEDICATION NAME] would be discussed. Causative patterns or trigger events and the effectiveness of interventions would be discussed. The behavior log audits would be completed weekly and reported at the meeting by the social worker. Record review on 06/03/15, revealed the Administrator, Director of Nursing Services, Assistant Director of Nursing, Social Services, Director of Education, and the Medical Director were present at an Ad Hoc meeting held 04/27/15 and Quality Assurance Improvement Process meetings on 04/29/15, 05/04/15, 05/14/15, and on 05/21/15.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' care plans were reviewed and revised after behaviors and falls were noted, for six (6) of twenty-nine (29) sampled residents, (Resident #1, #6, #10, #11, #12 and #29). The facility was aware of Resident #10's history of sexual acting out (SAO) behaviors and care planned the resident to be monitored. On 03/11/15, the resident was not supervised and was found by staff engaging in sexually inappropriate behaviors with another resident. The resident was sitting on a couch, on the secured unit, with another resident sucking on the other resident's breast. The facility failed to revise the care plan to include adequate supervision to monitor the resident for continued SAO behaviors and staff intervention. In addition, Residents #1, #6, #11, #12 and #29 had injurious falls and their care plans were not revised to prevent further falls. Resident #6's risk for falls care plan was not revised with interventions related to the resident laying his/her head in his/her lap and leaning forward or laying himself/herself down on the floor. Resident #1 sustained multiple falls without revision to the care plan to prevent further falls. Resident #29 had a history of [REDACTED]. However, the facility failed to revise the care plan to reflect the current mode of transfer for staff to follow. Resident #12 had a fall which resulted in a Subdural Hematoma that required hospitalization ; there was no revision to the care plan. Resident #11 sustained three (3) falls associated with going to the bathroom. The facility failed to determine the root cause and revise the care plan to address assistance when going to the bathroom. The facility's failure to have an effective system in place, to ensure care plans were revised for residents with behaviors and falls, was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on 03/11/15. The facility was notified of the Immediate Jeopardy on 04/24/15. An Acceptable Allegation of Compliance (AOC) was received on 04/29/15 which alleged removal of the Immediate Jeopardy on 04/29/15. The State Survey Agency (SSA) determined the Immediate Jeopardy was not removed on 04/29/15, as alleged; the SSA determined the Immediate Jeopardy was removed on 05/07/15. The Scope and Severity was lowered to a D while the facility implements and monitors the plan of correction for the effectiveness of the systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Condition Change of the Resident (Observing, Recording and Reporting), dated 01/26/15, revealed the facility was to compare the resident's condition to his/her previous level of functioning. Additionally, the facility would identify the underlying problems causing the condition change and establish a measurable goal and plan to treat the condition including preventative and safety measures. Review of the facility's policy regarding Behavior Management Guidelines, dated 02/12/15, revealed the facility was to develop behavior plans and medication regimens to optimize the functional abilities of residents while monitoring for adverse side effects and improved behaviors. Review of the facility's policy, Falls, dated 11/13/14, revealed the facility would evaluate for causative factors including changes in the environment. The facility would identify if the care plan was updated and new approaches were implemented immediately to reduce the potential for falls to reoccur. Review of the facility's policy titled, Content of the Medical Record, dated 10/07/13, revealed the care plan described the care and treatment provided to the residents. The care plan ensured the resident attained or maintained the highest practicable physical, mental, and psychosocial well-being. The care plan included any care or treatment that would otherwise be required for the provision of quality care. The care plan must have reflected the immediate steps for each goal if the identification of these steps enhanced the resident's ability to meet the goal. The interdisciplinary team utilized the care plan goals to monitor resident progress or lack of progress and documented this information in the medical record. The facility developed additional documentation for behavior management, including a care plan for residents exhibiting negative behaviors, establishing a monitoring system for targeted behaviors, interventions for those behaviors, and medication effectiveness. Review of the facility's policy for Resident Assessment Instrument (RAI) Process, dated 11/28/13, revealed the facility was to adhere to all Centers for Medicare and Medicaid Services (CMS) regulations which were considered the definitive source in completion of the RAI process, including completion of the Care Area Assessments (CAA) and the development of the comprehensive plan of care. The facility would utilize the CMS RAI Manual for completion and compliance of the RAI process. 1. Observation of Resident #10, on 04/21/15 at 11:30 AM, revealed the resident was spending time in the common areas of the ACU in the facility. Resident #10 sat in the common area of the unit, stood and walked around the unit, then went into his/her room. The resident was able to state that he/she was doing well and was able to answer brief closed questions. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 04/08/12 with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS assessment, completed on 12/23/14, revealed the facility completed a Brief Interview Mental Status (BIMS) examination. The facility assessed the resident to have a BIMS' score of eleven (11) out of fifteen (15), indicating the resident had moderate cognitive impairment. Review of Resident #10's Annual Minimum Data Set (MDS) assessment, completed on 04/13/15, revealed the facility assessed the resident as requiring only supervision or limited assistance to complete Activities of Daily Living (ADL). The resident was able to transfer and walk in the corridor with supervision only. Review of the Comprehensive Care Plan for Resident #10, dated 03/12/15, revealed the resident had a history of [REDACTED]. Review of the Progress Notes, dated 01/30/15 at 2:40 PM, revealed nursing staff documented they had placed Resident #10 on fifteen (15) minute checks due to increased behaviors and needing redirection of female residents. The record did not indicate what behavior the resident exhibited; what interventions staff used with the resident; or how long the resident would remain on fifteen (15) minute supervision checks. The facility did not include this information on the resident's behavior care plan. Review of the facility's Administrator's Stand-Up Meeting (morning meeting documentation), dated 02/02/15, revealed the facility did not add Resident #10 to the list of residents to discuss in the meeting. Review of the Psychiatric Consult/Follow-Up, dated 02/06/15, revealed the facility consulted with the Psychiatrist due to Resident #10 becoming more inappropriate with touching other residents and staff. The Consult further stated the resident had Dementia and Sexual Acting Out (SAO) behaviors. However, on 02/06/15 the care plan addressed an increase in high sex drive towards staff and residents, and the only intervention listed for 02/06/15 was medication changes for behavioral disturbances. The care plan did not provide the staff with interventions to address the actual behavior. There were no other interventions added to the care plan until after the incident of 03/11/15. Review of the Progress Notes for Resident #10, on 03/11/15 at 5:50 AM, revealed nursing staff made an entry into the Behavior Charting and noted Resident #10 was sitting in the common area sucking on the breast of Resident #18. The resident was upset and refused to leave the common area after the incident. Staff documented vital signs and reported the resident was calm within twenty (20) minutes of the incident. The care plan did not provide interventions for staff to ensure the safety of the residents. Interview with CNA #12, on 05/05/15 at 9:40 PM, revealed she was working on the AACU hallway giving care to a resident the morning of 03/11/15. The nurse was about to give nursing care to another resident on the AACU hallway. After a few moments, the nurse went back to the nurses' station for a needed item pertaining to the care she was giving. When she entered the nurses' station, she observed Resident #10 and Resident #18 sitting on the couch engaged in inappropriate behaviors. The nurse called for CNA #12 and separated the two (2) residents. The nurse called the night supervisor. The nurse and CNA assisted Resident #18 back to his/her room and Resident #10 stayed in the common area. The supervisor placed Resident #10 on one-on-one monitoring until the day shift came in to work. The CNA reported she and the nurse took turns sitting with Resident #10 throughout the remainder of the shift. CNA #12 stated Resident #10 had no further SAO behaviors that shift. However, review of the care plan revealed this information was not added. Review of the Verification of Investigation form for Resident #10, dated 03/11/15 at 5:50 AM, revealed staff observed Resident #10 sitting in the common area sucking on the breast of Resident #18, who was sitting next to him/her. The form stated staff immediately separated the residents for their protection and staff placed Resident #10 on one-on-one (1:1) supervision until he/she left the facility to go to the hospital. The facility staff did not complete the portions of the Verification of Investigation form labeled, Summary and Outcome of Investigative Findings, nor did the care plan reflect the interventions described in the report. Review of Resident #10's care plan, dated 03/12/15, revealed the facility initiated a care plan for behaviors that included inappropriate sexual behaviors toward staff and residents on 03/11/15. Review of the care plan for Resident #10, dated 03/12/15, revealed the facility updated the care plan on 03/12/15 and added three (3) interventions: place the resident on fifteen (15) minute checks when exhibiting behaviors; inpatient stay for psychiatric evaluation; and, allow the resident time to talk or answer questions about how he/she is feeling. On 03/24/15, the facility updated the care plan, adding the intervention of assessing the resident for inappropriate sexual behaviors and aggression. Interview with Certified Nursing Assistant (CNA) #5, on 04/22/15 at 2:15 PM, revealed Resident #10 had a history of [REDACTED]. The CNA stated she had to supervise Resident #10 around other residents as he/she had a history of [REDACTED]. Interview with the Alzheimer's Care Unit (ACU) Manager, on 04/23/15 at 11:00 AM, revealed Resident #10 had a history of [REDACTED].#10 had a history of [REDACTED]. The Unit Manager stated in order to increase monitoring of the resident, the nursing staff would put Resident #10 on fifteen (15) minute checks anytime he/she had SAO behaviors. The Unit Manager stated she had documented on Resident #10 on 01/30/15 that she had placed Resident #10 on fifteen (15) minute checks due to increased SAO behaviors. The ACU Manager further revealed that in the time leading up to the incident on 03/11/15, Resident #18, who also had SAO behaviors, and Resident #10 were focused on each other. The Unit Manager stated the staff had to redirect both of the residents away from each other many times; however, because of cognitive problems, the residents would quickly forget the redirection and start to focus on each other again. The Unit Manager stated nursing did not document these redirections in the Progress Notes and there was no evidence of the behavior or interventions used for Resident #10 in the care plan. Interview with Registered Nurse (RN) #6, on 04/23/15 at 1:45 PM, revealed the Supervisor requested the RN to put Resident #10 on one-on-one supervision. RN #6 stated Resident #10 had a history of [REDACTED]. However, review of the record revealed this behavior was not placed on the care plan. Interview with Staff Development, on 04/24/15 at 8:30 AM revealed the facility reviewed the care plans in morning meetings and revised them as needed. Interview with the ACU Manager, on 04/24/15 at 10:30 AM, revealed the facility was aware Resident #10 had inappropriate sexually acting out behaviors prior to 03/11/15. The ACU Manager stated Resident #10 would try to touch others inappropriately and would try to walk other residents into his/her room. ACU Manager also stated Resident #10 had frequently touched staff on the buttocks. The Unit Manager stated the facility monitored residents when they had SAO behaviors by placing the resident on the 24-hour report and on fifteen (15) minute checks, usually for three (3) days. She stated staff had observed Resident #10 in another resident's room standing over the other resident. The ACU Manager stated the facility did not change or increase supervision on the unit after Resident #10 returned from the hospital. Interview with the Director of Nursing Services (DNS), on 04/24/15 at 10:30 AM, revealed staff had to redirect both the residents leading up to the incident on 03/11/15. The DNS stated night nursing staff print out any documentation typed into the computer and place it in the charts each night. The DNS reviewed the Progress Notes and stated she could not find documentation pertaining to staff redirecting Resident #10 leading up to the incident on 03/11/15. After reviewing the Psychiatric Hospital's Assessment, the DNS stated she was unaware of the behaviors reported under the section titled Current Presenting Problems. The DNS further stated the facility had not added staffing on the night shift after the incident on 03/11/15 to ensure supervision. She stated the facility continued to staff the ACU and AACU Halls with one (1) nurse and one (1) CNA for both units. Interview with the Psychiatrist, on 04/24/15 at 2:05 PM, revealed Resident #10 had a [DIAGNOSES REDACTED]. Because of this, staff must redirect the resident many times. Resident #10 would have periods of doing well and would then impulsively exhibit SAO behaviors. The Psychiatrist was aware of the incident on 03/11/15. Further interview revealed Resident #10 required redirection often because he/she could not remember. He stated the facility sent the resident for inpatient treatment because the interventions in place were not working or because the environment was not safe due to his/her behaviors. The Psychiatrist further stated that a BIMS' score of eleven (11) for Resident #10 was not a good indicator of cognition because a resident could have a reserve of knowledge and score well one day and not well on another day. However, functionally, the resident could not care for himself/herself and did not have the cognition to solve problems. Review of the care plan revealed this information was not added to the care plan. Interview with the Administrator, on 05/05/15 at 8:40 AM, revealed the facility did not use behavior logs to track and monitor resident behaviors prior to the incident on 03/11/15. The Administrator stated the facility started using behavior logs to document resident behaviors in April 2015. When a behavior happened, the Unit Managers were to document that behavior in the Progress Notes or SBAR (Situation, Background, Assessment, and Recommendation). The SBAR triggered the incident report. The Administrator stated the facility conducted morning meetings, Monday through Friday, to discuss various issues including resident behaviors. The facility placed residents on the Administrator's Stand-Up Meeting form to discuss in the morning meetings. On the weekends, the Charge Nurse conducted meetings with the supervisors. The facility also held weekly Behavior Meetings to review behaviors in order to track the behaviors and prevent reoccurrence. However, review of the care plan revealed the behaviors were not added. Interview with CNA #15, on 05/06/15 at 9:30 AM, revealed CNAs attended a huddle at the beginning of each shift to discuss changes to care. Nurses would give CNAs their assignments at that time. The CNA stated she did not get the opportunity to read the actual care plans. Interview with CNA #5, on 05/06/15 at 10:00 AM, revealed the CNAs and nurses on the unit had a huddle each morning