Every finding on record at Martin County Health Care Facility

Based on observation, interview, record review, and review of facility policy, the facility failed to provide pharmaceutical services to ensure the accurate administration of drugs to meet the needs of each resident for one of 26 sampled medication observations. The finding include:Review of the facility's policy titled, Medication Administration, effective date 07/01/2024, last reviewed on 08/20/2025, revealed, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record and compare the medication and dosage schedule on the resident's MAR with the label. The policy also stated, Verify medication is correct three times before administering the medication. When pulling medication package from the med cart, when dose is prepared, and before dose is administered. Additionally, the policy indicated Medications are administered in accordance with written orders of the prescriber. Review of Resident (R)55's Face Sheet revealed the facility admitted the resident on 12/06/2011 with a diagnosis of epilepsy, aphasia, traumatic subdural hemorrhage, and contracture.Review of R55's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/27/2025, revealed the Brief Interview for Mental Status [BIMS] assessment indicated the resident was considered severely cognitively impaired.Review of R55's Physician's Orders, dated 07/16/2021, revealed an order for Potassium Chloride Solution 10 % (given to increase potassium) Give 7.5 milliliters (ml) by mouth one time a day for hypokalemia diluted in 4 to 6 ounces of water or juice.Review of R55's Medication Administration Record [MAR], dated 07/17/2021 revealed Potassium Chloride Solution 10 % Give 7.5 ml by mouth one time a day for hypokalemia diluted in 4 to 6 ounces of water or juice.Observation of medication administration on 11/19/2025 at 8:40AM revealed Certified Medical Technician (CMT)1 drew up 7.5millilters(ml) of Potassium Chloride 10% and mixed it in the same cup with 15ml of levetiracetam.During an interview on 11/19/2025 at 3:07 PM CMT1 stated she did not dilute the medication prior to administering but offered the resident a drink after administering the medication. CMT1 stated it was important to follow medication administration instructions to prevent medication errors. CMT1 stated she was not aware of the importance of diluting the medication.During an interview on 11/19/2025 at 3:26PM Registered Nurse (RN) 1 stated it was important to follow medication administration instructions to assess for side effects and for the safety of the resident. RN1 stated it was important to dilute potassium chloride to prevent ulcers and gastrointestinal upset.During an interview on 11/19/2025 at 3:31PM with the Director of Nursing (DON) she stated it was important to follow medication administration instructions to ensure the resident's right to receive the correct medication. The DON stated it was important to dilute potassium chloride to prevent stomach upset.During an interview on 11/19/2025 at 3:34PM the Assistant Director of Nursing (ADON)1 stated it was important to follow medication administration instructions to monitor for side effects or adverse effects. ADON1 stated it was important to dilute potassium chloride to prevent stomach upset.During an interview on 11/19/2025 at 2:53PM with Pharmacist, she stated medication administration labels were applied before medications were delivered. The Pharmacist stated the label for potassium chloride stated to dilute in 4-6 ounces of water or juice. The Pharmacist stated that adherence to administration instructions was necessary to prevent stomach irritation or ulcer formation.During an interview on 11/19/2025 at 3:39PM the Administrator stated it was important to follow medication administration instructions to prevent adverse effects and to prevent medication errors. She stated it was important to dilute potassium chloride, so the resident does not receive the full dose at once.

Based on interview, record review, facility document policy review, it was determined the facility failed to maintain an environment which protected residents from physical abuse by another resident for one (1) out of three (3) residents, Resident #32. Resident #49, who had a history of wandering and aggressive behaviors, wandered into Resident #32's room and hit the resident on the right arm with a grabber (a grabber or a reacher is an assistive device used to pick up items from the floor/shelves, turn off lights, etc.). Resident #32 experienced a red, dime-sized area to his/her right arm, as a result of being hit with the grabber. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed it was the facility's policy for each resident to have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Continued review revealed the facility did not condone resident abuse by anyone, including staff members, other residents, friends, or other individuals. The policy further revealed the facility's abuse prevention/intervention program included, but was not limited to: assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. In addition, review also revealed abuse prevention/intervention program included: assessing residents with signs and symptoms of behavior problems, and developing and implementing care plans which assisted in resolving behavioral issues. Review of the Long Term Care Facility-Self-Reported Incident Form dated 04/27/2022, revealed Resident #49 entered Resident #32's room and struck Resident #32 on the right arm with a grabber that belonged to Resident #32. Continued review of the Form revealed Resident #49 was removed from Resident #32's room and placed on one-on-one (1:1) supervision. Review further revealed Resident #32 had a small red area on his/her right arm; however, the resident stated he/she was not hurt. Review of the Facility Investigation-5 Day Final Report dated 05/02/2022, revealed the facility substantiated that a resident-to-resident altercation occurred. Continued review revealed Resident #32's left palm was a tiny bit sore but not really. Further review revealed Resident #32 stated he/she was not afraid of Resident #49 anymore and was just anxious when the incident occurred. 1. Review of Resident #49's Admission Record revealed the facility admitted the resident on 06/24/2020, with diagnoses that included Dementia with Behavioral Disturbance, Mood Disorder, Anxiety Disorder, and late onset Alzheimer's Disease. Continued review of Resident #49's medical record revealed the facility discharged the resident on 10/26/2022. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #49 to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was severely cognitively impaired. Further review revealed the facility also assessed Resident #49 as dependent on staff for his/here Activities of Daily Living (ADLs) and to have behaviors of wandering. Review of Resident #49's Care Plan dated 07/06/2020, revealed the facility care planned the resident with cognitive thought process impairment related to Dementia. Per review of the care plan, on 01/21/2022, documentation on the care plan revealed the resident had behavior problems related to wandering. Further review of the care plan revealed the facility developed interventions which included: anticipating and meeting the resident's needs; providing a program of activities that were of interest and supplying a personal busy box; and redirecting and offering to assist the resident to bed if he/she was tired. Review of Resident #49's Progress Note dated 04/27/2022 at 4:18 PM, revealed the nurse had spoken with the resident's Physician regarding an incident of him/her wandering into another resident's room and hitting that resident with a grabber. Review of the Note further revealed the Physician ordered Resident #49 to be transferred to the emergency room (ER) for a psychiatric evaluation. 2. Review of Resident #32's Admission Record revealed the facility admitted the resident on 04/23/2021, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Morbid Obesity. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed Resident #32 as having a BIMS score of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility additionally assessed Resident #32 as dependent on staff for care with his/her ADLs, and not to have displayed any behaviors. Review of Resident #32's Weekly Nursing Assessment, dated 04/27/2022, revealed the resident had been assessed to have a dime-sized red area to his/her right posterior forearm midway between the wrist and elbow. Review further revealed no bruising was noted. Interview on 01/03/2023 at 11:40 AM, with Resident #32 revealed the resident recalled the incident when Resident #49 entered his/her room. Per interview, when Resident #49 entered his/her room he/she saw the grabber, picked it up, and began hitting Resident #32 on the arm with it. Continued interview revealed Resident #32 started yelling and staff came into his/her room and removed Resident #49 from the room. Resident #32 stated he/she did not believe Resident #49 realized what he/she had been doing and did not think Resident #49 had been trying to intentionally hurt him/her. Further interview revealed Resident #32 stated his/her arm stung from the blows incurred from Resident #49 striking him/her with the grabber. In addition, Resident #32 stated the facility placed a stop sign on his/her room door after the incident, and no further incidents had occurred. Interview on 01/05/2023 at 10:34 AM, with State Registered Nurse Aide (SRNA) #5 revealed she was working the day of the incident but had not witnessed Resident #49 striking Resident #32. SRNA #5 stated it was common for Resident #49 to go into other residents' rooms and take those residents' stuff. Further interview revealed when staff attempted to redirect Resident #49 and take back other residents' items, Resident #49 would become aggressive. Interview on 01/05/2023 at 2:30 PM, with Assistant Director of Nursing (ADON) revealed Resident #49 wandered into other residents' rooms not realizing he/she was in the wrong room. The ADON stated she removed Resident #49 from Resident #32's room following the incident. Further interview revealed Resident #49 had opened the bathroom door and could not get out of Resident #32's room because the bathroom door blocked the bedroom door exit. The ADON further stated Resident #49 had not realized what he/she had done when the incident occurred. Interview on 01/06/2023 at 9:41 AM, with Social Services Director (SSD) revealed Resident #49 had Dementia and his/her mental condition had declined. The SSD stated there were numerous interventions in place to help with Resident #49's behaviors, which included having a family member try to calm the resident down when he/she was agitated. She further stated other interventions additionally included: a referral for a psychiatric consultation; one-on-one (1:1) supervision; stop signs were placed on residents' doors; and activities were to be provided which Resident #49 enjoyed. According to the SSD, Resident #49 pretty much required staff to sit with him/her 1:1 in order to manage the resident's behaviors. Further interview revealed Resident #49's behaviors were difficult to manage, and other residents complained of Resident #49 going into their room. Interview on 01/06/2023 at 11:07 AM, with the Director of Nursing (DON) revealed Resident #49 had Dementia with behaviors. The DON stated numerous interventions were in place to help reduce Resident #49's wandering and aggressive behaviors. According to the DON, Resident #49 had a urinary tract infection (UTI) at the time of the incident involving him/her hitting Resident #32 with the grabber. Further interview revealed Resident #49's aggression increased when he/she had a UTI. Interview on 01/06/2023 at 11:34 AM, with the Administrator revealed interventions had been in place to reduce Resident #49's behavior. The Administrator stated Resident #49 roamed and wandered off; however, no other residents had complained about Resident #49's going into their rooms. Further interview revealed the Administrator stated she had never witnessed Resident #49 being physically abusive toward other residents.

