Every finding on record at Mayfair Manor

Based on interview, record review, and review of the facility's document and policies, the facility failed to provide resolutions and/or provide precise documentation on resolutions related to reported missing items for 3 out of 13 sampled residents, Resident (R) 30, R95, and R119.R30 and R95 reported in the Resident Council meeting, on 02/10/2026, they had made grievances to staff related to missing items of clothing without ever having their grievances resolved. Review of the facility's document Grievance Logs, dated 09/17/2025, also revealed R119 reported missing items of clothing, and the resident was discharged on 09/26/2025 without having the resident's grievance resolved. The findings include:Review of the facility's policy titled, Grievances/Complaints, revised 01/20/2026, revealed the resident had the right to voice grievances to the facility or other agency or entity that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal. This policy was to ensure the prompt resolution of resident grievances. Per the policy, it was best customer service practice to resolve a grievance within three business days if applicable. The policy further stated the resolution should include the date the grievance was received; a summary statement of the resident's grievance; the steps taken to investigate the grievance; and a summary of the pertinent findings or conclusions regarding the residents concern(s). The summary of the pertinent findings or conclusions should include a statement as to whether the grievance was confirmed or not confirmed; any corrective action taken or to be taken by the facility as a result of the grievance; and the date the written decision was issued.Review of the facility's policy titled, Resident Damaged or Missing Property, revised 01/31/2025, revealed the facility would provide a process in the event of loss or damage to a resident's property. Per the policy, it was the organization's policy that our facilities would take reasonable steps to protect all personal items brought in by residents or their families and to search to the best of our ability for any lost items. Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed all residents had the right to be treated with respect and dignity. These rights would be promoted and protected by the facility. Review of the facility's Job Description, Social Services Director [SSD], dated May 2022, revealed the SSD would identify and participate in process improvement initiatives that improved customer experience, enhanced workflow, and/improved the work environment. During a Resident Council meeting on 02/10/2026 at 11:00 AM, R30 stated she had been missing a green North Face shirt since 09/11/2025. She stated the facility was aware of the missing shirt since that time, and as of 2/10/2026, she had not received a response or reimbursement.During a Resident Council meeting on 02/10/2026 at 11:00 AM, R95 stated he had been missing several pairs of pants and several shirts. He stated he had reported it to multiple staff members around the first part of February 2026. However, he stated he had not received a response/reimbursement or had the items returned to his possession. Review of the facility provided Grievance Logs, dated 09/17/2025, revealed R119 reported missing one pair of gray/black/white/pink flannel, size small, pants and one pair of navy/green/white flannel, size small, pants. Further review revealed the Laundry Account Manager documented those items were not found in the laundry, and the resident needed reimbursement. Review of the Facility's Matrix System, on 2/11/2026, revealed R119 was discharged from the facility on 09/26/2025, without the grievance being resolved. Additional review, for the last six months, revealed R95's grievance was not listed on the log. During an interview with the Laundry Account Manager on 02/11/2026 at 12:35 PM, he stated he was aware of R95's missing items and an investigation had begun, but it was not resolved yet. He stated he was informed of the grievances for his department from the Administrator, Social Services Director, and at stand-up meeting in the mornings. He stated he determined what was missing, got a brief description, and started an investigation to locate the items. He stated if the item(s) were not found, he would inform the Administrator or Social Services Director. He stated, after he reported the item(s) were not found, his department was no longer responsible for the missing item(s). During an interview with the Social Services Director (SSD) on 02/11/2026 at 12:46 PM, she stated when a resident filed a grievance for a missing item, she called the facility or resident representative, if one was available for the resident. She stated the resolution depended on what the family representative requested. She stated, if a reimbursement was needed, she had the family present the receipt, and the corporate office would disburse the funds. She stated if the resident or family representative did not have a receipt for the missing item, no reimbursement could be given.During an interview with the Social Services Assistant on 02/11/2026 at 12:55 PM, she stated residents needed a receipt to be reimbursed for items missing, lost, or stolen at the facility. She stated if there was no receipt provided; they would not be reimbursed. She stated when grievances were filed, the Social Services department gave the grievance to the appropriate department to prompt an investigation. She stated she and the SSD were responsible for keeping track of the logs for proper documentation and giving agreeable resolutions to the residents and/or family representatives. During an interview with the Administrator on 02/12/2026 at 3:30 PM, she stated the Social Services department was responsible for the documentation and resolutions for grievances filed by residents, family representatives, and visitors. She stated her expectation was for grievances to be resolved within five business days. She stated she expected staff to document the filed grievances on the log and document when and how the grievance was resolved.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement the comprehensive person-centered care plan for 1 of 18 sampled residents, Resident (R) 7. The findings include:Review of the facility's policy titled, Comprehensive Care Plans, revised [DATE], revealed each resident's comprehensive person-centered care plan would be developed and implemented and would include measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessment. Further review revealed each resident's care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and should be revised as necessary with changes. Review of R7's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses including type 2 diabetes with neuropathy and stroke. Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident was assessed to require substantial to maximum assistance with mobility tasks. Review of R7's, Comprehensive Care Plan, dated [DATE], revealed the resident's functional mobility status required two staff members when the resident transferred. Further review revealed R7 was listed as a two-person assist at all times because of previous false allegations the resident made against staff. In an interview with State Registered Nurse Aide (SRNA) 5 on [DATE] at 10:10 AM, he stated he provided care for R7. He stated the resident had experienced a stroke, her left side was weak, and she required two people for assistance with mobility. However, observation on [DATE] at 9:31 AM revealed when the State Survey Agency (SSA) Surveyor entered R7's room, she stated she just called for staff assistance because her brief needed to be changed. SRNA5 entered the resident's room and cleaned her without assistance from another staff member. The resident indicated she was not finished and asked SRNA5 for assistance to the bathroom. Further observation revealed SRNA5 assisted R7 to a sitting position on the bedside while he retrieved her wheelchair located on the other side of the bed. The SSA Surveyor observed R7 at the bedside with her feet on the floor. Further observation revealed the resident became weak, started to sway, and called out to SRNA5 for help. Once the resident steadied herself on the bed, SRNA5 transferred the resident from her wheelchair to the toilet in the bathroom. No other staff members were present. When asked what was on the resident's plan of care related to mobility assistance, SRNA5 stated he did not know off the top of his head. In an interview with SRNA4 on [DATE] at 10:06 AM, she stated R7 was not typically assigned to her, but she was today. SRNA4 stated the resident had left-sided weakness and required two people for assistance. In an additional interview with SRNA5 on [DATE] at 2:03 PM, when asked why extra assistance was not requested when he transferred R7 earlier in the day, he stated he thought he was just nervous because the SSA Surveyor was in the room. SRNA5 stated he normally changed R7's brief and pulled her up in bed by himself, but the resident needed two when she transferred. He further stated it was important that proper assistance was used when a resident transferred to prevent accidents or injury. In an interview with the MDS Coordinator on [DATE] at 2:26 PM, she stated not only MDS updated care plans, but also Nursing, Dietary, and Social Services. She stated the care plan guided staff, so they knew a resident's care needs. She further stated it was important care plans were correct, updated, and followed so residents were kept safe, and their needs were met. In an interview with the Director of Nursing (DON) on [DATE] at 2:53 PM, she stated R7 was at risk for falls, unable to get up without assistance, and had safety interventions listed on her care plan. The DON stated how a resident transferred was listed on the SRNA Kardex (plan of care). She stated because R7 was a potential fall risk, she required two staff members for transfers. She further stated the resident was also care planned for false accusations and therefore required two people for assistance with personal care at all times. The DON stated it was her expectation that staff followed care plans, so residents were kept safe. In an interview with the Administrator on [DATE] at 3:17 PM, she stated she attended care plan conferences and clinic meetings because it helped her know what was going on in the facility and with residents. She stated the purpose of a care plan was to help staff know where residents were in their care, what their preferences were, and any changes that occurred. The Administrator stated it was her expectation that staff followed interventions listed on the care plan, so residents were properly cared for and protected.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were adequately assisted to prevent accidents from occurring for 1 of 7 sampled residents, Resident (R) 7. The findings include: Review of the facility's policy titled, Resident Rights, revised [DATE], revealed all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the facility's policy titled, Accidents and Incidents, revised [DATE], revealed the facility intended to provide an environment free from accidents and incidents that were avoidable. Review of R7's, Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses including type 2 diabetes with neuropathy and stroke. Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident was assessed to require substantial to maximum assistance with mobility tasks. Review of R7's, Comprehensive Care Plan, dated [DATE], revealed the resident's functional mobility status required two staff members when the resident transferred. Further review revealed R7 was listed as a two-person assist at all times because of previous false allegations the resident made against staff and her need for substantial to maximum assistance with mobility tasks. Review of a daily Skilled Nursing Note, dated [DATE], revealed R7 was a fall risk and was provided education by nursing staff related to fall prevention and safety management. Review of point of care (POC, the facility's software) documentation, dated [DATE] to [DATE], revealed R7 required two people for transfer assistance. In an interview with State Registered Nurse Aide (SRNA) 5 on [DATE] at 10:10 AM, he stated he provided care for R7. He stated the resident had experienced a stroke, her left side was weak, and she required two people for assistance with mobility. However, observation on [DATE] at 9:31 AM revealed when the State Survey Agency (SSA) Surveyor entered R7's room, she stated she just called for staff assistance because her brief needed to be changed. SRNA5 entered the resident's room and cleaned her without assistance from another staff member. The resident indicated she was not finished and asked SRNA5 for assistance to the bathroom. Further observation revealed SRNA5 assisted R7 to a sitting position on the bedside while he retrieved her wheelchair located on the other side of the bed. The SSA Surveyor observed R7 at the bedside with her feet on the floor. Further observation revealed the resident became weak, started to sway, and called out to SRNA5 for help. Once the resident steadied herself on the bed, SRNA5 transferred the resident from her wheelchair to the toilet in the bathroom. No other staff members were present. When asked what was on the resident's plan of care related to mobility assistance, SRNA5 stated he did not know off the top of his head. During an interview with SRNA4 on [DATE] at 10:06 AM, she stated R7 was not typically assigned to her, but she was today. SRNA4 stated the resident had left-sided weakness and required two people for assistance. In an additional interview with SRNA5 on [DATE] at 2:03 PM, when asked why extra assistance was not requested when he transferred R7 earlier in the day, he stated he thought he was just nervous because the SSA Surveyor was in the room. SRNA5 stated he normally changed R7's brief and pulled her up in bed by himself, but the resident needed two staff when she transferred. He further stated it was important that proper assistance was used when a resident transferred to prevent accidents or injury. In an interview with the Director of Nursing (DON) on [DATE] at 2:53 PM, she stated from what she recalled, R7 was care planned for false accusations and therefore always required two staff members for personal care. The DON stated R7 was at risk for falls and depended on staff for assistance with mobility. She further stated the resident's mobility limitations were listed on the plan of care with appropriate interventions for resident safety. In an interview with the Administrator on [DATE] at 3:17 PM, she stated it was her expectation that staff followed each resident's functional mobility plan of care, so all residents were protected and kept safe.

Based on observation, interview, and review of the facility's policy, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 6 medication/treatment carts, a North Hall medication cart. The findings include: Review of the facility's policy titled, Medication Storage, dated 01/2025, revealed, In order to limit access to prescription medications, only licensed nurses, pharmacy staff, or those lawfully authorized to administer medications (such as medication aides) were allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. Observation on 02/10/2026 at 3:11 PM revealed the medication cart on the North Hall for Rooms 101-105 was unlocked and unattended. During an interview on 02/10/2026 at 3:12 PM with Licensed Practical Nurse (LPN) 2, she stated she just walked away from the cart for a minute and did not usually leave her cart unlocked. She stated this instance was a one off. She stated the medication cart should always be kept locked when not attended to prevent other people from getting into it. During an interview on 02/10/2026 at 2:21 PM with the North Hall Unit Manager, she stated the medication carts were, for the residents' safety, supposed to be locked anytime staff stepped away from the cart. During an interview on 02/12/2026 at 2:50 PM with the Director of Nursing (DON), she stated she was made aware of the cart being left unlocked. She stated it was her expectation that the medication carts would always be locked if unattended. She stated that it was important for resident safety and to prevent anyone from getting into it. During an interview on 02/12/2026 at 2:56 PM with the Administrator, she stated it was her expectation that the medication carts were locked so no one could get into the cart.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's documents, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents sampled for infection control, Resident (R) 66.Observation on [DATE] revealed Resident (R) 66, who was not on contact isolation for Clostridium Difficile (C-diff), was residing in a room with R62, who was on contact isolation for C-diff. According to CDC guidelines, residents who were positive for C-diff should be roomed with other C-diff positive residents when single patient rooms were not available. The findings include:Review of the facility's policy titled, Infection Control, revised date [DATE], revealed, Facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Review of the facility's policy titled, Transmission Based Precautions, revised [DATE], revealed, Transmission Based Precautions [TBP] are initiated when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy also revealed, The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission Based Precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures.Review of the CDC's guidelines, Summary of Recommendations, not dated, revealed, Determine patient placement based on the following principles: Route(s) of transmission of the known or suspected infectious agent; Risk factors for transmission in the infected patient; Risk factors for adverse outcomes resulting from a Hospital Acquired Infection (HAI) in other patients in the area or room being considered for patient placement; Availability of single patient rooms; Patient options for room sharing (e.g., cohorting patients with the same infection).Observation on [DATE] at 1:01 PM revealed R66, who was not on contact isolation for C-diff, was residing in a room with R62, who was on contact isolation for C-diff. No enhanced barrier precaution signage was noted to be visible to indicate that R66 was on Enhanced Barrier Precautions (EBP). Contact Precaution signage was hanging outside of the room with no indication of which resident it applied. The curtain between the two residents was not pulled closed to keep them separated, and both residents could be viewed from the doorway.1. Review of R66's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of seizures, aphasia, dysphagia, stroke, and gastrostomy tube (a tube inserted into the stomach to deliver nutritional products for individuals with swallowing disorders (dysphagia).Review of R66's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status [BIMS] was not conducted due to the resident being rarely/never understood.Review of R66's Care Plan revealed the resident was care planned for requiring Enhanced Barrier Precautions (EBP) related to enteral feedings, initiated on [DATE] and edited on [DATE].Review of R66's Orders revealed R66 had an order for EBP due to enteral feeding, dated [DATE].2. Review of R62's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of dementia, dysphagia, stroke, and gastrostomy tube.Review of R62 quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of three out of 15, indicating R62 was severely cognitively impaired.Review of R62's Care Plan revealed the resident was care planned for requiring Contact Precautions related to C-Diff, initiated on [DATE].Review of R62's Orders revealed R62 had an order for Contact Precautions, dated [DATE].Review of R62's Diagnostic Order Review revealed C-Diff was detected on [DATE].Review of the Daily Census Report for [DATE] to [DATE] revealed there were several rooms that had openings in which to move R66 with the correct precautions in place. On [DATE], one resident was discharged , one resident was on hospital leave, and one resident expired, leaving an in-house census documented at 88. On [DATE], two residents were discharged , one resident was on hospital leave, and there were three admissions, leaving an in-house census documented at 89. On [DATE], one resident was discharged , and one resident was on hospital leave, leaving an in-house census documented at 88. On [DATE], two residents were discharged , and one resident was on hospital leave, leaving an in-house census documented at 85. On [DATE], two residents were discharged , two residents were on hospital leave, and there were three admissions, leaving an in-house census documented at 85. On [DATE], two residents were on hospital leave, and there was one admission, leaving an in-house census documented at 86. On [DATE], there was one discharge, and two residents were on hospital leave, leaving an in-house census documented at 85.Review of the facility's document Residents in Isolation for the North Hall, dated February 2026, revealed for the residents' room, R66 was on EBP with isolation stocked and correct signage, and R62 was on Contact Isolation with isolation stocked and correct signage.The State Survey Agency (SSA) Surveyor unsuccessfully attempted to interview R66 and R62 on [DATE] at 1:01 PM due to their low BIMS score and R66 being aphasic.The SSA Surveyor unsuccessfully attempted to interview R66's representative on [DATE] at 9:09 AM.The SSA Surveyor unsuccessfully attempted to interview R62's representative on [DATE] at 9:14 AM.During an interview on [DATE] at 1:01 PM with Licensed Practical Nurse (LPN) 2 and the Infection Prevention Nurse (IP), they stated neither resident in their room used the restroom, and gown and gloves were required for all staff who cared for R62. They stated EBP was used for R66. They stated all staff had to use soap and water after caring for either resident and must don (put on) Personal Protective Equipment (PPE) if they went past the curtain.During an interview on [DATE] at 2:21 PM with the North Unit Manager (UM), she stated staff was treating both residents in their room (R62 and R66) as contact since they were sharing a room. She stated, When our beds are locked, they have to cohort if they are not using the same bathroom. When asked if the facility was in a bed lock when R62 was diagnosed with C-diff, she stated she was not sure.During an interview on [DATE] at 3:35 PM with the Nurse Practitioner (NP), he stated, I am not sure about the regulations. To my knowledge they're supposed to be in a private room when they have C-diff.During an interview on [DATE] at 10:32 AM with the IP, she stated the facility followed CDC guidelines for infection control. She stated she was not comfortable answering hypothetical questions when asked if R66 was at an increased risk of contracting C-diff while being roomed with R62 for seven days prior to being moved into a different room. She stated, Our signage says what we need to use the PPE for, and they were treating both residents in their room as on contact precautions. She stated it was her expectation for staff to follow infection control practices. She stated she rooms residents per CDC guidelines. She stated, ultimately you would place a resident with C-diff in a private room, but they might have to be in residence with another until a private room was available. She stated she believed R66 was not moved to another room because the facility was in a bed lock until [DATE]. She stated she did not have a room in which to move one of them. She stated the facility had a bed open up on Tuesday, [DATE], to her understanding, in which to move R66. She stated it was important to room residents appropriately to prevent the spread of infection.During an interview on [DATE] at 9:32 AM with the Director of Nursing (DON), she stated residents should only be roomed together if they had the same infection for infection control. In an additional interview on [DATE] at 2:50 PM with the DON, she stated the facility should be following the CDC guidelines for patient safety.During an interview on [DATE] at 2:56 PM with the Administrator, she stated she was not aware if the facility was in a bed lock that prevented R66 from being moved to a more appropriate room. She stated it was her expectation that staff would follow the CDC guidelines, and that it was important in preventing the spread of infections.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's document and policies, the facility failed to ensure each resident was offered and provided the COVID-19 vaccine for 1 of 18 sampled residents, Resident (R) 79. R79 requested COVID-19 vaccination; however, this was not ordered or provided. The findings include: Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life, and all residents had the right to participate in decisions and care planning. Review of the facility's policy titled, Vaccines and Immunizations, revised 1/30/2026, revealed the facility followed CDC guidance for immunizations to minimize the risk of residents acquiring, transmitting, or experiencing complications from communicable diseases. Review of the facility's policy titled, COVID-19, dated 01/31/2025, revealed guidelines for COVID-19 would be conducted following accepted national standards through the CDC, Centers for Medicare and Medicaid Services (CMS), and local state agencies. Review of CDC guidance found at www.cdc.gov/vaccines/hcp/vis/current-vis.html revealed the COVID-19 vaccine was recommended for everyone six months of age and older. It also revealed older adults and people of any age with certain underlying medical conditions (like heart, lung disease, or diabetes) were more likely to get very sick with COVID-19. Further review revealed people who were up to date with COVID-19 vaccination had a lower risk of severe illness, hospitalization, and death from COVID-19 than people who were not up to date. Review of R79's Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses including Huntington's disease, cerebrovascular disease, and personal history of COVID-19. Review of R79's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/01/2019, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed R79's COVID-19 vaccination status was marked as not up-to-date. Review of the facility's document Flu, Pneumococcal and COVID Consent, dated 10/31/2025, revealed R79 signed, dated, and consented Yes to the COVID vaccine. The State Survey Agency (SSA) Surveyor requested a list of residents that requested but were not given a COVID-19 vaccine. Review of the documentation provided revealed one current resident (R79) and one discharged resident that requested vaccination but were not given a COVID-19 vaccine. During an interview with R79 on 02/10/2026 at 11:27AM, she stated she asked the Infection Preventionist (IP) multiple times for administration of the COVID-19 vaccine. R79 stated she did not remember when she first asked for the vaccine but was promised multiple times by the IP that it would be ordered and given. Additionally, R79 stated she had not currently received the COVID-19 vaccine. During an interview with the IP on 02/12/2026 at 10:32 AM, she stated COVID-19 vaccines were not scheduled but rather offered/administered at admission and any other time a resident requested a vaccine. She stated a single vaccine could be ordered anytime and typically arrived within a few days. When asked about R79, the IP stated the resident requested a COVID-19 vaccine on more than one occasion, but she failed to ensure it was ordered. The IP was unable to state when R79 first requested the vaccine. She further stated she should have ordered the vaccine immediately. The IP stated it was important vaccines were administered timely, so the spread of infection was prevented and residents were protected. During an interview with the Activities Director (AD) on 02/12/2026 at 2:47 PM, she stated R79 initially requested a COVID-19 vaccine in October 2025. She further stated, to her knowledge, R79 had not yet received the vaccine. During an interview with the Director of Nursing (DON) on 02/12/2026 at 2:53 PM, she stated residents were initially asked about all vaccines including COVID-19 and consented at admission. She further stated if a resident declined vaccines at admission and later decided they wanted one, the vaccine was ordered and administered as soon as possible. The DON stated it was her expectation that staff obtained consent and administered vaccines in a timely manner to any resident that wanted one. She further stated residents had the right to receive vaccines at any time, and it was important they were administered so residents were protected and kept safe. During an interview with the Administrator on 02/12/2026 at 3:17 PM, she stated it was important residents were protected, and she was not sure why R79's COVID-19 vaccine was not received. The Administrator stated it was her expectation that residents were offered and received vaccines if they wanted them. She further stated it was important vaccines were administered timely to help prevent the spread of communicable diseases.