by the nurses' station to discuss any resident changes or issues. Interview with Licensed Practical Nurse (LPN) #5, on 05/06/15 at 10:30 AM, revealed nurses did not usually update resident care plans, but they could. The LPN stated the administrative staff updated care plans in the morning meeting. After the morning meeting, the Social Worker would tell the nurses verbally of any changes to the care plans. This was a verbal conversation with no documentation of the communication. The Nurses update the CNA care plans, or assignment sheets. She further stated the nurses obtained the information for the assignment sheet from the care plans. The LPN stated she read the care plans about one time per month. She stated if something happened with a resident, such as a behavior, then she would look at the care plan to ensure there was a care plan for that incident. Further interview revealed the nurses instructed the CNAs on what to do when a resident has a behavior. However, review of the care plan revealed no documented evidence the behaviors were added on the care plan for Resident #10. Interview with the ACU Manager, on 05/06/15 at 11:00 AM, revealed staff was to notify the Unit Manager or Nursing Supervisor when a behavior happened. The ACU Manager also stated the facility updated care plans in morning meeting. When the facility updated a care plan in the morning meeting, they communicated the information to the ACU Manager via the Enhanced Start-Up Sheet. The Unit Manager received the Enhanced Start-Up Sheet daily and placed the information on the assignment sheets or, on the 24-hour report. Interview with the MDS Coordinator, on 05/06/15 at 2:30 PM, revealed she developed care plans when the facility admitted a resident. The MDS Coordinator used orders, hospital notes, assessments, and information gathered during a 72 hour meeting with the family to develop the initial care plan in the computer. She completed daily updates to the care plans based on the SBAR and behaviors. The MDS Coordinator also updated care plans when residents returned to the facility from a hospitalization or when having behaviors. If a resident was having behaviors, the Social Worker would bring the behavior to the morning meeting and the MDS Coordinator would update the care plan with new interventions. The MDS Coordinator stated the facility did not update the care plan for Resident #10 after nursing placed the resident on fifteen (15) minute checks for increased behaviors on 01/30/15. However, the facility updated the care plan for Resident #10 after he/she returned from the hospital on [DATE]. The updates included adding an intervention saying the facility would monitor for increased SAO behaviors and would assess for inappropriate sexual behaviors. She further stated nursing staff did not place the incident on the 24-hour report. The MDS Coordinator stated since the facility did not update the care plan at that time, the interventions in place when the incident on 03/11/15 took place did not make sense for Resident #10. The MDS Coordinator reviewed the interventions in place after the 03/11/15 incident and stated two (2) of the three (3) interventions put in place for Resident #10 were not appropriate interventions to prevent the reoccurrence of the resident's SAO behaviors. Interview with the DNS, on 05/06/15 at 3:15 PM, revealed the facility made no updates to Resident #10's care plan after increased SAO behaviors on 01/30/15. The DNS stated the nurses did not document on SAO behaviors for Resident #10 for 01/30/15. She stated she was aware Resident #10 had been having problems with inappropriate touching of staff because the staff had reported that to her. 2. Observation during the initial tour, on 04/21/15 at 8:45 AM, of Resident #6, revealed the resident was lying in a low positioned bed with a mattress on the floor parallel to the bed. The bed was placed with one side next to the wall. Interview with the LPN #1 during tour, on 04/21/15 at 8:45 AM, revealed Resident #6 was at risk for falls, and had a history of [REDACTED]. He stated Resident #6 was ambulatory before his/her fall and currently used a geriatric chair for mobility. Observation, on 04/21/15 at 1:00 PM, of Resident #6, revealed he/she was in the geri-chair seated in front of the television (TV). He/she was tilted back facing the TV. The resident wore blue foam boots on his/her feet with both feet placed on the foot rest of the geri-chair. There was a cushion between the resident's upper legs. Review of Resident #6's clinical record revealed the facility admitted the resident on 06/04/13, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, completed on 11/11/14, revealed the facility assessed the resident as severely impaired for cognitive skills for daily decision making. The facility assessed the resident's functional status with transfers; walk in room and corridor, locomotion on and off the unit revealed self-performance required limited assistance and one (1) person physical assist with the identified activities. The MDS did not identify any mobility devices in use. Review of the Comprehensive Care Plan for Resident #6 revealed the facility developed a Fall care plan, on 06/04/13, for at risk for falls related to the history of falls, receiving psychoactive medications, required limited assistance at times with ambulation and transfers due to an unsteady gait and balance. In addition, the facility revealed additional contributing factors that increased the risk for falls included severe cognitive impairment, poor safety awareness, [MEDICAL CONDITIONS], history of Transient Ischemia Attacks (TIA) and [MEDICAL CONDITION]. Further review of the care plan revealed interventions that included assist with ambulation as needed; and, keep environment well lit and free of clutter, these were initiated on 06/04/13. The facility revised the same interventions, on 03/06/14, including for the call light to be kept within reach; however, the call light may or may not be utilized related to the resident's cognition. Additional interventions included to ensure proper footwear was worn; observe for fall related side effects of medications and report to the physician, if the side effects interfere with the resident's daily functioning; observe for tremors and increased difficulty with ambulation related to Parkinson; and, administer [MEDICATION NAME] as ordered, these were initiated on 10/25/13 and revised on 03/06/14. Interview with the MDS Coordinator, on 04/24/15 at 3:45 PM, revealed upon review of Resident #6's care plans she determined the interventions added were the same interventions already in place for the revision completed on 01/19/15. She stated the interventions for Resident #6 were not individualized specifically to the resident. 3. Observation during the facility tour, on 04/21/15 at 8:47 AM, of Resident #12 revealed the bed was placed against the wall. He/she appeared to be sleeping and was wearing head phones. Observation, on 04/21/15 at 1:10 PM, of Resident #12 during the lunch meal in the dining room revealed the resident was seated in a wheelchair at the table. Observation of the posterior head revealed an area of bruising in the occipital area and into the nape of the neck area. The area of bruising was visible through the resident's hair. Review of Resident #12's clinical record revealed the facility admitted the resident on 03/06/15 with [DIAGNOSES REDACTED]. Review of the facility's admission record revealed Resident #12 was originally admitted , on 02/19/15, with an additional [DIAGNOSES REDACTED]. Review of Resident #12's Admission Minimum Data Set (MDS) assessment, completed on 03/13/15, revealed the facility assessed the resident via a Brief Interview for Mental Status (BIMS) at a fifteen (15) of fifteen (15), being cognitively intact. The facility assessed the resident's functional status of transfers, walking in the room and corridor, locomotion on the unit and off the unit required limited assistance (staff provide guided maneuvering) and one (1) person physical assist for support. Further review revealed the facility assessed the resident's balance during transitions and walking in the areas of moving from a seated to standing position; walking with an assistive device; turning around and facing the opposite direction while walking; moving on and off the toilet and surface-to-surface (transfer between bed and chair or wheelchair) as not steady and only able to stabilize with staff assistance. Review of the Care Area Assessment (CAA) for Resident #12, dated 03/13/15, revealed the resident had a history of [REDACTED]. The MDS Nurse included knowledge the resident experienced fatigue, urinary incontinence, urge incontinence, was legally blind, hearing impaired, and had generalized weakness that predisposed Resident #12 to a risk for falls. Review of the Comprehensive Care Plan for Resident #12 revealed the facility developed a care plan on 03/09/15, with the target date of 05/29/15. Problems on the care plan included at risk for falls, impaired cardiovascular status, constipation, adverse drug reactions, gastrointestinal distress, alteration in respiratory status, ineffective communication, dehydration and fluid maintenance, risk for injuries due to vision impairment, requiring some assistance in participation in activities of choice related to vision, and alteration in activities of daily living functioning due to resident requires assistance for completion of care related to hard of hearing, legally blind and diminished physical abilities. Interview with Family Member #2, on 04/22/15 at 12:50 PM, revealed Resident #12 had fallen at the facility and required hospitalization . Family Member #2 stated the resident hit his/her head at the time of the fall. Further interview revealed Family Member #2 requested an alarm for Resident #12 upon the resident's return from the hospital on [DATE]. Family Member #2 stated she again spoke with the nurse on 04/18/15 about the resident having an alarm to alert the staff when he/she was up and about without supervision. She reported, as of this day, the resident still did not have an alarm. Interview with Resident #12, on 04/23/15 at 10:10 AM, revealed the staff do the best they can; however, when they were busy, the resident takes himself/herself to the bathroom. The resident stated recently he/she had been treated for [REDACTED]. Sometimes he/she helped himself/herself to the bathroom when staff could not come at the time the call light was activated. The resident further stated he/she had had a couple of falls. The last fall required a stay in the hospital after hitting his/her head. Interview with the MDS Coordinator, on 04/24/15 at 3:45 PM, revealed the interventions for Resident #12 were not individualized specifically to the resident. 4. Observation, on 04/21/15 at 8:33 AM, during the facility tour, revealed Resident #29 was seated on the side of bed, and a wheelchair was located in the room. Resident #29 smiled and greeted this surveyor, stating he/she was hard of hearing while putting in a hearing device. Review of Resident #29's clinical record revealed the facility admitted the resident on 04/15/15 with [DIAGNOSES REDACTED]. Review of the facility's Lift/Mobility Assessment for Residents, dated 04/15/15, for Resident #29 revealed the facility assessed the resident and determined the resident required a stand up transfer with the use of a mechanical transfer device. Review of the Initial Care Plan for Resident #29 revealed the facility developed a Fall Care Plan on 04/16/15, due to the resident's history of falls at home, poor activity intolerance, weakness associated with Systolic [MEDICAL CONDITIONS] with an Ejection Fraction (EF) (EF of 20-25%), [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), psychoactive medications, poor safety awareness, episodes of confusion, hard of hearing, a history of Spinal Fusion and left knee surgery. In addition, Resident #29 was at risk for bleeding or injuries with falls related to Aspirin therapy. Review of the CNA Care Plan utilized by CNA #9 and provided to the CNA by the facility, on 04/24/15, revealed Resident #29's care needs had not been updated for the CNA Care Plan since admission on 04/15/15. The CNA Care Plan included turn every two (2) hours as the only care need. Interview via telephone with RN #2, on 04/23/15 at 2:25 PM, revealed he was notified by the resident that he/she had fallen in the bathroom when he was making his morning rounds. He stated he was not notified in the shift report that Resident #12 had fallen. The alleged fall was not witnessed. He stated he completed an incident report because Resident #12 had reported the fall. He stated he had looked at the care plan and there was no need for a change; however, he did not assess the fall to make that determination. Interview with CNA #9, on 04/24/15 at 8:40 AM; and, at 10:04 AM, revealed she received her assignment information from the night shift supervisor upon her arrival. She stated she really just looked at the resident to see if she thought the resident could be transferred independently or if she needed the assistance of another person. She stated she was transferring Resident #29 by placing a wheelchair real close and holding onto the resident's pants to assist the resident to pivot and transfer with the resident was standing in front of the wheelchair. She stated Resident #29 was a tall person and it was difficult to transfer him/her because of his/her size. She stated her care plan for Resident #29 did not provide any care needs identified for Resident #29. She stated Resident #12 came to the facility with a Rolator walker. She stated she had spoken with the family and was told Resident #12 flops back on chairs when he/she sat down. She stated she told this information to the resident's nurse, LPN #3. Interview with East Unit Manager, on 04/24/15 at 9:15 AM and at 9:45 AM, revealed Resident #12 was admitted to the facility with a Rolator walker the resident used with ambulation. She stated the Resident's Daug

Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement the care plan for one (1) of twenty-nine (29) sampled residents (Resident #29) regarding the monitoring and reporting of the ordered weights and blood pressures readings. The findings include: Review of the facility's policy titled, Weight Monitoring, dated 02/12/15 revealed, weight was recorded upon admission, monthly and more often if the resident was identified to be at risk. Review of Resident #29's clinical record revealed the facility admitted the resident on 04/15/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 04/28/15, revealed the facility assessed Resident #29 utilizing the Brief Interview of Mental Status (BIMS) with a score of fifteen (15) out of possible fifteen (15), meaning Resident #29 was cognitively intact and was interviewable. Review of Resident #29's Physician Orders, dated May 2015, revealed Resident #29 was ordered [MEDICATION NAME] (anti-hypertension medication) 50 milligrams (mg) by mouth twice daily, [MEDICATION NAME] (diuretic) 40 mg daily by mouth, and Aspirin 81 mg by mouth daily. The physician's orders [REDACTED]. Review of Resident #29's Initial Care Plan, dated 04/16/15, revealed Resident #29 was care planned to monitor his/her weights and report significant changes; to monitor (not defined by the facility) for signs and symptoms of fluid overload such as shortness of air, [MEDICAL CONDITION], hypertension and jugular vein distension; and, to observe for abnormal vital signs and report. Review of Resident #29's Vital Signs and Weight Flow Sheet revealed Resident #29's weight, on 04/15/15 was 178.6 pounds (lbs); on 04/16/15 his/her weight was 177.6 lbs; and, on 04/17/15 the resident's weight was 177.8 lbs. Further review revealed no evidence the resident's weights were obtained monthly after these dates. Review of Resident #29's Progress Notes, dated 04/15/15, revealed Resident #29's blood pressure was one hundred and thirty-nine over seventy-six (139/76). In addition, the Progress Notes, dated 04/18/15, revealed a blood pressure of ninety over fifty (90/50), without physician notification. (Review of the Progress Notes revealed no documentation of shortness of air or fluid overload.) Interview with the Director of Nursing Services, on 05/06/15 at 11:25 AM, revealed she was unable to discuss how the staff was following the care plan. She stated the care plan drove the care of the residents and she monitored delivery of care through multiple meetings and review of the 24 hour reports. She further stated the Unit Managers were not involved in the care plan process. However, they ensured staff followed the care plan by monitoring the 24 hour reports, labs, orders, admissions, family meetings and working with the pharmacy.