Based on interview, and facility document and policy review, it was determined the facility failed to ensure a criminal background check was completed prior to employment for one (1) of five (5) sampled employees whose files were reviewed for background checks, State Registered Nurse Aide (SRNA) #11. The findings include: Review of the facility policy titled, Background Screening Investigations, dated 11/02/2017, revealed, It was the policy of this facility to conduct employment background screening checks, reference checks, screening and criminal conviction investigation checks on individuals who applied for employment with the facility. Continued review revealed the Personnel Director/Human Resources Director, or other designee, was to conduct employment background checks on staff to include: employees, Medical Director, and volunteers where appropriate. Review further revealed the employment background checks to be performed included reference checks, drug screening and criminal conviction checks (which might require fingerprinting as required by state law) on all persons making application for employment with the facility. Review of the facility's, Employee Handbook, revised December 2022, revealed, A criminal record check was required for all employees of the facility. Continued review revealed the facility would not knowingly employ a person in a position which involved providing direct services to a nursing facility resident if that person had been convicted of a felony: related to theft; abuse or sale of illegal drugs; abuse, neglect, or exploitation of an adult; or sexual crime. Review further revealed the facility would not knowingly employ a person convicted of a misdemeanor including abuse, neglect, or exploitation of an adult. In addition, if an employee was charged, arrested, indicted, or convicted of crime while employed at the facility, the employee was required to immediately inform the Administrator of such action, which might result in disciplinary action up to and including termination. Review of State Registered Nurse Aide (SRNA) #11's employee file revealed an application for employment was submitted on 04/15/2020, and documentation noting the SRNA was hired by the facility on 05/15/2020. Further review of SRNA #11's employee's file revealed no documented evidence a criminal background check had been completed as per facility policy and its Employee Handbook. Interview on 01/06/2023 at 8:50 AM, with the Administrator revealed she had contacted the Administrative Office of the Courts, who reported a criminal background check for SRNA #11 had not been completed upon hire at the facility. Interview on 01/06/2023 at 10:50 AM, with the Human Resources (HR) Manager revealed she completed all new employee paperwork and completed a checklist, which included obtaining a background check. She stated she was responsible for obtaining the criminal background checks for employees which included SRNA #11's. Further interview revealed however, the paperwork for the background check for SRNA #11 was not sent out to be completed prior to employment, but should have. Continued interview on 01/06/2023 at 10:39 AM, with the Administrator revealed she was required to sign off on the new-hire check list to ensure all required background checks and paperwork were completed. The Administrator stated however, the facility failed to complete a checklist for SRNA #11 which included criminal background checks. Further interview revealed the facility's process was for HR to complete a background check on all new hires prior to employment and for the Administrator to review the check list to ensure all items had been obtained prior to employment. A follow-up interview with the Administrator on 01/06/2023 at 11:10 AM, revealed it was the facility's expectation for background checks to be completed on all new employees prior to working in the facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure nebulizer equipment was sanitized after each use to prevent the possible spread of infection for one (1) of three (3) residents, Resident #50. Observation on 01/03/2023 at 2:25 PM, revealed Registered Nurse (RN) #1 opened the nebulizer cup, which contained drops of an unknown liquid around the inner wall of the cup. The RN opened the Ipratropium (an inhalation medication used to treat breathing problems) solution vial and emptied the contents of the vial into the nebulizer cup and turned the nebulizer machine on. At 2:52 PM, RN #1 stated the treatment had been completed and removed the nebulizer mask and placed the nebulizer apparatus inside a clear plastic bag and put it back on the resident's bedside table without sanitizing the equipment. The findings include: Review of the facility's policy titled, Specific Medication Administration Procedures, dated November 2021, revealed after a nebulizer treatment was complete, staff should rinse and disinfect the nebulizer equipment according to the manufacturer's recommendations or wash the pieces, except the tubing, with warm, soapy water daily. Rinse with hot water, and allow pieces to air dry completely on paper towel. Further review of the policy revealed when the equipment was completely dry, it should be stored in a plastic bag with the resident's name and the date on it. Review of the manufacturer guidelines for the nebulizer machine titled, User Manual - Sunset Compressor Nebulizer, undated, revealed after each use, the T-piece kit should be disassembled into three (3) sections. Continued review revealed the equipment should be washed in warm soapy water and rinsed well, then wiped with paper towels and allowed to air dry. Review of Resident #50's Admission Record revealed the facility readmitted the resident on 07/30/2021, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Hypoxemia (low oxygen level in blood). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #50 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Review of Resident #50's Care Plan, initiated on 10/29/2021, revealed the resident had a care plan for breathing pattern risk related to his/her diagnosis of COPD. Continued review of the care plan revealed the facility developed interventions which included daily care of the nebulizer equipment. Per review of the care plan, the exterior of the nebulizer machine was to be wiped down with mild soap and water, and noted to never use alcohol on the nebulizer mask or nasal pillows. Further review of the care plan revealed the nebulizer face masks and cushions were to be submerged in warm soapy water (mild soap) for approximately five (5) minutes, and then rinsed thoroughly with warm water. Review further revealed any excess water should be shook from the mask and the mask allowed to air dry on a clean surface every day shift and as needed. Review of Resident #50's Order Listing Report revealed a Physician's Order with a start date of 01/01/2023, for the resident to have DuoNeb (brand name for the ipratropium inhalation solution) Solution 0.5-2.5 (3) milligrams (mg) per three (3) milliliters (mL) to be given every six (6) hours as needed for chest congestion. Observation on 01/03/2023 at 11:04 AM, revealed Resident #50 lying on his/her bed with the head of the bed elevated approximately thirty (30) degrees. Interview with Resident #50, at the time of observation, revealed he/she was not feeling well because the resident had Pneumonia. Resident #50 stated the nebulizer machine sitting on his/her bedside table was used to give his/her treatments. The resident further stated it had been a few days since the nebulizer machine had been used. Further observation of the nebulizer inhalation apparatus revealed the mouthpiece, tubing, and T-piece, were lying on top of the nebulizer machine and not stored in a clean plastic bag for protection. Observation on 01/04/2022 at 2:15 PM, revealed Resident #50's nebulizer inhalation apparatus was stored in an undated plastic bag sitting on top of the resident's bedside table. Resident #50 stated he/she would like to have a nebulizer treatment administered which Licensed Practical Nurse (LPN #2) was notified of the resident's request at 2:19 PM. Interview with LPN #2, at the time of notification, revealed the LPN was still in training and was shadowing Registered Nurse (RN) #1. Continued observation at 2:25 PM, revealed RN #1 opened the nebulizer cup of Resident #50's inhalation apparatus, which had drops of an unknown liquid on the inner wall of the cup. The RN was observed to open the Ipratropium solution vial and empty the contents of the vial into the nebulizer cup of Resident #50's apparatus and turned the nebulizer machine on. Interview at 2:52 PM, revealed RN #1 stated Resident #50's treatment had been completed and the RN was observed to place the nebulizer apparatus inside the unlabeled clear plastic bag and placed it back on the resident's bedside table. Further observation revealed RN #1 and LPN #2 (her trainee) left Resident #50's room. Further interview at 2:55 PM, revealed RN #1 stated after administering Resident #50's nebulizer treatment, she should have cleaned the apparatus before placing it back in the clear bag. RN #1 stated she had not cleaned the apparatus because she had forgotten to take the bleach wipes in the resident's room with her. RN #1 further stated she only cleaned the areas of the apparatus where residents touched and stated she did not clean inside of their nebulizer canister/cup. Interview on 01/05/2023 at 5:50 AM, with RN #26 revealed once a nebulizer treatment had been completed staff should rinse out the canister/cup, turn the cup over, and make sure it was dry before placing it back in a storage bag. Interview on 01/05/2023 at 9:20 AM, with the Director of Nursing (DON) revealed after a nebulizer treatment had been completed staff should put the nebulizer apparatus inside a storage bag. Interview on 01/05/2023 at 9:21 AM with the Assistant Director of Nursing (ADON) revealed staff should take apart the apparatus, clean the inside of the canister/cup and let it air dry before placing it back inside the bag after a treatment. Interview on 01/05/2023 at 11:47 AM, with the Administrator revealed once a nebulizer treatment had been completed, staff should put the apparatus inside a bag. According to the Administrator, facility policy was that staff were to clean the apparatus once a day, not after each treatment. However, review of the facility's policy revealed staff should rinse and disinfect the nebulizer equipment according to the manufacturer's recommendations and review of the manufacturer's guidelines for the nebulizer machine revealed that, after each use, the T-piece kit should be disassembled into three (3) sections and the equipment should be washed in warm soapy water and rinsed well.