Based on interview and review of the facility's binder, the facility failed to ensure survey results, certification results, and results of complaints made during the three preceding years, and any related plan of correction was made available for any individual to view upon request. The findings include:Review, on 02/11/2026 at 3:13 PM, of the facility's provided binder that should have contained results of surveys, certifications, and complaints made during the preceding three years revealed it did not have the Recertification Survey results, conducted on 11/26/2024, or the Plan of Correction documents for that survey included in the binder for public viewing.During an interview with the Administrator on 02/12/2025 at 3:30 PM, she stated she was unaware of the binder missing any survey, certification, or complaints made during the three past years or any missing related Plan of Correction. She stated it was a requirement by the state to have the binder current and up to date, so it was available to anyone who would like to view the binder.

Based on interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents were free from exploitation. As the representative payee for Resident (R) 17, the facility failed to properly manage and account for the R17's personal funds for one of four sampled residents (Resident (R)17). Review of R17's financial record titled Resident Statement Landscape which provided documentation of Resident Fund Management Service (RFMS), revealed large amounts of withdrawals, without a check and balancing system, beginning 12/22/2021 through 12/19/2023. Immediate Jeopardy (IJ) was identified on 11/15/2024 at 5:16 PM and was determined to exist on 12/22/2021 and Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, Freedom from Abuse and Neglect, F602, related to KY00044055. The facility was notified of IJ and SQC on 11/15/2024 at 5:16 PM. On 11/15/2024 at 5:16 PM, the facility Administrator, Director of Nursing (DON), and Care Consultant were provided a copy of the IJ Template and notified that the facility failed to ensure it safeguarded, handled, and tracked monetary funds as the representative payee for Resident (R)17. This failure allowed resident(s) to potentially be exploited by family, staff, and friends. The facility provided an acceptable plan for removal of the IJ on 11/20/2024 alleging the deficient practice constituted Past IJ. The survey team validated the IJ was removed on 08/23/2024, following the facility's implementation of the plan for removal of the IJ. The deficient practice remained at a D scope and severity (S/S) following the removal of the IJ. The findings include: Review of the facility's policy titled, Resident Trust Fund (RTF), effective date 11/10/2014 and last reviewed and revised 12/01/2018, revealed the facility was entrusted with safeguarding, holding, handling, and tracking certain monetary funds belonging to its residents per their written request. Continued review revealed no more than the monthly state allowable amount would be issued in the form of cash to any one resident. Further review of the policy revealed larger amounts of the residents money would be issued as a check and required a minimum of a 24 hour notice. The policy revealed the authorized signer must evaluate the check for reasonableness and support. Continued review of the policy revealed the BOM should report immediately any unusual activity, to include the resident requesting large sums of cash, to the Administrator and the Business Services Consultant. In December of 2023, the facility reported to the State Survey Agency (SSA) that the Social Security Administration investigated concerns related to possible exploitation of a resident's money, in which the facility was the Representative Payee (Resident (R)17). According to the report, during an annual routine audit, the Social Security Administration discovered the resident's money was not spent according to the Social Security guidelines. Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 05/27/2016 with revision date of 09/15/2023, revealed the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property. The policy defined exploitation as taking advantage of a resident for personal gain through use of manipulations, initiation, threats, or coercion. Review of R17's Face Sheet revealed the facility admitted the resident on 12/17/2019 with diagnoses to include anxiety disorder, altered mental status, and transient cerebral ischemic attack (TIA). Review of R17's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of the Social Security Administration Correspondence to R17, dated 06/04/2020, revealed the Social Security Administration had chosen the facility to become her representative payee, and the facility would use the resident's money for her needs. Review of the Social Security Administration Correspondence to the facility, dated 10/11/2023, revealed the Protection and Advocacy conducted a review of the facility's residents. Further review revealed the Protection and Advocacy evaluated the facility's service provided as the residents representative payee, on behalf of the Social Security Administration. Review of the former Social Service Progress Note, dated 11/16/2023 at 2:45 PM, revealed the resident had verbal outbursts regarding her money. Per the progress note, R17's child had recently gotten out of jail and was calling her and asking for funds. Continued review revealed R17 was educated to spend money on self, but she still became angry. Review of R17's Progress Note, dated 11/22/2023 at 2:57 PM, revealed R17 had requested $2000 for her child and grandchildren for Christmas, monies (cash), and gift cards. The note stated the request was denied, and R17 became irate and demanded money. Additional review revealed R17's BIMS score was 12 on this date, indicating a moderate cognitive deficit. Review of the Protection and Advocacy Correspondence to the facility, dated 03/19/2024, revealed the Protection and Advocacy met with the facility on 11/02/2023 and reported its findings to the facility. Further review of the correspondence revealed the facility had inadequate controls for safeguarding beneficiary funds, receipts for large and unusual purchases, missing records not retained for two (2) years, and accounting reports were not returned on time. Review of the Social Security Administration Correspondence to the facility, dated 05/20/2024, revealed the facility had met with the Protection and Advocacy representative on 11/02/2023 to conduct a review of the facility's Corrective Action Plan. Further review revealed the Protection and Advocacy Analyst determined the facility had implemented its Corrective Action Plan and it was determined the facility had fulfilled its duties as the representative payee. Review of R17's document titled Resident Statement Landscape [Facility's Name] Resident Trust Acct, revealed debits titled as personal needs deductions, with no distinction between cash or gift cards, of $100 or greater per day as follows: 12/22/2021 - $2000; 02/23/2022 (1) - $100 (2) $22.00; 02/28/2022 - $100; 04/06/2022 - $200; 04/12/2022 - $2000; 05/09/2022 - (1) $60 and (2) $60; 06/17/2022 - (1) $150 and (2) $45; 06/22/2022 - (1) $2000, (2) $25, and (3) $45; 06/28/2022 - $180; 07/05/2022 - (1) $130 and (2) $500; 07/11/2022 - $200; 07/13/2022 - (1) $120 and (2) $30; 07/27/2022 - (1) $55 and (2) $65; 08/01/2022 - $290; 08/09/2022 - $3000; 08/22/2022 - (1) $50 and (2) $80; 08/25/2022 - (1) $1200 and (2) $20; 09/01/2022 - (1) $60 and (2) $40; 09/30/2022 - (1) $60, (2) $2760.96, and (3) $100; 11/22/2022 - (1) $1700 and (2) $60; 12/28/2022 - $1900; 01/12/2023 - $1773.19; 01/25/2023 - $150; 02/24/2023 - $1900; 03/23/2023 - $150; 03/30/2023 - (1) $75, (2) $18, and (3) $150; 04/12/2023 - $250; 05/08/2023 - $1000; 05/30/2023 - $850; 07/05/2023 - $2150; 08/08/2023 - $400; and 12/19/2023 - $300. Review of R 17's document titled Resident Statement Landscape [Facility's Name] Resident Trust Acct, dated 12/28/2023, revealed the facility reimbursed the resident 18,594. During interviews with R 55 on 11/11/2024 at 9:15 AM, R 44 on 11/11/2024 at 10:00 AM, and R 15 on 11/11/2024 at 9:00 AM, they stated they had no concerns with their funds at the facility, and the facility took good care of them. R 15's daughter was present during the resident's interview and reported no concerns. During an interview on 11/12/2024 with R 17, she stated she had no concerns with money other than she did not get enough of it. Further, she stated she just wanted to go home and did not want to discuss her funds. In an interview with Family Member (FM)17, on 11/15/2024 at 11:38 AM, he stated he, his wife, and children no longer received gift cards or cash from his mother, R17. FM 17 stated in the past his cousin or his father would pick up gift cards and large amounts of cash from the facility that the former Social Services Director (SSD) would leave in an envelope at the front desk to be picked up. FM 17 stated, if his cousin or his father were not able to stop by the facility to pick up the gift cards and cash, the former SSD would mail them to him, his wife, and kids, which was out-of-state where they resided. He stated he would call and text the former SSD on her personal cellular phone to make the request for gift cards and cash from R17. The FM 17 stated he was not sure if the former SSD informed R17 of the amounts requested for gift cards and cash. During an interview with the former BOM on 11/13/2024 at 1:15 PM, she stated she was now employed as the Social Services Assistant but had been the BOM during the time R17s funds were distributed to her family. The former BOM stated she could not recall the policy or process for the distribution of the resident's funds during that time. During an interview with the current BOM on 11/13/2024 at 10:25 AM, he stated he was not employed at the facility during 2023 and could not speak to R17's distribution of funds. He stated his tasks as BOM included keying in all deposits and keeping track of most all of the transactions. He stated the Administrator was in charge as the representative payee, but he did not know who was responsible in 2023 since he did not work at the facility then. He stated the process now was that residents made a request to the Assistant BOM. He stated then the BOM would check to see if the funds were available to cover the request. Further, he stated the facility would make out the check, and each check must have two signatures and proof of what the funds were for, with the Administrator signing the check last. He stated if the funds were not being spent for the resident's needs, the transaction would not go through. He stated if the request was for a large amount of money, usually above the resident's $60 monthly allowance, then that would be broken up in increments over a few days. During an interview with the Protection Agency Analyst Representative on 11/14/2024 at 8:57 AM, she stated her job title was representative payee analyst. She stated her department looked at the representative payee for social security payees. Per the interview, she stated she was familiar with R17's financial statements for November and December of 2023. However, she stated she was prohibited by the Social Security Administration to report her findings to anyone. She advised the State Survey Agency (SSA) Surveyor to ask the facility for reports of the Corrective Action Plan and the Verification of Correction, which were given to the facility. In an interview with the former Social Service Director (SSD), on 11/15/2024 at 11:46 AM, she stated she was unaware the facility was R17's representative payee. The former SSD stated R17 came to her office and made requests to send FM 17, his wife, and her grandchildren gift cards and cash. The former SSD stated once R17 made the request, the former Administrator would write her a check. The former SSD stated once she received the check, she would cash the check to make the requested purchases for R17. The former SSD stated if she was busy and was not able to attend to R17's request right away, R17 would come to her office angry, irate, yelling, and harassing her to get her request filled immediately. She further stated she gave R17's son, wife, and grandchildren gift cards and cash. Per the interview, she stated she did not feel as though she was doing anything wrong at the time, as she thought she was meeting the needs of the resident. Further interview with the former SSD, on 11/15/2024 at 11:46 AM, she stated she was never paid for goods and services. The former SSD stated in November 2023 the former BOM handed her a reconciliation form and told the former SSD she needed to complete the form. The former SSD stated the former BOM explained to her that a form should have been completed as the facility was the resident's representative payee. Further, the former SSD stated she was informed at that time that the previous BOM had applied on the facility's behalf to become the resident's representative payee so that the resident's monthly expenses could be covered. In continued interview, on 11/15/2024 at 11:46 AM, the former SSD stated an investigation was initiated by the Regional Business Office Consultant and Adult Protective Services. The former SSD stated in 12/2023 the investigation was completed, and she came to the facility and handed the former Administrator her resignation letter, which was effective immediately. The former SSD stated she was devastated to learn the facility was the resident's representative payee and would have never given the resident large sums of money to give away to her family and friends. In an interview with the former Social Worker (SW), on 11/14/2024 at 10:40 AM, she stated she remembered R17. She stated she remembered there had been a huge investigation about R17's funds, and when it was discovered no one at the facility knew the facility was the resident's representative payee (RP). She stated when R17 was first admitted , there were issues with her son taking funds. She stated that in order for the facility to receive payment, the BOM had to request to become the resident's RP, on behalf of the facility. The SW stated the previous BOM should have informed staff of the facility's responsibility as R17's RP, prior to leaving the facility. However, she did not tell anyone. During an interview with the Regional Business Office Consultant (RBOC) on 11/14/2024 at 3:00 PM, she stated she had been doing this for about [AGE] years. She stated her job duties included making sure facilities were following guidelines set forth by the Social Security Administration and assuring facility documents were filled out correctly. She stated she was still performing monthly random audits as guided by the Corrective Action Plan. She stated she discovered R17's discrepancies when she looked at the RP audits. She stated she found all the receipts for gifts and monies. She stated she felt the facility did not follow the RP procedures at that time, but the old policy was very vague. She stated the policy was revised after R17's incident to reflect segregation of duty and to include more specifics. In continued interview with the Regional Business Office Consultant (RBOC), on 11/14/2024 at 3:00 PM, she stated currently R17 was the only resident the facility had listed as its Representative Payee (RP), adding this facility had very few people that used the RP services. She stated the purchase of the gift cards was very excessive and staff was allowing R17 to have more money than she should have received. During an interview with the former Administrator on 11/14/2024 at 9:19 AM, she stated she was the Administrator from April 2023 to August 2024. She stated she reported the allegation of exploitation to the SSA back in December of 2023. She stated the report was based on an audit the Social Security Administration performed. She stated she really could not remember the findings, but until that time the facility was unaware they were R17's RP and that was why the distribution of monies happened. She stated the prior BOM had left employment at the facility, and no one knew the facility was R17's RP. She stated the former SW would purchase items for the resident, but was unsure of what really happened with R17's funds. In an interview with the former [NAME] President of the facility on 11/15/2024 at 4:33 PM, she stated the complaint reported was self-reported by the facility. The former [NAME] President stated she found out the Social Security Administration had visited the facility to complete the RP audits. The former [NAME] President stated the SSD bought everything R17 had asked for and that included purchasing gift cards and large amounts of cash available for family to pick up at the facility. The [NAME] President stated the facility reimbursed R17 in a check due to the facility taking responsibility and recognizing the facility failed to protect the resident from exploitation. She stated the former SSD was suspended while this incident was investigated. During an interview with the facility's current Interim Administrator on 11/14/2024 at 9:43 AM, he stated the facility acted as a gatekeeper for all transactions when assigned as the RP for a resident. He stated if the facility saw a resident was giving away monies to family, there would be a concern since those monies were there for resident needs and supplies. Further, he stated if there was any suspicious activity in a resident's account, the facility would look into it as soon as possible. The facility provided an acceptable IJ Removal Plan on 11/20/2024 that read verbatim: 1. Resident #17 account was audited by the Signature Compliance Department on 11/22/23 and credited by the facility for $18,594.15 on 12/13/23. The facility is the representative payee for Resident 17. The ResidentTrust Fund policy was reviewed and revised on 3/26/24 by the Signature Compliance Department and Signature Business Services Department to include requirements for disbursement logs for petty cash box, remaining funds deposited back into a resident trust account after shopping, direct debit, and representative payee. Resident 17 was interviewed on 8/19/24 by the Administrator. Resident stated she had no issues, complaints, or concerns on how her money was being handled at that time. Resident 17 was concerned about the personal needs allowance being $40 and was reminded by the Facility Administrator that the amount was increased to $60 in July 2024, and she expressed understanding. Business Services Consultant audited Resident 17's trust account on 8/19/24 to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. No concerns were noted. Resident followed by psychiatric services and social services and remains at her baseline. Resident also continues to participate actively in group and individual activities with no concerns noted. Required updates are being provided to the Social Security Administration regarding representative payee account for Resident #17 by the Business Office Manager as indicated. Business Office Manager reviews Resident#17'strust account monthly to ensure all monies dispersed are for resident care needs and receipts/invoices are present to account for the monies dispersed. 2. The facility is the representative payee for no other residents. Out of an abundance of caution, starting on 8/19/24 and completed on 8/21/24, the Business Services Consultant audited all resident trust accounts to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. Starting 8/19/24 and completed on 8/21/24, all current residents with a Brief Interview for Mental Status (BIMS) score of 8 or above were interviewed by the Social Services Director to inquire if they had any concerns about their trust account. Starting 8/19/24 and completed on 8/21/24, resident representativesfor residents with BIMSbelow8 were interviewed by Social Service Director to inquire if they had any concerns about the resident trust account. No concerns were noted. 3. The Resident Trust Fund policy was reviewed and revised on 3/26/24 by the Signature Compliance Department and Signature Business Services Department to include requirements for disbursement logs for petty cash box, remainingfunds deposited back into a resident trust account after shopping, direct debit, and representative payee. The Regional Business Services Consultant educated the Signature Care Consultant (SCC) on the ResidentTrust Fund Policy on 8/19/24. A posttestwasgiven and 100% was obtained.The sec educated the Interim Administrator on the Resident Trust Policy on 8/19/24. A posttest was given and 100% was obtained.The Interim Administrator educated the Director of Nursing, Social Service Director, Business Office Manager, and Assistant Business Office Manager on the Resident Trust Policy on 8/19/2024 and completed by 8/21/24. A posttest was given to these staff members after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. All new Administrators, Business Office Managers, Social Service Directors, and Assistant Business Office Managers will be required to have all education and posttest during orientation by the Administrator or Regional Business Services Consultant prior to their working. A score of 100% is required and anyone not receiving a 100% score will be re educated and provided another posttest. This process will continue until a 100% score is obtained by all staff. The Signature Care Consultant educated the Interim Administrator, Social Service Director, Unit Managers, Staff Development Coordinator, Activities Director, Minimum Data Set Coordinator, Business Office Manager and Interim Director of Nursing on the Abuse, Neglect and Misappropriation of property policy starting on 8/16/2024 and completed by 8/20/24. A Post test was given to these staff members starting on 8/16/24 and completed by 8/20/24 after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. The Interim Administrator, Social Service Director, Unit Managers, Staff Development Coordinator, Activities Director, Minimum Data Set Coordinator, Business Office Manager and Interim Director of Nursing educated all facility staff which included certified nurse aides, Kentucky Medication Aides, Licensed Nurses, Therapy staff, Environmental Staff, activities staff, maintenance staff and business office staff on the Abuse, Neglect and Misappropriation of property policy starting on 8/17/24 and completed by 8/22/24. Post test given to these staff members starting on 8/17/24 and completed by 8/22/24 after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. Any Staff not receiving this education and posttest by 8/22/24 will receive this education and post test prior to being able to work their next shift. A score of 100% will be required and anyone not receiving a 100% score will be re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. The facility does not utilize agency staff. All new hires to the facility will receive education on Abuse, Neglect and Misappropriation of funds and posttest during orientation by the Administrator, Director of Nursing, or Staff Development Coordinator prior to their working. A score of 100% is required and anyone not receiving a100% score will be re-educated and provided another posttest. This process will continue until a 100% score is obtained by all staff. Starting 8/24/24 ongoing, the Business Office Manager conducts a monthly audit of all residents for whom the facility is the representative payee to ensure that all monies dispersed are for resident care needs and receipts/invoices are present to account for the monies dispersed. The Social Services Director, Business Office Manager, or Assistant Business Office Manager will conduct interviews of 5 random residents or resident representatives to determine if they have any concerns related to the resident trust account. This will occur weekly x 4 weeks, then reduce to monthly x 2 months. Results of the audits will be presented to the QAPI Committee for review and recommendation, once the committee determines the problem no longer exists the audits will be conducted on a random basis. The Regional Business Services Consultant will audit 2 resident trust accounts weekly x 4 weeks and then reduce to 2 resident trust accounts monthly x 2 months to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. 4. An Ad Hoc Quality Assurance meeting was held on 8/19/24 with the Medical Director, the Facility Administrator, the Director of Nursing, and the Signature Care Consultant (SCC) regarding plan of correction that was formulated and implemented at that time on 8/19/24. The facility administrator presented the plan and information at the QAPI meeting on 8/19/24. The Medical director attended on 8/19/24 and was notified of implementation of plan of correction. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate. Starting on 8/19/24 the Facility Administrator held a Quality Assurance meeting weekly for 4 weeks to review audits and discuss any concerns related to those audits regarding resident #17 exploitation. No concerns for exploitation or misappropri ati on were noted in the audits dating back to 8/19/24. QAPI meetings were then decreased to monthly for recommendations and further follow up regarding the above stated plan. No concerns for misappropriation or exploitation have been identified and 100% compliance has been maintained. Moving forward the facility administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee willdetermine at what frequency any ongoing audits will need to continue. The Administrator is responsible for implementing this plan.