Based on interviews and review of facility staffing, it was determined the facility failed to have an effective system to ensure adequate staffing for supervision of residents with behaviors for two (2) of seven (7) residential units. This failure affected two (2) of twenty-nine (29) sampled residents, Residents #10 and #18. (Refer to F323) Record review and interview revealed on 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch next to Resident #18 sucking on his/her right breast. The clinical record identified the resident to have a history of fondling, touching other residents, and exposing self to others. Review of the facility's staffing for 03/11/15 revealed one nurse and one nurse aide was scheduled to care for thirty-one residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, revealed there were two locked units, Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU) with the Nurses' Station between the units. She revealed she and Certified Nursing Assistant (CNA) #12 was on the AACU at the time of the incident and left fifteen (15) residents on the ACU unsupervised. The facility's failure to monitor Resident #10's behaviors and provide adequate supervision resulted in an unsafe environment for other residents. The facility's failure to have an effective system in place to ensure sufficient staffing was available to monitor behaviors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 03/11/15. An Acceptable Allegation of Compliance (AOC) was received on 05/28/15 which alleged removal of the Immediate Jeopardy on 05/28/15. The State Survey Agency determined the Immediate Jeopardy was removed on 05/28/15 prior to exit of the survey on 06/03/15. The scope and severity was lowered to a D while the facility monitors the implementation of the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Nursing Services (DNS), on 04/24/15 at 10:30 AM, revealed the facility did not have a specific policy for staffing. She stated the Alzheimer Care Units (ACU) were staffed with one nurse and one nurse aide at nights. She stated that had been sufficient staffing before and she thought it was adequate. She stated the House Supervisor could help if needed. She stated Residents' #10 and #18 exhibited behaviors and required redirection. Review of the progresss notes for Resident #10, revealed on 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch next to Resident #18 sucking on his/her right breast. The facility placed Resident #10 on 1:1 supervision and requested inpatient psychiatric hospitalization . Review of the intake assessment conducted by the hospital, on 03/11/15 at 1:00 PM, revealed the resident was exhibiting sexually acting out (SAO) behaviors. The hospital Intake Coordinator documented the sexually acting out behaviors presented a threat of harm to other residents. The facility identified the resident had a history of [REDACTED]. Review of the daily census, dated 03/11/15, revealed the Alzheimer's Care Unit (ACU) and the Advanced Alzheimer's Care Unit (AACU) had thirty-one (31) residents on the units combined. Review of the facility's staffing for the night shift (11 PM-7:00 PM) on 03/11/15, revealed one nurse and one nurse aide was scheduled to care for the thirty-one residents. Interview with Registered Nurse (RN) #6, on 04/23/15 at 1:45 PM, revealed there were two locked units: Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU). She revealed she was the nurse on duty at the incident of 03/11/15. RN #6 stated she was working on the AACU passing medications and the Certified Nursing Assistant (CNA) was also on the AACU providing care to another resident. The RN stated when she returned to the nurses' station she observed Resident #10 with his/her mouth on the breast of Resident #18. At the time of the incident, no staff was present to supervise the ACU side. The RN revealed on the night shift the facility only had one nurse and one CNA for the ACU and AACU. RN #6 stated Resident #10 had a history of [REDACTED]. Interview with CNA #13, on 05/05/15 at 3:55 PM, revealed the CNA was unable to see both the ACU and the AACU when working on one of the two units. She worked third (3rd) shift for both units and revealed the facility staffed the two units with one (1) nurse and one (1) CNA. CNA #13 stated it was not policy to ensure that if the nurse was working on one hallway, the CNA would be on the other hallway. The CNA stated the ACU and AACU contained residents who wandered and who would get up early in the morning. Often a resident would wander into other residents' rooms. If a situation existed that required staff to provide one-on-one monitoring or other resident issues, such as working with a resident who had fallen or who was exhibiting behaviors, then the CNA would not have been able to monitor the rest of the unit. Additionally, CNA #13 revealed she could not supervise both the ACU and the AACU at the same time. The CNA stated it was impossible to view both units at the same time. The CNA stated she tried to ensure she was on the opposite unit then the nurse, but that was not a facility policy. Interview with CNA #14, on 05/05/15 at 4:14 PM, revealed the CNA was not able to supervise both the ACU and the AACU at the same time with one nurse and one CNA working the units at night. The CNA stated she could not visually see both units unless she was in the nurses' station, and then she could only see the front half of the ACU. The CNA stated residents would frequently get up in the night and several residents would wander into other residents' rooms. She stated at times both the CNA and the nurse were required to work on the same unit at the same time, leaving the other unit unsupervised. A telephone interview with CNA #12, on 05/05/15 at 9:40 PM, revealed when third shift was staffed with only one (1) nurse and one (1) CNA, she could not adequately supervised the ACU and AACU. The CNA stated she was unable to see both units at the same time. CNA #12 stated that from the nurses' station one could see down the AACU and could see about half of the rooms on the ACU hall. From the nurses' station, one would not be able to view down the back half of the ACU. The CNA stated many of the residents on the backside of the ACU wandered. Those residents wandered into each other's rooms frequently, including at night. CNA #12 stated there were times when the nurse and the CNA would have to work on the same unit, leaving the other unit unsupervised. She stated when this happened there was no way to know what was happening on the other unit. Further, CNA #12 stated many of the residents on the unit had behaviors, including SAO's and fighting. Many residents were often up at all hours of the night. Review of facility staffing from March 1 through March 11, 2015 revealed one nurse and one nurse aide scheduled for the night shift in the ACU and AACU Units to care for 30-32 residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, revealed there were two locked units, the Alzheimer's Care Unit (ACU) and the Advanced Alzheimer's Care Unit (AACU). She stated she and the nurse aide were on the AACU together leaving the ACU with fifteen (15) residents unsupervised during the incident. Continued review of the facility's staffing schedule for March 12 through 04/27/15 revealed it continue to schedule one nurse and one nurse aide to the AACU and ACU for the night shift for 30-32 residents. Interview with the Staffing Coordinator, on 05/06/15 at 8:41 AM, revealed she was told to staff the locked units with one nurse and one aide for the night shift. She stated she had scheduled two nurse aides for the night shift (11 PM-7 AM) in the ACU Units since 04/28/15. She stated the only day there was not two aides for the night shift was on Saturday, 05/03/15. She stated the night shift was the only shift to have additional staff added. She stated the facility did not use agency staff. She stated she had PRN (as needed) staff to pull from when there was a call in and other staff would pick up an extra shift. The facility took the following actions to remove the Immediate Jeopardy on 05/28/15 by implementing the following: 1. Resident #10 was separated from the female residents and placed in sight of staff until transferred to a behavior unit for treatment on 03/11/15. Resident #10's documentation was noted in the Caretracker and Point Click Care by the Unit Manager on 04/26/15. On 03/11/15 the Charge Nurse and Certified Nursing Assistant took immediate action to ensure the safety of other residents by closely monitoring Resident #10 until transfer to the behavior treatment unit at approximately 5:20 PM. No other behaviors occurred. 2. On 04/28/15, The Nursing Home Administrator and Director of Nursing Services discussed staffing patterns in the Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU) on the 11-7 shift. It was determined one Certified Nursing Assistant was added to the 11 PM-7 AM shift on the Alzheimer's Care Unit. 3. On 04/25/15 and 04/26/15 conference calls were conducted with the Administrator and Director of Nursing Services. The facility's Health Care Council guided the Administrator and the Director of Nursing Services through the location on the Policy Center and existence of behavior monitoring guidelines and log. The Area Vice-President and Field Services Clinical Director were present for both calls. On 04/27/15 the Field Services Clinical Director provided additional education to the Administrator, Director of Nursing Services, Assistant Director of Nursing, ACU/AACU Director, Director of Clinical Education, and Social Services Director on behavior management guidelines and monitoring. The Director of Nursing Services and Assistant Director of Nursing Services received education on the Behavioral Management Guideline Policy, on 03/26/15, during the quarterly clinical guideline training hosted by the Field Services Clinical Director. On 04/25/15, the Administrator received education related to the Behavior Guideline and Monitoring by the Health Care Council. The Administrator ensured the Director of Nursing Services began education and no employee would work unless they received the education. The Administrator monitored progress at least daily in the Clinical Start-Up meeting at least daily. On 04/27/15, the Files Services Clinical Director provided additional education to the Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Education, ACU/AACU Director, and Social Services Director on behavioral management guidelines and behavior monitoring and charting. On 04/27/15, the Administrator consulted with the Field Services Clinical Director for investigations and incidents that may result as a reportable. There were two (2) incidents reported in April and eight (8) incidents reported in May. 4. An Ad Hoc Quality Assurance Process Improvement meeting, consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Clinical Director of Education and the Medical Director by phone was held on 04/27/15 to discuss the event of 03/11/15 and to develop a plan to prevent reoccurrence. The behavioral management guidelines and monitoring plan that the facility had implemented was discussed with the Medical Director via phone. A Quality Assurance Process Improvement Committee meeting will be held weekly x 4 weeks, then monthly thereafter. The committee will review results of the care plan and behavior log audits, behavior monitoring, and any investigations or [MEDICATION NAME]. The Behavior Monitoring Log is utilized for residents who are exhibiting behaviors. The audit identifies patterns and positive or triggering events and effectiveness of interventions. The audits will be completed weekly by the Social Worker and Director of Nursing Services and/or Assistant Director of Nursing Services. The Administrator held Quality Assurance Process Improvement meetings to review behavior care plan logs, audits, [MEDICATION NAME], and investigations on 05/04/15, 05/14/15, 05/21/15. The State Survey Agency validated the removal of Immediate Jeopardy on 06/03/15 prior to exit as follows: 1. Interview with Licensed Practical Nurse #13, on 06/01/15 at 2:55 PM, revealed until Resident #10 was transferred to a local behavioral unit he/she was kept in staff view. Review of Caretracker and Point Click Care revealed the resident was placed on 1:1 supervision until transferred on 03/11/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed Resident #10 was placed on observations for the safety of ACU/AACU residents. Review of the Discharge Summary from the behavior unit on 06/02/15 revealed, Resident #10 was admitted for evaluation on 03/11/15 and discharged on [DATE] back to the facility. Interview with Licensed Practical Nurse #7, on 06/02/15 at 6:25 AM, revealed on the morning of 03/11/15 she separated the residents without difficulty and reported the incident to the House Supervisor. She stayed with the female resident and the male resident was taken to his room. Resident #10 was then monitored. 2. Interview with the Director of Nursing on 06/03/15 at 8:30 AM, revealed the staffing schedule was revised to include two (2) Certified Nursing Assistants were now scheduled on the 11:00 PM to 7:00 AM shift daily for the ACU/AACU unit. She was to be notified of any scheduling difficulty and a staff member would be mandated to meet the ACU/ACCU staffing schedule. Interviews with the Licensed Practical Nurse (LPN) #7 on 06/02/15 at 9:40 AM, LPN #11, at 9:45 AM, CNA #18 at 9:46 PM, CNA #1 at 2:10 PM, validated there were now two (2) CNAs scheduled for the ACU/AACU on the 11 PM to 7 AM shift. Review of the staffing guidelines, received 06/02/15, revealed one nurse and two CNAs are scheduled for the ACU/AACU for the 11 PM-7 AM shift. Review of the daily staffing sheet from 04/28/15 to 06/02/15 revealed there were one nurse and two CNAs scheduled for the units on the 11 PM-7 AM shift except for 05/03/15. 3. Interview with the Area Vice-President on 06/02/15 at 3:35 PM, revealed she was present at the 04/25/15, the 04/26/15, and the 04/27/15 conference calls for the education of the Behavioral Guidelines and Monitoring log and could validate the Administrator and the Director of Nursing Services was in attendance. Interview with the Field Service Clinical Director on 06/03/15 at 1:35 PM, validated she was the moderator for the education on the Behavior Policy and Guideline Log, on the conference calls, and she attended the Ad Hoc and all Quality Assurance Process Improvement meetings. In addition, she revealed education of the Behavioral Management Guideline Policy was provided to the Director of Nursing Services and Assistant Director of Nursing Services during the quarterly clinical training on 03/26/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the Assistant Director of Nursing Services, on 06/03/15 at 3:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the ACU/ACCU Manager/Director on 06/03/15 at 1:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Telephone interview with the former Administrator, on 05/22/15 at 4:35 PM, revealed he had received training on the Behavior Policy and Log on 04/25/15 from the Field Service Director. In addition, he stated the Director of Nursing Services was assigned to begin education and no employee was allowed to work until they were trained. Record review of the Human Resource employee roster on 06/03/15 revealed, all staff were trained except for: two (2) staff not on schedule, two (2) new hired that began their employment 06/01/15 and were in orientation. Training for behaviors and the behavior log was now part of orientation. Three (3) staff were on Family Medical Leave and one (1) PRN staff had not worked. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed training on the Behavior Policy and log was completed on 04/27/15. Staff that were off received training before their shift. Staff not trained were notified they would not be scheduled to work, until they were trained. In the morning meetings the behavior logs were reviewed. To date one resident on the ACU unit had to be placed on a 1:1 for behaviors. Any resident on [MEDICAL CONDITION] medications or that exhibited behaviors was placed on the behavior log. They are placed in the medication administration binder. Review of the quarterly Clinical Guideline training sign in sheet, dated 03/26/15, revealed the Director of Nursing Services and the Assistant Director of Nursing were trained on the policies by the Field Services Clinical Director. Interview with the Field Services Clinical Director on 06/03/15 at 2:35 PM, revealed the Administrator reports all incidents and [MEDICATION NAME] to her. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed she reports to the Field Services Clinical Director. Review of reportable incidents, on 06/03/15, revealed from 04/23/15 to 05/31/15 the Administrator reported twelve (12) incidents to the Field Services Clinical Director and State Agencies. 4. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed Quality Assurance Improvement Process meetings would be held weekly for four (4) weeks, bi-weekly for four (4) weeks, and then monthly thereafter. At the meetings care plans, behavior log audits, behavior monitoring, investigations, and [MEDICATION NAME] would be discussed. Causative patterns or trigger events and the effectiveness of interventions would be discussed. The behavior log audits would be completed weekly and reported at the meeting by the social worker. Record review on 06/03/15, revealed the Administrator, Director of Nursing Services, Assistant Director of Nursing, Social Services, Director of Education, and the Medical Director were present at an Ad Hoc meeting held 04/27/15 and Quality Assurance Improvement Process meetings on 04/29/15, 05/04/15, 05/14/15, and on 05/21/15.