Based on interview, and facility document and policy review, it was determined the facility failed to ensure staff members received a COVID-19 vaccination or an exemption for two (2) of seventy-eight (78) employees, Dietary Aide (DA) #20 and Maintenance Assistant (MA) #21. The facility failed to ensure DA #20 and MA #21 received the second dose of their two (2) dose series of the COVID-19 vaccination. The findings include: Review of the facility's policy titled, COVID-19 Policy and Procedures, undated, revealed where COVID-19 vaccination required multiple doses, the staff member should be provided with current information regarding those additional does, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine to that individual as soon as possible. Continued review revealed the facility would require as a condition of employment that all individuals who provided care, treatments, and services for residents including employees, trainees, and contractors were to be fully vaccinated by March 15th, 2022. Further review revealed if the staff member declined to partake in the facility's vaccination requirement, they would be subject to termination. The policy further revealed the facility was required to track and document staff vaccinations, as well as document staff who had been granted exemptions and those whose vaccine were temporarily delayed. In addition, the policy revealed documentation of each staff member's vaccination status was expected to be performed (which should include the specific vaccine received, the dates of each dose received, or the date of the next scheduled dose for multi-dose vaccine). Interview with the Administrator, during the entrance conference, on 01/03/2023 at 9:00 AM, revealed the Director of Nursing (DON) was the facility's Infection Preventionist and the Assistant Director of Nursing (ADON) was responsible for the facility's vaccination efforts. Review of the facility's COVID-19 Staff Vaccination Status for Providers form revealed two (2) staff members, DA #20 and MA #21, were only partially vaccinated. Interview on 01/05/2023 at 9:25 AM, with the Administrator revealed the partially vaccinated employees (MA #21 and DA #20) were newly hired employees. The Administrator stated Human Resources (HR) was responsible for ensuring employees received the second dose of the COVID-19 vaccine, and the employees knew they needed to have the second dose. Interview on 01/05/2023 at 10:34 AM, with Maintenance Assistant (MA) #21 revealed he had been hired in September 2022 and received the 1st dose of his COVID-19 vaccination before he started. MA #21 further stated he had received a Moderna vaccine; however, did not know he needed a second dose until the Administrator notified him of that earlier in the day. Interview on 01/06/2023 at 10:49 AM, with the Dietary Manager revealed DA #20 was on the schedule to work later that day. The DM stated however, DA #20 would need to have a Physician's note when she came to work indicating a vaccine exemption, or was to be fully vaccinated in order to work her shift. Interview on 01/05/2023 at 2:25 PM, with the HR Manager revealed DA #20's hire date was 05/31/2022, and DA #20 received the first dose of her two (2) part COVID-19 vaccination on 05/31/2022. Continued interview revealed MA #21's hire date had been 09/20/2022 and MA #21 received the first dose of his two (2) part COVID-19 vaccination on 09/07/2022. Further interview revealed there was no documentation of a second dose vaccination which could be located for either of those employees. The HR Manager further stated she had not monitored employees' COVID-19 vaccination status in over a year, as the Administrator now monitored staffs' vaccinations. Interview on 01/05/2023 at 2:30 PM, with the DON/Infection Preventionist revealed the ADON provided staffs' vaccinations and would be the person who knew how staff were monitored to ensure they received their second dose of the COVID-19 vaccine. The DON stated the expectation was that somebody was assigned to make sure staff received the second dose of the two (2) part series of their vaccinations within a month. Further interview revealed unless an employee had an exemption for the COVID-19 vaccinations, employees were required to obtain both doses of the COVID-19 vaccine as a condition of their employment. Interview on 01/05/2023 at 2:37 PM, with the ADON revealed she did not track staffs' vaccinations because HR tracked staffs' vaccination status. The ADON stated however, the staff members (DA #20 and MA #21) should have received their second dose of their two (2) part vaccination one (1) month after the first dose was administered. Interview on 01/06/2023 at 8:33 AM, with the Administrator revealed the expectation was for the facility to track employees' vaccination status. The Administrator stated employees were expected to either be fully vaccinated or have an exemption documented on file.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure that the medical record for one (1) of three (3) residents (Resident A) contained the appropriate information related to the resident's discharge from the facility. On 04/26/18, the facility discharged Resident A due to the facility's inability to meet the resident's needs. However, the facility failed to ensure the resident's medical record contained documentation by the physician of what specific resident need the facility could not meet, the facility's prior attempts to meet the resident's need, and the services available at the receiving facility which could meet the resident's needs. The findings include: Review of the facility's policy titled Notice of Transfer and/or Discharge, dated 08/01/13, revealed the policy did not address the required documentation to be made prior to discharging a resident from the facility. Review of Resident A's closed record revealed the facility admitted the resident on 04/25/18 with [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #6 on 05/02/18 at 4:18 PM, revealed Resident A was admitted to the facility from an acute care hospital on [DATE], utilizing a Life Vest (external defibrillator). RN #6 stated upon the resident's arrival to the facility she was notified by the resident and family that the Life Vest had delivered a shock to the resident during transport to the facility. Review of Resident A's nurse's notes revealed on 04/26/18, the facility transferred Resident A to the Emergency Department (ED) due to having received the shock from the life vest on 04/25/18, and discharged the resident from the facility. However, continued review of the resident's medical record revealed [REDACTED]. In addition, there was no documentation of the facility efforts to meet the resident's needs or the specific services the receiving facility could provide to meet the needs of the resident. Interview with the Administrator on 05/03/18 at 10:05 AM, revealed the facility discharged the resident from the facility on 04/26/18. The Administrator stated due to Resident A utilizing the Life Vest, which would require the resident to be monitored and hospitalized should the vest deliver a shock, she felt the facility could not meet the resident's needs. The Administrator stated she made the decision to discharge the resident without involving Resident A's physician.

Based on interview, closed record review, and review of the facility policy, it was determined the facility issued a discharge notice to one (1) of three (3) sampled residents (Resident A) which failed to contain the required information. In addition, interview with staff revealed the form completed on 04/26/18 for Resident A was completed as a transfer form only to accompany the resident to the hospital, and was not intended to serve as a discharge notice for Resident A. The findings include: Review of the facility's policy titled Notice of a Transfer and/or Discharge, dated 08/01/13, revealed the policy stated that the resident and/or representative (sponsor) would be provided with information including the following: the reason for transfer or discharge, the name, address, and telephone number of the long-term care ombudsman, and the name, address, and telephone number of the Cabinet for Health Services, the agency that has been designated to handle appeals of transfers and discharge notices. However, the policy failed to address the facility's requirement to send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. Review of Resident A's closed record revealed the facility admitted the resident on 04/25/18 with [DIAGNOSES REDACTED]. Review of a Transfer and Discharge form for Resident A, dated 04/26/18, revealed that the facility had documented that the effective date of Resident A's transfer or discharge was 04/26/18, that the resident was being transferred or discharged to the local hospital, and the reason for the transfer or discharge was due to defibrillator vest shocked on 04/25/18 has pacemaker. The form also indicated that Resident A's spouse was notified of the facility's intentions on 04/26/18. Further review of the form for Resident A revealed the form failed to contain the e-mail address of the entity which received requests for information on how to obtain an appeal form and assistance in completing the form and the address (mailing and e-mail) of the State Ombudsman. Interview with Resident A's Spouse on 05/03/18 at 10:55 AM, revealed the facility never spoke with Resident A or the Spouse related to the resident being discharged from the facility due to the facility not being able to meet the resident's needs. The Spouse also stated she was never given a discharge notice by the facility, and was never made aware that Resident A was being discharged from the facility until the hospital called the facility to inform them that Resident A was ready to return. Resident A's spouse stated at that time the facility notified the hospital that they would not accept the resident back at the facility. Interview with RN #1 on 05/03/18 at 11:20 AM, revealed she was the nurse who completed the Transfer and Discharge form for Resident A on 04/26/18. RN #1 stated when she completed the form on 04/26/18, she was filling out the form as a transfer form to accompany Resident #1 to the hospital, and did not intend for the form to serve as a discharge notice. RN #1 stated she informed Resident A's Spouse that the resident was being transferred to the hospital, but never discussed the facility's ability to meet the resident's needs or informed the Spouse that Resident A was going to be discharged from the facility. The RN stated she did not send a copy of the Transfer and Discharge form to anyone including the spouse or the State Long Term Care Ombudsman, because it was a transfer form being sent to the hospital with Resident A. Interview with the Administrator on 05/02/18 at 12:38 PM and 05/03/18 at 10:05 AM, revealed the facility had never sent Resident A's Spouse or the Long Term Care Ombudsman a discharge notice. The Administrator stated the only form completed related to Resident A's transfer/discharge was the form sent with the resident to the hospital on [DATE] completed by RN #1.

Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the Resident Assessment Instrument User Manual, it was determined the facility failed to ensure that the Minimum Data Set (MDS) assessment for one (1) of seventeen (17) sampled residents (Resident #37) accurately reflected the resident's wandering status. Record review and interviews with staff revealed Resident #37 wandered daily and attempted to leave the facility through exit doors. In addition, on 01/25/18, Resident #37 left the facility without staff knowledge and a passing motorist had to alert the facility that the resident was outside. However, the facility failed to accurately assess the resident's wandering and the resident's risk for getting in potentially dangerous places when the facility completed an MDS assessment on 02/05/18 (refer to F656 and F689). The facility's failure to ensure residents were accurately assessed for wandering has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Resident Assessment Instrument User Manual, Version 3.0 revealed wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless and the wandering resident may be oblivious to his or her physical or safety needs. The user manual stated some residents who wander are at potentially higher risk for entering an unsafe situation. When completing the Minimum Data Set (MDS), staff should consider the previous review of the resident's wandering behaviors identified in the seven day look-back period and should determine whether those behaviors place the resident at risk for getting in potentially dangerous places. If it is determined that the wandering places the resident at risk, staff should code a 1 on the MDS. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with [DIAGNOSES REDACTED]. Review of Resident #37's Admission Minimum Data Set (MDS) assessment dated [DATE], and the quarterly assessment dated [DATE], revealed the resident exhibited no wandering behavior. However, review of the resident's care plan dated 04/22/17 revealed the facility developed a care plan due to the resident being at risk for elopement related to wandering and propelling his/herself up and down the hallways going to exit doors. Review of the 07/31/17, 10/22/17, and 01/15/18 Quarterly MDS Assessments revealed the facility assessed the resident to have wandering daily. Review of a Resident Accident/Incident Report revealed the facility received a call from a passing motorist on 01/25/18, who stated a resident was unattended outside the facility. Review of the report revealed the resident exited the facility without staff knowledge and was returned to the facility and assessed to have an abrasion/bruise to the right knee. Review of Resident #37's Elopement Risk Assessments dated 01/12/18 and 02/05/18 revealed the facility assessed the resident to be cognitively impaired with poor decision-making skills, confusion, and anxiety and wandered aimlessly with decreased safety awareness. The Elopement Risk Assessments further indicated the resident was a possible risk for elopement and wore a code alert bracelet on the right ankle related to attempts to exit the facility by pushing on exit doors looking for (the resident's) mom and stating, I want to go home, I want my mom. Review of Behavior Tracking for Resident #37 dated (MONTH) (YEAR) revealed the resident displayed wandering behavior and tried to exit the facility daily with the exception of 01/15/18 and 01/22/18. Review of Resident #37's Behavior Tracking for (MONTH) (YEAR) revealed the resident wandered daily with the exception of 02/02/18. Interview with State Registered Nurse Aide (SRNA) #9 on 03/02/18 at 9:30 AM, Kentucky Medication Aide (KMA) #2 on 03/02/18 at 9:15 AM, Registered Nurse (RN) #3 on 03/02/18 at 9:35 AM, Licensed Practical Nurse (LPN) #1 on 03/02/18 at 11:25 AM, and SRNA #5 on 03/01/18 at 3:30 PM revealed Resident #37 frequently wandered to exit doors in the facility. Interview with SRNA #4 on 03/01/18 at 3:25 PM, SRNA #7 on 03/02/18 at 9:20 AM, and RN #2 on 03/01/18 at 4:58 PM revealed Resident #37 propelled him/herself to exit doors more often when the resident was agitated. RN #2 stated agitation was an indication that the resident would have increased exit-seeking behavior. According to SRNA #10 on 03/02/18 at 9:40 AM, Resident #37 attempted to leave the facility through an exit door approximately twenty (20) or more times per day. Review of Resident #37's Annual MDS assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitively impaired and not interviewable. The facility assessed Resident #37 to wander one to three days during the previous seven days, even though facility staff had documented the resident wandered six of seven days during the look-back period. In addition, the MDS assessment revealed the resident's wandering behavior did not place the resident at significant risk of getting to a potentially dangerous place such as outside the facility, despite the resident trying to exit facility according to the Behavior Tracking, and having successfully eloped from the facility on 01/25/18. Interview with the Social Services Director (SSD) on 03/06/18 at 2:10 PM, revealed she assessed Resident #37's wandering on the 02/05/18 MDS assessment. She stated the resident's MDS should have indicated the resident wandered four to six days during the seven day look-back period ending 02/05/18, not one to three as stated on the MDS. However, the SSD did not feel that Resident #37's wandering placed the resident at significant risk of getting to a potentially dangerous place, such as outside the facility, and did not foresee dangers for the resident due to the alarms helping protect the resident. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.

Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the facility's policy, it was determined the facility failed to develop a comprehensive person-centered plan of care for one (1) of seventeen (17) sampled residents (Resident #37). Due to the facility's failure to accurately conduct a comprehensive assessment for Resident #37, the facility failed to develop a care plan with interventions which minimized the resident's risk for leaving the facility without staff knowledge. On 01/25/18, facility staff was unaware that Resident #37 had exited the facility and was outside unattended until a passing motorist notified them that the resident was outside. The facility's failure to ensure resident care plans were developed to minimize elopement risk has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Care Plan Goals and Objectives and Using the Care Plan policies dated 08/01/13, revealed the facility's goal for developing a care plan was to achieve the desired outcome for a specific resident problem. Information would be derived from the resident's comprehensive assessment and be resident oriented and measurable. The policies also stated that the care plan would be developed utilizing the resident's daily care routines and would be available to all staff that were responsible for providing care or services to the resident. Review of the Resident Assessment Instrument User Manual, Version 3.0 revealed wandering could be the pursuit of exercise, pleasurable activity, or it may be related to tension, anxiety, agitation, or searching; therefore, the care planning process should include an assessment of the resident's wandering to determine the frequency of the occurrence and to identify any factors that triggered the behavior or decreased the episodes in order to ensure an individualized, person-centered plan of care was implemented. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with [DIAGNOSES REDACTED]. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway of the facility. Review of the resident's care plan dated 04/22/17 revealed the facility identified that the resident was at risk for elopement due to wandering in the facility and to exit doors. However, the facility only developed interventions to monitor equipment utilized to alert staff when the resident exited a door. Staff were to ensure the device was in place and functional. The facility failed to develop interventions, including adequate supervision and specific diversional activities consistent with the resident's needs and goals, in order to eliminate/reduce the risk if possible, of the resident exiting the facility or being placed at risk for harm. Review of a Resident Accident/Incident Report revealed on 01/25/18, a passing motorist notified the facility that a resident was outside unattended. Review of the Report revealed Resident #37 had exited the facility without staff knowledge, was assisted back into the facility, and assessed to have an abrasion/bruise to the right knee. Review of RN #1's witness statement dated 01/25/18, and interview with RN #1 on 03/01/18 at 4:43 PM, revealed on 01/25/18 she last observed Resident #37 at approximately 4:30 PM, just prior to the resident leaving the facility. Although RN #1 redirected the resident from the Hall 3 door, the RN took no further action to ensure Resident #37's safety or prevent the resident from further attempts to exit the facility. RN #1 stated she had called out to (Resident #37) from the nurses' station, but implemented no further interventions such as diversional activities or increased supervision. Review of Resident #37's care plan dated 01/25/18 revealed the facility revised the resident's care plan to include the resident's elopement from the facility. The facility developed interventions to prevent the resident from exiting the facility that included fifteen (15) minute safety checks for twenty-four hours; attempt to redirect the resident to a common area as much as possible; offer snacks; and monitor the code alert bracelet placement every hour and functionality daily. However, there was no evidence the facility developed interventions that described the specific steps staff should implement to achieve the resident's goals that could be measured, quantified, and/or verified. The care plan stated staff should conduct fifteen-minute safety checks for twenty-four hours; however, the care plan did not address the potential need for future increased supervision, or who should implement increased supervision when the resident's behavior warranted. The facility also developed an intervention to attempt to redirect the resident to a common area as much as possible. However, the intervention did not direct staff on the steps to take should redirection of the resident not be possible; and the interventions did not include diversional activities consistent with the resident's activity preferences. In addition, interviews with State Registered Nurse Aide (SRNA) #6 on 03/02/18 at 9:10 AM, Kentucky Medication Aide (KMA) #2 on 03/02/18 at 9:15 AM, SRNA #7 on 03/02/18 at 9:20 AM, KMA #1 on 03/02/18 at 9:00 AM, RN #2 on 03/02/18 at 4:58 PM, SRNA #4 on 03/01/18 at 3:25 PM, and SRNA #5 on 03/01/18 at 3:30 PM, revealed they were aware that Resident #37 had exit-seeking behavior. They stated they were all made aware that the resident should be redirected; however, specific redirection for Resident #37 was not detailed on the resident's care plan for the staff to follow or what staff should do if redirection was not possible. In addition, SRNA #4, KMA #2, SRNA #4, and RN #2 stated when Resident #37 was agitated, the resident's exit-seeking behavior increased. However, there was no evidence the facility identified this trigger for the resident and no interventions were developed to prevent/address the increased likelihood that the resident may elope from the facility when this behavior occurred. Interviews with the MDS Coordinator and the MDS Nurse (LPN #1) on 03/02/18 at 11:25 AM, revealed if a resident was at risk for elopement, an assessment was completed and interventions were implemented to offer the resident snacks and activities, and to redirect the resident. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.

Based on observation, interview, record review, review of the facility's Accident/Incident report, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents for one (1) of seventeen (17) sampled residents (Resident #37). On 01/25/18 at approximately 4:30 PM, an alarm sounded to the exit door on the facility's 200 Unit for several minutes. Facility staff and a visitor turned off the alarm; however, staff failed to ensure that a resident had not exited the building. Subsequently Resident #37, who had a [DIAGNOSES REDACTED]. Staff determined that Resident #37 had exited the building without staff knowledge, assisted the resident back inside, and assessed the resident to have an abrasion/bruise to the right knee. The facility's failure to ensure residents were supervised to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/02/18, and determined to exist on 01/25/18 at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 03/02/18. An acceptable Allegation of Compliance was received on 03/16/18, which alleged removal of the Immediate Jeopardy on 03/09/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/09/18, prior to exit, which lowered the scope and severity to D at 42 CFR 483.20 Resident Assessment (F641), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's protocol titled Elopement/Wander Risk, undated, revealed it was the expectation that the facility would ensure that each resident received adequate supervision and assistance to prevent accidents. Residents who were identified through the Elopement Risk Assessment process as being at risk for elopement, would have interventions in place to minimize such risk. Interview with the Director of Nursing (DON) on 03/02/18 at 2:48 PM, and the Minimum Data Set (MDS) Coordinator on 03/02/18 at 9:42 AM, revealed when an exit door alarm sounded, staff were required to check outside the door to ensure a resident had not exited the building. Observation of Resident #37 on 02/28/18 at 4:43 PM and on 03/01/18 at 1:44 PM revealed the resident was self-propelling his/her wheelchair in the hallway. Review of Resident #37's medical record revealed the facility admitted the resident on 02/03/17, with [DIAGNOSES REDACTED]. Review of Resident #37'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), indicating the resident was cognitively impaired. The facility also assessed the resident to wander daily (Wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless and the resident wandering may be oblivious to his or her physical or safety needs.). The MDS Assessment further revealed Resident #37 required the extensive assistance of two (2) staff members for all activities of daily living (ADLs) with the exception of locomotion on and off the unit, which required the supervision/oversight of one individual. The assessment further revealed Resident #37 was unsteady and utilized a walker and a wheelchair for mobility. Review of Resident #37's Elopement Risk assessment dated [DATE] revealed the facility assessed the resident to be physically able to leave the facility on his/her own. Further review of the Elopement Risk Assessment revealed the resident was cognitively impaired with poor decision-making skills, confusion and anxiety, and wandered aimlessly with decreased safety awareness. The Elopement Risk Assessment further indicated the resident was a possible risk for elopement and wore a code alert bracelet on the right ankle related to attempts to exit the facility by pushing on exit doors looking for (the resident's) mom and stating, I want to go home, I want my mom. Review of Resident #37's Comprehensive Plan of Care dated 02/03/17 revealed the facility identified the resident had an alteration in thought processes related to dementia. The facility developed interventions for staff to provide frequent cues, reminders, and supervision and to invite and encourage daily activities for the resident. The facility also developed a care plan dated 02/03/17 related to the resident's potential for impaired physical mobility; attempted self-transfers at times; and wheelchair utilization for long distances. The Comprehensive Plan of Care dated 04/22/17 further revealed the facility identified that Resident #37 had the potential for elopement related to wandering, propelling independently in hallways and to exit doors, and removing his/her code alert bracelet. The facility developed interventions to monitor the resident's code alert bracelet and check functioning daily, and to check placement every hour. Review of a Resident Accident/Incident Report revealed the facility received a call from a passerby on 01/25/18 at 4:30 PM, informing them that a resident was outside the facility. The Report stated two (2) staff members found Resident #37 outside the facility and assisted the resident back into the building through the door on Hall 2. According to the investigation, the alarm for the Hall 2 door sounded and a visitor reset the door code. The State Registered Nurse Aide (SRNA) stated the door was bypassed and only the small alarm sounded. The Report stated staff did not check outside the Hall 2 door to determine why the alarm sounded. Review of the weather history for 01/25/18 at 4:15 PM for the area where the facility was located revealed the temperature was 45.5 degrees Fahrenheit (F). At 4:35 PM, the temperature was 45.7 degrees F with a wind chill of 43.4 degrees F. Interview with SRNA #2 on 03/01/18 at 4:19 PM revealed on 01/25/18 she heard an alarm sounding, and was instructed by Registered Nurse (RN) #1 to enter the door code to silence the alarm. SRNA #2 stated as she went down the Unit 200 Hallway, a visitor stepped out into the hallway near the alarming door and asked the SRNA if she wanted her to enter the code to stop the alarm from sounding, and the SRNA said yes. The SRNA stated after the door alarm was silenced, she then turned the alarm off at the nurses' station, and resumed her previous duties, without checking to determine why the alarm had sounded. According to SRNA #2, Resident #37 was found outside the facility between the creek and the road approximately 10-15 minutes later, after someone passing by the facility reported a resident was outside unattended. According to SRNA #2, Resident #37 was wearing pants, a shirt, sweater, and shoes. Review of RN #1's witness statement dated 01/25/18, and interview with RN #1 on 03/01/18 at 4:43 PM, revealed on 01/25/18 when she heard the alarm sounding, she instructed SRNA #2 to check the alarm. RN #1 stated she observed the SRNA turn off the alarm at the nurses' station, but RN #1 did not take any action to determine why the alarm sounded. RN #1 stated she had redirected Resident #37 from both the 300 and 400 Hallway doors earlier in the shift. Continued interview and review of RN #1's statement revealed she had last observed Resident #37 at approximately 4:30 PM, attempting to exit the facility via the Hall 3 exit door by pushing on the door handle. The statement revealed RN #1 called out to (Resident #37) from the nurses' station and instructed the resident to come toward the nurses' station. Interview with a Facility Visitor on 03/02/18 at 11:30 AM revealed she heard the alarm sounding from her mother's room. She stated the alarm sounded for several minutes. The Visitor stated she normally ignored alarms at the facility but the alarm went off so long that she walked into the hallway to see what was happening. She stated she saw SRNA #2 trying to turn off the alarm at the nurses' station and asked the SRNA if she wanted her to turn off the alarm at the door. The Visitor stated she turned off the alarm, but she did not see anyone outside the door. She stated she did not know a resident went out the door until a nurse came back several minutes later and asked her not to enter the code to turn off the door alarm again. Interview with RN #2 on 03/01/18 at 4:58 PM, revealed she was assigned to provide care for Resident #37 on 01/25/18. She stated Resident #37 was more agitated than usual, which was an indication that the resident would have increased exit-seeking behavior. However, there was no evidence the RN took any action to supervise the resident when the resident's agitation and exit-seeking behavior increased. Interview with SRNA #10 on 03/02/18 at 9:40 AM revealed Resident #37 attempted to leave the facility through an exit door approximately twenty (20) or more times per day. *The facility alleged removal of the Immediate Jeopardy as follows: 1. The resident's care plan was updated on 01/25/18 to include the actual elopement from the facility and every fifteen (15) minute checks were implemented with interventions to redirect the resident to common areas as much as possible, offer snacks, and monitor the resident's code alert placement and functioning every hour. Activities were added to the resident's activity plan which includes one to one activity, pictures, newspaper and magazines, snack socials, talking and reminiscing, nail care, and pillow stuffing. 2. Following the elopement a check of all residents was conducted, specifically the eleven (11) residents identified as elopement risks. All residents were safe. 3. Immediately (01/25/18) an in-service was conducted by the Director of Nursing (DON) for all staff working on 01/25/18 and the remainder of the staff were educated the following day re-enforcing that when door alarms sound, staff members are to always check outside before clearing the alarm at the door and panel. In addition, key elements of the elopement protocol were reviewed on 01/25/18 and 01/26/18 with staff. The facility practice related to responding to alarms has always been that the employee closest to the alarm responds to the door alarm, and checks outside to make sure no resident has exited the facility. When the staff member is certain no one has left the building the door alarm can be cleared. As a secondary security measure, the alarm panel at the nurses' station sounds even when a code is entered at the exit door. This alerts staff that someone has entered or exited the door. This is a secondary level of security for residents and staff. The Administrator and DON will oversee the process of responding to alarms Monday through Friday, 9:00 AM to 5:00 PM, and the Charge Nurse will oversee the process after hours and on weekends. 4. The DON immediately (01/25/18) held a meeting with the family member who offered to turn off the alarm at the door. The family was informed of the dual alarms for resident and staff protection. These exits are to be used by only authorized personnel. Staff members were educated on 01/25/18 and ongoing that if unauthorized personnel are seen using this exit, staff were required to notify the Administrator or DON immediately. 5. It has been a practice of this facility to periodically change the codes to the exit doors; however, a log has not been maintained to this point. In the future, the code changes will be logged monthly. 6. Care plans were reviewed for all residents at risk for elopement to ensure each had a care plan for potential elopement and interventions. No problems were identified. 7. An elopement manual is maintained at the nurses' station and front desk. This manual includes a list of residents at risk for elopement and a wander risk identification sheet which includes a picture of each resident at risk. This manual contains recommended diversional activities for each resident who is at risk for elopement. This manual is maintained daily by the Assessment Nurse and reviewed quarterly and is available to all staff. 8. All residents at risk for elopement are checked hourly per protocol. 9. As part of the facility's ongoing Quality Assurance/Performance Improvement (QA/PI) program, the facility will conduct an elopement/missing resident drill at least monthly to ensure staff reacted to alarms by checking all exit doors and accounting for all residents. These drills will be made part of the monthly QA/PI meeting. Members of this committee include the Administrator, Director of Nursing, Maintenance, Housekeeping, Activities, Social Services, and the Medical Director. Drills will be conducted by the Administrator and Director of Nursing and assisted by their designee. The facility conducted a drill on 03/08/18, and staff responded appropriately. 10. In addition to elopement/missing resident drills, the DON began interviewing staff on 01/26/18, following the in-services to ensure the staff was competent related to alarm response/missing resident drills and diversional activities. Approximately fifty (50) percent of staff members have been interviewed on all three (3) shifts by the DON. Monthly, ten (10) percent of staff will be interviewed by the DON to determine proper responses to elopement drills, missing resident, unauthorized personnel using the ambulance entrance, and location of the elopement risk notebook. **The SA verified the removal of Immediate Jeopardy as follows: 1. Review of resident #37's care plan revealed the facility updated the care plan on 01/25/18 to reflect the resident's elopement and an intervention was implemented to include checking on the resident every fifteen (15) minutes for twenty-four hours, attempt to redirect the resident to a common area as much as possible, offer snacks, and monitor the code alert bracelet placement every hour and functioning daily. Record review revealed the facility checked on the resident every fifteen (15) minutes on 01/25/18, for twenty-four hours. Review of the resident's activity log revealed activities were documented. 2. Review of facility documentation revealed the DON documented that all residents were accounted for on 01/25/18, after Resident #37 eloped from the facility 3. Review of in-service rosters dated 01/25/18 and 01/26/18, revealed all staff had attended an in-service given by the DON related to action to be taken when an alarm sounds. Review of an in-service dated 03/05/18 revealed the DON educated all staff that nursing was required to conduct a check of the alarm panel each shift with the oncoming nurse to ensure the alarm had not been bypassed and exit doors were working properly. Nurses were required to document the check was completed on the shift report. SRNAs were also required to do a walking round with the oncoming SRNA each shift to visualize each resident and ensure their safety. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed if an alarm sounded, the employee closest to the alarm was responsible for responding to the door alarm. Two (2) staff members were required to split up and walk completely around the building to ensure no resident had exited the building. The staff stated the alarm could only be cleared when all the residents were accounted for. The staff stated the Administrator, DON, or the Charge Nurse responded to all alarms to oversee the process. Continued interviews with nursing staff revealed they were required to check the alarm panel to ensure it had not been bypassed and to document the information on the shift report every shift. They stated they were also required to check the door alarms to ensure they were working correctly. The SRNAs stated they were required to do walking rounds with the oncoming SRNA each shift to visualize each resident and to ensure the resident's safety. 4. Interview with the DON on 03/16/18 at 3:16 PM, revealed she spoke with the family member on 01/25/18 and instructed him/her not to turn off alarms at the doors. The DON stated she had also in-serviced staff regarding not giving door codes to families and visitors. The DON stated staff was required to notify her or the Administrator immediately if a family member or visitor was observed turning off a door alarm. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed staff were knowledgeable that they were required to notify the DON or the Administrator immediately if any family member or visitor was observed to enter the code to turn off a door alarm. 5. Review of a Code Alert Door Check revealed the door exit codes were changed on 03/02/18. The log also revealed the door alarms were checked weekly by the Maintenance Department. Interview with the Maintenance Supervisor on 03/16/18 at 3:11 PM, revealed she changed the door codes on 03/02/18 and would be changing them every month. The Maintenance Supervisor stated she documented the changes on the Code Alert Door Check log. 6. Review of elopement assessments revealed the MDS Nurse assessed all residents' elopement risk on 03/05/18. The assessments revealed the facility assessed eleven (11) residents to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210). A review of the residents' care plans revealed the care plans were reviewed and updated on 03/05/18. Interview with the MDS Nurse on 03/16/18 at 2:10 PM revealed she assisted with completing elopement risk assessments for all residents in the facility. The MDS Nurse also revealed she and the MDS Coordinator, who was not at the facility on 03/16/18, had reviewed all residents' care plans who had been assessed by the facility to be at risk for elopement to ensure each had interventions to address the potential for elopement. The MDS Nurse stated she was responsible for ensuring the Elopement Notebook was reviewed quarterly and remained available for staff. 7. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed an elopement book was kept at the nurses' stations and the front desk that contained the face sheet, picture, and a list of activities that had been developed for every resident who had been assessed by the facility to be at risk for elopement. Staff stated they were required to redirect a resident if they attempted to leave the facility. Staff further stated they were also required to check the elopement book, turn to the resident's name, and use one of the interventions listed to redirect the resident. Review of the Elopement Notebook at the nurses' station and at the front desk, revealed all residents who had been assessed by the facility to be at risk for elopement were included in the book and a list of interventions were documented. In addition, the elopement notebook also was observed to contain a picture of the resident and the resident's face sheet. Interview with the MDS Nurse on 03/16/18 at 2:10 PM, revealed she was responsible for ensuring the Elopement Notebooks were reviewed quarterly and remained available for staff. 8. Review of the record for the residents who were assessed to be at risk for elopement (Resident #2, Resident #7, Resident #8, Resident #14, Resident #17, Resident #19, Resident #29, Resident #37, Resident #44, Resident #47, Resident #50, Resident #56, and Resident #210) revealed staff documented that they checked their whereabouts at least once every hour. Interviews with SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, and SRNA #14 on 03/16/18 at 2:46 PM, revealed they monitored all residents who were at risk for elopement every hour and more often if needed. 9. Review of Elopement Drills revealed on 03/08/18 the facility had an individual attempt to exit the facility and the alarm sounded. Staff responded promptly and the door did not open because staff reached the resident before the door could open. Interviews conducted with the MDS Nurse on 03/16/18 at 2:10 PM, Social Services on 03/16/18 at 2:20 PM, SRNA #9 on 03/16/18 at 2:35 PM, SRNA #12 on 03/16/18 at 2:37 PM, SRNA #11 on 03/16/18 at 2:39 PM, SRNA #13 on 03/16/18 at 2:40 PM, SRNA #6 on 03/16/18 at 2:42 PM, SRNA #10 on 03/16/18 at 2:44 PM, SRNA #14 on 03/16/18 at 2:46 PM, RN #1 on 03/16/18 at 2:53 PM, and RN #3 on 03/16/18 at 2:59 PM, revealed they had participated in an elopement drill on 03/08/18. 10. Interview with the DON on 03/16/18 at 3:16 PM and review of documentation revealed she interviewed fifty percent of the staff after the in-services were completed to ensure staff were competent. The DON stated she would be interviewing ten (10) percent of the staff every month to ensure staff gave the proper response regarding elopement drills, missing residents, unauthorized personnel using the door codes, and the location of the elopement notebook.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents (Resident #26) received the appropriate catheter care to prevent urinary tract infections. Observation of catheter care for Resident #26 on 02/28/18 at 10:30 AM, revealed staff cleaned the resident from the back to the front and then down the indwelling urinary catheter tubing with a baby wipe. A small amount of stool was observed on the baby wipe. Staff was observed to continue providing urinary indwelling catheter care to the resident without discarding her soiled gloves and washing/sanitizing her hands and applying clean gloves. The findings include: Review of the facility's policy titled Hand Hygiene (hand washing policy), undated, revealed that personnel should wash their hands when they were visibly dirty or contaminated with proteinaceous material, soiled with blood or other body fluids, after going to the restroom, before eating, before performing an invasive procedure, and after providing care to a resident with a spore-forming organism. Review of the facility's policy titled Providing Catheter Care, undated, revealed staff were required to provide hand hygiene, don clean gloves, and clean the urinary meatus using a circular motion, moving outward. Review of Resident #26's medical record revealed the facility admitted the resident on 04/26/17, with [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. The MDS further revealed the resident required the limited assistance of one person for toileting and was frequently incontinent of urine. Review of Resident #26's physician's orders [REDACTED]. Review of the comprehensive plan of care for Resident #26 revealed an intervention dated 02/08/18, for the resident to have an indwelling urinary catheter to bedside drainage. Review of the Nurse Assistant Care Plan for Resident #26 dated (MONTH) (YEAR) revealed an intervention for indwelling urinary catheter care to be provided by State Registered Nursing Assistants (SRNAs). Observation of catheter care for Resident #26 on 02/28/18 at 10:30 AM, revealed SRNA #1 was observed to clean the resident from the back of the perineal area to the front, and then down the indwelling urinary catheter tubing with a baby wipe. A small amount of stool was observed on the baby wipe. Further observation revealed SRNA #1 then continued providing urinary indwelling catheter care to the resident without discarding the soiled gloves and washing/sanitizing her hands and applying clean gloves. Interview with SRNA #1 on 02/28/18 at 4:30 PM, revealed she was aware she should have washed/sanitized her hands before providing indwelling urinary catheter care to Resident #26. She stated she should have cleaned the resident from front to back. The SRNA stated she was aware she should have cleansed the catheter tubing from inside to outside in a circular motion and should have washed/sanitized her hands and changed gloves after she had gotten feces on her gloves when providing indwelling urinary catheter care. The SRNA stated she had just been nervous. Interview with the Director of Nursing (DON) on 03/02/18 at 2:48 PM, revealed she made rounds frequently throughout the day. The DON stated she had not identified any concerns with indwelling urinary catheter care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an infection control program was established and maintained to provide a sanitary environment and help prevent the development and transmission of disease and infection for one (1) of seventeen (17) sampled residents (Resident #26). Observations during indwelling urinary catheter care on 02/28/18 at 10:30 AM, revealed State Registered Nurse Aide (SRNA) #1 failed to properly handle soiled trash to prevent the development and transmission of infection for Resident #26. SRNA #1 was observed to touch her dirty gloved hands to her hair and her left brow after performing indwelling urinary catheter care for Resident #26. In addition, SRNA #1 was observed to pull up Resident #26's blanket after providing indwelling urinary catheter care without changing her soiled gloves and washing/sanitizing her hands. She also failed to wash/sanitize her hands after disposing of the trash in the soiled utility room. The findings include: Review of the facility's policy titled Hand Hygiene, undated, revealed a hand washing policy that stated personnel should wash their hands when they are visibly dirty or contaminated with proteinaceous material, soiled with blood or other body fluids, after going to the restroom, before eating, before performing an invasive procedure, and after providing care to a resident with a spore-forming organism. Review of the facility's policy titled Providing Catheter Care, undated, revealed staff was required to provide hand hygiene and discard gloves after providing indwelling urinary catheter care. Review of Resident #26's medical record revealed the facility admitted the resident on 04/26/17, with [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. The MDS further revealed the resident required the limited assistance of one person for toileting and was frequently incontinent of urine. Review of Resident #26's physician's orders [REDACTED]. Review of the comprehensive plan of care for Resident #26 revealed an intervention dated 02/08/18 for the resident to have an indwelling urinary catheter to bedside drainage. Review of the Nurse Assistant Care Plan for Resident #26 dated (MONTH) (YEAR) revealed an intervention for indwelling urinary catheter care to be provided by SRNAs. Observation of indwelling urinary catheter care for Resident #26 on 02/28/18 at 10:30 AM, revealed SRNA #1 was observed to clean the resident from the back to the front and then proceed down the indwelling urinary catheter tubing with a baby wipe. Then she was observed to place the baby wipe on the resident's sheet. The baby wipe was observed to have a small amount of tan stool on it. The SRNA was then observed to cleanse the resident again with another baby wipe and place the baby wipe on the resident's sheet. Further observation revealed SRNA #1 was then observed to pick up the baby wipes and place them in Resident #26's geri-chair, and then observed to flip her hair back and wipe her left brow with her dirty glove. SRNA #1 was then observed to pull up Resident #26's blanket while still wearing the dirty gloves. The SRNA placed the dirty baby wipes in a trash bag, and carried them to the dirty utility room with her dirty gloves. She then disposed of the wipes in the trash along with her gloves, but she then failed to wash/sanitize her hands. Interview conducted with SRNA #1 on 02/28/18 at 4:30 PM, revealed she was aware she should have washed/sanitized her hands before touching her hair and brow. The SRNA stated she should have placed the baby wipes in the trash and not laid them on the resident's sheet and geri-chair. She stated she should have washed/sanitized her hands prior to touching the resident's blanket and also after disposing of the trash. The SRNA stated she had just been nervous. Interview with Registered Nurse (RN) #1 on 02/28/18, at 4:35 PM, revealed she made rounds every two (2) hours to ensure residents were receiving the care and treatment they required, and had not identified any concerns. The RN confirmed that SRNA #1 should have washed/sanitized her hands before touching her hair and brow, should not have placed the baby wipes on the resident's sheet and geri-chair, and should have washed/sanitized her hands after disposing of the trash. Interview conducted with the Director of Nursing (DON) on 03/02/18 at 2:48 PM, revealed she made rounds frequently throughout the day. The DON stated she had not identified any concerns with hand washing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care was provided in accordance with the resident's written plan of care for three (3) of fifteen (15) sampled residents (Residents #5, #10, and #12) related to Oxygen Administration. The findings include: Review of the Care Plan Policy dated 08/01/13 revealed comprehensive care plans were developed upon admission and revised when resident conditions changed. Review of the Care Plan Policy titled Using the Care Plan, dated 08/01/13, revealed daily care and documentation must be consistent with the resident's care plan. 1. Review of Resident #5's medical record revealed the facility readmitted the resident on 04/01/16 with a [DIAGNOSES REDACTED]. Review of Resident #5's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #5 to be non-interviewable. Review of Resident #5's Comprehensive Care Plan note dated 01/19/17 revealed the resident was to receive oxygen as ordered. Review of January 2017 physician's orders [REDACTED]. Review of the January 2017 Treatment Record for 01/24/17 and [MEDICAL CONDITION] Assessment/Oxygen Therapy Record for 01/24/17 and 01/25/17 revealed oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 2 LPM. Observations on 01/24/17 at 8:43 AM, 10:25 AM, 11:03 AM, and 12:35 PM and on 01/25/17 at 9:09 AM and 10:10 AM revealed Resident #5's oxygen was being administered