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure there was sufficient qualified staff available at all times to provide nursing and related services to meet the residents' needs in a manner that promoted each resident's rights, physical, mental and psychosocial wellbeing. On 11/12/2024 observation and interviews revealed only two nurse aides scheduled for 7:00 AM to 7:00 PM on the South Hall, with a census of 37 residents. The findings include: Review of the facility's policy titled, Facility Assessment, dated 2024, revealed the average full time employee per day for the year ending 2023 was 27 nurse aides. Review of the staffing schedule for 11/11/2024 revealed 14 nurse aides were scheduled for the 24-hour period from 7:00 AM on 11/11/2024 to 7:00 AM on 11/12/2024. Further review of the staffing schedule revealed from 7:00 AM on 11/12/2024 to 7:00 AM on 11/13/2024, 12 nurse aides were scheduled for the 24-hour period. Review of the staffing sheet on 11/11/2024 revealed three Certified Nursing Aides (CNA) were scheduled for the South Hall of the facility. Observation of facility staff on 11/12/2024 at multiple times revealed only two CNAs working the 7:00 AM to 7:00 PM shift on the South Hall. Review of the facility's Census, dated 11/12/2024 for the South Hall, was 37 residents. During an interview on 11/12/2024 at 1:57 PM with CNA2, he stated there were three CNAs on the North Hall and two CNAs on the South Hall. He stated he felt rushed because he had 17 to 18 residents to take care of during his shift. He stated the nurses would help if they had time. However, most of the time there were only two aides on the South Hall. CNA2 stated the unit had a lot of rehab residents, and they required more attention than some of the residents on the North Hall. He also stated with the current outbreak of COVID in the facility, it took so much more time when donning (putting on) and doffing (removing) Personal Protective Equipment (PPE) when providing care, passing lunch trays, and taking the bags of garbage from the residents' rooms from all the PPE. In an interview on 11/14/2024 at 10:32 AM with CNA2, he stated on 11/12/2024 because there were only two CNAs on the South Hall, a medical records person gave showers but did not take assignments. In an interview on 11/12/2024 at 5:02 PM, CNA4 stated she had not given R63's shower that day because she had not had time. She further stated R63 was supposed to get a shower on Tuesdays and Fridays. CNA4 stated the medical records aide had given showers that morning, but she did not know if she had been able to do R63's shower. In an interview on 11/25/2024 at 10:39 AM, CNA7 stated she had seen two aides working on the South Hall several times, although she did not remember exactly how many. She further stated when there were only two CNAs on South that would make each CNA responsible for 20 to 25 residents each. CNA7 stated when each aide was responsible for that large of a group, residents were likely to get their food late, which could make it cold, and it was hard to answer call lights timely. CNA7 further stated aides having more than 20 residents in their assignment would mean incontinent residents would have to wait more than two hours to get changed, which would be upsetting to the resident and could cause skin issues. Per interview, CNA7 stated management sometimes answered call lights, but would tell residents to wait for their aide to provide incontinence care. Additionally, CNA7 stated that CNAs tried to honor resident's preferences regarding showering, but it was not always possible due to staffing. In an interview on 11/14/2024 at 12:22 PM, CNA8 stated the facility needed more than two or three CNAs on the South Hall to meet the needs of the residents because residents needed to get up for therapy and tended to have more care needs than those residents on the North Hall. During an interview on 11/13/2024 at 11:22 AM with the Director of Therapy, she stated her staff would assist residents in moving from one area of the facility to another if staff was busy. She stated there were times when therapy staff had to help because nursing staff could not get to residents because of other duties. In an additional interview at 11/25/2024 at 11:17 AM, CNA4 stated when there were only two CNAs working the South Hall, residents had longer wait times to get their call lights answered, and she did not have as much time to talk to them to determine their needs and preferences. She further stated it was almost impossible to give showers with only two aides, and even if an additional staff member gave the showers, they often did not communicate with the CNAs effectively so they would know which showers they had given. CNA4 stated if someone who was not assigned a CNA group answered a call light, they would often only take care of the resident's issue if it could be done quickly and would not take a resident to the bathroom, change a brief, or perform other more time-consuming care tasks. During an interview on 11/12/2024 at 2:50 PM with CNA7, she stated on the North Hall if there were three CNAs, they had between 12 to 14 residents each, and if there were four aides, they had 10 to 12 residents each. She stated there were more shower aides on the weekend. She stated they would pull someone from the South Hall if the North Hall was short-staffed. In an interview on 11/25/2024 at 9:59 AM, Kentucky Medication Aide (KMA) 6 stated when she was working as a KMA, she typically spent most of her time administering medications but might help CNAs with short tasks, such as repositioning a resident or passing a tray. She further stated when she was working as a KMA, she did not have time to assist with a longer task, such as giving a shower, as well as administering medications on time. She stated she was responsible for a large group of residents' medications, so she likely would not have spare time to assist CNAs with their tasks. During an interview on 11/14/2024 at 11:59 AM with Licensed Practical Nurse (LPN) 1, she stated typically on the South Hall there were two to three CNAs, two nurses, and no KMA. She stated, on the North Hall there were two nurses, a KMA, and four CNAs. She stated every day at lunch, one of the nurses from the South Hall had to go to the dining room to observe and help with lunch. She stated that left one nurse on the floor to administer medication, obtain glucose checks, take new admissions, chart, and perform resident care. She stated it made it really hard to get work done. She stated there was one day they asked her to go to the dining room, but she declined because she had just received a new admission and could not receive orders and take care of the new resident. She also stated on 11/12/2024 there were only two CNAs on the South unit. She stated on 11/12/2024, she helped change four different residents during lunch and helped with lunch trays. She stated it was extremely busy on the South Hall because the shorter stay residents had higher needs, and staff did not really know them as well as the long term residents. She stated having to do the CNAs' tasks took away from her ability to administer medication or respond if there was a resident who coded or had a medical emergency. During an interview on 11/13/2024 at 2:15 PM with Registered Nurse (RN) 1, she stated staffing was an issue at the facility. RN1 stated staffing was low due to employees calling out on their assigned shifts, and when call outs happened the facility could not run to its full potential and meet the expectations required for the residents. RN1 stated for instance, on 09/19/2024, R2 was not fed breakfast before he left for church at 9:30 AM due to low staffing in dietary and trays not being prepared at the scheduled mealtime of 7:30 AM. RN1 stated the facility would call CNAs on their scheduled days off to come in and assist with giving showers. RN1 stated that considering the current number of COVID residents and low staffing in dietary and floor staff, it was taking the aides a longer time or they were not able to complete tasks to care for residents with answering call lights, giving showers, and distributing evening snacks. During an interview on 11/13/2024 at 2:07 PM with the Director of Nursing (DON), she stated she had only been at the facility for three weeks. She stated she was always on the floor assisting staff with resident care and making sure all residents' needs were met. She stated it had been challenging because of COVID in the facility and not knowing if staff would come to work or call out sick. During an interview on 11/13/2024 at 10:54 AM with the [NAME] President of Operations (VPO), he stated the facility's assessment was created to determine the staffing needs based on resident acuity, number of residents assigned to each staff member, and patterns of resident care. He stated the facility tried to staff toward 3.20 hours per resident/day. He stated the facility's assessment did not provide those numbers. The VPO stated the facility used a staffing formula created for the company to determine residents' needs and the number of staff to meet those needs. During an additional interview on 11/14/2024 at 10:54 AM with the [NAME] President of Operations, he stated the facility's staffing ratios were determined by the Minimum Data Set (MDS) assessment and by a system (Strive) which was created by the Centers for Medicare and Medicaid Services (CMS) to determine per patient day (PPD) hours for staff. He stated the facility was projected to be 3.03 hours/PPD. The VPO stated, during situations where the facility might be experiencing higher acuity, the Administrator had the ability to go 30 percent above projections to account for the increased workload, which would equal 3.93 hours/PPD. During an interview on 11/14/2024 at 10:17 AM with the Administrator, he stated there was a formula used to determine staffing. He stated the formula took into account the level of care required, the MDS assessment, and other variables. He stated, on the South Hall, most of the residents were short term and it required nurse aides to spend more time and answer call lights for those residents than the residents on the North Hall, who had a longer relationship with staff, so the staff could better anticipate their needs. He stated when an aide calls out (did not come to work) or was late, management would pull some other staff to take an assignment. He stated the other staff might pass trays or answer lights because they would take on the load left open by the aide who was not present. The Administrator stated management pulled salaried staff to take assignments. Further, he stated this was reflected in the schedule for Payroll Based Journal (PBJ) tracking because these employees communicated with the business office and made sure those hours were documented in the PBJ to reflect coverage of hours in the facility. In continued interview, with the Administrator on 11/14/2024 at 10:17 AM, he stated, when management staff assisted on the floor, their hours needed to be accounted for in the PBJ to help ensure it did not trigger the facility for low staffing. He stated each time a member of management covered an hourly assignment, they were required to indicate that on the staffing sheet. The Administrator stated he expected all the administrative staff to be on call or fill in when necessary. He stated he could be seen on the floor assisting staff and residents to ensure each resident was receiving the assistance they needed. Further, he stated he expected the facility to have enough staff to adequately address all residents' needs and provide them with appropriate care. 46710

Based on observation, interview, record review, and review of the facility's policy, the facility failed to honor the resident's right to make choices about aspects of his or her life in the facility that were significant to the resident for one of eight residents investigated for choices, Resident (R) 63. The facility failed to honor the resident's choice of days for a bath. The findings include: Review of the facility's policy titled, Resident Rights, dated 09/13/2024, revealed the facility would respect the resident's individuality and value their input by providing them a dignified existence through self-determination. Review of R63's Face Sheet revealed the facility admitted the resident on 09/17/2024 with diagnoses including surgical aftercare, muscle weakness, and difficulty walking. Review of R63's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This score indicated moderate cognitive impairment. Further review revealed R63 indicated it was very important for her to choose a bath or a shower as part of her daily routine. Review of R63's Care Plan, dated 09/19/2024, revealed the facility identified R63's need for assistance with personal care, including the intervention of receiving showers for schedule. Review of the facility's document Point of Care History, dated 10/16/2024 - 11/15/2024, revealed the facility documented providing a shower for R63 on 10/22/2024, 10/29/2024, 11/05/2024, and 11/12/2024, which were all Tuesdays. Per the shower documentation, the showers on 10/29/2024 and 11/05/2024 were given after 6:00 PM. Further review revealed the facility documented giving R63 a partial bed bath on 10/18/2024, 10/25/2024, 11/01/2024, and 11/08/2024, which were all Fridays. Observation on 11/11/2024 at 10:49 AM revealed R63 sitting in bed, wearing a beige sweatshirt. Further observation revealed the resident's hair was dirty and unbrushed. In an interview on 11/11/2024 at 10:49 AM, R63 stated she did not get to choose when she received her shower. She further stated she preferred to get her shower in the morning, but staff often told her they did not have time. R63 stated staff would give a bed bath every few days; however, staff told her they did not have time to give a full shower except for once per week. Per interview, R63 preferred a shower because she felt cleaner after a shower than a bed bath. R63 stated she felt frustrated because she could not choose when to have her shower. Additionally, R63 stated the facility scheduled showers based on what was convenient for them, not on what the residents wanted. Observation on 11/12/2024 at 10:56 AM revealed R63 was still in the same beige sweatshirt she was wearing on 11/11/2024 at 10:49 AM. Per further observation, R63 asked Certified Nurse Aide (CNA) 4 for a shower and stated she had not had one in two weeks. Per observation, CNA4 told R63 she had given her a shower last week. CNA4 continued to state she would check to see if the resident's shower was due today. Observation at 11/12/2024 at 4:58 PM revealed R63's hair was still dirty and unkempt. During interview, at that time, R63 stated her daughter had helped her change her shirt because CNA4 had been running and running all day, and no one had come back to give her a shower. In an interview on 11/12/2024 at 5:02 PM, CNA4 stated she had not given R63's shower because she had not had time due to being staffed with only two CNAs on the South Hall. She stated the resident was supposed to get a shower on Tuesdays and Fridays. In an additional interview on 11/25/2024 at 11:17 AM, CNA4 stated when there were only two aides on the South Hall, it was nearly impossible to give showers. She further stated sometimes other staff members, such as the medical records keeper would give some showers, but not all of them, and there was not a good system for communicating which residents had been given showers and which still needed them. In continued interview, CNA4 stated residents who were due a shower typically did not want a bed bath instead because they told her bed baths did not make them feel clean in the same way as a shower. In an interview on 11/13/2024 at 8:30 AM, R63 stated staff gave her a shower last night after dinner. R63 further stated she would have preferred to wait until this morning to have a shower, but she was afraid she would have to wait another week if she did not take a shower when offered. In an interview on 11/15/2024 at 3:12 PM, the Unit Manager/Assistant Director of Nursing (ADON) stated he was aware residents made complaints about not getting a shower on the South Hall but did not recall specific residents at that time. He further stated that when he was aware a resident had not received a shower, he would personally ensure they received a shower that day so they could feel better. The ADON stated the shower schedule was set when he started in this role, and residents generally adapted to the twice weekly schedule on admission. Per interview, if the resident stated to the admitting nurse they would prefer a shower on a different day or time, the facility would try to accommodate that preference. Additionally, the ADON stated the facility would go above and beyond to give a resident a third shower in a week if the resident wanted it, and if staff was available to give one. He stated, to make sure showers were done, reports were run to check the Point of Care documentation. He stated this was what the direct care staff used to document baths, meals, and other direct care services. He stated if the showers were not done or documented, it was followed up by the management. He stated it would be discussed in the Interdisciplinary Team (IDT) meeting. He stated, if no shower was given, it would be addressed by the Unit Manager and the staff responsible. In an interview on 11/15/2024 at 3:37 PM, the Director of Nursing (DON) stated the facility's shower schedules were already developed when she started as DON in 10/2024. She further stated the process was for residents to be scheduled for a shower twice per week on the days and shifts assigned for each room. The DON stated she recalled the IDT discussing a missed shower but did not recall further details. Per interview, the DON's expectation was for residents to get to choose when their shower was given because that was their right and should be something the facility could find a way to accommodate. In an interview on 11/15/2024 at 4:29 PM, the Administrator stated the facility's process for developing a shower schedule was for the Unit Manager to develop and adjust a schedule based on the resident's needs, while also working to distribute the workload for staffing so there were not too many showers due on the same day and shift. He further stated it would be his expectation that the admitting nurse would ask the resident about shower preferences on admission, but he did not know if the facility did that consistently. Additionally, the Administrator stated resident centered care was important to meet the resident's expectations for care. 50192

Based on observation, interview, record review, review of the facility's job description, and review of the facility's policies, the facility failed to provide R46 with devices necessary to maintain hearing for 1 of 3 residents investigated for hearing device use, Resident (R) 46. The facility failed to provide alternate communication devices to R46 when his hearing aid was not functioning appropriately, starting in 07/2024. This adversely affected R46's ability to receive private information and participate in life-enrichment activities from 07/20/2024 until 11/13/2024 because he did not have a supplemental communication device. As a result of not providing a more private method of communication, and the staff resorting to yelling in the resident's ear, his care needs and any personal information was exposed to everyone in the area. The findings include: Review of the facility's policy titled, Resident Rights, effective 06/01/2015 and last revised 09/15/2023, revealed federal and state laws guaranteed certain basic rights to all residents of the facility. These rights included the resident's right to privacy and confidentiality. Review of the facility's policy titled, Activity Program, effective and revised date 08/22/2023, revealed one-to-one activities would engage residents to their capacity level within each activity session to promote and provide social, cognitive, physical, and emotional well being and would stimulate or provide solace to promote self-respect, self expression, personal responsibility, and choice. Per the policy, the Activity Director, should provide appropriate adaptations for a resident who required them as needed. Review of the Job Description for Social Services Director, dated 05/2022, revealed this position would identify and provide for each resident's social, emotional, and psychological needs. It also stated the Social Services Director (SSD) would provide for the continuing development of the resident's full potential during his/her stay at the facility. Review of R46's Face Sheet revealed the facility admitted the resident on 07/17/2024 with diagnoses of hemiplegia and hemiparesis following a cerebral infarction (stroke), cognitive communication deficit (extreme hearing deficit), need for assistance with personal care, and depression. Review of R46's Grievance Report, filed in 7/2024, revealed R46's daughter stated her father's hearing aid had been washed with his bed linens on 07/20/2024. Per the report, R46's daughter/Power-of-Attorney (POA) took the hearing aid to an outside audiologist who claimed it was repaired and confirmed it was working by a computer. However, per the report, R46's daughter stated it still was not working for the resident to hear human voices without static. Review of R46's Activity Note, from 10/2024, revealed the resident enjoyed music, television, and bingo. Review of R46's Point of Care (POC) Certified Nurse Aide (CNA) documentation on 11/13/2024 revealed a new entry that R46 had impaired communication, and the intervention was a communication board and an amplifier. Observation on 11/12/2024 at 9:28 AM revealed R46 was in his pajamas with his face unshaven. He did not respond to the knock at the door or conversation with his roommate. When the State Survey Agency (SSA) Surveyor tried to communicate with him, he did not respond. His roommate stated he was deaf, and you would need to yell in his right ear. Further observation revealed R46 was able to read lips but not well. During an interview on 11/11/2024 at 7:21 PM with R46's daughter/POA, she stated she had concerns as she reported in her complaint to the facility about the 07/20/2024 incident. She stated R46 had not been able to hear correctly since his hearing aid was broken, and she was concerned that the audiology service provided by anyone else besides the company that sold them to her, might interfere with the warranty of the hearing aids. During an interview on 11/12/2024 at 9:38 AM with the Activity Director (AD), she described R46 as more of an observer. She stated R46 used to come out of his room and hang out, but since the facility had COVID he had spent more time in his room. She stated staff provided R46 with one-to-one activities in his room. The AD stated the resident was hard of hearing and required staff to elevate their voices to his right ear, but he responded within expected accuracy. The SSA Surveyor told the AD that R46 was asked if he had used a communication board, and he stated he had not, but he had an interest in one. The AD stated that was a good idea, and she would supply this for him. During an interview on 11/12/2024 at 1:18 PM, the SSD stated R46 had his right hearing aid washed with his sheets. She stated his daughter took it to an outside provider, and it tested to be in working order. She stated the daughter had declined the audiology service the facility used at that time due to warranty or insurance concerns. She stated the damage occurred on 07/20/2024 per the grievance log, and they were deemed in good repair on 08/29/2024 by the outside audiologist to whom the daughter took the hearing aid. During an interview on 11/13/2024 at 9:40 AM with the Staff Development Coordinator (SDC), she stated she did not recall any occasion when R46's communication needs were addressed with staff education. During an interview on 11/13/2024 at 9:57 AM with the Director of Nursing (DON), she stated she felt R46 currently communicated well with the staff when he chose to. She stated staff had to speak loudly for him to understand. During an interview on 11/14/2024 at 11:05 AM with the Minimum Data Set (MDS) Director, she stated she had access to communication boards and Super Ear headphones but did not know where they were kept. She stated she did not recall ever using either with R46. During an interview on 11/13/2024 at 10:33 AM with R46, he expressed he was very happy with the amplified headset provided to him by the SSD today. He exhibited no confusion during the conversation. During an interview on 11/15/2024 at 3:37 PM with the Director of Nursing (DON), she stated, as a result of R46 having the headphone-style amplifier, he would likely enjoy life better now that he was able to hear. During an interview on 11/13/2024 at 1:20 PM, the Administrator stated he spoke with the Social Worker about the facility's audiology company, and R46's family preference of using their audiology company. He stated a Super Ear (headphone amplifier) was purchased, and R46 would be allowed to borrow them. He further stated that if it [headphone amplifier] gave him peace of mind, he would work with R46's family.