Based on interviews, record review, and review of facility policies, it was determined the facility's Administrator failed to have an effective system to ensure the facility policies and procedures were implemented to monitor residents with behaviors and to provide adequate supervision to protect all residents in the locked Alzheimer's Care Units. In addition, the Administration failed to utilize resources (corporate policy and guidelines for behaviors) and failed to provide adequate staffing for adequate supervision of residents with identified Sexual Acting Out (SAO) behaviors. On 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch next to Resident #18 sucking on his/her right breast. The clinical record identified the resident to have a history of fondling, touching other residents, and exposing self to others. The resident required hospitalized from [DATE] to 03/24/15. Review of the hospital Intake Coordinator's documentation revealed Resident #10's SAO behaviors presented a threat of harm to other residents. Review of the facility's staffing for 03/11/15 revealed one nurse and one nurse aide was scheduled to care for thirty-one residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, revealed there were two locked units, the Alzheimer's Care Unit (ACU) and the Advance Alzheimer's Care Unit (AACU). She revealed she and the nurse aide were on the ACCU at the same time of the incident leaving the ACU with fifteen (15) residents unsupervised. The facility's failure to monitor Resident #10's SAO behaviors and provide adequate supervision resulted in an unsafe environment for other residents. Interview and record review revealed the facility failed to implement their policy and procedures related to behaviors, staffing, revision/implementation of care plans, and maintaining accurate clinical records. (Refer to F-280, F-323, F353, and F-514). The facility Administration's failure to administer effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on 03/11/15. An Acceptable Allegation of Compliance (AOC) was received on 05/28/15 which alleged removal of the Immediate Jeopardy on 05/28/15. The State Survey Agency determined the Immediate Jeopardy was removed on 05/28/15 prior to exit of the survey on 06/03/15. The scope and severity was lowered to a D while the facility monitors the implementation of the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes The findings include: Review of the facility's policy regarding Behavior Management Guideline, dated 02/12/15, revealed the facility was to develop behavior plans and medication regimens to optimize the functional abilities of residents while monitoring for adverse side effects and improved behaviors. The facility was supposed to utilized the Antecedent Behavior Monitoring Log for residents with behaviors that negatively affect functioning or quality of life. The Behavior Committee members were to review the log to identify patterns and causative triggering events for the behaviors and to measure the effectiveness of interventions. Additionally, the policy stated when the facility used an antipsychotic medication to treat an enduring condition; the facility must clearly and specifically identify and document the target behaviors. The facility must have clear documented evidence in the medical record that the situation or condition continued or recurred over time and the behaviors negatively affected the resident's quality of life. Review of the Corporate guidelines for Communication and Documentation of an Event, dated 02/10/10, defined an event as an incident that resulted in, or had the potential to result in, physical or mental harm to a resident. Per the guidelines, an event included resident-to-resident altercations and demonstrated high-risk patient behaviors or situations. When an event occurred, the facility was always to complete a thorough and objective Verification of Investigation form. Interview with the Administrator, on 04/22/15 at 4:00 PM, revealed he was informed of the incident between Residents #10 and #18 on 03/11/15. He stated he met with the Director of Nursing Services (DNS) and they decided it was not a reportable incident, it was just behaviors. However, review of the Corporate guidelines for Communication and Documentation of an Event revealed an event included resident-to-resident altercations and demonstrated high-risk patient behaviors or situations. He stated no investigation was conducted regarding the residents' behaviors because Resident #10 was placed on 1:1 supervision and then transferred to a Psychiatric Hospital for treatment. However, per the Corporate guidelines, the facility was always to complete a through and objective investigation when an event occurred. Continued interview with the Administrator revealed Resident #18's family was aware of the incident and had no concerns. The Administrator stated neither he nor the DNS looked at staffing and he was unaware the residents were left unsupervised because of staffing issues. The Administrator stated he did not discuss the SAO behaviors (or any behaviors) during the monthly QA meetings with the facility staff and had not discussed this with the Medical Director. He stated behaviors had not been a routine topic discussed at the quarterly QA meetings; just discussion of [MEDICAL CONDITION] medication use. Further interview with the Administrator, on 05/06/15 at 10:53 AM, revealed the facility did not utilize the Antecedent Behavior Monitoring Log before the Immediate Jeopardy. However, per the facility's policy Behavior Management Guideline, the facility was supposed to utilized the Antecedent Behavior Monitoring Log for residents with behaviors that negatively affect functioning or quality of life. He further stated the log was available in the Corporate policies on-line and he was to utilize the form; however, neither he or the DNS had implemented the form, per the facility's policy. Therefore, the Behavior Committee did not review residents' behaviors at the weekly meetings according to the Corporate policy. He stated he could not recall when the Behavior Management Guidelines went into effect and could not recall if he received an e-mail regarding the new policy as was the practice of the Corporation. Additional interview with the Administrator, on 05/22/15 at 4:35 PM, revealed he was unaware of either of the Behavior Monitoring and Management policies. He had no system in place for documenting and monitoring residents' behaviors. In addition, he stated monitoring and documentation for resident behaviors was a nursing function. Interview with the Field Services Clinical Director on 06/03/15 at 1:15 PM, revealed on 03/26/15 at the quarterly Clinical Guideline training, she reviewed all on-line policies with the Director of Nursing and the Assistant Director of Nursing. In addition she said all incidents and [MEDICATION NAME] were reported to her by the Administrator. However, interviews with the Administrator and Director of Nursing revealed they did not think the incident was reportable. Review of the daily census, dated 03/11/15, revealed the Alzheimer's Care Unit (ACU) and the Advanced Alzheimer's Care Unit (AACU) had thirty-one (31) residents on the units combined. Review of the facility's staffing for the night shift (11 PM-7:00 PM) on 03/11/15, revealed one nurse and one nurse aide was scheduled to care for the thirty-one residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, and Certified Nursing Assistant (CNA) #12 on 05/05/15 at 9:40 PM revealed on the morning of the incident (03/11/15) both staff were on the ACCU and left the ACU unsupervised. Both employees stated they were aware of Resident #10's SAO behaviors. Refer to F323. Additional interviews with CNA #13, on 05/05/15 at 3:55 PM, and CNA #14, on 05/05/15 at 4:14 PM, revealed they could not supervise both the ACU and the AACU at the same time with only one nurse and one CNA working the units at night. The CNAs stated they could not visually see both units unless she was in the nurses' station, and then she could only see the front half of the ACU. CNA #13 stated residents would frequently get up in the night and several residents would wander into other residents' rooms. She stated there were times when the nurse and the aide had to be on the same unit at the same time, leaving the other unit unsupervised. Record review revealed Resident #10 exhibited SAO behaviors on 06/06/14, 08/12/14, 12/20/14, 01/12/15, 01/30/15, and 02/06/15. However, the supervision of the resident was not increased unless the resident exhibited a SAO behavior and then for a very short time. However, interview with the ACU Manager, on 04/23/15 at 11:00 AM, revealed she had failed to document in the clinical record what specific behaviors the resident was exhibiting on 01/30/15 that required closer supervision of the resident. The Unit Manager indicated nursing did not always document behaviors in the clinical record. Refer to F514. The facility took the following actions to remove the Immediate Jeopardy on 05/28/15 by implementing the following: 1. Resident #10 was separated from the female residents and placed in sight of staff until transferred to a behavior unit for treatment on 03/11/15. Resident #10's documentation was noted in the Caretracker and Point Click Care by the Unit Manager on 04/26/15. On 03/11/15 the Charge Nurse and Certified Nursing Assistant took immediate action to ensure the safety of other residents by closely monitoring Resident #10 until transfer to the behavior treatment unit at approximately 5:20 PM. No other behaviors occurred. 2. On 04/28/15, The Nursing Home Administrator and Director of Nursing Services discussed staffing patterns in the Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU) on the 11-7 shift. It was determined one Certified Nursing Assistant was added to the 11 PM-7 AM shift on the Alzheimer's Care Unit. 3. On 04/25/15 and 04/26/15 conference calls were conducted with the Administrator and Director of Nursing Services. The facility's Health Care Council guided the Administrator and the Director of Nursing Services through the location on the Policy Center and existence of behavior monitoring guidelines and log. The Area Vice-President and Field Services Clinical Director were present for both calls. On 04/27/15 the Field Services Clinical Director provided additional education to the Administrator, Director of Nursing Services, Assistant Director of Nursing, ACU/AACU Director, Director of Clinical Education, and Social Services Director on behavior management guidelines and monitoring. The Director of Nursing Services and Assistant Director of Nursing Services received education on the Behavioral Management Guideline Policy, on 03/26/15, during the quarterly clinical guideline training hosted by the Field Services Clinical Director. On 04/25/15, the Administrator received education related to the Behavior Guideline and Monitoring by the Health Care Council. The Administrator ensured the Director of Nursing Services began education and no employee would work unless they received the education. The Administrator monitored progress at least daily in the Clinical Start-Up meeting at least daily. On 04/27/15, the Files Services Clinical Director provided additional education to the Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Education, ACU/AACU Director, and Social Services Director on behavioral management guidelines and behavior monitoring and charting. On 04/27/15, the Administrator consulted with the Field Services Clinical Director for investigations and incidents that may result as a reportable. There were two (2) incidents reported in April and eight (8) incidents reported in May. 4. An Ad Hoc Quality Assurance Process Improvement meeting, consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Clinical Director of Education and the Medical Director by phone was held on 04/27/15 to discuss the event of 03/11/15 and to develop a plan to prevent reoccurrence. The behavioral management guidelines and monitoring plan that the facility had implemented was discussed with the Medical Director via phone. A Quality Assurance Process Improvement Committee meeting will be held weekly x 4 weeks, then monthly thereafter. The committee will review results of the care plan and behavior log audits, behavior monitoring, and any investigations or [MEDICATION NAME]. The Behavior Monitoring Log is utilized for residents who are exhibiting behaviors. The audit identifies patterns and positive or triggering events and effectiveness of interventions. The audits will be completed weekly by the Social Worker and Director of Nursing Services and/or Assistant Director of Nursing Services. The Administrator held Quality Assurance Process Improvement meetings to review behavior care plan logs, audits, [MEDICATION NAME], and investigations on 05/04/15, 05/14/15, 05/21/15. The State Survey Agency validated the removal of Immediate Jeopardy on 06/03/15 prior to exit as follows: 1. Interview with Licensed Practical Nurse #13, on 06/01/15 at 2:55 PM, revealed until Resident #10 was transferred to a local behavioral unit he/she was kept in staff view. Review of Caretracker and Point Click Care revealed the resident was placed on 1:1 supervision until transferred on 03/11/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed Resident #10 was placed on observations for the safety of ACU/AACU residents. Review of the Discharge Summary from the behavior unit on 06/02/15 revealed, Resident #10 was admitted for evaluation on 03/11/15 and discharged on [DATE] back to the facility. Interview with Licensed Practical Nurse #7, on 06/02/15 at 6:25 AM, revealed on the morning of 03/11/15 she separated the residents without difficulty and reported the incident to the House Supervisor. She stayed with the female resident and the male resident was taken to his room. Resident #10 was then monitored. 2. Interview with the Director of Nursing on 06/03/15 at 8:30 AM, revealed the staffing schedule was revised to include two (2) Certified Nursing Assistants were now scheduled on the 11:00 PM to 7:00 AM shift daily for the ACU/AACU unit. She was to be notified of any scheduling difficulty and a staff member would be mandated to meet the ACU/ACCU staffing schedule. Interviews with the Licensed Practical Nurse (LPN) #7 on 06/02/15 at 9:40 AM, LPN #11, at 9:45 AM, CNA #18 at 9:46 PM, CNA #1 at 2:10 PM, validated there were now two (2) CNAs scheduled for the ACU/AACU on the 11 PM to 7 AM shift. Review of the staffing guidelines, received 06/02/15, revealed one nurse and two CNAs are scheduled for the ACU/AACU for the 11 PM-7 AM shift. Review of the daily staffing sheet from 04/28/15 to 06/02/15 revealed there were one nurse and two CNAs scheduled for the units on the 11 PM-7 AM shift except for 05/03/15. 3. Interview with the Area Vice-President on 06/02/15 at 3:35 PM, revealed she was present at the 04/25/15, the 04/26/15, and the 04/27/15 conference calls for the education of the Behavioral Guidelines and Monitoring log and could validate the Administrator and the Director of Nursing Services was in attendance. Interview with the Field Service Clinical Director on 06/03/15 at 1:35 PM, validated she was the moderator for the education on the Behavior Policy and Guideline Log, on the conference calls, and she attended the Ad Hoc and all Quality Assurance Process Improvement meetings. In addition, she revealed education of the Behavioral Management Guideline Policy was provided to the Director of Nursing Services and Assistant Director of Nursing Services during the quarterly clinical training on 03/26/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the Assistant Director of Nursing Services, on 06/03/15 at 3:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the ACU/ACCU Manager/Director on 06/03/15 at 1:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Telephone interview with the former Administrator, on 05/22/15 at 4:35 PM, revealed he had received training on the Behavior Policy and Log on 04/25/15 from the Field Service Director. In addition, he stated the Director of Nursing Services was assigned to begin education and no employee was allowed to work until they were trained. Record review of the Human Resource employee roster on 06/03/15 revealed, all staff were trained except for: two (2) staff not on schedule, two (2) new hired that began their employment 06/01/15 and were in orientation. Training for behaviors and the behavior log was now part of orientation. Three (3) staff were on Family Medical Leave and one (1) PRN staff had not worked. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed training on the Behavior Policy and log was completed on 04/27/15. Staff that were off received training before their shift. Staff not trained were notified they would not be scheduled to work, until they were trained. In the morning meetings the behavior logs were reviewed. To date one resident on the ACU unit had to be placed on a 1:1 for behaviors. Any resident on [MEDICAL CONDITION] medications or that exhibited behaviors was placed on the behavior log. They are placed in the medication administration binder. Review of the quarterly Clinical Guideline training sign in sheet, dated 03/26/15, revealed the Director of Nursing Services and the Assistant Director of Nursing were trained on the policies by the Field Services Clinical Director. Interview with the Field Services Clinical Director on 06/03/15 at 2:35 PM, revealed the Administrator reports all incidents and [MEDICATION NAME] to her. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed she reports to the Field Services Clinical Director. Review of reportable incidents, on 06/03/15, revealed from 04/23/15 to 05/31/15 the Administrator reported twelve (12) incidents to the Field Services Clinical Director and State Agencies. 4. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed Quality Assurance Improvement Process meetings would be held weekly for four (4) weeks, bi-weekly for four (4) weeks, and then monthly thereafter. At the meetings care plans, behavior log audits, behavior monitoring, investigations, and [MEDICATION NAME] would be discussed. Causative patterns or trigger events and the effectiveness of interventions would be discussed. The behavior log audits would be completed weekly and reported at the meeting by the social worker. Record review on 06/03/15, revealed the Administrator, Director of Nursing Services, Assistant Director of Nursing, Social Services, Director of Education, and the Medical Director were present at an Ad Hoc meeting held 04/27/15 and Quality Assurance Improvement Process meetings on 04/29/15, 05/04/15, 05/14/15, and on 05/21/15.