at 3 LPM by nasal cannula. Interview with Registered Nurse (RN) #2 on 01/26/17 at 4:50 PM revealed residents' oxygen was monitored during rounds, medication pass, and any time staff was in resident rooms. Interview further revealed RN #2 was not aware Resident #5's oxygen was being delivered at the wrong flow rate. 2. Review of Resident #10's medical record revealed the facility readmitted the resident on 01/04/15 with [DIAGNOSES REDACTED]. Review of Resident #10's annual MDS assessment dated [DATE] revealed the facility assessed Resident #10 to have a Brief Interview for Mental Status (BIMS) score of five (5) which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan note dated 11/17/16 revealed the resident was to receive oxygen as ordered at 2 LPM by nasal cannula. Review of January 2017 physician's orders [REDACTED]. Review of the January 2017 Treatment Record for 01/24/17 and 01/25/17 and [MEDICAL CONDITION] Assessment/Oxygen Therapy Record for 01/24/17, 01/25/17, and 01/26/17 revealed oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 3 LPM. Observations on 01/26/17 at 1:52 PM, 2:33 PM, and 3:43 PM revealed Resident #10's oxygen was being administered at 3.5 LPM by nasal cannula. Interview with RN #2 on 01/26/17 at 4:50 PM revealed residents' oxygen was monitored during rounds, medication pass, and any time staff was in resident rooms. Interview further revealed RN #2 stated that Resident #10's oxygen was ordered at 3 LPM and she was not aware of oxygen being administered at the wrong flow rate. 3. Review of Resident #12's medical record revealed the facility readmitted the resident to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #12 to have a BIMS score of six (6), which indicated severe cognitive impairment. Review of Resident #12's Comprehensive Care Plan dated 06/12/13 revealed the resident was to receive oxygen as ordered. Review of January 2017 physician's orders [REDACTED]. Review of the January 2017 Treatment Record for 01/24/17 and 01/26/17 revealed Oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 2 LPM. Observations of Resident #12 on 01/24/17 at 8:55 AM and 01/26/17 at 1:58 PM, 2:38 PM, 2:58 PM, and at 4:44 PM revealed Resident #12 was wearing oxygen at 3 LPM instead of 2 LPM as ordered. Interview on 01/26/17 at 4:52 PM with Licensed Practical Nurse (LPN) #1, who worked on 01/26/17 when Resident #12's oxygen was not on as ordered, revealed Resident #12 was ordered oxygen at 2 LPM and when she was in the room during medication pass and in the room throughout the day the oxygen was on 2 LPM. Further interview with LPN #1 revealed she was not aware and did not know why the oxygen was on the wrong flow rate. Interview on 01/26/17 at 5:37 PM with RN #1, who worked on 01/24/17 when Resident #12's oxygen was not on as ordered, revealed Resident #12 should have been wearing oxygen as ordered. Further interview with RN #1 revealed she was not aware and did not know why Resident #12's oxygen was on the wrong flow rate. Interview with the Director of Nursing (DON) on 01/26/17 at 5:11 PM revealed the Interdisciplinary Team (IDT) was responsible for the development of the care plan. Further interview revealed care plan interventions were followed by all nursing staff. Further interview revealed she was not aware the care plan interventions for residents were not followed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure four (4) of fifteen (15) sampled residents (Residents #5, #9, #10, and #12) received proper treatment related to respiratory care as evidenced by Oxygen not being delivered at the prescribed rate. Review of January 2017 Physician order [REDACTED].#5's oxygen was being delivered at three (3) LPM by nasal cannula. Review of January 2017 Physician order [REDACTED].#10 revealed the physician ordered oxygen to be administered at three (3) LPM; however, observations on 01/24/17 at 12:10 PM and 1:09 PM for Resident #9 revealed that Resident #9 was receiving oxygen by nasal cannula at two (2) LPM. Observations for Resident #10 on 01/26/17 at 1:52 PM, 2:33 PM, and 3:43 PM revealed Resident #10's oxygen was being delivered at three and one-half (3.5) LPM. Resident #12 had a physician's orders [REDACTED].#12 was wearing oxygen at three (3) LPM. The findings include: Review of facility policy titled Monitoring Clients receiving Oxygen, (undated) revealed staff was to monitor residents' oxygen by checking the physician's orders [REDACTED]. 1. Review of Resident #5's medical record revealed the facility readmitted the resident on 04/01/16 with [DIAGNOSES REDACTED]. Review of Resident #5's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #5 to be non-interviewable. Review of Resident #5's comprehensive care plan note, dated 01/19/17, revealed the resident was to receive oxygen as ordered. Review of January 2017 Physician order [REDACTED]. Review of the January 2017 Treatment Record for 01/24/17 and [MEDICAL CONDITION] Assessment/Oxygen Therapy Record for 01/24/17 and 01/25/17 revealed Oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 2 LPM. Observations on 01/24/17 at 8:43 AM, 10:25 AM, 11:03 AM, and 12:35 PM and on 01/25/17 at 9:09 AM and 10:10 AM revealed Resident #5's oxygen was being administered at 3 LPM by nasal cannula. Interview with Registered Nurse (RN) #2 on 01/26/17 at 4:50 PM revealed residents' oxygen was monitored during rounds, medication pass, and any time staff was in resident rooms. Interview further revealed RN #2 was not aware of Resident #5's oxygen being administered at the wrong liter flow rate. 2. Review of Resident #9's medical record revealed the facility admitted the resident on 11/29/16 with [DIAGNOSES REDACTED]. Review of Resident #9's annual MDS assessment dated [DATE] revealed the facility assessed Resident #9 to have a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Record review for Resident #9's physician's orders [REDACTED].#9 at a rate of 3 LPM by nasal cannula. Review of the January 2017 Treatment Record for 01/24/17 and [MEDICAL CONDITION] Assessment/Oxygen Therapy Record for 01/24/17 revealed oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 3 LPM. Observation on 01/24/17 at 12:10 PM and at 1:09 PM revealed Resident #9's oxygen was being delivered by nasal cannula at a rate of 2 LPM. Interview with RN #2 on 01/26/17 at 4:50 PM revealed residents' oxygen was monitored during rounds, medication pass, and any time staff was in resident rooms. Interview further revealed RN #2 was not aware of oxygen being administered at the wrong liter flow rate for Resident #9. 3. Review of Resident #10's medical record revealed the facility readmitted the resident on 01/04/15 with [DIAGNOSES REDACTED]. Review of Resident #10's annual MDS assessment dated [DATE] revealed the facility assessed Resident #10 to have a BIMS score of five (5) which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan note dated 11/17/16 revealed the resident was to receive oxygen as ordered at 2 LPM by nasal cannula. Review of January 2017 physician's orders [REDACTED]. Review of the January 2017 Treatment Record for 01/24/17 and 01/25/17 and [MEDICAL CONDITION] Assessment/Oxygen Therapy Record for 01/24/17, 01/25/17, and 01/26/17 revealed oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 3 LPM. Observations on 01/26/17 at 1:52 PM, 2:33 PM, and 3:43 PM revealed Resident #10's oxygen was being administered at 3.5 LPM by nasal cannula. Interview with RN #2 on 01/26/17 at 4:50 PM revealed residents' oxygen was monitored during rounds, medication pass, and any time staff was in resident rooms. Interview further revealed RN #2 stated that Resident #10's oxygen was ordered at 3 LPM and she was not aware of oxygen being administered at the wrong liter flow rate. 4. Review of Resident #12's medical record revealed the facility readmitted the resident to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #12 to have a BIMS score of six (6), which indicated severe cognitive impairment. Review of Resident #12's comprehensive care plan, dated 06/12/13, revealed the resident was to receive oxygen as ordered. Review of January 2017 Physician order [REDACTED]. Review of the January 2017 [MEDICAL CONDITION] Flow sheet for 01/24/17 and 01/26/17 revealed Oxygen was initialed by nursing staff ensuring oxygen was delivered at the ordered rate of 2 LPM. Observations of Resident #12 on 01/24/17 at 8:55 AM and on 01/26/17 at 1:58 PM, 2:38 PM, 2:58 PM, and 4:44 PM revealed Resident #12 was wearing oxygen at 3 LPM instead of 2 LPM as ordered. Interview on 01/26/17 at 4:52 PM with Licensed Practical Nurse (LPN) #1, who worked on 01/26/17 when Resident #12's oxygen was not on as ordered, revealed Resident #12's oxygen was ordered at 2 LPM and when she was in the room during medication pass and throughout the day the oxygen was on 3 LPM. Further interview with LPN #1 revealed she was not aware and did not know why the oxygen was on the wrong liter flow rate. Interview with RN #1 on 01/26/17 at 5:37 PM who worked on 01/24/17 when Resident #12's oxygen was not on as ordered, revealed Resident #12 should have been wearing oxygen as ordered. Further interview with RN #1 revealed she was not aware and did not know why Resident #12's oxygen was on the wrong liter flow rate. Interview with the Director of Nursing (DON) on 01/26/17 at 5:11 PM revealed nurses were responsible to review residents' physician orders [REDACTED]. Further interview with the DON revealed all nursing staff was responsible to ensure residents were wearing oxygen as ordered and at the correct liter flow rate as prescribed by the physician. Additional interview with the DON revealed the facility staff did random audits to ensure residents were receiving oxygen as ordered by the physician.

Based on observation, interview, record review, and facility policy review, the facility failed to review and revise the comprehensive care plan for one (1) of fifteen (15) sampled residents (Resident #10) when a change in condition occurred related to Resident #10's noncompliance with keeping the indwelling catheter leg anchor strap in place. The comprehensive care plan for Resident #10 had not been revised to reflect the change in the resident's condition. The findings include: A review of the facility's care plan policy titled Care Plan-Comprehensive, dated 08/01/13, revealed care plans were revised when information about the resident and the resident's condition changed. Review of the medical record revealed the facility readmitted Resident #10 on 01/04/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated severe cognitive impairment. Review of Resident #10's comprehensive care plan dated 12/19/16 revealed the use of an anchor strap related to an indwelling catheter. Observation of indwelling catheter care on 01/26/17 at 2:33 PM revealed Resident #10 was not wearing an indwelling catheter leg anchor strap. Interview with Registered Nurse #2 on 01/26/17 at 4:50 PM revealed she was aware that Resident #10 would remove his/her leg anchor strap. Interview further revealed the Minimum Data Set (MDS) Coordinator was responsible for updating resident care plans when residents' conditions changed. Interview with the MDS Coordinator on 01/26/17 at 4:59 PM revealed she was responsible to update the care plans and to document on the care plan when residents' conditions changed. The MDS Coordinator stated she was not aware that Resident #10 was refusing to wear his/her leg anchor strap. The Director of Nursing (DON) confirmed in interview on 01/26/17 at 5:11 PM the MDS Coordinator was responsible to update/revise the residents' care plans when she became aware of a change in the residents' conditions. The DON stated the care plans were reviewed daily by the MDS Coordinator and she had not identified any problems concerning care plan revision.