Based on observation, interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) signage, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 3 out of 83 current residents, Resident (R) 2, R65, and R30. Observations on 11/11/2024 revealed Certified Nurse Aide 11 (CNA11) delivered a food tray to another room while still wearing her contaminated face shield that had been worn in a droplet/contact isolation room; and, CNA11 did not use the correct procedure to don (put on) and doff (remove) personal protective equipment (PPE) in a droplet/contact isolation room. The findings include: Review of the facility's policy titled, Infection Control, effective date 01/23/2024, revealed it was intended to help the facility maintain a safe, sanitary, and comfortable environment to prevent and manage transmission of diseases and infections. Additional review revealed the objectives of infection control policies and procedures were to prevent, detect, investigate, and control infections in the facility. Continued review revealed additional objectives included establishing guidelines for implementing Isolation Precautions including Standard and Transmission-Based Precautions. The policy revealed all personnel would be trained on infection control policies and practices upon hire and periodically on how to use pertinent procedures and equipment related to infection control. Review of the facility's policy titled, Transmission-Based Precautions, effective date 09/15/2023 and review date 06/12/2024, revealed Transmission-Based Precautions were initiated when a resident developed signs and symptoms of a transmissible infection or a laboratory confirmed infection and was at risk at transmitting the infection to other residents. Further review revealed Transmission-Based Precautions could include Contact Precautions, Droplet Precautions, or Airborne Precautions. Per the policy, when Transmission-Based Precautions were implemented, the Infection Preventionist, or designee clearly identified the precautions and the personal protective equipment (PPE) that must be used. The policy revealed posted signage informed staff on instructions for PPE. Review of the facility's signage (procedure to be used and posted by the resident's room) for Contact Precautions, from the CDC and undated, revealed the provider and staff must clean hands, put on gloves and gown, and discard them prior to exiting the room. Review of the facility's signage for Special Droplet/Contact Precautions, from the CDC and undated, revealed everyone must clean hands, wear PPE, which included face mask, eye protection, and gown and gloves at the resident's room door. The signage for removing PPE prior to exiting the room included removing goggles or face shield and place them in a receptacle if reusable, otherwise discard in the waste container. 1. Observation on 11/11/2024 at 9:10 AM revealed CNA11 exited R2's and R65's room with a face shield donned. Further observation revealed the residents' room was designated as a droplet/contact isolation room. Continued observation revealed CNA11 then delivered a food tray to room [ROOM NUMBER], which was not designated as a droplet/contact isolation room, wearing the same face shield. a. Review of R2's Face Sheet revealed the facility admitted the resident on 09/13/2017 with diagnoses to include chronic obstructive pulmonary disease (COPD), diabetes, and heart disease. Review of R2's Physician's Orders, placed on 11/05/2024, revealed they included COVID Isolation Droplet/Contact Precautions every shift. Review of R2's Comprehensive Care Plan (CCP), dated 11/05/2024, revealed a problem of infection control. Further review revealed the goal and approach was to maintain droplet/contact isolation precautions. b. Review of R65's Face Sheet revealed the facility admitted the resident on 04/16/2024 with diagnoses to include anemia, high blood pressure, and depression. Review of R65's Physician's Orders, placed on 11/05/2024, revealed they included COVID Isolation Droplet/Contact precautions every shift. Review of R65's CCP, dated 11/05/2024, revealed a problem listed as active infection: positive COVID-19. Further review revealed the goal and approach was to maintain droplet/contact isolation precautions. 2. Observation on 11/11/2024 at 4:45 PM revealed CNA11 donned PPE prior to entering R30's room, which was designated as a droplet/contact isolation room. Additional observation revealed CNA11 donned an N-95 mask (a more effective respirator/facepiece that filtered out 95 percent of airborne particles) over the top of the medical mask already donned and then entered the room. Continued observation revealed after CNA11 donned the PPE, she opened the door to R30's room, and while standing in the doorway she gave R30 a glass of water. Further observation revealed CNA11 then doffed the PPE in the doorway with the door open and discarded it in the waste receptacle inside the room. Review of R30's Face Sheet revealed the facility admitted the resident on 09/05/2024 with diagnoses to include cerebral infarction (stroke), congestive heart failure (condition where the heart did not pump blood as it should), and diabetes. Review of R30's Physician's Orders, placed on 11/05/2024, revealed they included COVID Isolation Droplet/Contact precautions every shift. Review of R30's CCP, dated 11/05/2024, revealed a problem listed as active infection: positive COVID-19. Further review revealed the goal and approach was to maintain droplet/contact isolation precautions. During an interview with CNA11 on 11/11/2024 at 4:45 PM, she stated she received training from the Staff Development Coordinator (SDC) on proper donning/doffing of PPE and had been trained to remove face shields after providing care to residents in isolation for COVID. The SDC stated it prevented the spread of germs. When interviewed why she had not removed her face shield after exiting a droplet/contact precautions room, she stated she got a little mixed up and should not have done it. During the interview she stated she had placed a N-95 mask over her medical mask, as it made her she feel safer, but she had not been trained to do this. During an interview with the Infection Preventionist/SDC on 11/14/2024 at 4:00 PM, she stated droplet/contact precaution signage was placed on room doors to ensure staff members knew the procedure for donning and doffing PPE. She stated training did not include to double mask prior to entering a droplet/contact precautions room because wearing a mask under an N-95 mask could interfere with the seal of the N-95 mask. When asked what staff was trained to do with face shields after using in a droplet/contact isolation room, she stated face shields should be removed and disposed with other PPE prior to exiting the room. She stated staff members were trained on this, and she expected them to follow their trainings to prevent the spread of infection. During an interview with the Director on Nursing (DON) on 11/15/2024 at 3:37 PM, she stated it was her expectation staff abided by the facility's policies. She stated it was important to follow infection control policies to prevent the spread of germs and decrease the risk of infection to staff and residents. During interview with the Medical Director on 11/14/2024 at 12:15 PM, he stated his expectations were for staff to follow trainings, policies, and procedures for infection control to prevent the spread of infections. When asked how often he was updated for COVID infections in the building, he stated he was updated weekly, and at this time, the cases were decreasing. During an interview with the Administrator on 11/14/2024 at 9:43 AM, he stated his expectation of staff was to follow infection control guidelines and COVID policies to keep residents safe. He stated he expected staff to follow all trainings performed by the SDC including for infection control. The Administrator stated there were no issues with the PPE and supplies were plentiful.

Based on interview, record review, review of the facility's policies, and review of the facility's investigation, the facility failed to have an effective system to ensure residents' baseline care plans were developed and implemented to include instructions needed to provide person-centered care related to residents assessed to be at possible risk of elopement for 1 of 39 sampled residents, Resident (R) 6, who exited the facility on 07/10/2023 without staff knowledge. On 07/18/2024 at 7:27 PM, the Chief Executive Office (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure elopement risk interventions were added to R6's baseline care plan to prevent elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.21 (F655). The IJ was determined to exist on 07/10/2023 when the facility discovered R6 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on 07/24/2024 at 11:27 AM. This plan alleged the IJ was removed, and the deficient practice was corrected on 07/14/2023, prior to the initiation of this investigation. The plan provided by the facility alleged the following: 1. On 07/10/2023 R6 was dressed in pants, pull over shirt, and tennis shoes. The temperature was 84 degrees Fahrenheit (F). R6 was placed on one-on-one supervision upon coming back into the facility on [DATE]. R6 was helped to her room and a head-to-toe assessment by the Director of Nursing (DON) was completed on 07/10/2023 with no injuries or concerns noted. R6 had a pain assessment completed by a licensed nurse on 07/10/2023 with no concerns identified. R6 had a new elopement risk assessment and a care plan update completed on 07/10/2023 by the RNC. R6 had a Brief Interview for Mental Status (BIMS) completed on 07/10/2023 with a score of 12 (moderate cognitive impairment). R6's physician and family were notified of the elopement on 07/10/2023. Certified Nurse Aide (CNA) 3 who was on her 15-minute break sitting in her car in front of the facility, saw R6 come outside. This CNA notified staff inside the facility by calling them on the phone while continually watching the resident until staff came out, and the resident went back inside the facility with staff. 2. A head count of all residents was completed by the Social Services Director (SSD) and the DON on 07/10/2023, and all residents were accounted for. The Director of Maintenance (DOM) rechecked all door locks and alarms, and all were in working order on 07/10/2023. The Regional [NAME] President (RVP) and Chief Executive Officer (CEO) also checked all door locks and alarms on 07/10/2023, and all were in working order. A review of all door checks for the previous 30 days before the elopement, 06/10/2023 to 07/10/2023, was performed by the RVP on 07/10/2023, and all checks had been completed. On 07/10/2023 the RVP reviewed elopement drills for the last 90 days, 04/10/2023 to 07/10/2023, and all had been completed. On 07/10/2023 the DON reviewed the last 30 days, 06/10/2023 to 07/10/2023, of events for current residents for any noted attempts of elopements. No concerns were identified. The RNC and the [NAME] President of Clinical Operations (VPCO) reviewed the last 30 days, 06/10/2023 to 07/10/2023, of progress notes looking for signs of elopement or exit seeking, and none were noted on 07/10/2023. All residents received a new elopement risk assessment on 07/10/2023 by the DON, Assistant Director of Nursing (ADON), Unit Manager (UM), or RNC. Any resident who was at risk based on the assessment had their care plan reviewed and revised as needed, and the elopement binders were reviewed to ensure residents were in the binder. 3. Initiated and completed on 07/10/2023, the RNC educated the CEO and the DON on the Comprehensive and Baseline care plan policies. Education was started on 07/10/2023 and was completed for all staff including clinical staff, housekeeping, dietary, administrative, business office, therapy, and activities by 07/11/2023 on the Comprehensive and Baseline care plan policies by the CEO, DON, UM, ADON, Minimum Data Set (MDS) Nurse Coordinator, or the RNC. A post-test was administered to all staff until a test score of 100% was achieved. Test questions were as follows: 1. What is a code green? 2. How do you know who is an elopement risk? 3. If you see a resident walking up to doors, pushing on doors, or talking of leaving, what should you do? 4. If a regular visiting family member asks for the door code, is it ok to give it to them? 5. If you hear a door alarm ringing, you go to the door, and you see no resident around, what should you do? 6. What is the difference in exit seeking and wandering? 7. How or where are interventions updated for exit seeking residents? 8. Where are the elopement books located? 9. What is tailgating? 10. What do you do when a code green is paged? 11. Do you let anyone out of exit doors if you are unsure if they are a resident? 12. How does anyone alert a nurse to a change in condition or behaviors of a resident? Any staff not educated by 07/11/2023, new staff, or new agency staff would be educated by the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC prior to them working. Starting on 07/10/2023, the post-test on the education of policies would be given to 15 random staff weekly for 30 days, then 10 random staff for the next 30 days, and then five random staff for the next 30 days to make sure staff members were retaining knowledge. A grade of 100% was required or re-education was to be completed. The post-test was to be administrated by the CEO, DON, ADON, UMs, or SSD. Starting on 07/11/2023, elopement drills would be conducted daily for 10 days by the Director of Maintenance (DOM) or Weekend Manager and then monthly thereafter. Starting on 07/13/2023, all residents' progress notes would be read seven days a week for any exit seeking behavior or elopement concerns by the CEO, DON, UM, SSD, ADON, or RNC for 30 days and then Monday through Friday in the daily clinical morning meeting for 60 days. Any resident identified would have an elopement assessment completed, and if determined to be at risk, would have interventions put in place, such as the care plans reviewed/revised as needed and the elopement binder reviewed/revised as needed. Starting on 07/13/2023 the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC would review all new admissions Monday through Friday with Saturday and Sundays being reviewed on Mondays. This would occur for 90 days to ensure any resident who was assessed on admission as being an elopement risk would have this on the baseline care plan or a comprehensive care plan and would be implemented addressing the elopement risk. 4. A Quality Assurance Performance Improvement (QAPI) meeting was held on 07/11/2023 to review this plan of correction. The QAPI committee members, the Medical Director, CEO, DON, Activities Director, UM, ADON, SSD, DOM, Therapy Director, and MDS Nurse Coordinator attended and would attend as able to do so. The Medical Director had no other recommendations. Starting on 07/11/2023 QAPI would be held weekly for four weeks. On 07/11/2023 the DOM, Rehabilitation Services Manager, MDS Nurse Coordinator, Activities Director, SSD, Medical Director, ADON, and the DON were present for the QAPI meeting. An Extended Survey was initiated on 07/15/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/30/2024. Based on the findings of this survey, it was determined the IJ was removed and the deficient practice was corrected as alleged on 07/14/2023, prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: Review of the facility's policy titled, Baseline Care Plan, revised 09/15/2023, revealed it was developed and implemented to increase resident safety and safeguard against adverse events that were most likely to occur right after admission. Per the policy, baseline care plans would be developed and implemented within 48 hours of a resident's admission. Review of the facility's policy titled, Elopement, revised 09/15/2023, revealed a care plan would be developed and implemented with interventions in place for each resident identified as an elopement risk. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating she was moderately cognitively impaired. Review of R6's electronic medical record (EMR) Face Sheet, revealed the facility admitted the resident on 06/30/2023 with diagnoses to include urinary tract infection, adult failure to thrive, and anxiety disorder. Review of R6's admission Observation Detail List Report, dated 06/30/2023, revealed R6 was assessed to be at risk for elopement. Review of R6's Baseline Care Plan, dated 06/30/2023 revealed no documented evidence the facility developed a care plan to address R6's risk for elopement. Review of the Facility Reported Incident, dated 07/10/2023, revealed R6 was observed by Certified Nurse Aide (CNA) 3 walking in the front parking lot at 10:37 AM unsupervised. In an interview with Registered Nurse (RN) 3 on 07/18/2024 at 4:20 PM, she stated the initial or baseline 48-hour care plans were completed by the nurses on the floor. She stated care plans could be created or revised by the Licensed Practical Nurse (LPN) or RN. She stated observation assessment documentation did not trigger for anything to be added to care plans. She stated nurses on the floor were expected to revise the care plan for any change in the resident's condition. She stated the facility had 21 days to complete the comprehensive care plan (after the comprehensive admission assessment was completed). She stated she assumes care plan changes get discussed at morning meetings with the clinical team after progress notes were reviewed. In an interview with the Director of Nursing (DON) on 07/18/2024 at 2:15 PM, she stated according to the baseline care plan policy, when the resident was assessed as being at risk for elopement, the nurse should have developed and implemented a care plan with interventions in place for the resident identified as an elopement risk. In an interview with the CEO on 07/30/2024 at 4:30 PM, she stated care plans were essential to providing resident-centered care for the resident, and it was her expectation that staff followed the care plan and revised them as necessary.