Based on observation, interview, and record review it was determined the facility failed to have an effective Quality Assurance (QA) Committee to ensure ongoing compliance of corrected deficiencies. The facility was cited for not maintaining correction of identified quality deficiencies with their infection control program for three (3) consecutive Recertification Surveys. Review of the Plan of Correction submitted for the 2014 survey revealed the facility was to monitor noncompliance through the QA committee for two (2) quarterly meetings. If there were any issues with the lack of compliance, staff would be retrained. Annually, nursing staff would have infection control proficiency checks by the Director of Clinical Education (DCE). Observation during this Recertification/Extended Survey (April 21-May 7, 2015) revealed the facility failed to consistently implement plans of actions to correct identified deficiencies and remain in compliance with state and federal regulations. In addition, the facility failed to identify quality deficiencies related to behaviors and failed to develop and implement plans of action to correct those deficiencies. Observations revealed deficient practice was found for issues regarding infection control. The facility failed to maintain compliance in areas that would prevent cross-contamination during a wound dressing, isolation precautions, catheterization and hand hygiene. Refer to F441. The facility identified Residents #10 and #18 with sexually acting out (SAO) behaviors. On 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch with his/her mouth on Resident #18's breast. The facility identified Resident #10 had a history of [REDACTED]. The facility failed to investigate the incident and failed to conduct an Quality Assurance meeting to discuss these behaviors. Refer to F323 The Quality Assurance Committee's failure to sustain compliance of corrected deficiencies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on 03/11/15. An Acceptable Allegation of Compliance (AOC) was received on 05/28/15 which alleged removal of the Immediate Jeopardy on 05/28/15. The State Survey Agency determined the Immediate Jeopardy was removed on 05/28/15 prior to exit of the survey on 06/03/15. The Scope and Severity was lowered to a D while the facility monitors the implementation of the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review on 04/23/15 at 2:30 PM of the QA Signature Sheets, revealed the facility conducted QA meetings at least quarterly with the required members. WHAT DOES THE QA POLICY SAY ?? Review of the facility's policy for [MEDICAL CONDITION] (MDRO), dated August 2014, revealed the facility would take appropriate precautions when caring for residents with MDRO. The use of Contact Precautions would be determined on a case by case basis. Residents with a risk for transmission include residents with total dependence for activities of daily living may require contact precautions. A resident with a MDRO may need to be separated from a roommate who has a gastronomy feeding tube. Review of the clinical record for Resident #1 revealed the facility readmitted the resident on 04/14/15 status [REDACTED]. Interview with the Director of Nursing Services (DNS), on 04/23/15 at 11:25 AM, revealed contact precautions were not necessary for residents with multiple drug resistant organisms (MDRO) infections if the infection was contained. The DNS stated Resident #1's roommate had a gastrostomy tube, and that was missed, and residents with those types of tubes should not be in rooms with residents having MDRO infections. She stated she was aware that Resident #1 [MEDICAL CONDITION] in the surgical wound but missed having staff place the resident in contact precautions. Interview with the Director of Continued Education (DCE)/Infection Control Nurse, on 04/24/15 at 7:54 AM, revealed she was unaware Resident #1 [MEDICAL CONDITION] in the wound. That fact had not been communicated to her because she did not attend the morning clinical meetings. She said she would review Physician Orders, SBAR reports, and lab results and once a month obtain a cumulative report to help track and trend infections. She stated the corporation required specific monthly in-service education, but they pick the topic, not her. She stated nurses must complete annual competency training with check offs required. However, the last check off on skills with return demonstration was in April 2014. She indicated the corporation did all the scheduling of training without her input. A training on infection control was scheduled for July 2015. Observation of wound care treatment for [REDACTED].#1, on 4/22/15 at 3:05 PM, revealed the nurse did not create a clean field for the treatment supplies used for the wound care and dressing change. The wound on the bottom of the foot revealed a small amount of clear drainage. Treatment Nurse/LPN #1 measured the wounds, but he did not remove his gloves and wash his hands before leaving the room to retrieve cotton applicators from the treatment cart. Treatment Nurse/LPN #1 left the room and returned; however, he did not remove his gloves and wash his hands prior to cleansing and dressing the wounds. Interview with the Director of Nursing (DNS), on 4/23/15 at 11:10 AM, revealed she regularly monitored wounds and had observed dressing changes done by Treatment Nurse/LPN #1. She stated she had observed the nurse not performing hand hygiene between dirty and clean and had to remind him to changes his gloves. She stated when concerns were identified, education was provided on the spot but was not documented. She stated the bedside tables should be cleaned before supplies are laid on them. She stated there was not an audit tool in place to monitor for infection control during dressing changes. 3. Observation, on 04/23/15 at 11:25 AM, revealed LPN #5 assisted Resident #7 to the bathroom to urinate prior to a straight catheterization. The resident was assisted to bed, and it was noted the resident's brief was soiled with a small amount of feces. The nurse disposed of the soiled brief, but did not provide incontinent care; she washed her hands and applied clean gloves. The nurse opened the sterile catheterization kit and placed the container on the resident's bedside table. The table had not been cleaned and no sterile field had been created. The nurse opened the package and applied the sterile gloves. She cleaned the urinary meatus with a [MEDICATION NAME] swab, touching the resident's inner thigh. She removed the swab and threw it onto the paper container the sterile gloves came in. The other clean [MEDICATION NAME] swabs were placed on the paper too. The nurse took another swab and cleansed the urinary meatus outside first. The nurse placed the used swab onto the paper with the other clean swab. The nurse could not obtain a urine return and after several attempts had to stop. She removed the catheter and placed a clean brief on the resident without incontinent care. Interview with LPN #5, on 04/23/15 at 11:50 PM, revealed she normally did not provide a sterile field and would place supplies onto the sterile gloves package. She stated she had not cleaned the resident after removal of the soiled brief as it was such a small amount of feces and she had placed the sterile pad under the resident's buttocks. and failed to drape the resident before the procedure. She indicated she had been taught on the procedure in nursing school, but did not think that procedure was included in the annual competency skills at the nursing facility. Review of the clinical record for Resident #7 revealed the facility admitted the resident on 01/20/14 with the [DIAGNOSES REDACTED]. The resident was under the care of an Urologist that ordered for the resident to be straight catheterized (in and out) four times a day. The clinical record revealed the resident experienced several chronic Urinary Tract Infections [MEDICAL CONDITION] in January and February 2015 and was recently treated with antibiotic medication for a UTI on 04/09/15. 4. On 03/11/15 at 5:50 AM, the facility staff observed Resident #10 sitting on a couch next to Resident #18 with his/her mouth on the resident's right breast. The facility placed Resident #10 on 1:1 supervision and requested inpatient psychiatric hospitalization . Review of the intake assessment conducted by the hospital, 03/11/15 at 1:00 PM, revealed the resident was exhibiting sexually acting out (SAO) behaviors. The hospital Intake Coordinator documented the SAO behaviors presented a threat of harm to other residents. The facility identified the resident had a history of [REDACTED]. The resident required hospitalized from [DATE] to 03/24/15. Refer to 323. Interview with the Administrator, on 04/22/15 at 4:00 PM, revealed he was informed of the incident between Residents #10 and #18 on 03/11/15. He stated he met with the DNS and they decided it was not a reportable incident, it was just behaviors. He stated no investigation was conducted regarding the residents behaviors because Resident #10 was placed on 1:1 supervision and then transferred to a Psychiatric Hospital for treatment. The Administrator stated Resident #18's family was aware of the incident and had no concerns. He further stated neither he nor the DNS looked at staffing and he was unaware the residents were left unsupervised because of staffing issues. The Administrator stated he did not discuss the Sexual Behaviors during the monthly QA meetings with the facility staff and had not discussed this with the Medical Director. He stated behaviors had not been a routine topic discussed at the quarterly QA meetings, just discussion of [MEDICAL CONDITION] medication use. Another interview with the Administrator, during the QA review task, on 04/23/15 at 2:30 PM, revealed infection control was included for discussion during the quarterly QA meetings. The Administrator stated the Infection Control Nurse brought the lab reports on infections and antibiotic use from pharmacy to discuss at the QA meetings. In addition, he stated the daily clinical meetings should discuss what was happening with the residents. He only attended a portion of the clinical meetings related to the discussion of falls. He stated the DNS has oversight of the clinical practice of nursing that would include skin reports, hand hygiene, precautions, and infection control. He had not been informed of any problems noted with non-compliance with infection control practices. He stated the facility had developed a plan of correction to correct the deficient practice cited under the infection control tag last year; however, they had not ensured all aspects of the tag was monitored for compliance. The facility took the following actions to remove the Immediate Jeopardy on 05/28/15 by implementing the following: 1. Resident #10 was separated from the female residents and placed in sight of staff until transferred to a behavior unit for treatment on 03/11/15. Resident #10's documentation was noted in the Caretracker and Point Click Care by the Unit Manager on 04/26/15. On 03/11/15 the Charge Nurse and Certified Nursing Assistant took immediate action to ensure the safety of other residents by closely monitoring Resident #10 until transfer to the behavior treatment unit at approximately 5:20 PM. No other behaviors occurred. 2. On 04/28/15, The Nursing Home Administrator and Director of Nursing Services discussed staffing patterns in the Alzheimer's Care Unit (ACU) and Advanced Alzheimer's Care Unit (AACU) on the 11-7 shift. It was determined one Certified Nursing Assistant was added to the 11 PM-7 AM shift on the Alzheimer's Care Unit. 3. On 04/25/15 and 04/26/15 conference calls were conducted with the Administrator and Director of Nursing Services. The facility's Health Care Council guided the Administrator and the Director of Nursing Services through the location on the Policy Center and existence of behavior monitoring guidelines and log. The Area Vice-President and Field Services Clinical Director were present for both calls. On 04/27/15 the Field Services Clinical Director provided additional education to the Administrator, Director of Nursing Services, Assistant Director of Nursing, ACU/AACU Director, Director of Clinical Education, and Social Services Director on behavior management guidelines and monitoring. The Director of Nursing Services and Assistant Director of Nursing Services received education on the Behavioral Management Guideline Policy, on 03/26/15, during the quarterly clinical guideline training hosted by the Field Services Clinical Director. On 04/25/15, the Administrator received education related to the Behavior Guideline and Monitoring by the Health Care Council. The Administrator ensured the Director of Nursing Services began education and no employee would work unless they received the education. The Administrator monitored progress at least daily in the Clinical Start-Up meeting at least daily. On 04/27/15, the Files Services Clinical Director provided additional education to the Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Education, ACU/AACU Director, and Social Services Director on behavioral management guidelines and behavior monitoring and charting. On 04/27/15, the Administrator consulted with the Field Services Clinical Director for investigations and incidents that may result as a reportable. There were two (2) incidents reported in April and eight (8) incidents reported in May. 4. An Ad Hoc Quality Assurance Process Improvement meeting, consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Social Service Director, Clinical Director of Education and the Medical Director by phone was held on 04/27/15 to discuss the event of 03/11/15 and to develop a plan to prevent reoccurrence. The behavioral management guidelines and monitoring plan that the facility had implemented was discussed with the Medical Director via phone. A Quality Assurance Process Improvement Committee meeting will be held weekly x 4 weeks, then monthly thereafter. The committee will review results of the care plan and behavior log audits, behavior monitoring, and any investigations or [MEDICATION NAME]. The Behavior Monitoring Log is utilized for residents who are exhibiting behaviors. The audit identifies patterns and positive or triggering events and effectiveness of interventions. The audits will be completed weekly by the Social Worker and Director of Nursing Services and/or Assistant Director of Nursing Services. The Administrator held Quality Assurance Process Improvement meetings to review behavior care plan logs, audits, [MEDICATION NAME], and investigations on 05/04/15, 05/14/15, 05/21/15. The State Survey Agency validated the removal of Immediate Jeopardy on 06/03/15 prior to exit as follows: 1. Interview with Licensed Practical Nurse #13, on 06/01/15 at 2:55 PM, revealed until Resident #10 was transferred to a local behavioral unit he/she was kept in staff view. Review of Caretracker and Point Click Care revealed the resident was placed on 1:1 supervision until transferred on 03/11/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed Resident #10 was placed on observations for the safety of ACU/AACU residents. Review of the Discharge Summary from the behavior unit on 06/02/15 revealed, Resident #10 was admitted for evaluation on 03/11/15 and discharged on [DATE] back to the facility. Interview with Licensed Practical Nurse #7, on 06/02/15 at 6:25 AM, revealed on the morning of 03/11/15 she separated the residents without difficulty and reported the incident to the House Supervisor. She stayed with the female resident and the male resident was taken to his room. Resident #10 was then monitored. 2. Interview with the Director of Nursing on 06/03/15 at 8:30 AM, revealed the staffing schedule was revised to include two (2) Certified Nursing Assistants were now scheduled on the 11:00 PM to 7:00 AM shift daily for the ACU/AACU unit. She was to be notified of any scheduling difficulty and a staff member would be mandated to meet the ACU/ACCU staffing schedule. Interviews with the Licensed Practical Nurse (LPN) #7 on 06/02/15 at 9:40 AM, LPN #11, at 9:45 AM, CNA #18 at 9:46 PM, CNA #1 at 2:10 PM, validated there were now two (2) CNAs scheduled for the ACU/AACU on the 11 PM to 7 AM shift. Review of the staffing guidelines, received 06/02/15, revealed one nurse and two CNAs are scheduled for the ACU/AACU for the 11 PM-7 AM shift. Review of the daily staffing sheet from 04/28/15 to 06/02/15 revealed there were one nurse and two CNAs scheduled for the units on the 11 PM-7 AM shift except for 05/03/15. 3. Interview with the Area Vice-President on 06/02/15 at 3:35 PM, revealed she was present at the 04/25/15, the 04/26/15, and the 04/27/15 conference calls for the education of the Behavioral Guidelines and Monitoring log and could validate the Administrator and the Director of Nursing Services was in attendance. Interview with the Field Service Clinical Director on 06/03/15 at 1:35 PM, validated she was the moderator for the education on the Behavior Policy and Guideline Log, on the conference calls, and she attended the Ad Hoc and all Quality Assurance Process Improvement meetings. In addition, she revealed education of the Behavioral Management Guideline Policy was provided to the Director of Nursing Services and Assistant Director of Nursing Services during the quarterly clinical training on 03/26/15. Interview with the Director of Nursing Services, on 06/02/15 at 10:10 AM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the Assistant Director of Nursing Services, on 06/03/15 at 3:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Interview with the ACU/ACCU Manager/Director on 06/03/15 at 1:53 PM, revealed she was present for the education conference calls, attended the Ad Hoc and all Quality Assurance Process Improvement meetings. Telephone interview with the former Administrator, on 05/22/15 at 4:35 PM, revealed he had received training on the Behavior Policy and Log on 04/25/15 from the Field Service Director. In addition, he stated the Director of Nursing Services was assigned to begin education and no employee was allowed to work until they were trained. Record review of the Human Resource employee roster on 06/03/15 revealed, all staff were trained except for: two (2) staff not on schedule, two (2) new hired that began their employment 06/01/15 and were in orientation. Training for behaviors and the behavior log was now part of orientation. Three (3) staff were on Family Medical Leave and one (1) PRN staff had not worked. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed training on the Behavior Policy and log was completed on 04/27/15. Staff that were off received training before their shift. Staff not trained were notified they would not be scheduled to work, until they were trained. In the morning meetings the behavior logs were reviewed. To date one resident on the ACU unit had to be placed on a 1:1 for behaviors. Any resident on [MEDICAL CONDITION] medications or that exhibited behaviors was placed on the behavior log. They are placed in the medication administration binder. Review of the quarterly Clinical Guideline training sign in sheet, dated 03/26/15, revealed the Director of Nursing Services and the Assistant Director of Nursing were trained on the policies by the Field Services Clinical Director. Interview with the Field Services Clinical Director on 06/03/15 at 2:35 PM, revealed the Administrator reports all incidents and [MEDICATION NAME] to her. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed she reports to the Field Services Clinical Director. Review of reportable incidents, on 06/03/15, revealed from 04/23/15 to 05/31/15 the Administrator reported twelve (12) incidents to the Field Services Clinical Director and State Agencies. 4. Interview with the new Administrator, on 06/03/15 at 2:43 PM, revealed Quality Assurance Improvement Process meetings would be held weekly for four (4) weeks, bi-weekly for four (4) weeks, and then monthly thereafter. At the meetings care plans, behavior log audits, behavior monitoring, investigations, and [MEDICATION NAME] would be discussed. Causative patterns or trigger events and the effectiveness of interventions would be discussed. The behavior log audits would be completed weekly and reported at the meeting by the social worker. Record review on 06/03/15, revealed the Administrator, Director of Nursing Services, Assistant Director of Nursing, Social Services, Director of Education, and the Medical Director were present at an Ad Hoc meeting held 04/27/15 and Quality Assurance Improvement Process meetings on 04/29/15, 05/04/15, 05/14/15, and on 05/21/15.