Based on interview, record review, and review of the facility's policy, it was determined that the facility failed to develop a comprehensive care plan with goals and approaches to address Oxygen administration for one (1) of fifteen (15) sampled residents (Resident #9). Observations on 01/24/17 at 12:10 PM and 1:09 PM revealed Resident #9 had Oxygen in place by nasal cannula at 2 liters per minute (LPM). Record review of Resident #9's Physician order [REDACTED]. The findings include: A review of the facility's care plan policy titled Care Plans-Comprehensive, dated 08/01/13, revealed comprehensive care plans were developed and maintained for each resident that identifies the highest level of functioning the resident may be expected to attain. Comprehensive care plans were developed within seven (7) days of the completion of the resident's comprehensive assessment. Further review of the care plan policy revealed assessments of residents were ongoing and care plans were revised when information about the resident and the resident's condition changed. Record review for Resident #9 revealed the facility admitted the resident on 11/29/16 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#9 at a rate of 3 LPM by nasal cannula. Review of Resident #9's comprehensive assessment dated [DATE] revealed resident use of oxygen, however, review of the comprehensive care plan dated 12/07/16 - 03/07/17 revealed no evidence of interventions to address the resident's use of oxygen. Observation on 01/24/17 at 12:10 PM and at 1:09 PM revealed Resident #9's Oxygen was being delivered by nasal cannula at a rate of 2 LPM. Interview with Registered Nurse #2 on 01/26/17 at 4:50 PM revealed the Minimum Data Set (MDS) Coordinator was responsible for developing/updating care plans. Interview with the MDS Coordinator on 01/26/17 at 4:59 PM revealed care plans were developed upon admission and updated when there were changes in the resident's condition. Further interview with the MDS Coordinator revealed she was responsible for initiating and updating care plans when residents' conditions changed. The MDS Coordinator stated she reviewed telephone orders daily and revised care plans when residents' conditions changed. The MDS Coordinator stated she had not identified any problems with care plan development and did not know why a care plan was not developed for Resident #9. Interview on 01/26/17 at 5:11 PM with the Director of Nursing (DON) revealed care plans were initiated upon admission and updated when residents' conditions changed. The DON stated care plans were reviewed and updated daily by the MDS Coordinator. The DON stated she had not identified any problems with development of care plans.

Based on interview, record review, and review of facility policy it was determined the facility failed to report an allegation of resident-to-resident abuse to state agencies in accordance with state laws involving one (1) of fifteen (15)sampled residents and one (1) unsampled resident (Resident #6 and Resident B). A visitor at the facility reported to facility staff on 09/18/16 that Resident #6 inappropriately touched Resident B's breast when the two (2) residents passed in the hallway. The facility immediately initiated an investigation into the allegation and reported the allegation to the administrator; however, there was no evidence the allegation was reported to state agencies as required. The findings include: Review of the facility policy titled Resident Protection, (no date) revealed all inquiries concerning the reporting of abuse should be referred to the facility Administrator. The policy further noted all violations and all substantiated incidents of abuse would be immediately reported to appropriate state agencies and other entities or individuals as required by law. Review of the medical record revealed the facility admitted Resident #6 on 03/19/09 with [DIAGNOSES REDACTED]. Review of the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #6's Brief Interview for Mental Status (BIMS) score to be nine (9) indicating the resident had moderately impaired cognition. Further review of the MDS assessment revealed the resident was assessed to have other behavioral symptoms within the seven-day assessment period. Additional review of the MDS assessment revealed the resident required limited assistance with bed mobility and transfers, and supervision with ambulation in the facility corridor, and usually utilized a walker or wheelchair for mobility. A quarterly MDS assessment completed on 01/19/17 for Resident #6 revealed the resident's BIMS score was five (5) which indicated the resident had severely impaired cognitive skills and not interviewable. Review of the resident's comprehensive care plan, last revised on 07/26/16, revealed the resident was identified to have an alteration in mood and behavior exhibited by yelling out at staff and an increase in agitation and aggression toward staff. Interventions to address this behavior included to explain why the behaviors were inappropriate, to redirect and provide support as needed, and to use a calm and unhurried approach with the resident. Medical record review for Resident B revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 04/19/16, revealed the facility assessed the resident's BIMS score to be four (4) indicating the resident had severely impaired cognition and was not interviewable. Further review of the MDS assessment revealed the resident was assessed to have no behavioral symptoms during the seven-day assessment period. Additional review of the MDS assessment revealed the resident required extensive assistance with transfers and limited assistance with locomotion on the nursing unit and corridors while utilizing a wheelchair. Interview with State Registered Nurse Aides (SRNAs) #3, #4, #5, #6, and #7 on 01/26/17 from 10:00 AM to 10:35 AM revealed these SRNAs had never witnessed Resident #6 touch a female resident inappropriately and did not witness the resident touch Resident B's breast on 09/18/16. The SRNAs stated Resident #6 would sometimes become agitated/hateful with staff and threaten to punch them. The SRNAs stated they each had been trained to protect the residents during incidents of resident-to-resident altercations and to report the incidents and all allegations of abuse immediately to their supervisors. Interview with the facility Social Services Director (SSD) on 01/26/17, at 10:35 AM, revealed a visitor at the facility reported the allegation on 09/18/16 involving Resident #6 and Resident B. The SSD stated an investigation was done and the allegation was reported to the facility administrator, but she did not know if the allegation was reported to the state agencies. Interview with the facility Administrator on 01/26/17, at 4:30 PM, revealed Resident B frequently would reach out and touch residents/staff as he/she passed them in the hallway. The Administrator stated she reviewed the facility video and saw Resident B reach out and grab Resident #6's hand and in response, Resident #6 reached across Resident B. Resident B then knocked Resident #6's hand away and propelled on down the hallway and there was no further contact between the two residents. The Administrator stated that according to the video Resident #6 did not touch Resident B's breast as alleged. The Administrator confirmed she did not report the allegations to the appropriate state agencies as a result of the findings from the video and facility investigation.

Based on observation, interview, record review, and review of the facility policy titled Evidence Based Nursing Practice, (undated) it was determined the facility failed to ensure indwelling catheter tubing was secured to prevent possible injury for one (1) of fifteen (15) sampled residents (Resident #10). Observation of indwelling urinary catheter care for Resident #10 on 01/26/17 revealed the catheter tubing was not secured to the resident's leg to prevent excessive tension. The findings include: Review of the facility policy titled Evidence Based Nursing Practice, (undated) revealed indwelling catheters should be secured with tape or a commercial holder. Record review of Resident #10's medical record revealed the facility readmitted the resident on 01/04/15 with [DIAGNOSES REDACTED]. Review of Resident #10's annual Minimum Data Set (MDS) assessment with reference date of 11/14/16 revealed the facility assessed Resident #10 to have a Brief Interview for Mental Status (BIMS) score of five (5) which indicated severe cognitive impairment. Record review of Resident #10's comprehensive care plan dated 12/19/16 revealed the use of an anchor strap related to an indwelling catheter; the assessment further revealed the resident utilized an indwelling urinary catheter. Interview with State Registered Nurse Aide (SRNA) #1 on 01/26/17 at 4:47 PM revealed nurses were responsible for placement of leg anchor straps on residents who have Foley catheters. SRNA #1 stated, I did not pay any attention, I was nervous; I would look at residents' care plans for leg anchors but I don't put them on, the nurse does. Interview with RN #2 on 01/26/17 at 4:50 PM revealed nurses were responsible for putting leg anchor straps on residents with indwelling catheters. Further interview with RN #2 revealed she was not aware that Resident #10 was not wearing a leg anchor strap. Interview with the Director of Nursing (DON) on 01/26/17 at 5:11 PM revealed she was not aware that Resident #10 was not wearing a leg anchor strap and she would expect residents with indwelling catheters to have a leg anchor strap in place. The DON stated she had not identified any problems with residents not wearing leg anchor straps.

Based on facility policy, observation, record review, and interview, it was determined the facility failed to follow the menu spreadsheet at the noon meal on 01/24/17. The menu spreadsheet specified the meat (ham) to be served should have been a three (3) ounce portion. However, the meat was weighed, and it was only a two (2) ounce portion. Eleven (11) resident trays were taken out of the kitchen containing the two (2) ounce portion of ham. The findings include: Review of the facility policy, Menus, (dated 2013) revealed the menus are planned to be nutritionally adequate and to meet the nutritional needs of the client (resident). Observation of the noon meal at 11:32 AM on 01/24/17 revealed a food cart (first) containing eleven (11) resident trays went out of the kitchen to the unit. Observation of the steam table revealed the ham portions did not appear to be the correct size. The surveyor requested the Dietary Manager (DM) to weigh a ham portion. Observation revealed the ham portion was two (2) ounces. Review of the menu spreadsheet revealed the menu specified a three (3) ounce portion was supposed to be the correct serving size for the ham portion. Interview with the cook and DM at 12:00 PM on 01/24/17 revealed she had weighed the ham portions earlier in the day, but she stated the ham was tender and falling apart and she was having to guess at the portion size. The DM stated she did tray audits to ensure menu spreadsheets were followed.

Based on review of the facility policy, observation, record review, and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner. The grease trap underneath the stovetop had liquid spills and a buildup of food debris. In addition, the can opener had an accumulation of food and paper around the blade. The findings include: Review of the facility policy, Stove Top, (no date) revealed the daily procedure was to wipe all spills and items cooked over immediately with cloth of warm sudsy water and rinse with clear water. Further review of the policy revealed all surfaces of the range were to be scrubbed weekly. Review of the policy, Can Opener, (no date) revealed the can opener was to be cleaned after each meal. Observation at 2:30 PM on 01/26/17 revealed the grease trap under the stovetop burners were heavily soiled with spills and a buildup of food debris. Further observation at 2:15 PM on 01/26/17 revealed the blade to the can opener was heavily soiled with food debris and paper. Review of the cleaning schedule revealed the stove/grease trap was last cleaned on 01/21/17. According to the cleaning schedule, the can opener was last cleaned on 01/24/17. Interview with the Dietary Manager (DM) at 2:45 PM on 01/26/17 revealed the stove/grease trap had been cleaned on 01/21/17. However, the spills and food debris should have been cleaned. The DM stated the can opener was supposed to be cleaned after each meal. The DM did not know why the can opener had not been cleaned after the noon meal on 01/26/17.