Based on interview, record review, review of the facility's policies, review of the facility's investigation, and review of the website Weatherchannel.com, the facility failed to have an effective system in place to ensure residents' safety for 1 of 39 sampled residents (Resident (R) 6). On [DATE], R6 eloped from the facility unescorted, unsupervised, and without staff knowledge. On [DATE] at 7:27 PM, the Chief Executive Officer (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from further elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The IJ was determined to exist on [DATE] when the facility discovered R6 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on [DATE] at 11:27 AM. This plan alleged the IJ was removed, and the deficient practice was corrected on [DATE], prior to the initiation of the investigation. The plan provided by the facility alleged the following: 1. On [DATE] R6 was dressed in pants, pull over shirt, and tennis shoes. The temperature was 84 degrees Fahrenheit (F). R6 was placed on one-on-one supervision upon coming back into the facility on [DATE]. R6 was helped to her room and a head-to-toe assessment by the Director of Nursing (DON) was completed on [DATE] with no injuries or concerns noted. R6 had a pain assessment completed by a licensed nurse on [DATE] with no concerns identified. R6 had a new elopement risk assessment and a care plan update completed on [DATE] by the RNC. R6 had a Brief Interview for Mental Status (BIMS) completed on [DATE] with a score of 12 (moderate cognitive impairment). R6's physician and family were notified of the elopement on [DATE]. Certified Nurse Aide (CNA) 3 who was on her 15-minute break sitting in her car in front of the facility, saw R6 come outside. This CNA notified staff inside the facility by calling them on the phone while continually watching the resident until staff came out, and the resident went back inside the facility with staff. 2. A head count of all residents was completed by the Social Services Director (SSD) and the DON on [DATE], and all residents were accounted for. The Director of Maintenance (DOM) rechecked all door locks and alarms, and all were in working order on [DATE]. The Regional [NAME] President (RVP) and Chief Executive Officer (CEO) also checked all door locks and alarms on [DATE], and all were in working order. A review of all door checks for the previous 30 days before the elopement, [DATE] to [DATE], was performed by the RVP on [DATE], and all checks had been completed. On [DATE] the RVP reviewed elopement drills for the last 90 days, [DATE] to [DATE], and all had been completed. On [DATE] the DON reviewed the last 30 days, [DATE] to [DATE], of events for current residents for any noted attempts of elopements. No concerns were identified. The RNC and the [NAME] President of Clinical Operations (VPCO) reviewed the last 30 days, [DATE] to [DATE], of progress notes looking for signs of elopement or exit seeking, and none were noted on [DATE]. All residents received a new elopement risk assessment on [DATE] by the DON, Assistant Director of Nursing (ADON), Unit Manager (UM), or RNC. Any resident who was at risk based on the assessment had their care plan reviewed and revised as needed, and the elopement binders were reviewed to ensure residents were in the binder. 3. Initiated and completed on [DATE], the RNC educated the CEO and the DON on the Comprehensive and Baseline care plan policies. Education was started on [DATE] and was completed for all staff including clinical staff, housekeeping, dietary, administrative, business office, therapy, and activities by [DATE] on the Comprehensive and Baseline care plan policies by the CEO, DON, UM, ADON, Minimum Data Set (MDS) Nurse Coordinator, or the RNC. A post-test was administered to all staff until a test score of 100% was achieved. Test questions were as follows: 1. What is a code green? 2. How do you know who is an elopement risk? 3. If you see a resident walking up to doors, pushing on doors, or talking of leaving, what should you do? 4. If a regular visiting family member asks for the door code, is it ok to give it to them? 5. If you hear a door alarm ringing, you go to the door, and you see no resident around, what should you do? 6. What is the difference in exit seeking and wandering? 7. How or where are interventions updated for exit seeking residents? 8. Where are the elopement books located? 9. What is tailgating? 10. What do you do when a code green is paged? 11. Do you let anyone out of exit doors if you are unsure if they are a resident? 12. How does anyone alert a nurse to a change in condition or behaviors of a resident? Any staff not educated by [DATE], new staff, or new agency staff would be educated by the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC prior to them working. Starting on [DATE], the post-test on the education of policies would be given to 15 random staff weekly for 30 days, then 10 random staff for the next 30 days, and then five random staff for the next 30 days to make sure staff members were retaining knowledge. A grade of 100% was required or re-education was to be completed. The post-test was to be administrated by the CEO, DON, ADON, UMs, or SSD. Starting on [DATE], elopement drills would be conducted daily for 10 days by the Director of Maintenance (DOM) or Weekend Manager and then monthly thereafter. Starting on [DATE], all residents' progress notes would be read seven days a week for any exit seeking behavior or elopement concerns by the CEO, DON, UM, SSD, ADON, or RNC for 30 days and then Monday through Friday in the daily clinical morning meeting for 60 days. Any resident identified would have an elopement assessment completed, and if determined to be at risk, would have interventions put in place, such as the care plans reviewed/revised as needed and the elopement binder reviewed/revised as needed. Starting on [DATE] the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC would review all new admissions Monday through Friday with Saturday and Sundays being reviewed on Mondays. This would occur for 90 days to ensure any resident who was assessed on admission as being an elopement risk would have this on the baseline care plan or a comprehensive care plan and would be implemented addressing the elopement risk. 4. A Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] to review this plan of correction. The QAPI committee members, the Medical Director, CEO, DON, Activities Director, UM, ADON, SSD, DOM, Therapy Director, and MDS Nurse Coordinator attended and would attend as able to do so. The Medical Director had no other recommendations. Starting on [DATE] QAPI would be held weekly for four weeks. On [DATE] the DOM, Rehabilitation Services Manager, MDS Nurse Coordinator, Activities Director, SSD, Medical Director, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. Weekly QAPI meetings were held to discuss reportables, elopement education, to review audits, to verify this plan was working, and to achieve compliance. QAPI meetings would then go to monthly thereafter. The QAPI committee would make any recommendations or changes to this plan if compliance was not being achieved. There were no concerns with compliance through the QAPI process. An Extended Survey was initiated on [DATE], and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. Based on the findings of the survey, it was determined the IJ was removed and the deficient practice was corrected as alleged on [DATE], prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: Review of the facility's policy titled, Elopement, revised [DATE], revealed each resident should be evaluated for elopement risk upon admission and re-evaluated as needed. Additionally, a care plan would be developed and implemented with interventions in place for each resident identified as an elopement risk. Review of R6's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include urinary tract infection, adult failure to thrive, and anxiety disorder. Further review revealed R6 was discharged from the facility on [DATE] at 6:03 PM and sent to an acute care facility for an evaluation. Review of R6's admission Observation Detail List Report, dated [DATE], revealed R6 was assessed to be at risk for elopement. Review of R6's Baseline Care Plan, dated [DATE], revealed no documented evidence the facility developed a care plan to address R6's risk for elopement. Review of R6's quarterly MDS, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating she was moderately cognitively impaired. The MDS also revealed R6 required partial/moderate assistance with ambulation. Review of R6's Progress Note, dated [DATE], revealed R6 was seen by Licensed Practical Nurse (LPN) 1, walking up the hall with her belongings packed stating she was going to be picked up by the sheriff. Review of R6's Progress Note, dated [DATE], by Registered Nurse (RN) 1 revealed R6 exhibited more confusion than she did on [DATE]. Review of the Facility Reported Incident, dated [DATE], revealed R6 was observed by CNA3 walking in the front parking lot on [DATE] at 10:37 AM unsupervised, and the facility was unable to determine the cause of the elopement. According to the internal investigation documentation, the Weather Channel revealed the outside temperature for [DATE] was 86 degrees F, sunny skies with a breeze. This was verified by the State Survey Agency (SSA) Surveyor at Weatherchannel.com. In an interview with R6's daughter and emergency contact on [DATE] at 9:22 AM, the daughter stated R6 was confused and recently diagnosed with dementia by two separate hospitals. The daughter stated R6 was admitted to the facility on [DATE] to be with her spouse, who had suffered a heart attack a couple of days after R6's arrival to the facility and was transferred to a local hospital. The daughter stated R6's spouse expired the day she eloped from the facility. The daughter stated the facility's staff reported to her that R6 walked out the front door. She stated the facility's staff told her R6 was dressed in normal clothing, and staff failed to recognize R6 was not a visitor. She stated the facility's staff told her R6 had told staff she was going to visit her spouse. In an interview with CNA3 on [DATE] at 12:00 PM, she stated she was the aide who witnessed R6 in the facility's parking lot. She stated the facility had conducted an elopement drill earlier that morning. She stated after the elopement drill, CNA3 went out of the building at 10:30 AM to take a 15-minute break in her car. She stated she saw R6 walking outside in the parking lot approximately 20 feet from the building's entrance, and she recognized R6. She stated she then called CNA1, who was working inside the building, to ask about R6 being outside. She stated staff immediately came out and helped assist R6 back inside. According to CNA3, R6 stated she was going to the hospital to see her husband. When CNA3 was asked how R6 exited the building, CNA3 stated, I'm guessing she followed someone out. CNA3 stated she was parked in the fourth spot on the north side of the facility, and R6 was seen walking away from the building toward the road and was approximately 20 feet from the front door at the round landscaping circle area. In an interview with LPN1 on [DATE] at 8:02 PM, she stated R6 was mostly confused. LPN1 stated she felt R6 was an elopement risk the day she was assigned to her on [DATE]. LPN1 stated she did not remember if the provider was notified regarding R6's increased confusion and wandering behaviors. A telephone interview with RN5, who was present at the time of the elopement and one of R6's nurses, was attempted on [DATE] at 3:00 PM and again at 7:45 PM. Voice messages were left by the SSA Surveyor for a return call; however, no return call was received. In an interview with the Business Office Manager (BOM) on [DATE] at 9:15 AM, she stated she was working the front desk the day of the incident. She stated her job during the elopement drill was to watch/check the front desk, front door, front porch, and front conference room. She stated she was not familiar with the resident and did not know what R6 looked like. The BOM stated she did not remember if she opened the door or if she was at the front desk at the time of the elopement. In an interview with the former Social Worker (SW) on [DATE] at 9:20 PM, she stated R6 was alert and oriented with intermittent confusion, and sundowning (when residents with dementia experience increased confusion and wandering from late afternoon into the night) was a concern. In an interview with the DOM on [DATE] at 3:45 PM, he stated he was working the day of the elopement; however, he did not know how R6 got out. He stated the surveillance cameras were updated after [DATE], and therefore no surveillance tapes were available for review. In an interview with the ADON on [DATE] at 1:13 PM, she stated R6 arrived at the facility to be with her spouse, who was a resident at the facility. She stated CNA3, who was taking a break and sitting in her car in the front parking lot, called into the building to ask if R6 was allowed to be outside unsupervised, and CNA3 was told no. She stated staff then went out to bring R6 back inside the building. She stated she attempted to call and notify R6's spouse, since he was listed as next of kin and was in the hospital, and then called R6's daughter and made her aware of the elopement. The ADON stated, I assumed the resident got out by tailgating behind someone else leaving. In an interview with the DON on [DATE] at 2:15 PM, she stated it was her expectation that the staff member responsible for managing the front door would ensure that no resident walked out behind any visitor, and they should verify the door was fully closed to prevent an elopement. In an interview with the CEO on [DATE] at 1:40 PM, she stated she was scheduled to be off work the day of the incident. She stated she was not in the building at the time of the elopement and was called into the facility after the elopement occurred. The CEO stated R6 made it to the front of the building and was brought back in by CNAs. She further stated elopement education was provided to all staff. The CEO stated she was unsure how R6 exited the building.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide a safe, clean, comfortable, and home like environment for all of the 77 current residents. Observation throughout the survey dates, 07/15/2024 to 07/30/2024, revealed gnats were in the building and observed in resident rooms [ROOM NUMBERS], the conference rooms, hallways in the North and South Wings, the kitchen, the day room on the North Wing, and in the dining room. Interviews with residents and staff revealed gnats had been an ongoing concern in the facility. The findings include: Review of the facility's policy titled, Resident Rights, revised 09/15/2023, revealed all residents would be treated in a manner and in an environment that promoted maintenance of enhancement of quality of life. Review of the pest control company's contract revealed the facility contracted with the service on 06/01/2015 to provide monthly and as needed pest control. Review of the pest control company's invoices service documentation revealed the company noted that sanitation issues in the kitchen could cause pest problems as follows: 1) the invoice dated 01/11/2024 revealed the floor under the cook/steam line was in need of cleaning, and the dishwasher area and under the shelves needed to be scrubbed; 2) the invoice dated 02/28/2024 noted trash cans in the kitchen area needed cleaning to reduce pest attraction and source of breeding and, to help prevent pest breeding sites, the facility needed to clean regularly in and around the cook line and floor drains where food debris and build up was found; 3) the invoice dated 03/18/2024 noted, to prevent the pest breeding sites, the area around the floor drains needed to be cleaned; 4) the invoice dated 04/25/2024 revealed there were structural concerns that could cause pest problems in the kitchen to include loose or missing floor tiles, baseboards, and floor grout lines, which were worn in the dish room area allowing water and food debris to accumulate and providing a breeding location for small flies which contributed to pest problems, and food debris found under the shelves and in the cook line and floor drains were in need of cleaning and was going to be a bad issue if we don't get the drains cleaned with flies - grease build up in/on/by and by residue and film build up on the kitchen floor and by dishwasher area. Please clean. Additional review of the pest control company's invoices service documentation revealed 5) the invoice dated 06/12/2024 noted small flies in the kitchen area underneath the counter and sink where dishes were washed with food materials and excess water found on the floor and in the dish area under the sink which were a breeding ground for fruit flies, and instructions included, Please clean to reduce pest attraction and source for breeding; 6) the invoice dated 06/19/2024, revealed the facility requested an as needed service to address small flies. According to the service report its purpose was to provide and identify sanitation deficiencies contributing to pest infestations. Per the comments, the kitchen was the source of the infestation, and the facility needed to address sanitation concerns in the kitchen to control pests. The report cited under the sink, underneath the counters, and the dishwashing area needed to be scrubbed and cleaned to prevent small flies feeding off of the biofilm on the walls and the undersides of the stainless steel equipment. It stated, It's unlikely the problem will get better if this issue isn't resolved first. 1. Observation of room [ROOM NUMBER] on 07/15/2024 at 2:10 PM, revealed there were several gnats flying around the room. The State Survey Agency (SSA) Surveyor attempted an interview with Resident (R) 2, who resided in room [ROOM NUMBER], on 07/15/2024 at 2:10 PM; however, the resident was uninterviewable. In an interview with R2's daughter on 07/16/2024 at 4:30 PM, she stated, There are gnats everywhere. She stated she had made complaints to the Director of Nursing (DON) and the Chief Executive Office (CEO), but stated, Nothing is done about it [the gnats]. 2. Observation of room [ROOM NUMBER] on 07/15/2024 at 2:25 PM, revealed there were several gnats flying around the room. Also, gnats were observed on R1's food, which was left over from lunch. In an interview with R1, who resided in room [ROOM NUMBER], on 07/15/2024 at 2:25 PM, she stated she had gnats in her room all the time, and they bothered her when she ate. R1 stated she did not remember anyone coming in her room to treat bugs. 3. Observation in the front hall on the South Wing on 07/16/2024 at 2:56 PM revealed there were gnats, and there were no food carts in the hallway at the time of the observation. 4. Observation in the front hall of the North Wing on 07/17/2024 at 12:56 PM revealed there were gnats. Further observation revealed that gnats were in the day area and near the nurse's station. Also, residents were eating lunch in their rooms, and meal carts were out in the hall. 5. Observation of the North Wing nurse's station on 07/22/2024 at 5:30 AM revealed there were gnats present . During an interview with R3 on 07/15/2024 at 2:15 PM, she stated she had observed gnats in her room on multiple occasions. R3 further stated gnats had been a problem in the facility for at least several months. She stated the gnats were annoying, especially when she was trying to eat her meals. R3 stated she did not remember anyone coming in her room to treat bugs. During an additional interview with R3 on 07/22/2024 at 1:45 PM, she stated gnats were flying in the building. During an interview with R9 on 07/22/2024 at 1:30 PM, R9 stated there were gnats flying around when eating meals. During an interview with Certified Nurse Aide (CNA) 4 on 07/22/2024 at 7:12 AM, she stated gnats were seen everywhere. She stated uncovered food contributed to the problem, and a particular resident liked to leave her food out in her room for an extended amount of time. During an interview with CNA5 on 07/22/2024 at 7:40 AM, she stated there were gnats everywhere, but there were not as many as she had noticed in the past. She stated that if residents saw gnats, they could report it to the nurse or maintenance. During an interview with CNA20 on 07/24/2024 at 4:34 PM, she stated she noticed gnats in the facility during the summertime. During an interview with Licensed Practical Nurse (LPN) 5 on 07/24/2024 at 11:00 AM, she stated gnats were a problem in the facility. During an interview with LPN9 on 07/26/2024 at 4:00 PM, she stated there were gnats in the facility. She stated the problem was from residents who kept food in their rooms. LPN9 further stated staff would check resident rooms for open containers or food left out and encourage residents to put food away or discard. She stated that if staff saw gnats, she could report it to maintenance. During an interview with the Director of Maintenance (DOM) on 07/17/2024 at 2:10 PM, he stated the facility had a full service contract with a pest control company. He stated the pest control company provided routine and as needed pest control services to the facility. The DOM stated, The gnats are bad. He further stated the pest control company had been out to treat for gnats, but they were not controlled. He stated the most recent routine service was on 07/08/2024, and at that time, no issues of concern were noted. The DOM further stated some residents kept food in their rooms, contributing to the gnat problem. During an interview with the Regional Nurse Consultant (RNC) on 07/30/2024 at 4:05 PM, she stated it was her expectation the facility was clean and maintained in such a manner to promote a homelike environment within the guidelines. She stated it was important because this was the residents' home. During an interview with the Chief Executive Officer (CEO) on 07/30/2024 at 4:30 PM, she stated she was aware of gnats but was unaware of where they were coming from. She stated the DOM was responsible for overseeing the contract with the pest control company. She stated she had the pest control company out multiple times whenever there was a concern with gnats. Per interview, the CEO stated it was her expectation for departmental leadership to ensure staff followed facility policies to provide a homelike environment and enhance the quality of life for all residents. She stated it was essential to maintain a pest control program and adhere to cleanliness to inhibit insects in the building to ensure residents were safe and to maintain a happy, healthy, and comfortable environment. 51155