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to have an effective system to ensure supervision to prevent accidents related to residents who were identified at risk for elopement/wandering. The facility Administration failed to have an effective system to ensure staff was knowledgeable of residents who the facility had identified as being at risk for elopement. The facility Administration failed to have an effective system to ensure the secure alarm code alert system and the door code system to the Alzheimer's Care Unit (ACU) was effective in protecting residents who were assessed to be an elopement risk. The facility failed to have an effective system to ensure the Comprehensive Plan of Care was implemented to ensure continuous supervision and monitoring to prevent elopement. (Refer to F-282 and F-323). On 01/22/12, between 3:00 PM and 3:20 PM, Resident #8 who the facility identified as a risk for elopement, exited the locked Alzheimer's Care Unit (ACU), traveled through the building and exited out the front door without staff identifying the resident and the code alert system alarming. The resident was found on a sidewalk next to a busy street, which was approximately one mile from a rail road track. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/27/12 and determined to exist on 01/22/12. Observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable Allegation of Compliance (AOC) on 02/01/12. However, non compliance continued to exist at a scope and severity of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) to ensure the facility established and maintained an effective system to ensure a safe environment, free from accidental hazards. The findings include: Review of the facility's "Elopement Policy and Procedure Guide", dated 01/11, revealed the purpose of the elopement policy was to identify residents at risk for elopement; minimize episodes of elopement; protect residents who were not capable of protecting themselves; provide techniques and equipment to minimize safety risks; and educate staff. The Policy stated, all new employees would be inserviced on the elopement policy during orientation. Review of the "Risk for Elopement" Quarterly Interdisciplinary Resident Review, dated 11/23/11, revealed Resident #1 was assessed by the facility and determined to be at risk for elopement. The Comprehensive Plan of Care, dated 04/02/11, revealed Resident #1 was placed on the ACU for safety due to increasing confusion related to Dementia. Continued review revealed the resident was ambulatory, at risk for wandering/exit seeking behavior, and was unable to make safe and appropriate decisions. However, interviews on 01/25/12 at 1:00 PM and 01/31/12 at 10:15 AM with the ACU Unit Manager/Licensed Practical Nurse (LPN) #9, 01/31/12 at 9:30 AM with the Alzheimer's Care Director, 01/25/12 at 3:30 PM with Certified Nursing Assistant (CNA) #9, 01/25/12 at 5:30 PM with CNA #1, and 01/26/12 at 4:00 PM with Dietary Assistant #5, revealed they gave the families the codes to the locked unit without ensuring that residents from the building were not exiting unsupervised, and also gave out the codes to the other main entrances. Additional staff interviews revealed the facility had not trained all staff to recognize those residents who were assessed to be at risk for wandering and elopement. Interview, with Dietary Assistant #1, on 01/26/12 at 3:45 PM, revealed she as hired at the facility in 08/11. She stated on 01/22/12 at approximately 3:20 PM, she passed Resident #8 who was going out the front entrance main doors as she was coming in the doors. She further stated she and this resident were the only ones passing through the doors at that time, and she did not recognize Resident #8 to be a resident of the facility. Further interview revealed the resident's code alert bracelet did not alarm. She stated she did not realize Resident #8 was a resident of the facility because she/he looked like a visitor, wearing a jacket and carrying a purse and a bag. She further stated she was not oriented to the ACU unit on orientation, nor was she oriented to any type of book which had photographs of residents who were at risk for elopement. Interview, on 01/27/12 at 1:30 PM, with the Staff Development Nurse, revealed she told new employees about the "Hikers Handbook" which was a book with the Face Sheet and photographs of residents in the facility who were at risk for elopement, and was kept in the front office. Further interview revealed she did not show the book to staff during orientation and there was no other Hikers Handbooks except for the one in the front office. She stated she toured new staff to the ACU and Advanced Alzheimer's Care Unit (AACU) either before or after hire; however, she did not make a point of introducing each resident to the staff. Review of the facility's investigation, dated 01/22/12, revealed Resident #8 exited the ACU on 01/22/12, between 3:00 PM and 3:20 PM, by following another resident's family off the locked unit without staff knowledge, entered the West Wing Unit, proceeded to walk through the lobby, and out the front main entrance. The resident proceeded to the facility's main entrance and passed a dietary staff member at 3:20 PM. The dietary staff member was unaware Resident #8 was a resident of the facility and let the resident exit the facility unsupervised. Resident #8's code alert bracelet did not activate the system to alarm as the resident exited through the main entrance door. Resident #8 exited the building and went down the facility driveway to a sidewalk next to a busy street. (Refer to F-323) Interview, on 01/26/12 at 4:10 PM, with the Administrator revealed he felt like an employee may have turned off the alarm as Resident #8 was going through and did not recognize she/he as a resident or a family member of another resident may have turned off the alarm. He stated he was aware families knew the codes to get out the doors in the past; however, did not know of any resident following a family member out of the ACU until this incident. Continued interview revealed the Hikers Book was in the front office and there were no Hikers Handbooks on the other nursing units or in the other departments for the employees to review. He further stated he felt there was a breakdown in the system and staff may not have known to go outside and check the premises for a missing resident when the alarm went off, and staff did not recognize Resident #8 to be a resident on the ACU. He indicated the staff failed to follow the Plan of Care by failing to monitor the movements of Resident #8, as evicenced by the resident leaving the building unsupervised and without staff knowledge. The facility provided an Acceptable Credible Allegation of Compliance (AOC) on 02/01/12 that alleged removal of the IJ effective 02/01/12, based on the following; 1) The codes to exit the ACU were changed on 01/22/12 and will be changed on the first Monday of each month by the Maintenance Director, and reported to the Administrator upon completion. 2) All staff in all departments was inserviced by the Administrator and Director of Nursing on 01/22/12 related to the unit exit door code change and the code change to the front and back door secure care alarm. The inservice informed staff they were not to give out door codes to families or visitors. Subsequent shifts, in all departments were not allowed to work until they completed the inservice. 3) The DON and the ADON reviewed all the current elopement assessments and Care Plans for all active residents to ensure all residents at risk for elopement had been identified and all Care Plans were up to date and listed appropriate interventions on 01/22/12. 4) The elopement Hikers Handbook was reviewed by the DON to ensure all residents at risk for elopement were listed in the manual with their picture on 01/22/12. 5) A letter to all families/responsible parties was issued by the Executive Director to provide education to watch for residents following them through the doors and informing them there was a code change for exiting the unit. 6) On 01/22/12 and 01/23/12 a Quality Assurance Meeting was held to discuss the root cause of the incident and the steps to be taken to prevent further incidents to Resident #8 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 7) On 01/24/12 and 01/25/12 the Executive Director, the DON and the ADON conducted door alarm drills to evaluate the staff response to alarms sounding. 8) On 01/26/12 an additional interior key pad and external button to the main entrance was installed. 9) On 01/27/12 inservice training was provided related to installation of the new key pad to the main entrance door and response of staff to search outside for a resident prior to disabling the secure care alarm. Also the staff was instructed to not give out secure care codes to anyone who was not employed at the facility. Staff who was not present for the inservice were contacted by phone. 10) The ADON made additional Hiker Handbooks for all departments and units that included resident face sheets and pictures of each resident identified to be at risk for elopement. The DON, ADON and the Director of Education conducted training on 01/31/12 in small groups and by phone to all department staff to inform the staff of the additional elopement manuals, locations, and the need for staff to be familiar with residents identified at risk for elopement. Staff was not allowed to work until they had received the inservice. 11) Monthly elopement drills are to be completed by the DON, ADON or the Director of Clinical Education. 12) The Quarterly Elopement Review will be done monthly for three months by the ADON and brought to the QA Meetings. 13) New employees are to be trained on the elopement system upon hire by the Director of Clinical Education. The elopement Hikers Handbook will be reviewed during orientation of new staff. The revised elopement policy and procedure have been included in the new hire orientation material beginning 1/31/12. On 02/01/12 it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 02/01/12 based on the following: Observation, on 02/01/12 from 09:45 AM until 1:25 PM, revealed there were Hikers Handbooks on all the nursing units including the East 1 Nurses Station, East 2 Nurses Station, Alzheimer's Nurses Station, Therapy Department, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including the Occupational Therapist, on 01/31/12 at 3:05 PM, the Physical Therapist on 01/31/12 at 3:20 PM, the Restorative Nurse on 01/31/12 at 3:40 PM, LPN #7 on 02/01/12 at 10:55 AM, LPN #8 on 02/01/12 at 11:05 AM, the MDS Coordinator on 02/01/12 at 11:15 AM, RN #3 on 02/01/12 at 10:10 AM, CNA #3 on 02/01/12 at 10:20 AM, LPN #5 on 02/01/12 at 10:30 AM, LPN #6 on 02/01/12 at 10:40 AM, Dietary Assistant #1 on 02/01/12 at 1:25 PM, Dietary Assistant #3 on 02/01/12 at 1:30 PM, and Dietary Assistant #4 on 02/01/12 at 1:35 PM revealed they were aware of the Hikers Handbook and the elopement policy. They were also aware they were not to give out secure code alarms for the front and back doors at any time, they were not allowed to give out door codes for the AACU and the ACU doors at any time, staff were to open doors which required a code for families and visitors, and they were not to turn off a code alarm until the resident was found. Interview, on 02/01/12 at 9:45 AM, with the Staff Development Nurse, revealed she had assisted with the changes in the new elopement policy and the policy would be given to each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Interview with the Administrator and review of the new Elopement Policy, on 02/01/12 at 3:00 PM , revealed the Policy was updated 01/31/12 to include bullet points which stated; staff was not to give out the secure care alarm codes which were located at the front and back entrance, staff was not to give out door codes to the AACU and ACU, and there was to be a Hikers Handbook located on each nurses station and in each department. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on interview, record review, and review of the facility's investigation, it was determined the facility failed to ensure services were provided in accordance with each resident's written Comprehensive Plan of Care for one (1) of twenty-eight (28) sampled residents (Resident #8). The facility identified Resident #8 as at risk for wandering/exit seeking behaviors. The facility placed Resident #8 on the Alzheimer's Care Unit (ACU) and detailed staff was to monitor the resident's movements, and redirect from situations as needed. On 01/22/12, between 3:00 PM and 3:20 PM, Resident #8 followed another resident's family off the locked ACU without staff knowledge, entered the West Wing Unit, proceeded through the lobby, and out the front main entrance. Although the resident passed a nursing station on the West Wing Unit, and passed a dietary staff member at 3:20 PM at the main front entrance. No staff recognized Resident #8 as a resident of the facility, allowing the resident to exit the facility unsupervised. The front main entrance door had a code alert system, (which required a code to be entered on the keypad in order to keep the system from alarming when a resident with a code alert bracelet was exiting), however, Resident #8's code alert bracelet, which was on her/his ankle, did not activate the system to alarm when the resident exited through the main entrance door. Resident #8 exited the building, went down the facility driveway to a sidewalk which was next to a busy street, approximately one mile from a railroad track, without staff knowledge. At 3:34 PM, the House Supervisor received a call from an employee who left work early and noticed Resident #8 standing on the sidewalk. The facility was knowledgeable the staff gave visitors and families the codes to the locked unit keypad system without ensuring that staff was monitoring residents movements, based on their supervision policy, in order to prevent the resident from exiting the unit/building unsupervised. The facility's failure to have an effective system in place to ensure services were provided in accordance with each resident's written Plan of Care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/27/12 and was determined to exist on 01/22/12. Observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable credible Allegation of Compliance (AOC) on 02/01/12. However, non-compliance continued to exist at a scope and severity of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) to ensure the facility implemented plans of care to ensure residents' safety. The findings include: Review of the facility's "Elopement Policy and Procedure Guide", dated 01/11, revealed residents on the secured unit will be deemed at risk for elopement and the documentation guidelines included a Care Plan that addressed the potential to wander or exit the living center and the measures taken to prevent wandering/elopement. Interview with the Director of Nursing (DON), on 01/26/12 at 1:30 PM and on 02/01/12 at 9:15 AM, revealed there was no policy related to Care Plans. She stated the Certified Nursing Assistants (CNAs) carried the Assignment Sheets in their pockets and used it as a reference for the care they were to provide and could also check resident's Comprehensive Care Plans if needed. However, she stated there was no actual audit of the Plans of Care to ensure they were followed. Although the ACU was a locked unit for residents who had been assessed as being at risk for exit seeking/elopement and required a keypad code to prevent residents from exiting the doors unsupervised, staff interviews revealed visitors and families were aware of the code. In addition, interviews with staff who worked on the ACU, revealed there was to be a staff member in the common area or at the nurse's station at all times to view the common area. However, on 01/22/13, CNA #4 left the common area without ensuring staff was monitoring the area. Resident #8 followed a family member off the unit without staffs knowledge. Interview with the Staff Development Nurse, on 01/27/12 at 1:30 PM, revealed she stressed during orientation, staff was not to give out the codes to the doors, and was to escort families to the doors and open the doors for them. Interview, on 01/31/12 at 9:30 AM with the Alzheimer's Care Director, revealed there was always the potential for a resident to follow a visitor or family member out of the ACU, and the staff on the ACU had always been allowed to give the visitors codes. Interview with the Unit Manager/Licensed Practical Nurse (LPN) #9 of the ACU, on 01/25/12 at 1:00 PM and 01/31/12 at 10:15 AM, revealed she had informed staff on the ACU they needed to make sure someone was covering the common areas at all times, and the CNAs were to make sure the nurse was aware if they were leaving the common area to give a shower or be in a resident room providing care. Interview with LPN #12, on 01/31/12 at 2:40 PM, revealed she worked the ACU and Advanced Alzheimer's Care Unit (AACU) Units and a staff member should be in the common area or the nurse's station at all times on both units. Interview with Registered Nurse (RN) #5, on 01/25/12 at 3:45 PM and on 01/31/12 at 4:00 PM, revealed she was assigned to Resident #8 on 01/22/12 when the resident left the building. She stated, the resident had not demonstrated exit seeking behaviors prior to the incident on 01/22/12; however, she stated a staff member should always be in the common area or in the nurses' station where the common area could be viewed. Interview, on 01/31/12 at 10:00 AM with CNA #5, revealed she consistently worked the day shift on the ACU and she always let the nurse know when she was leaving the common area to go in a resident's room or the shower room because someone needed to visualize the common area at all times. Review of Resident #8's clinical record revealed the facility admitted the resident on 03/23/11 with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care, dated 04/02/11, revealed the resident was placed on the ACU for safety due to increasing confusion related to Dementia, was ambulatory, at risk for wandering/exit seeking behavior, and was unable to make safe and appropriate decisions. The Care Plan goal stated the resident would not wander out of the facility or into unsafe areas. The interventions included: monitoring the resident's movement about the unit; redirecting with programming; redirecting from situations, areas, as needed to keep resident safe and secure; and code alert bracelet. Review of the Care Area Assessment Summary (CAAS), dated 04/05/11, revealed the resident was admitted to the facility following an acute care stay at an area hospital secondary to mental status changes and was placed on the ACU as it was felt she/he would be in a safe environment. Further review revealed the resident had cognitive loss and communication difficulty suggested by a Brief Interview of Mental Status (BIMS) score of four (4), which indicated the resident had severely impaired cognitive status. Documentation in the medical record revealed the resident had episodes of inattention, disorganized thinking, and presence of behaviors such as wandering episodes. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/23/11, revealed the facility assessed Resident #8 as severely impaired in cognitive skills for decision making and required supervision with ambulation. Review of the "Risk for Elopement" section of the Quarterly Interdisciplinary Resident Review, dated 11/23/11, revealed the resident was physically able to leave the building, was cognitively impaired, had impaired decision making skills, and had a history of [REDACTED]. She further stated, according to the completed Quarterly Interdisciplinary Resident Review, dated 11/23/11 which she completed, Resident #8 was considered to be at risk for elopement. Review of the facility's investigation, dated 01/22/12, revealed Resident #8 followed a family member out of the ACU and walked past a nursing station, to the front lobby and exited the front door. Further review revealed the resident walked down the driveway and was observed by a staff member who stopped her car and brought the resident back to the facility. Interview, on 01/25/12 at 5:30 PM, with CNA #1 revealed she had left work early on 01/22/12 and was pulling out of the facility parking lot when she observed Resident #8 standing on the sidewalk next to the facility's driveway. She stated she parked across the street from the facility's driveway and walked across the street to the resident and called House Supervisor/ RN #4. Continued interview revealed she walked the resident back across the street and attempted to assist the resident into her truck; however, the resident declined. She stated she stayed with the resident until the House Supervisor/RN #4, CNA #9, and LPN #12 arrived, and the staff walked the resident back across the street to the facility. Interview with RN/Supervisor #4 on 01/25/12 at 3:20 PM, revealed she received a call on 01/22/12 at 3:34 PM from Certified Nursing Assistant (CNA) #1 who informed her Resident #8 was on the sidewalk by the street. RN/Supervisor #4 explained she called Licensed Practical Nurse (LPN) #12 and asked the LPN to meet her at the front door, and took CNA #6 with her. She stated Resident #8 was observed with CNA #1 across the street from the facility. She, LPN #12 and CNA #6 walked Resident #8 across the street and back to the facility. Continued interview revealed the resident's code alert bracelet, which was on her/his ankle, alarmed at the door as they were walking back in the front entrance. Interview with LPN #12, on 01/31/12 at 2:40 PM, revealed she was working on the Advanced Alzheimer's Care Unit AACU, which was connected to the ACU by another door, on 01/22/12 when she received a call from the House Supervisor/RN #4 asking for assistance. She stated, she and House Supervisor/RN #4 went across the street where Resident #8 and CNA #1 were standing and assisted with walking the resident back into the facility. Further review of the investigation, revealed a head to toe assessment was completed and revealed no injuries. Review of the Progress Notes, dated 01/22/12 at 3:35 PM, revealed Resident #8 left the building and was found on the sidewalk in front of the building. The Note stated, the resident was alert and oriented to self which was baseline for this resident. Interview with RN #5, on 01/25/12 at 3:45 PM and on 01/31/12 at 4:00 PM, revealed she had written the Progress Note, was assigned to Resident #8 on 01/22/12 and had arrived on the unit at 2:45 PM when she observed the resident sitting in a chair in the common area. She stated she was completing finger stick blood sugars about 3:30 PM when Licensed Practical Nurse (LPN) #12, who was working the AACU, informed her she was leaving the unit because she had received a phone call stating a resident had left the unit; however, did not say which resident. RN #5 stated she was unaware Resident #8 left the unit, and staff brought the resident back to the unit at approximately 3:40 PM. Continued interview revealed she completed a head to toe assessment of the resident, and no visible injuries were noted. She stated upon return to the unit, the resident was wearing two (2) pairs of pants, a long sleeve top and a heavy red sweater, and was carrying a purse which was usual for this resident. According to the Investigation, Resident #8 was observed by a visitor who was sitting on a couch on the West Wing to follow a family member out of the locked unit. Further review of the Investigation, revealed Resident #8 passed a dietary employee when going through the front exit doors, but the employee did not recognize she/he was a resident. The resident was placed on one on one (1:1) for forty-eight (48) hours. The investigation was signed by House Supervisor/Registered Nurse (RN) Supervisor #4. Interview, on 01/27/12 at 3:15 PM with CNA #4, revealed she was assigned to Resident #8 on 01/22/12 at the time of the incident. She stated she arrived on the unit at 3:00 PM and observed the resident sitting by the wall next to the Advanced Alzheimer's Care Unit (AACU). She reported she was the only CNA assigned on the unit; however CNA #8/Restorative Aide was on the unit when she assisted another resident to the bathroom. She stated she usually told the nurse when she was leaving the common area to assist a resident; however, she had not notified the nurse this time because the restorative aide was on the floor. Continued interview revealed she had not asked the restorative aide to watch the common area for her, and the restorative aide had gone over to the AACU unit while CNA #4 was in the bathroom with the other resident. She verified some visitors knew the code to the double doors that led from the locked unit to the West Wing, and there was no code alert on that door. Interview further revealed she was aware Resident #8 had a Plan of Care related to wandering behaviors with an intervention to monitor the resident's movements. Observation of Resident #8 on 01/24/12 at 6:00 PM revealed the resident was ambulating down the hallway on the locked Alzheimer's Care Unit (ACU) with a steady gait. She/he had a purse on her/his shoulder, and was accompanied by a staff member. Interview with LPN #12, on 01/31/12 at 2:40 PM revealed she sometimes worked the ACU. She verified a lot of the families knew the code to get out of the ACU and did not have to be escorted out of the unit by staff prior to the incident. Interview, on 01/31/12 at 9:30 AM with the Alzheimer's Care Director, revealed, it "stands to reason" if the CNA was to leave the common area to give a shower or provide care, they should inform the nurse to ensure residents were monitored per their Plans of Care. Continued interview revealed there was normally one nurse and one CNA on the ACU and there was an unspoken dependence on the staff to ensure the residents did not leave the unit. She stated the Care Plans were updated as needed for new interventions if residents were exit seeking. Interview with the Director of Nursing (DON), on 01/26/12 at 1:30 PM and on 02/01/12 at 9:15 AM, revealed the staff development nurse oriented new hires to the Missing Resident and Elopement Policy, and also to the door alarms and code alert bracelets. She was unsure if staff was told in orientation not to give out door codes to families and visitors; however, it was the facility's philosophy to not give out the codes. She stated she was aware some families were punching in codes to take families out the doors without staff assistance. She further stated, Resident #8's intervention on the Care Plan to monitor movement was referring to staff monitoring residents for exits seeking behaviors and to re-direct from doors if needed to ensure they were safe. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/01/12 that alleged removal of the IJ effective 02/01/12, based on the following; 1) The codes to exit the ACU were changed on 01/22/12 and will be changed on the first Monday of each month by the Maintenance Director, and reported to the Administrator upon completion. 2) All staff in all departments was inserviced by the Administrator and Director of Nursing on 01/22/12 related to the unit exit door code change, and the code change to the front and back door secure care alarm. The inservice informed staff, they were not to give out door codes to families or visitors. Subsequent shifts, in all department were not allowed to work until they completed the inservice. 3) The DON and the ADON reviewed all the current elopement assessments and Care Plans for all active residents to ensure all residents at risk for elopement had been identified and all Care Plans were up to date and listed appropriate interventions on 01/22/12. 4) The elopement Hikers Handbook was reviewed by the DON to ensure all residents at risk for elopement were listed in the manual with their picture on 01/22/12. 5) A letter to all families/responsible parties was issued by the Executive Director to provide education to watch for residents following them through the doors and informing them there was a code change for exiting the unit. 6) On 01/22/12 and 01/23/12, a Quality Assurance Meeting was held to discuss the root cause of the incident and the steps taken to prevent further incidents to Resident #8 and other residents. Also, during the meeting, the incident, investigation, actions taken, and the effectiveness of the actions taken were discussed. The Medical Director was contacted by phone. 7) On 01/24/12 and 01/25/12, the Executive Director, the DON, and the ADON conducted door alarm drills to evaluate the staff's response to alarms sounding. 8) On 01/26/12, an additional interior key pad and external button to the main entrance was installed. 9) On 01/27/12, inservice training was provided for all staff related to installation of the new key pad to the main entrance door and the responsibility of staff to search outside for a resident prior to disabling the secure care alarm. Also the staff was instructed to not give out secure care codes to anyone who was not employed at the facility. Staff who was not present for the inservice were contacted by phone. 10) The ADON made additional Hiker Handbooks for all departments and units that included resident face sheet and pictures of each resident identified to be at risk for elopement. The DON, ADON, and the Director of Education conducted training on 01/31/12 in person in small groups, and by phone to all department staff to inform the staff of the additional elopement manuals, locations, and the need for staff to be familiar with residents identified to be at risk for elopement. Staff was not allowed to work until they had received the inservice. 11) Monthly elopement drills are to be completed by the DON, ADON, or the Director of Clinical Education. 12) The Quarterly Elopement Review will be done monthly for three months by the ADON and brought to the QA Meetings. 13) New employees are to be trained on the elopement system upon hire by the Director of Clinical Education. The elopement Hikers Handbook will be reviewed during orientation of new staff. The revised elopement policy and procedure have been included in the new hire orientation material beginning 1/31/12. On 02/01/12, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 02/01/12 based on the following: Observation on 02/01/12 from 09:45 AM until 1:25 PM revealed there were Hikers Handbooks on all the nursing units including the East 1 Nurses Station, East 2 Nurses Station, Alzheimer's Nurses Station, Therapy Department, Dietary Department, Housekeeping Office, Laundry Department, and the Front Office. Interviews with staff including the Occupational Therapist on 01/31/12 at 3:05 PM, the Physical Therapist on 01/31/12 at 3:20 PM, the Restorative Nurse on 01/31/12 at 3:40 PM, LPN #7 on 02/01/12 at 10:55 AM, LPN #8 on 02/01/12 at 11:05 AM, the MDS Coordinator on 02/01/12 at 11:15 AM, RN #3 on 02/01/12 at 10:10 AM, CNA #3 on 02/01/12 at 10:20 AM, LPN #5 on 02/01/12 at 10:30 AM, LPN #6 on 02/01/12 at 10:40 AM, Dietary Assistant #1 on 02/01/12 at 1:25 PM, Dietary Assistant #3 on 02/01/12 at 1:30 PM, and Dietary Assistant #4 on 02/01/12 at 1:35 PM revealed they were aware of the Hikers Handbook, and the elopement policy. They were also aware they were not to give out secure code alarms for the front and back doors at any time, they were not allowed to give out door codes for the AACU and the ACU doors at any time, staff was to open doors which required a code for families and visitors, and they were not to turn off a code alarm until the resident was found. Interview, on 02/01/12 at 9:45 AM, with the Staff Development Nurse, revealed she had assisted with the changes in the new elopement policy and the policy would be given to each new hire. She further stated most current staff had been inserviced on the new policy and if they had not received the inservice, they were not to clock in until they had been inserviced and signed that they had received the inservice. Interview with the Administrator and review of the new Elopement Policy, on 02/01/12 at 3:00 PM, revealed the Policy was updated 01/31/12 to include bullet points which stated; staff was not to give out the secure care alarm codes which were located at the front and back entrance, staff was not to give out door codes to the AACU and ACU, and there was to be a Hikers Handbook located on each nurses station and in each department. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on interview, record review, review of the facility's investigation and the facility's policy, it was determined the facility failed to provide adequate supervision and monitoring to prevent accidents for one (1) of twenty-eight (28) sampled residents (Resident #8). The facility assessed and identified Resident #8 and forty-six (46) additional residents as at risk for wandering or elopement; however, the facility failed to ensure staff was knowledgeable of residents who the facility had identified as being at risk for elopement. In addition, the facility failed to ensure the code alert system and the door code system for the Alzheimer's Care Unit (ACU) was effective as an assistive device in protecting residents who were assessed to be an elopement risk. The facility did not ensure the Plan of Care was implemented related to monitoring the resident's movements and redirect from situations as needed to ensure supervision and monitoring to prevent elopement for Resident #8. On 01/22/12, between 3:00 PM and 3:20 PM, Resident #8 followed another resident's family off the locked unit without staff knowledge, entered the West Wing Unit, proceeded to walk through the lobby and out the front main entrance. Although the resident passed a nursing station on the West Unit, and at the facility's main entrance, passed a dietary staff member at 3:20 PM, the dietary staff member was unaware Resident #8 was a resident of the facility and let the resident exit the facility unsupervised. The front main entrance had a code alert system, (which required a code to be entered on the keypad in order to keep the system from alarming when a resident with a code alert bracelet was exiting). However, Resident #8's code alert bracelet did not activate the system to alarm as the resident exited through the main entrance door. Resident #8 exited the building, went down the facility driveway to a sidewalk next to a busy street, which was approximately one mile from a rail road track, without staff knowledge. The temperature outside was forty-eight (48) degrees and it was a cloudy day. At 3:34 PM, the House Supervisor received a call from an employee who left work early and saw Resident #8 standing on the sidewalk. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents who were at risk for wandering/elopement behaviors was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/27/12 and was determined to exist on 01/22/12. Substandard Quality of Care (SQC) was identified at 483.25, Quality of Care F-323. Observations, staff interviews, and in-service record reviews were conducted on 02/01/12 to verify removal of Immediate Jeopardy as alleged in the acceptable Allegation of Compliance (AOC) on 02/01/12. However, non compliance continued to exist at a scope and severity of a "D" as the facility had not completed the development and implementation of the Plan of Correction (POC) to ensure the facility established and maintained an effective system to ensure a safe environment, free from accidental hazards. The findings include: Review of the facility's "Elopement Policy and Procedure Guide", dated 01/11, revealed the purpose of the elopement policy was to identify residents at risk for elopement; minimize episodes of elopement; protect residents who were not capable of protecting themselves; provide techniques and equipment to minimize safety risks; and educate staff. The policy stated, each resident was to be assessed upon admission for the potential for elopement, using the Clinical Health Status Form, and all residents at risk for elopement would be assessed quarterly and as needed. Photographs of residents were to be taken on admission and placed in the Medication Administration Record (MAR). Staff was to observe, every shift, that each resident's bracelet/alarm device was in place, and document on the Treatment Administration Record (TAR). Further review revealed all new employees would be inserviced on the elopement policy during orientation. Interview, on 01/26/12 at 1:30 PM with the Director of Nursing (DON), revealed the staff development nurse oriented new hires to the missing resident and elopement policy, and to the door alarms and code alert bracelets. She stated she was unsure if staff was taught not to give out door codes to families and visitors; however, it was the facility's philosophy to not give out the codes. She further stated she was aware families were punching in codes to take families out the doors without staff assistance. Continued interview revealed the code alert bracelets were checked by the nurses every shift and this was documented on the TAR. Also, maintenance checked the door alarms to ensure they were working properly Monday through Friday, and the Manager of the Day was to check the alarms on the weekends. She stated the Hikers Handbook was in the front office as a reference to recognize residents who were at risk for elopement; however, the book was not kept on the nursing units or in the other departments. Interview, on 01/25/12 at 1:00 PM and 01/31/12 at 10:15 AM with the Unit Manager/LPN #9 of the ACU, revealed the nurses were to test each code alert bracelet on the unit with a transmitter and document this on the Treatment Administration Record (TAR) each shift. She further stated there were pictures of the residents on the Medication Administration Record (MAR), and all residents on the ACU were at risk for elopement. Continued interview revealed she had informed staff on the ACU they needed to make sure someone was covering the common areas at all times, and the Certified Nursing Assistants (CNAs) were to make sure the nurse was aware if they were leaving the common area to give a shower or be in a resident's room providing care. She stated she had given out codes to the locked doors from the ACU to the West Wing and was aware family members opened the door to the ACU without assistance from staff at times. Interview, on 01/25/12 at 3:30 PM, with CNA #9, revealed he usually worked the East Wing and gave families codes to get out the doors. He stated, he had just given a family member a code to get out the East Wing back door. Interview, on 01/25/12 at 3:45 PM and on 01/31/12 at 4:00 PM with Registered Nurse (RN) #5, who worked the Alzheimer's Care Unit (ACU) consistently, revealed a staff member should always be in the common area or in the nurses' station where the common area could be viewed. Interview, on 01/25/12 at 5:30 PM, with CNA #1 revealed she had found Resident #8 on the sidewalk unsupervised on 01/22/12. She stated, either the staff gave the visitors the code to get out the front doors or put the code in for them. She further stated, a code was not needed to get out the front doors unless there was a resident with a code alert bracelet, and then the secure code would need to be entered. Interview, on 01/27/12 at 3:15 PM with CNA #4, who was assigned to Resident #8 on 01/22/12 when the resident left the building unsupervised, revealed some visitors knew the code to the double doors that led from the ACU locked unit to the West Wing and there was no code alert on that door. Interview, on 01/31/12 at 9:30 AM, with the Alzheimer's Care Director, revealed there was always the potential for a resident to follow a visitor or family member out of the ACU, and the staff on the ACU had always been allowed to give the visitors codes until after the incident when Resident #8 got off the unit. She stated it "stands to reason" if the CNA was to leave the common area to give a shower or provide care, they should communicate this to the nurse. She further stated there was normally one nurse and one CNA on the ACU. Interview, on 01/31/12 at 2:40 PM, with Licensed Practical Nurse (LPN) #12, revealed she sometimes worked the ACU and there was to be a staff member in the common area or the nurses station at all times on the ACU. Continued interview revealed a lot of the families knew the code to get out of the ACU unit and did not have to be escorted out of the unit by staff. Interview, on 01/31/12 at 10:00 AM with CNA #5, revealed she consistently worked the day shift on the ACU and the visitors knew the codes to open the doors from the ACU to the West Wing; however, since the incident on 01/22/12, staff was not to give out the code. She stated she always let the nurse know when she was leaving the common area to go in a resident's room or the shower room because someone needed to visualize the common area at all times. Record review revealed the facility admitted Resident #8 on 03/23/11 with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care, dated 04/02/11, revealed the resident was placed on the ACU for safety due to increasing confusion related to Dementia. Continued review revealed the resident was ambulatory and at risk for wandering/exit seeking behavior, and was unable to make safe and appropriate decisions. The goal stated the resident would not wander out of the facility or into unsafe areas. Interventions included: monitoring the resident's movement about the unit; redirecting with programming; redirecting from situations, areas, as needed to keep the resident safe and secure; and the use of the code alert bracelet. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/23/11, revealed the facility assessed the resident as being severely impaired in cognitive skills for decision making and requiring supervision with ambulation. Review of the Quarterly Interdisciplinary Resident Review, dated 11/23/11, section titled "Risk for Elopement" revealed the resident was physically able to leave the building, was cognitively impaired, had impaired decision making skills, and had a history of [REDACTED]. In addition, she completed the "Risk for Elopement" section of the Quarterly Interdisciplinary Resident Review Form on a quarterly basis for each resident in the facility. Continued interview revealed if the resident was able to leave the building on their own and was cognitively impaired, they were automatically considered a risk for elopement. She stated she had completed the Quarterly Interdisciplinary Resident Review, dated 11/23/11, and stated Resident #8 was considered at risk for elopement. Review of the facility's investigation, dated 01/22/12, revealed Resident #8 followed a family member out of the ACU, walked to the front lobby and exited the front door. The resident walked down the driveway and was observed by a staff member less than one (1) block away. Further review of the Investigation revealed the staff member stopped her car and brought the resident back to the facility. Interview, on 01/25/12 at 5:30 PM, with CNA #1 revealed she had left work early on 01/22/12 and was pulling out of the facility parking lot when she saw Resident #8 standing on the sidewalk next to the facility's driveway. She stated she quickly parked across the street from the facility's driveway, walked across the street to the resident and called House Supervisor/ RN #4. She further stated she walked the resident back across the street and attempted to assist the resident into her truck; however, the resident declined. Continued interview revealed she stayed with the resident until the House Supervisor/RN #4, CNA #9, and LPN #12 arrived. She stated the resident walked back across the street with the staff. Interview, on 01/25/12 at 3:20 PM, with RN/Supervisor #4, revealed she was called on 01/22/12 at 3:34 PM by Certified Nursing Assistant (CNA) #1 who reported Resident #8 was on the sidewalk by the street. The Nurse stated, she called Licensed Practical Nurse (LPN) #12 and asked the LPN to meet her at the front door, and took CNA #9 with her. Continued interview revealed Resident #8 was across the street from the facility with CNA #1, and she and the other staff walked Resident #8 across the street and back to the facility. She stated Resident #8's code alert bracelet, which was on her/his ankle, alarmed the door as they were walking back in the front entrance. Interview, on 01/25/12 at 3:30 PM, with CNA #9, verified he went to help House Supervisor/ RN #4 on 01/22/12, and noted Resident #8 was across the street from the facility with CNA #1. Interview, on 01/31/12 at 2:40 PM, with LPN #12, revealed she was working on the Advanced Alzheimer's Care Unit (AACU), on 01/22/12 when she received a call from the House Supervisor/ RN #4 asking for assistance. She stated she went with House Supervisor/RN #4 across the street where Resident #8 and CNA #1 were standing and assisted with walking the resident back into the facility. Continued review of the Investigation, revealed a head to toe assessment of Resident #8 revealed no injuries. Review of the Progress Notes, dated 01/22/12 at 3:35 PM, revealed Resident #8 left the building and was found on the sidewalk in front of the building, and was alert and oriented to self which was baseline for this resident. Interview, on 01/25/12 at 3:45 PM and on 01/31/12 at 4:00 PM with RN #5, revealed she had written the Progress Note. She further stated she was assigned to Resident #8 on 01/22/12 and had arrived on the unit at 2:45 PM when she visualized the resident sitting in a chair in the common area. She stated she was completing blood sugar checks about 3:30 PM when Licensed Practical Nurse (LPN) #12, who was working the AACU, informed her she was leaving the unit because she had received a phone call from someone stating a resident had left the ACU, but did not say which resident. RN #5 was unaware Resident #8 left the unit, and stated staff brought the resident back to the unit at approximately 3:40 PM. Continued interview revealed she completed a head to toe assessment of the resident, who had no visible injuries. She stated the resident was wearing two (2) pairs of pants, a long sleeve top and a heavy red sweater, and was carrying a purse which was usual for this resident. She stated the resident had not demonstrated exit seeking behaviors prior to the incident on 01/22/12. Further review of the Investigation revealed Resident #8 was observed following a family member out of the locked unit by a visitor who was sitting on the couch on the West Wing. Interview, on 01/25/12 at 6:10 PM, with Unsampled Resident D's private sitter, revealed on 01/22/12 she was on the West Wing when she noticed a woman with a child, who she could not identify, coming out of the ACU, followed by a lady with a red sweater, about 3:00 PM. Interview, on 01/31/12 at 3:20 PM, with the daughter of Unsampled Resident C, revealed she had visited her family member on the AACU on 01/22/12 and left the unit about 3:30 PM and went out to the West Wing through the ACU door. She stated she knew the code to get out because staff let the regular visitors know the codes. She further stated she went through the ACU door with her daughter, and was unaware of Resident #8 leaving the unit at that time. Continued review of the Investigation, revealed Resident #8 passed a dietary employee when going through the front exit doors, but the employee did not recognize she/he was a resident. Interview, on 01/26/12 at 3:45 PM, with Dietary Assistant #1, revealed she was hired at the facility in 08/11. She stated on 01/22/12 at approximately 3:20 PM, she passed Resident #8 who was going out the front entrance main doors as she was coming in the doors after her break. She further stated she and this resident were the only ones passing through the doors at that time, and she did not realize Resident #8 was a resident of the facility. Continued interview revealed the resident's code alert bracelet did not alarm. She stated she "had no clue" Resident #8 was a resident of the facility because she/he looked like a visitor, wearing a jacket and carrying a purse and a bag. She stated she was not oriented to the ACU unit on orientation, nor was she oriented to any type of book which had photographs of residents who were at risk for elopement. The investigation further revealed, the resident was returned to the facility and was placed on one on one (1:1) for forty-eight (48) hours. The investigation was signed by House Supervisor/Registered Nurse (RN) Supervisor #4. Continued interview, on 01/25/12 at 3:20 PM, with RN/Supervisor #4, revealed when she arrived on duty 01/22/12 she went to every door and checked with a transmitter to ensure the doors and the code alerts were working properly, as she did every weekend when she was the House Supervisor. Continued interview revealed she notified Administrative Staff and stayed at the front doors to monitor the door and to take statements from staff and visitors after the incident. She further stated, on 01/22/12 after the incident, she helped give inservices to staff to ensure they were aware they could not give out door codes to visitors and families. She further stated she was aware families knew the codes to the doors in the past. During interview, on 01/31/12 at 11:00 AM, the Manager of the Day, revealed he worked the day shift on 01/22/12. He verified that he checked all the doors and alarms that morning when he arrived. He further stated he usually sat in the front office window where he could see the front door entrance; however, he had left the office to get water temperatures on the units at 3:00 PM which took about one and a half hours and was not at the front office window at the time of the incident. Interview, on 01/27/12 at 3:15 PM with CNA #4, revealed she was assigned to Resident #8 on 01/22/12 at the time of the incident. She stated she remembered giving Resident #8 ice cream when snacks came to the unit. CNA #4 reported she was the only CNA assigned on the unit; however CNA #8/Restorative Aide was on the unit when another resident was noted to come out in the common area requiring assistance. Continued interview revealed she took that resident to the bathroom and when she came back out to the common area she was informed Resident #8 was gone. She stated she usually told the nurse when she was leaving the common area to assist a resident with incontinence care or a shower; however, she had not notified the nurse this time because CNA #8/Restorative Aide was on the floor. Continued interview revealed she had not asked CNA #8/Restorative Aide to watch the floor for her, and the restorative aide had left the unit while she was in the bathroom with the other resident. Interview, on 01/25/12 at 1:30 PM, with Restorative Aide/CNA #8, revealed he was doing restorative on the ACU until shortly after 3:00 PM on 01/22/12 and he saw Resident #8 go to her/his room and then come back out into the common area and sit down by the double locked doors which led to the West Wing. He confirmed shortly after 3:00 PM he left the ACU. Interview, on 01/26/12 at 4:05 PM, with the Dietary Manager, revealed she was unaware of any book which had photographs of residents who were at risk for elopement and she did not take dietary staff to the units to learn which residents were at risk for elopement on hire unless the facility received a new resident who looked like a visitor. She did not remember orienting new staff to Resident #8. Interview, on 01/27/12 at 1:30 PM, with the Staff Development Nurse, revealed new orientees received inservices related to elopement, keypad codes to doors, code alert bracelets, missing residents, and elopement risk assessments. She stated she told new employees about the "Hikers Handbook" which was a book with the Face Sheet and photographs of residents in the facility who were at risk for elopement, and was kept in the front office. Continued interview revealed she did not show the book to staff during orientation and there was no other Hikers Handbooks except for the one in the front office. Continued interview revealed she toured new staff to the ACU either before or after hire; however, she did not make a point of introducing each resident to the staff. She further stated she stressed during orientation, staff was not to give out the codes to the doors, and was to escort families to the doors and open the doors for them. Continued interview, on 01/31/12 at 9:30 AM, with the Alzheimer's Care Director, revealed she was in charge of the programming or activities on the unit, and was in charge of visiting homes and facilities to ensure new admissions were appropriate for the ACU. When asked how she ensured residents did not leave the unit unsupervised, she stated there was an unspoken dependence on the staff, and the Care Plans were updated as needed for new interventions if residents were exit seeking. Further interview, on 01/25/12 at 1:00 PM and 01/31/12 at 10:15 AM with Unit Manager/LPN #9 of the ACU, revealed Resident #8 had no history of leaving the unit without an escort. She was unaware of any residents following the visitors out the doors. However, she stated, on 01/22/12 Resident #8 followed Unsampled Resident C's family out the doors from the ACU to the West Wing, and was witnessed by another family member who was sitting on the West Wing. Observation of Resident #8 on 01/24/12 at 6:00 PM revealed the resident was ambulating down the hallway on the locked Alzheimer's Care Unit (ACU) with a purse on her/his shoulder, and was accompanied by a staff member. Interview, on 01/26/12 at 1:30 PM with the Director of Nursing (DON), revealed there was no policy related to Care Plans and there was no reference source used related to care plans. She stated the CNA's carried the Assignment Sheets in their pockets and used it as a reference for the care they were to provide. She stated Resident #8's intervention on the Care Plan to monitor movement was referring to staff monitoring residents for exits seeking behaviors and to re-direct from doors if needed to ensure they were safe. Interview, on 01/26/12 at 4:10 PM, with the Administrator, revealed he came in on 01/22/12 when he was notified of Resident #8 getting out of the building. He stated Maintenance, House Supervisor/ RN #4, and also an outside vendor checked all the door alarms to ensure the doors and alarms were working properly. He stated there were no problems found with the doors and alarms, and felt like the front entrance door code alarmed as Resident #8 went through the door since she/he had a code alert bracelet on when she/he was found, and the code alert alarmed the door when staff brought the resident back in the building through the same front entrance. Further interview revealed he felt like an employee may have turned off the alarm as Resident #8 was going through and did not recognize she/he as a resident. He further stated a family member of another resident may have turned off the code when it alarmed as Resident #8 went through the door. He stated a code would not have been needed to open the front door until 9:00 PM; however, the code alert system should have alarmed if a resident wearing a code alert bracelet passed through without punching in the code to the secure code alarms. Continued interview revealed the Hikers Book was in the front office and was mainly used for the police as needed if there was a missing resident and there were no Hikers Handbooks on the other nursing units or in the other departments. He further stated he felt there was a breakdown in the system and staff may not have known to go outside and check the premises for a missing resident when the alarm went off, and staff did not recognize Resident #8 as a resident on the ACU.