Based on interview, record review, and review of the facility's policies, the facility failed to maintain correct recordkeeping of all controlled drugs on four of four medication carts, which ensured an accurate inventory of medications by accounting for controlled medicines the facility received, dispensed, and administered affecting 77 out of 77 residents. The facility failed to ensure individual residents' narcotic records were documented as signed when a controlled substance was administered for 2 of 39 sampled residents (Resident (R) 8 and R18). Additionally, the facility failed to provide pharmaceutical services, including dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 out of 39 sampled residents (R30). Review of narcotic count sheets for four of four medication carts revealed staff failed to sign inventory sheets for controlled narcotics, sign narcotic count sheets at the change of shift, and sign narcotic sheets prior to shift's end. Additionally, licensed staff failed to sign out narcotic medications as given to R8 and R18. Review of R30's medication administration record (MAR) revealed that Licensed Practical Nurse (LPN) 12 signed out three narcotic pills as being given, but LPN12 did not administer the medication to R30. Additionally, LPN12 signed out one dose of a narcotic analgesic administered by LPN4. The findings include: Review of the facility's policy titled, Controlled Medication, dated 05/30/2024, revealed the facility would ensure controlled medications were handled, stored, and disposed of, and record keeping was in place in accordance with federal, state and other applicable laws and regulations. Further review of the policy revealed that at shift change or when the keys were rendered a physical inventory of all controlled medications was conducted by two licensed nurses/medication aide and was documented on the controlled medication accountability record. Per the policy, the off going nurses/medication aide, along with the nurses/medication aide assuming the keys, would review, locate, and count the controlled medication accountability record for each resident's medication. Both nurses/medication aides would ensure the count of the remaining medications matched the medication accountability book and verify together the correct or incorrect accounting of the medication. Review of the facility's policy titled, Medication Administration, dated 09/2018, revealed medications were to be administered as prescribed and in accordance with good nursing practices. Further review of the policy revealed the individual who administered the medication dose recorded the administration on the resident's MAR immediately following the medication being given. According to the policy, staff should not report off duty without first recording the administration of any medication. The resident's MAR was initialed by the person administrating the medication in the space provided under the date and on the line for that specific medication dose administration and time. 1. a. Review of the Controlled Substance Count sheet for South Wing Front Hall on 07/24/2024 at 10:35 AM, revealed Kentucky Medication Aide (KMA) 1 did not sign the sheet when she came on shift according to the facility's policy. During an interview with KMA1 on 07/24/2024 at 10:35 AM, she stated the oncoming nurse counted the narcotic cards in the locked narcotic drawer, and the offgoing nurse had the narcotic inventory sheets and read them off. She stated both nurses ensured all narcotics were accounted for. She stated if the count was incorrect, the nurses notified the DON. She stated both should sign the narcotic sheets, signifying they counted, and it was correct. Additionally, KMA1 stated the nurse/medication aide should not sign the Controlled Substance Count sheet ahead of time or sign out narcotics medication unless the nurse/medication aide administered them to the resident. She stated following facility policy regarding verifying the narcotic count was important for the safety of residents and staff. Review of the Controlled Substance Count sheet for the North Wing revealed LPN3 did not sign the inventory shift count as the oncoming nurse on 07/24/2024. Additionally, LPN3 had signed as the offgoing nurse in a blank spot without a date. During an interview with LPN3 on 07/24/2024 at 10:55 AM, she stated that she did the narcotic count with the offgoing nurse but failed to sign the Controlled Substance Count sheet. She stated she should not have documented that she signed the sheet ahead of actually doing the count. She stated following facility policy related to verifying the narcotic count was important for the safety of residents and staff. She stated accurate documentation protected the nurse's license. Further review of the Controlled Substance Count sheets for North Wing revealed there was a missing second signature on 06/30/2024 for the subtraction of one Oxycodone (an opioid pain reliever) 10 mg card; on 07/02/2024 for the addition of two Lorazepam (an anti-anxiety agent) 0.5 mg cards; on 07/17/2024 for the addition of two Oxycodone 10 mg cards; on 07/18/2024 for the subtraction of one Norco (an opioid pain reliever) 5/325 mg card and for the addition of one Norco 10/325 mg card; on 07/19/2024 for the subtraction of one Hydrocodone (an opioid pain reliever with no dose was indicated) card; on 07/22/2024 for the addition of one Norco 10/325 mg card; and on 7/23/2024 there was a missing second signature for the subtraction of one Oxycodone (no dose was indicated) card. b. Review of R8's Individual Patient's Narcotic Record for Gabapentin (pain reliever for nerve pain and an ant-convulsant) 600 milligrams (mg), revealed on 07/22/2024 at 8:11 PM, the medication was not signed out as administered, yet it was marked as subtracted from the count in the narcotic record. c. Review of R18's Individual Patient's Narcotic Record for Acetaminophen with Codeine, revealed on 07/19/2024 at 11:00 AM, the medication was not signed out as administered, yet it was marked as subtracted from the count in the narcotic record. During an interview with LPN5 on 07/24/2024 at 10:25 AM, she stated narcotics should be signed out at the time of administration, and stated, You document after you give it. 2. Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Review of R30's electronic medical record (EMR) Physician Orders, dated 10/01/2023, revealed the physician ordered hydrocodone-acetaminophen 10/325 mg two tablets by mouth two times per day as needed for pain. Review of R30's EMR Physician Orders, dated 10/06/2023, revealed the physician ordered hydrocodone-acetaminophen 10/325 mg one tablet by mouth two times per day. Review of the narcotic count sheets for R30's hydrocodone-acetaminophen 10-325 mg, one tablet by mouth, two times per day, revealed on 10/17/2023 the paper count showed LPN12 signed out four hydrocodone tablets at 8:00 AM and 12:00 PM and two tablets at 6:00 PM. The State Survey Agency (SSA) Surveyor attempted to interview LPN12. However, the facility did not have a telephone number for the nurse. The SSA Surveyor attempted to interview LPN4 on 07/24/2024 at 11:00 AM. However, there was no answer on her phone. LPN4 had recently resigned from the facility. During a telephone interview with the former Director of Nursing (DON) on 07/24/2024 at 11:12 AM, she stated she was not working on 10/17/2023, and the Chief Executive Officer (CEO) prepared an investigative report. During an interview with the CEO on 07/24/2024 at 5:00 PM, she stated on 10/17/2023 there was a call-in for the shift and she was down one nurse. She stated she contacted a nurse agency service to get a replacement nurse. She stated LPN12 accepted the shift and began working at 11:00 AM. Per the CEO, the LPN4 was on the medication cart and surrendered the narcotic keys to LPN12 when she arrived at the facility. She stated the count was correct. The CEO stated that around 5:00 PM that evening she received a phone call from a colleague who informed her that LPN12 had been reported to the state Board of Nursing for diversion of narcotic pain medications. The CEO stated she went to the medication cart and told LPN12 because she was under investigation for drug diversion, she would need to leave the facility. The CEO stated she escorted LPN12 out of the facility. The CEO stated, when LPN4 took over the cart after the agency nurse was told to leave, LPN4 and the CEO performed a narcotic count and discovered three hydrocodone-acetaminophen 10/325 mg tablets were missing. During the continued interview with the CEO on 07/24/2024 at 5:00 PM, she stated R30 told her R30 received her scheduled 8:00 AM dose of hydrocodone-acetaminophen 10/325, which was administered by LPN4. However, according to the CEO, LPN4 did not sign the Controlled Drug Record sheet to document the medication was given. Per the CEO, LPN12 initialed Controlled Drug Record sheet #1, indicating she had given the 8:00 AM dose. The CEO stated she could not explain why LPN12 initialed it for LPN4. Additionally, the CEO stated LPN12 documented on Controlled Drug Record sheet #1 that she administered three additional hydrocodone-acetaminophen 10/325 mg tablets at 12:00 PM and 6:00 PM and then signed out another hydrocodone-acetaminophen 10/325 mg tablet at 6:00 PM as given on Controlled Drug Record sheet#2. The CEO stated the inventory was correct for the amount of medication that was signed out, but three pills were not administered to R30. per R30. The CEO stated R30 told her she received her 8:00 AM dose but did not receive any of the pain medication signed out as given during the day. Furthermore, the CEO stated she contacted the police and the state Board of Nursing. She stated the facility reimbursed R30 for the missing medication. During an interview with LPN11 on 07/25/2024 at 4:20 PM, she stated per policy, narcotics should be signed out at time of administration and two nurses were required to perform the controlled substance count. She stated following policy was important to prevent drug diversion. During an interview with Registered Nurse (RN) 4 on 07/25/2024 at 4:25 PM, she stated per policy, narcotics should be signed out at time of administration and two nurses were required to perform the controlled substance count. She stated following policy was important for the safety of residents and nursing staff. She stated ensuring an accurate count at the beginning of the shift helped to prevent drug diversion, which could impact a nurse's license. During an interview with the Infection Prevention/Staff Development Coordinator (IP/SDC) on 07/24/2024 at 10:50 AM, she stated narcotics should be signed out at time of administration, and all narcotic inventory sheets should be signed by two nurses when inventory was received or removed. The IP/SDC stated that following facility policy regarding verifying the narcotic count was important for the safety of residents and staff. She further stated that accurate documentation protected the nurse's license. During an interview with the Assistant Director of Nursing (ADON) on 07/25/2024 at 4:12 PM, she stated the oncoming nurse counted the controlled substances located in the locked narcotic drawer, and in contrast, the offgoing nurse had the Controlled Substance Count sheets and read them off. She stated both nurses ensured the accuracy of the narcotics count. She stated if the count was incorrect, they notified the DON. She stated both nurses should sign the narcotic sheets, signifying they had completed the count, and it was correct. The ADON stated a nurse should never sign the Controlled Substance Count sheets ahead of time or sign out a narcotic substance unless the nurse had administered the medication to the resident. The ADON stated this was important to keep an accurate narcotic count, adhere to facility policy, and protect the license of the nurses. During an interview with the Interim DON (IDON) on 07/30/2024 at 3:45 PM, she stated all licensed staff should follow facility policy regarding verifying the narcotic count because it was important for the safety of residents and staff. She further stated that accurate documentation protected the nurse's license. During an interview with the Regional Nurse Consultant (RNC) on 07/30/2024 at 4:05 PM, she stated it was her expectation that licensed nurses and KMAs followed facility policy concerning signing out controlled medication when given and verifying the narcotic count sheets with the addition and removal of narcotic cards. The RNC stated the facility's nurses and KMAs needed education. Additionally, the RNC stated her expectation moving forward was that the DON would be the leader of the nursing team and should ensure that nursing staff performed a complete and accurate narcotic drug count according to guidelines. She stated this was important for the safety of residents and staff and for maintaining accurate narcotics accounting to prevent diversion. During an additional interview with the CEO on 07/30/2024 at 4:30 PM, she stated it was her expectation that licensed nurses and KMAs follow facility policy regarding verifying the narcotic count because it was important for the safety of residents and staff and to prevent the diversion of narcotics.

Based on observation, interview, record review, and review of the contracted company's policies and documents, it was determined the facility failed to maintain the kitchen in a safe and sanitary manner. This affected all 77 current residents. Observation of the kitchen revealed areas under counters, sinks, and prep areas were dirty with debris and dirty build up. Observation of the kitchen wash area revealed food stains on the walls, the floor, the area around the window, sink area, and under the sink. There was debris on the floor. Further observation revealed gnats flying near the dirty sink area. The findings include: Review of the Contract between the facility and the facility's contracted company, undated, revealed the company was responsible for routine cleaning and sanitation in the food preparation and service areas including dietary service equipment, daily kitchen floor cleaning, all kitchenware and food contact surfaces, and daily cleaning of cooking surfaces, at such intervals as to keep them in a clean and sanitary condition. Furthermore, the Contract revealed the Registered Dietitian (RD) shall inspect all areas of the dietary department including but not limited to sanitation equipment functioning and compliance with pertinent federal state and local laws. Review of the contracted company's policy titled, Environment, revised 09/2017, revealed all food preparation areas, food service areas, and dining areas would be maintained in a clean and sanitary condition. Per the policy, the Dietary Manager (DM) would ensure the kitchen was maintained in a clean and sanitary manner including floors, walls, ceilings, lighting, and ventilation. Per the policy, the DM would ensure that a routine cleaning schedule was in place for all cooking equipment food storage areas and surfaces. Review of the contracted company's policy titled, Equipment, 09/2017, revealed all food service equipment would be clean, sanitary, and in proper working order. Review of the contracted company's job description Dining Services Account Manager (DM), no date, revealed the DM managed the dining services program in a single site according to the contracted company's policies and procedures and federal and state requirements. The DM's responsibilities included touring the kitchen several times per day to assess work quality. Per the job description, the DM was a department head in the facility and must conduct themselves and their department in a professional manner. Additionally, the DM ensured established sanitation and safety standards were maintained. Review of the facility's document Kitchen Cleaning Checklist and Expectation In-service, dated 07/10/2024, revealed all employees were required to take part in the daily/weekly checklists posted in the kitchen. According to the in-service, all kitchen staff members should clean their workstations as they work and after using any equipment. Also, the in-service stated at the end of the day, staff should make sure that all equipment was wiped down following the daily or weekly checklist, and the account manager would oversee the completion of all tasks by the kitchen staff. Review of the contracted company's Facility Visit Recap Report, dated 06/26/2024, 07/12/2024, and 07/15/2024, revealed no observation or notes related to the cleanliness of the kitchen by the RD. Observation of the kitchen, during the tour on 07/17/2024 at 1:50 PM, revealed areas under shelving, counters, sinks, and prep areas were dirty with food debris, dust, and dirt. Paper wrappers, napkins, straws, and straw wrappers were also observed on the floor. There was thick, black grease and dirty build up on the stove hood and frying equipment. Continued observation of the kitchen showed areas had food stains on the walls, floor, the area around the window, sink area, and under the sink. Observation near the floor drain revealed several gnats were observed flying near the drain. During an interview with Dietary Aide (DA) 2 on 07/25/2024 at 2:00 PM, she stated staff followed the cleaning schedule in the kitchen. She further stated the kitchen staff had recently had an in-service on completing daily/weekly tasks. Additionally, DA2 stated it was important to keep the kitchen clean to prevent contamination and disease. During an interview with the Dietary [NAME] on 07/25/2024 at 2:05 PM, she stated all kitchen staff followed a cleaning schedule to include cleaning up as you go when cooking or preparing for meals. She stated equipment was cleaned on a regular basis. Additionally, she stated it was important to keep the kitchen clean and sanitary to prevent foodborne illnesses. During an interview with the DM on 07/17/2024 at 1:55 PM, she stated the kitchen was cleaned routinely according to the cleaning checklist schedule. She stated she had not noticed gnats since the kitchen drain had been cleaned. During an additional interview with the DM on 07/30/20204 at 11:25 AM, she stated there was a daily schedule for cleaning. The DM stated that all equipment was wiped down after use, the dish room was cleaned three times daily, and all other equipment was cleaned at least twice a month or as needed. She stated one specific area of the kitchen was scheduled for a weekly deep clean, for example, the refrigerator on one day and the stove on another. When asked about the unclean condition of the kitchen during observation by the State Survey Agency (SSA) Surveyor, she attributed it to being short-staffed at the time and assured the kitchen was fully staffed now. Additionally, the DM stated she had provided new training, had in-serviced staff on the cleanliness of the kitchen, and would adhere to a daily and weekly cleaning schedule. She stated it was her expectation that all staff did their daily assignments, and she would hold them accountable. She stated having a sanitary kitchen was necessary for the safety of residents and to prevent the spread of infection and disease. During an interview with the Regional Dietary Manager (RDM) on 07/30/20204 at 11:25 AM, he stated he was in the facility twice monthly; however, he stated that the RD was in the facility weekly, and provided observation and plans of correction if deficiencies were found. He stated the kitchen was not clean at the time of the SSA Surveyor's observations. He stated staffing issues had contributed to routine tasks being delayed. He stated, I don't want to eat anywhere where it [kitchen] isn't clean. Seeing the kitchen this week was an eye-opener. The RDM stated it was his expectation the kitchen remained clean and sanitary. He stated a clean and sanitary kitchen was important to prevent infection control issues such as insects, pests, and foodborne illnesses. During a telephone interview with the RD on 07/30/20204 at 1:00 PM, she stated she provided an inspection once a month and would document any issues on an audit form. She stated the form was given to the facility's Chief Executive Officer (CEO), the DM, and the RDM. Per interview, the RD's last visit was on 07/11/2024, and she didn't notice anything major. She stated the kitchen normally was kept clean. The RD stated it was her expectation that staff was cleaning up after themselves and following the cleaning schedule. The RD stated it was important because the kitchen had the potential to put the residents at risk for foodborne illnesses. During an interview with the Director of Maintenance (DOM) on 07/17/2024 at 2:10 PM, he stated the facility had a full service contracted company to provide for the day to day running of the kitchen. He stated the facility had a contracted pest control company to provide routine and as need pest control services to the facility. The DOM stated, The gnats are bad. He stated the pest control company had been to the facility to treat for gnats, but they were not controlled. He stated the most recent routine service was on 07/08/2024, and at that time no issues of concern were noted. During an interview with the Regional Nurse Consultant (RNC) on 07/30/2024 at 4:05 PM, she stated it was her expectation that the kitchen was clean and maintained in such a manner to promote a homelike environment within the guidelines. She stated it was important because this was the residents' home, and an unsanitary kitchen was an infection control issue and had the potential to put residents at risk. During an interview with the CEO on 07/30/2024 at 4:30 PM, she stated kitchen staff should follow cleaning schedules to maintain a sanitary environment. She stated the facility had contracted out its dietary services to a third-party service group. The CEO stated her role related to dietary services was to ensure adequate food inventory and audit the kitchen for safety and cleanliness. The CEO stated the frequency of audits varied, but she did not have any documentation of auditing the kitchen for cleanliness. She stated she was not aware of the condition of the kitchen. The CEO stated the last three kitchen reports, from the contracted company and completed by the RD, did not show any concerns related to cleanliness of the kitchen. The CEO stated it was important to maintain a clean kitchen to ensure a safe and healthy environment for the residents.

Based on observation, interview, record review, review of the facility's policies, review of the Center for Medicare and Medicaid Services (CMS) memo, and review of the directions for use (DFU) of disinfecting products, the facility failed to identify and correct problems related to infection prevention practices for 3 out of 39 sampled residents (Resident (R) 4, R31, and R32). This failure placed the residents at increased risk for healthcare-associated infections (HAI). Observation of R4's room revealed there was a personal protective equipment (PPE) container outside of the room. There was no sign on the door indicating it was a Contact/Droplet isolation room. Interviews revealed R4 was tested and suspected to be COVID-19 positive. Observation of the Assistant Director of Nursing (ADON) revealed she did not wear gloves when administering eye and nose drops to R31 and did not perform hand hygiene after providing care to R31. Additionally, the ADON did not don (put on) PPE before entering R32's room with enhanced barrier precautions (EBP) and did not clean and disinfect a portable blood pressure cuff and pulse oximeter correctly after using them on R32. Observation of Certified Nurse Aide (CNA) 2, revealed he wore contaminated gloves in the hall and failed to perform hand hygiene after doffing (taking off) the gloves. Observation of the Business Office Manager (BOM) revealed she failed to don PPE before entering room H, a Contact precaution room. The findings include: Review of the Center for Medicare and Medicaid Services (CMS) memo titled, QSO-24-08-NH, dated 03/20/2024, revealed Enhanced Barrier Precautions (EBP) were recommended for residents with chronic wounds or indwelling medical devices and during resident care activities regardless of their multidrug-resistant organism (MDRO) status. EBPs were used in conjunction with standard precautions and expanded the use of PPE to donning of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. Review of the facility's policy titled, Infection Control, dated 01/24/2024, revealed the purpose of the policy was to maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infection. In addition, all personnel would receive training on infection prevention and control practices (IPCP) during their hiring process and periodically thereafter. Review the facility's policy titled, Transmission-Based Precautions (TBP), revised 06/12/2024, revealed transmission based precautions were initiated when a resident developed signs and symptoms of transmission of a transmissible infection or had a laboratory confirmed infection; and was at risk for transmitting the infection to other residents. Per the policy, if a resident was suspected of or identified as having a communicable infectious disease a licensed nurse notified the physician for evaluation of appropriate TBPs. The Infection Preventionist (IP) had the authority to determine appropriate TBPs. Transmission-based precautions might include Contact, Droplet, or Airborne precautions. The signage on the door informed the staff of the type of TBP and instructions for use of PPE. Review of the facility's policy titled, Enhanced Barrier Precaution Policy, revised 03/25/2024, revealed EBPs were additional measures to attempt to decrease the transmission of MDROs. Per the policy, when the resident was placed on EBPs, signs were placed on the door to inform staff of instructions on PPE use. Review of the facility's policy titled, Hand Hygiene - Procedures/Guidelines, revised 09/15/2023, revealed ensuring proper hand hygiene was crucial for staff involved in direct resident contact. Per the policy, hand hygiene should be performed before handling clean or sterile supplies, before performing any aseptic task such as administration of medications, after touching a resident, and after removing gloves. Review of the cleaning and disinfecting instructions for Sani-Cloth Germicidal Disposable Wipes revealed to clean and disinfect non-porous surfaces, the user would use one or more wipes as necessary to wet surfaces sufficiently and thoroughly to clean the surface. Further review revealed the user was to unfold a clean wipe to thoroughly wet the surface and allow the treated surface to remain wet for a full two minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. Review of the cleaning and disinfecting instructions for Sani-Cloth Bleach Wipes revealed the user would use one wipe to remove visible soil first and clean the surface. Further review revealed the user was to unfold another wipe and thoroughly wet the surface and allow the treated surface to remain wet for a full four minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. 1. Review of R4's EMR Physician Orders revealed the resident was placed in Contact/Droplet Isolation on 07/15/2024. During an observation of the North Wing, on the initial facility tour on 07/15/2024 at 11:16 AM, a PPE container with supplies was located outside of the resident's room. There was no TBP signage on the door. During an interview with CNA4 on 07/22/2024 at 7:20 AM, she stated there was a rumor that R4 had tested positive for COVID-19. CNA4 stated she was assigned to care for R4 a couple of nights before, and she noticed R4 was not feeling well. She stated Licensed Practical Nurse (LPN) 13 told her R4 had COVID-19. She stated LPN13 put signs on the resident's door after it was confirmed only a few hours before the shift was over; however, CNA4 stated there were no signs on the door or PPE outside the room for most of the night. During an interview with LPN13 on 07/22/2024 at 6:45 AM, she stated she suspected R4 had COVID-19. She stated when the resident's daughter showed her the positive test, she placed R4 in Contact/Droplet isolation. She stated she placed PPE outside the room and TBP signage on the door. She stated the signage was on the door during the entire shift. During an interview with the Infection Prevention/Staff Development Coordinator (IP/SDC) on 07/15/2024 at 3:15 PM, she stated R4's daughter, who was a physician, tested the resident and found her to be positive for COVID-19 on 07/14/2024. She stated the daughter notified the staff on 07/14/2024 during the evening shift, but she did not know the time. According to the IP/SDC, once a resident was suspected of having COVID-19, staff should have put up TBP signage. When asked how staff was made aware of a resident in TBP, the IP/SDC stated that it was discussed during change of shift reports and in morning meetings. The IP/SDC stated signage alerted staff that the resident was under TBPs. During an interview with the former Director of Nursing (DON) on 07/16/2024 at 11:00 AM, she stated, On Sunday [07/14/2024] it was only a rumor that R4 was COVID-19 positive. She stated the facility was not convinced R4 had COVID-19. The DON stated R4's daughter told staff she believed her mother had signs and symptoms of COVID-19. She stated, the daughter, a physician, tested the resident, and according to staff, the test was positive. The DON stated the facility ordered COVID-19 testing on 07/15/2024, and test results on 07/16/2024 confirmed R4's status as COVID-19 positive. According to the DON, nursing staff placed a Contact/Droplet isolation signage on the residet's door when staff suspected R4 of having COVID-19. She did not know why the sign was not in place during the State Survey Agency (SSA) Surveyor's observation. 2. During an observation of the ADON on 07/15/2024 at 11:20 AM, revealed she was not wearing gloves when she administered nose drops to R31. The ADON then administered eye drops without using gloves or performing hand hygiene (HH) before going from the nose to the eyes. Furthermore, the ADON did not perform hand hygiene after leaving the room. During an interview with the ADON on 07/15/2024 at 11:32 AM, she stated she should have used gloves when administering eye/nose drops and performed HH after providing direct care to the resident. During an observation of the ADON on 07/15/2024 at 11:40 AM, revealed she went into an EBP room and provided direct care to R32. The ADON did not don any PPE. The ADON obtained vital signs. She exited the room without performing hand hygiene. The ADON placed the shared blood pressure cuff and pulse oximeter on the medication cart and used an alcohol wipe to clean the pulse oximeter and wrist blood pressure cuff. Review of R32's EMR Physician Orders revealed the resident was placed in EBP on 04/25/2024. During an interview with the ADON on 07/15/2024 at 11:46 AM, she stated the policy was to use bleach wipes to clean shared equipment, but she did not have any on her cart. She stated she took the equipment to the nurse's station to get bleach wipes. She stated it was her understanding that taking vitals signs was not direct care and therefore, she would not need to don PPE. She stated she was going to perform hand hygiene after she cleaned the shared equipment. During an interview with the IP/SDC on 07/15/2024 at 3:15 PM, she stated all staff were educated to put on PPE for all direct care of residents in EBP. She stated, If you lay hands on the resident or resident belongings, you need PPE. She stated further, all shared equipment should be cleaned with Bleach or Purple Top wipes depending on need, and according to the manufacturer's instruction. She stated disinfectant wipes were kept on the medication cart. She stated alcohol wipes should not be used to clean and disinfect shared equipment. Additionally, the IP/SDC stated nursing staff did infection surveillance based on resident signs and symptoms. She stated following the facility's policies on IPCP was important for the safety and well-being of the residents and staff and to prevent the spread of infections. 3. During an observation on 07/16/2024 at 1:05 PM, CNA2 was seen in the North Wing hallway cleaning a television remote control. After disposing of the disinfectant wipe and removing his gloves, CNA2 did not perform hand hygiene. Additionally, CNA2 was observed throwing trash in a red biohazard container outside room [ROOM NUMBER], which had Contact Precaution signage on the door. Continued observation revealed CNA2 entered room [ROOM NUMBER], obtained a glove from behind the door, put on a glove, and then opened the red biohazard trash can to retrieve the trash. After wrapping the trash inside the glove, CNA2 removed the glove. However, CNA2 did not perform hand hygiene. After that, CNA2 started pushing the meal cart down the hall. During an interview with CNA2 on 07/16/2024 at 1:15 PM, he stated he should have followed proper hand hygiene procedures both before and after putting on gloves. He did not explain why he took the trash out of the red biohazard container, but he stated he should not have done so and should have washed his hands immediately after handling contaminated items. During an interview with the IP/SDC on 07/16/2024 at 1:25 PM, she stated the biohazard trash receptacle should not have been on the outside of the room. She stated staff had been educated to remove gloves and perform hand hygiene. She stated staff should not wear gloves in the hall. 4. Observation of the BOM on 07/26/2024 at 11:45 AM, revealed while passing lunch trays, she opened the door and stepped into room H, a Contact/Droplet isolation room. The BOM did not don the required PPE prior to entering the room. When the BOM saw the SSA Surveyor, she backed out of the room. During an interview with the BOM on 07/26/2024 at 12:50 PM, she stated she did not don PPE before entering room H. She stated as soon as she put her foot in, she realized her mistake and backed out. She stated she did not notice the PPE container on the outside of the room or signage on the door. She stated following infection control measures were important to prevent the spread of infection and keep residents and staff safe. During an interview with the IP/SDC on 07/24/2024 at 10:50 AM, she stated the facility followed CDC guidelines and recommendations related to infection control. She stated it was her expectation that all staff followed the facility's IPCP. The IP/SD stated it was important to always use standard precautions and wear appropriate PPE based on the type of TBP to prevent the spread of infection. During an interview with the ADON on 07/25/2024 at 4:12 PM, she stated it was her expectation that all staff followed IPCP. She stated it was important to prevent the spread of infection. During an interview with the Interim DON (IDON) on 07/30/2024 at 3:45 PM, she stated the facility followed state and federal guidelines and recommendations related to infection control. She stated it was her expectation that all staff followed the facility's IPCPs. She stated it was her expectation the nursing staff monitored for infection control breeches. The IDON stated it was important to prevent the spread of infection. During an interview with the Medical Director on 07/25/2024 at 1:00 PM, he stated it was his expectation that the facility and staff followed IPCP to ensure a safe environment for the residents and staff. During an interview with the Regional Nurse Consultant (RNC) on 07/30/2024 at 4:05 PM, she stated it was her expectation that all staff would follow state and federal guidelines for IPCP. She stated this was important for the safety of residents and staff. During an interview with the Chief Executive Officer (CEO) on 07/30/2024 at 4:30 PM, she stated it was her expectation that all staff followed state and federal and guidelines for IPCP. She stated this was important for the safety of residents and staff and for maintaining a clean and safe environment.

Based on observation, interview, record review, review of the facility's policies, and review of the audit findings from Kentucky Protection and Advocacy, the facility failed to protect Resident (R) 15 from exploitation of personal funds. The facility did not keep adequate accounting documentations to ensure R15 was safeguarded from misappropriation of funds. The findings include: Review of the facility's policy titled, Resident Rights, revised 09/15/2023, revealed all residents had the right to be treated with respect and dignity, and all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, revised 09/15/2023, revealed exploitation as taking advantage of a resident for personal gain by using manipulation, initiation, threats or coercion. The policy also defined misappropriation of resident property as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the letter to the facility from Kentucky Protection and Advocacy, dated 03/19/2024, revealed the facility met with them for a representative payee review on 11/02/2023. Per the letter, the audit found recordkeeping corrections were needed because the facility had inadequate controls for safeguarding residents' funds; was missing receipts for large and unusual purchases; and had records not being retained for two years. The letter stated the facility had to submit a POC by 04/18/2023 (should be 04/18/2024) to correct the deficiencies. Review of the facility's response with a POC to Kentucky Protection and Advocacy, undated, revealed the facility implemented an updated Resident Trust Fund policy, reeducation of staff on the Resident Trust Fund policy and resident payee system, enhanced monitoring of expenditures, and resident personal needs spending compliance. Specifically, the POC stated the facility's Social Services Director (SSD) undertook additional training to ensure documentation and accounting practices met the highest standards of accountability and care. Review of the letter to the facility from the SSA, dated 05/20/2024, revealed the SSA had reviewed the facility's POC and determined the facility, with implementation, of the POC, fulfilled their duty as representative payee. Review of R15's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 12/17/2019 with diagnoses that included stroke, anemia, and anxiety disorder. Review of R15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Review of the R15's checking deposit slip, dated 12/12/2023, revealed R15's account was credited for $18,594.15 on 12/13/2023 for money given to family, friends, and taken with and without her consent. Review of the former SW's personnel file revealed she was suspended while the investigation was ongoing and then was allowed to return to work with no disciplinary action. She resigned in 12/2023. During an interview with R15 on 07/14/2024 at 2:30 PM, she stated she asked for an investigation by the SSA on the use of personal funds when they were in the facility preforming a random audit. R15 stated she felt like her account balance was low, and she could not figure out why. R15 stated the SSA looked over everything in her room for items listed on the facility reports of items the Social Worker (SW) had listed as purchased. Per the SSA audit, she stated it revealed that R15 should have lotions, clothing, and jewelry that were not in her possession at the time. R15 stated after the investigation she was told by the SSA that the former SW had stolen her money. R15 stated she would give the former SW money to buy things for her such as clothes, jewelry, lotion, and gifts cards. R15 stated she gifted $21,950 to family and friends in the form of gift cards and cash. R15 stated she never paid the former SW any money for the services she performed for her. R15 stated the facility did reimburse her for the money given out to family and friends in the form of cash and gift cards. R15 did not agree that her money should be used for her personal use only, as R15 stated, It's my damn money. I can use it how I want. R15 stated she currently had no communication with the former SW. R15 stated, after the investigation, the former SW no longer came around to her room to visit or to assist her with care. During a telephone interview with R15's representative, her son, on 07/17/2024 at 8:03 PM, he stated his mother was paralyzed on the left side from a stroke. He stated he agreed with the facility that R15 needed 24-hour care at home if she was released from the facility. He stated R15 would give lots of money to the grandchildren in forms of gift cards and cash. He stated he was no longer able to receive money from R15 as he had been told the money was for R15's personal use only. He denied using R15's money for his personal use or opening any credit card accounts in R15's name, but stated he was under investigation for exploitation, and nothing came from it. He stated he was currently living out-of-state, but at one time was living in R15's home when she was on the rehabilitation side of the facility. He stated R15's home was currently empty because he could not pay the bills once the financial assistance agency stopped assisting with paying the utilities. During a telephone interview with Adult Protective Services worker (APS) on 07/22/2024 at 1:38 PM, she stated she worked for the local government Adult Protective Services. The APS stated she was the payee for R15's personal money starting in 2017. The APS stated R15 entered a financial assistance program to help with her financial debt (medical). The APS stated she helped get R15's finances in order and assisted in paying her bills. She stated a goal she worked on with R15 was keeping her family from her personal funds and giving allowances. The APS worker stated she believed R15's son was her power of attorney (POA). However, no documentation had ever been presented for verification. She stated multiple meetings were scheduled for plans for R15 to go home to family once R15 was able to be discharged from the facility. However, she stated R15's son and her ex-husband failed to show up for the last meeting for R15 to return home. The APS worker stated she documented on 02/04/2020 that R15's son told R15, Mom you can't come home right now. At this point, she stated R15's son was living in R15's home while an assistance agency was paying the utilities. The APS worker stated she had all the utilities cut off, and R15 got mad. The APS worker stated she explained to R15 that her funds were for her personal use only. On 02/19/2020, the APS worker stated the Business Office Manager (BOM) and APS discussed the facility taking over as payee for R15. The APS worker stated she did not have any issues with the former SW; however, it was hard to get to the bottom of the payee transition and the plan moving from rehabilitation to home. In continued interview with the APS worker on 07/22/2024 at 1:38 PM, she stated she had a discussion with the former SW about keeping funds from R15's son and him being reported for exploitation. She also stated he had been arrested many times for selling drugs, and he never worked. Further, she stated she had asked R15 many times about the role of her son. The APS worker stated that R15's son had opened a credit card in R15's name, and the amount of the card was $1000. She stated the card was activated and on the same day maxed out at a local gaming store. The APS worker stated she called the credit card company and was told R15's son applied for the card. She stated she asked R15 if she authorized the credit card, and R15 stated, No. The APS worker stated she asked R15 if she wanted to press charges, and R15 stated, No. The APS worker stated R15 had a pension with the local school system, and there was a possibility that it could have been taken by R15's son. Observation and in an interview on 07/18/2024 at 1:23 PM, R15 stated she had no issues, complaints, or concerns on how her money was being handled at this time. R15 stated she was using her money for her own personal use. Observation revealed R15 got a soda out of the vending machine, using her own money. R15 stated her personal funds were used to purchase phone cards to add minutes to her cell phone by the Business Office. During an interview with Social Service Director (SSD) on 07/26/2024 at 1:15 PM, she gave a brief job description of her roles in the facility which included care plan meetings, observations, providing basic information needed for short or long-term stays, setting up rehabilitation, setting up transportation, and scheduling for meals on wheels. The SSD stated she did not handle personal funds, but the business office did. The SSD was asked, if a resident was trying to give her money or asked her to cash a check, would she be willing to take the money or cash the check? The SSD stated she would not touch the cash or check, and she would escort the resident to the business office. During an interview with the BOM on 07/26/2024 at 3:15 PM, she stated no resident was allowed to give a check or cash for deposit or to request to buy any items outside of the facility. The BOM stated she had no direct contact with the former SW and had never given her any money. The BOM stated if residents wanted money, they came to her. She stated she gave the resident the cash and had them sign a receipt. She stated a check was made out to the Chief Executive Officer (CEO), who would cash the check and reimburse the resident's trust fund account. During an interview with the CEO on 07/26/2024 at 2:53 PM, she stated she had been with corporate since 2020 and had received many of the trainings on residents rights and abuse, neglect, and exploitation. The CEO stated the facility had a check and balance system where they were able to check to verify the residents were receiving and the facility was performing at the highest level of care. The CEO stated the BOM allocated the funds to other employees to go outside the facility to purchase any items a resident requested. During an additional interview with the CEO on 07/30/2024 at 4:31 PM, she stated every resident should be free from abuse, neglect, and exploitation due to the facility being their home. The CEO stated residents would be allowed to spend their money per the rules and regulations of the SSA and CMS. During an interview with the Regional Nurse Consultant (RNC) on 07/30/2024 at 4:02 PM, she stated it was very important to have all things documented such as with accounting and to have effective checks and balances within the facility to make sure everything was correct.

Based on interview, record review and review of the facility's policy, the facility failed to document grievances related to reported missing items for 2 out of 39 sampled residents, Resident (R) 21 and R28. R21 and R28 reported missing items to staff. However, these items were not documented on the grievance log, found, or replaced by the facility. The findings include: Review of the facility's policy titled, Grievance/Complaints, revised 07/19/2024, revealed the resident had a right to voice grievances to the facility or other agency or entity that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal. This policy was to ensure the prompt resloution of resident grievances. Review of the Grievance Logs, dated for 07/01/2023 to 07/31/2023, revealed no documentation of R21's and R28's missing items logged on the sheet. 1. Review of R21's electronic medical record (EMR) revealed the facility admitted the resident on 05/23/2023 with diagnoses that included diabetes type 2, depression, and bipolar disorder. Review of R21's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating he had severe cognitive impairment. Review of the facility's Investigative Report, dated 07/10/2023 at 3:47 PM, revealed R21 stated concerns regarding missing items left at the facility when she had been discharged and stated she had concerns about the former Social Worker (SW). Per the report, the nurse (not identified) reported that R21 did leave a box of belongings and a cane. The nurse stated the items remained in R21's room until taken to the therapy gym. Per the report, the nurse stated she told this to the Social Services Assistant. The housekeeper for that hall recalled the belongings being in the therapy gym at the time of the deep clean on 06/26/2023. The items were no longer there. An investigation was initiated, and the former SW was suspended pending the investigation. In an interview with R21 on 07/23/2024 at 5:28 PM, she stated the former SW put her to the street. R21 stated the SW told R21 she would keep her clothes in the SW's office, but when R21 called to retrieve her box of clothes and pink cane, they were not able to be located. R21 stated the Social Services Director (SSD) told her she needed to leave the facility because her insurance was not going to cover her stay at the facility. R21 stated staff at a housing program rented a room for her so she could have a place to stay. R21 stated the SW told her the facility would replace the items that could not be located. However, nothing was replaced, and R21 did not receive any further communications from the SW. In an interview with Housekeeping Aide (HA) 5 on 07/24/2024 at 11:53 AM, she stated the box of clothes and the pink cane remained in R21's room after she was discharged . HA5 stated the aides were supposed to box the stuff up, but they did not, and someone else boxed it and left it in the room. HA5 stated the room was deep cleaned, and a nurse (HA5 could not recall the name) told HA5 to put the items in the SW's office. HA5 stated she placed the box of clothes in the pathway to the SW's desk and laid the pink cane on top of the box of clothes. HA5 stated she believed the Rehabilitation Service Manager (RSM) saw the box of clothing and the pink cane. In an interview with the Regional Nurse Consultant (RNC) on 07/23/2024 at 4:15 PM, she stated R21 called her own taxi and left abruptly without taking all her belongings. The RNC stated R21 took a taxi to her niece's residence in a nearby town. 2. Review of R28's EMR Face Sheet revealed the facility admitted the resident on 01/05/2022 with diagnoses which include infection in the bone, paraplegia, and dysfunction of the bladder. Review of R28's admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of 6 out of 15, indicating his cognition was severly impaired. In an interview with R28's representative on 07/23/2024 at 7:53 PM, she stated she was R28's sister. She stated two blankets were stolen from her brother during his stay at the facility. She stated when she visited the facility, she looked in every room to see if the blankets were being used by other residents. She stated she reported the misplaced blankets to the SW on two separate occasions. She stated she also told the Chief Executive Officer (CEO) about the blankets and R28's fast charge block being taken and the cell phone charging card lying on the bed. She stated she never received any feedback from the facility about replacing the items. In an interview with the CEO on 07/30/2024 at 4:31 PM, she stated her expectation was to look for any misplaced or stolen items in the facility. The CEO stated the resident must show proof of purchase on the items that were reported missing. In an interview with the RNC on 07/30/2024 at 4:02 PM, she stated she expected any grievance to be taken and entered in the grievance log binder by any staff member who received a report from the resident. She stated as soon as the grievance was taken, an investigation would be initiated to find the missing item. The RNC further stated the item(s) would be replaced, without the resident providing proof of purchase of the item. The RNC stated it was very important to have all things documented such as grievances for checks and balances within the facility and to make sure everything was correct.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Comprehensive Care Plan was revised as determined by the resident's needs for one (1) of seventeen (17) sampled residents (Resident #1). Record review revealed Resident #1 had an exit attempt, on [DATE] at 8:00 AM, during which he/she was able to get his/her feet through the threshold of the facility's door, which triggered the egress door alarm. Record review revealed staff performed an Elopement Risk Evaluation (ERE), on [DATE], and assessed Resident #1 to be at high risk for elopement. Review of the Progress Notes revealed this evaluation was conducted due to increased wandering, as well as exit seeking behavior. On [DATE], a Wander Guard bracelet, (a tracking device designed to prevent persons at risk for wandering from leaving the facility unaccompanied) was placed on the resident. However, there was no documentation the care plan was revised to include the Wander Guard and no documentation the facility monitored the device as per the facility's policy. Staff interviews revealed Resident #1 experienced increased wandering, specifically on [DATE] and on [DATE]. Continued interviews, and review of progress notes, revealed Resident #1 was agitated and exit seeking, pushing on doors to the point of triggering the egress alarms. Additional interviews revealed, on [DATE], Resident #1 was stating he/she needed to go to the store. However, there was no documentation the care plan was revised to include increased supervision. Review of the facility's security camera video recording revealed Resident #1 rolled to the exit door, on [DATE] at 7:56 AM, sat at the door while pushing on it, then exited the building at 7:57 AM, without staff knowledge. Further review revealed the Physical Therapist found Resident #1 in the rear parking lot when coming to work and returned the resident to the facility. The facility's failure to have an effective system in place to ensure each resident's care plan was updated with interventions to reduce or prevent the likelihood of an elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a Scope and Severity (S/S) of a J and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. Licensed Practical Nurse (LPN) #2 The findings include: Review of the facility's policy titled, Comprehensive Care Plans, last revised [DATE], revealed person-centered care plans were developed that included measurable objectives to meet medical, nursing, mental, and psychological needs for each resident. Further review of the policy revealed care plans were developed based on a thorough assessment that included, but was not limited to, the Resident Assessment Instrument. Continued review of the policy revealed care plans were designed to incorporate identified problem areas as well as associated risk factors. Additional review revealed care plans identified the professional services that were responsible for each element of care and aided in preventing or reducing declines in the resident's functional status and/or functional levels. Review of the policy also revealed that the MDS was used to assess a resident's condition, cognitive and functional status, and that the Care Area Assessments (CAA) were used in the development of the care plan. Review of the policy further revealed that care plans were ongoing and revised as information about the resident and the resident's condition changed. The continued policy review also revealed that the Nurse/Interdisciplinary Team (IDT) was responsible for the review and updating of care plans, with updating when there had been a significant change in condition, change in goals, and completed at least quarterly. Review of the facility's policy titled, Elopement/Wandering, last reviewed [DATE], revealed that the facility's intent was to maintain resident safety by identifying those who were at risk for wandering/elopement behavior. Further review revealed that any resident displaying significant wandering behavior would be assessed for elopement/wandering risk and care planned appropriately. Review of the facility's policy titled, Care of the Wandering Resident, last reviewed and revised [DATE], revealed that care should be planned to reduce the risk from exit seeking behavior and that the facility should increase supervision as deemed necessary by the IDT. Review of Resident #1's Electronic Medical Record (EMR) revealed the facility admitted the resident, on [DATE], with diagnoses including Non-Hodgkin's Lymphoma, Unspecified, Spleen; Unspecified Dementia with Behavioral Disturbance; Altered Mental Status, Unspecified; and Syncope and Collapse. Upon admission, Resident #1 the facility assessed the resident with a Brief Interview of Mental Status (BIMS) a score of five (5) of fifteen (15), which indicated severe cognitive impairment. An Elopement Risk Evaluation (ERE) was conducted at the same time, which revealed Resident #1 was a low risk for elopement. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed a new Problem area for Elopement, with a start date of [DATE], after an ERE completed on [DATE], demonstrated the resident was at risk for elopement. The category was further defined with the statement that the resident was at risk for elopement as evidenced by both wandering and exit seeking behaviors. The approaches, at that time, included: to monitor for tailgating (trying to exit right after another person when the door was open); use cues for redirection; and, to use diversionary activities to prevent elopement. There were no approaches to elopement to increase supervision or to apply a Wander Guard bracelet at that time. Continued review revealed that, after Resident #1's overt exit seeking behaviors on [DATE] and an ERE that assessed the resident as an elopement risk, no nurse or facility staff modified the care plan to reflect the behavior and risk. In addition, the facility failed to add the Wander Guard to the care plan, which had been applied on [DATE]. Additional review revealed that, after subsequent exit seeking behavior on [DATE], the care plan was not updated to reflect any need for increased supervision or other interventions to prevent elopement. Review of Resident #1's Physician's Orders revealed the addition of orders, Encourage activities twice daily and encourage out of bed daily due to altered mental status on [DATE]. Further review revealed the addition of an order for Psych consult, please ensure has been done. on [DATE]. Review of Progress Notes revealed an entry, dated [DATE], describing receipt of an order for a psychiatric consult for the following Friday, [DATE]. Continued review of Physician's Orders revealed the addition of instructions to Check function of Wander Guard daily and Check placement of Wander Guard every shift as well as Monitor expiration of battery of Wander Guard monthly on [DATE]. These interventions were after the elopement. Review of Resident #1's Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed staff had only documented Wander Guard placement and function checks on each shift beginning [DATE], after the elopement. Review of Resident #1's Progress Notes in his/her EMR revealed aggressive behaviors as of the night of [DATE] and [DATE]. No undue behaviors were noted prior to this date. Review of the second ERE, dated [DATE], reflected that Resident #1 was at risk for elopement, but there was no evidence of such in the Progress Notes. Further review revealed a Progress Note, dated [DATE], when Licensed Practical Nurse (LPN) #8 found Resident #1 going toward an exit door stating that he/she wanted to go home that night. Continued review of Resident #1's Progress Notes revealed an exit attempt on [DATE] at 8:00 PM, during which he/she was able to get his//her feet through the threshold. Resident #1 stated that he/she was looking for his/her children. The resident was returned inside the building, then redirected to his/her room. Additional review revealed the attending nurse reported the event to the Unit Manager (UM). Further review review revealed the following day she conducted the third ERE, which confirmed that Resident #1 was a high risk for elopement; a Wander Guard ankle bracelet was applied. Continued review of the Progress Notes revealed exit seeking behavior with redirection on [DATE]; and, again on [DATE] when he/she was able to trigger door alarms. Review of the facility's security camera video recording, viewed on [DATE] at 1:51 PM, revealed Resident #1 advanced in a wheelchair to the Northeast door, by the residents' library, on [DATE] at 7:56:54 AM. He/she was at the door, alternating pushing on the door and looking back down the hall, for forty (40) seconds before exiting through the door. The next image revealed Resident #1 returning through the door with Physical Therapist (PT) #1 pushing his/her wheelchair at 7:59:56 AM. Interview with Resident #1, on [DATE] at 1:40 PM, while resting in bed revealed that he/she did not remember leaving the building nor recalled any reason he/she might have attempted to leave. The resident stated he/she felt safe in the facility. Observation at this time revealed the resident had a one-to-one (1:1) staff member assigned. Interview with Certified Nursing Assistant (CNA) #3, on [DATE] at 3:52 PM, revealed Resident #1 had dementia and that he/she should be on a dementia unit as he/she is constantly wandering, always. She stated that she had worked night shift prior to Resident #1's ([DATE]) exit incident. The CNA stated that the resident had been wandering during the night. She further stated that Resident #1 was at the door over and over, but did not push on it long enough to trigger the alarm. CNA #3 stated the resident was very persistent on pursuing the door, having stated that he/she had to get up and go to work at the store. She stated that Resident #1 was determined to get out the door, but finally got tired, was helped to bed, and then slept the remainder of the night. Further interview revealed she did not report the behavior to the nurse on duty, LPN (Licensed Practical Nurse) #2. Interview with CNA #6, on [DATE] at 1:29 PM, revealed the day before the elopement, on [DATE], Resident #1 was antsy, stating he/she wanted to leave and was looking for the door. She stated she was on light duty, so she was walking around with Resident #1, trying to redirect and occupy the resident's time. CNA #6 further stated that while wandering, Resident #1 was sitting by the Northwest door, pushed on the door, and the alarm sounded. She stated she and CNA #7 responded to the door alarm, redirected Resident #1 to the dining area, and settled him/her for dinner. She stated she reported this to the Director of Nursing (DON), who asked her to stay with the resident until the end of the shift for the resident's safety. CNA #6 further stated Resident #1 had been anxious about his/her glasses being broken and was calmed when the DON was able to repair them. She stated she gave report to the oncoming staff about Resident #1's wandering. After dinner, CNA #6 stated Resident #1 roamed the dining room after dinner and was reading instructions on the door about egress and the fifteen (15) second wait when doors opened, but was not close enough to trigger the Wander Guard door alarm. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 4:05 PM, revealed, on Monday night, [DATE], Resident #1 had gone to the middle door, but was redirected to the nurses' station. Interview with LPN #2, on [DATE] at 8:20 PM, revealed Resident #1 had been exit seeking before the elopement, pushing the doors, and setting off alarms. She stated Resident #1 was exit seeking last week, on [DATE], and that she had redirected the resident, put the code in to cancel the alarm, and called maintenance for assistance, as well as documented the behavior in the EMR. Further interview revealed LPN #2 had not updated Resident #1's care plan. Interview with the Unit Manager, on [DATE] at 11:24 AM, revealed that elopement care plans and CNA Point of Care (POC) plans for residents, who were elopement risks started with the nurse, then received subsequent oversight from the Director of Nursing (DON) and the Administrator. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:00 AM, revealed care planning was the responsibility of many across the whole staff, with the MDS Coordinator adding problems and approaches related to what the resident's assessments revealed. Continued interview revealed that nursing staff was expected to add to care plans in response to new events or Physician's Orders. Additional interview revealed the Social Services Director (SSD) might add problems such as behavior management goals or approaches. Further interview revealed nurses were responsible for noting an event then adding an intervention in the care plan, while the facility's Interdisciplinary Team (IDT) might meet the next day to add more details, also using the Progress Notes and 24 Hour Report (a document that detailed significant events that have occurred in the past twenty-four (24) hours on a given unit) to review and revise the care plan. She stated the IDT included the MDS Coordinator, SSD, Activities Director, DON, UM, and Medical Records Director. Continued interview revealed revising the care plan was a collaborative effort, and no single person was responsible for all residents' care plans. The MDS Coordinator stated that her phone number was available in the communication book so nurses could call for guidance on adding to care plans if she was not in the facility. Interview with the Assistant Director of Nursing (ADON) #2, on [DATE] at 1:29 PM, revealed the [DATE] ERE occurred after Resident #1 had exhibited behaviors changes. She further reported that the [DATE] occurred in response to overt exit seeking, to include getting feet over the threshold of a door and that a Wander Guard was applied because of this event. Further interview revealed that she was able to make the decision to apply the Wander Guard and then take it to the IDT for review. Continued interview revealed that she did not necessarily need a doctor's order, though the staff would notify the Physician with the change of condition anyway. ADON #2 stated that in response to any resident who was exit seeking, the nurse was expected to notify the Director of Nursing (DON), who would in turn inform the Unit Manager (UM). She stated the DON could also give the instruction to apply the Wander Guard, start every fifteen (15) minute supervisory checks or whatever was necessary for the situation. ADON #2 stated the expectation was that staff observing exit seeking behavior would notify leaders, keep a closer observation of the resident or provide interventions to prevent elopement, and revise the care plan, if a nurse. Interview with the DON, on [DATE] at 3:42 PM, revealed she had been in her position since [DATE]. Further interview revealed that she had observed Resident #1 wandering with glasses in his/her/hand during the late afternoon, before dinner, on [DATE]. She stated she repaired Resident #1's glasses. Since CNA #6 was on light duty she asked her to keep an eye on Resident #1, due to agitation. The DON stated the instructions, to the CNA, were to stay with him/her, keep him/her company, and help the resident avoid exit doors. Continued interview revealed that she made no assignment of one-to-one (1:1) supervision for the night because the resident was wandering but did not exhibit exit seeking at the time. Additional interview revealed she was not aware of Resident #1's prior exit seeking behavior, and if that had happened, the nurse should have notified her or placed the resident on the 24 Hour Report. The DON also stated she expected observations of exit seeking behaviors from residents would be carried forward in report from shift to shift, and the residents' care plans should be revised to reflect the interventions undertaken to prevent elopement. Interview with the Administrator, on [DATE] at 2:12 PM, revealed she was aware of Resident #1's increased exit seeking, but had personally observed that he/she was able to be redirected easily prior to this incident. She stated she had not been aware of the details of changes in behaviors due to time of day or any specific precipitator. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE] that alleged removal of the IJ on [DATE]. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On [DATE] Resident #1 was placed on one-to-one (1:1) supervision immediately upon being brought back into the facility. One on one was provided by the Unit Manager (UM) and then she was replaced by a Certified Nurse Assistant (CNA). Resident #1 was assisted to his/her room and received a head-to-toe assessment by UM LPN. No new concerns. Vital signs were obtained by UM: BP ,d+[DATE], HR 74, RR 20, Temp 97.4 O2 saturation 98%. No concerns noted. A pain Assessment was completed, the Wander Guard was tested , and the Physician and family were notified by the UM. No noted concerns. 2. On [DATE], prior Residents reviewed that had been identified to be an elopement risk and validation was completed that their Wander Guard was working, not expired, was monitored for function and placement, elopement binder up to date, elopement assessment and care plan up to date by Social Worker (SSD) Director of Nursing (DON), Plant Director, and Minimum Data Set (MDS) Nurse. 3. Elopement risk evaluation were completed on 100% of residents on [DATE] by the DON, UM, ADON and Regional Nurse. All residents had been assessed correctly. 4. An audit was completed on [DATE] of the care plans of current residents who were at risk for exit seeking/elopement behavior and the care plans and CNA point of care plans were revised by the DON, UM, ADON and Regional Nurse. No other elopement issues were identified that were not on the care plans. 5. On [DATE] Maintenance checked all doors and alarms and changed door codes. The door in question was malfunctioning and alarm was not sounding when release bar held for 15 seconds. The Plant Operations Director (DOP) was placed at this door and rotated out with both plant operations assistants until it could be repaired. Maintenance immediately requested servicing from Pads and Mags Doors to come and inspect the malfunctioning alarm. Delayed egress controller was found to have an internal faulty wire which caused door to not alarm, per the technician with Pads and Mags Doors. Administrator reviewed the past 30-day door checks completed by Plant Director and found no concerns. All facility doors with and without Wander Guards will be checked Monday-Friday by facility maintenance and the same checks done on Saturday and Sunday by the facility Manager on Duty. 6. Signature Care Consultant educated Administrator, Staff Development Coordinator (SDC), DON, UM's and MDS nurse on [DATE] on the following Elopement/missing person policy, care of a wandering resident policy, comprehensive care plan update related to elopement risk residents and changes in behaviors. 7. Re-education started on [DATE] and was completed by [DATE] on Elopement/Missing Resident, Elopement/Wandering Residents, Care of Wandering Resident, and Revision of the Comprehensive Care Plans by the SDC for all staff (Elopement) and nurses for comprehensive care plans, and what to include, door alarms and door codes, use of entrances and exits, behavior management of residents at risk for elopement and wandering, and the wander guard test box system. All stakeholders working [DATE] were educated on that day and all stakeholders were educated from then on, before they worked. As of midnight, on [DATE], 36 of 75 stakeholders had been educated. Agency staff were educated before they worked per the schedule by the Staff Development Coordinator. Stakeholders who have not received the re-education by start of shift [DATE] will be expected to complete the education prior to the next shift they work given by the Administrator, DON and SDC. This education will also be included in orientation for all new staff. Any elopement concerns by nursing will be placed on the 24-hour shift report. 8. Elopement drills were conducted daily starting on [DATE] and going through [DATE]. Elopement drills were completed by Plant Operations. Following the elopement drills for five (5) days, then elopement drills will be conducted three (3) times per week on different shifts for thirty (30) days and two (2) times per week for the next thirty (30) days and one (1) time per week for the next thirty (30) days. Any issues identified will be immediately corrected, re-education provided, up to and including disciplinary action as deemed necessary by the Director of Nursing and Administrator. 9. All residents' progress notes will be read during the daily clinical meeting for monitoring of any exit seeking behavior by the Interdisciplinary Team (IDT), (the team includes DON, UM, ADON, SSD, Activities Director and Therapy) seven (7) days per week for thirty (30) days at stand-up meeting and on Saturday and Sunday the progress notes will be read by the DON and Administrator starting on [DATE] and continuing for next thirty (30) days. Any resident identified will have elopement assessment completed and if determined to be at risk will have an intervention put in place, appropriate care plans updated, and the elopement binders updated. 10. All exit doors in the facility, both with and without the Wander Guard system, will have monitoring seven days per week, Monday through Friday by the facility Maintenance and Saturday and Sunday by the facility Manager on Duty. 11. A Quality Assurance Meeting was conducted on [DATE] and again on [DATE], reviewing all proposed education and action plan with Medical Director, DON, SDC, UM and Regional Nurse. On [DATE] the Quality Assurance Committee, consisting of Administrator, DON, ADON, UM, Regional Nurse, SDC, and SSD met to review all interventions put in to place thus far and the plan moving forward. It was determined that the SDC or DON would educate all stakeholder who had not yet worked before they worked from [DATE] forward. 12. Regional oversight has been in place daily for this plan since [DATE]. Regional oversight has occurred on site or by phone from the Signature Care Consultant, the Regional [NAME] President, or a member of the Regional Team. This will continue until immediate jeopardy is abated. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Resident #1's EMR revealed a progress note and care plan additions for 1:1 supervision as of [DATE]. Interview with the UM on [DATE] at 11:24 AM revealed she provided initial 1:1 supervision after Resident #1 was returned to his/her room, until that supervision was scheduled with aides for each shift. The UM stated she assisted Resident #1 to his/her room after being returned inside the facility from the parking lot, she performed a measure of vital signs and all were within normally defined limits, she assessed Resident #1's pain, Resident #1's Wander Guard was tested and shown to be in working order after return to his/her room and found no concerns. Review of staffing schedules for the shifts subsequent to the elopement demonstrated CNA assignments for Resident #1's supervision. Review of Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed placement and function testing was completed on [DATE]. Review of the Event Report post incident revealed a pain assessment was completed. Interviews with LPN #6 on [DATE] at 09:29 PM, and the DON on [DATE] at 11:26 AM revealed that the physician and Resident #1's son were notified on the date of the event and review of the Event Report documented notification at [DATE] by 12:17 PM. Review of the Resident #1's progress notes revealed that his/her son arrived shortly after 09:15 AM on [DATE], post incident. Interview with POA revealed they had been notified that morning, and Resident #1's son went to the facility right away. 2. Interview with the SSD on [DATE] at 11:40 AM revealed she had completed all Wander Guard reviews, ensuring all were in place, working and not expired. Continued interview revealed she then reviewed and revised care plans, including Wander Guard interventions, in conjunction with the MDS nurse, the DON and Administrator as well as reviewed and confirmed entries in the Elopement Binder to be accurate, and that Wander Guard interventions were in those care plans. Observation revealed appropriate testing of Wander Guard placement and function with no concerns noted. 3. Interview with the DON on [DATE] at 11:56 AM revealed she had completed Elopement Risk Assessments on each resident in the facility on [DATE], in conjunction with ADON, UM and Regional Nurse. Review of residents' EMRs revealed Elopement Risk Assessments were documented for each resident on [DATE]. 4. Interview with DON on [DATE] at 11:56 AM revealed that she, the UM, ADON and Regional Nurse audited, and revised resident care plans as needed by [DATE], for exit seeking/elopement based on latest ERE. Further interview revealed no elopement issues identified that were not on the care plans. Review of resident care plans, identified to be at risk of elopement revealed that those had been reviewed as reported. 5. Interview with DPO on [DATE] at 11:49 AM revealed the door alarms were all checked and passed on [DATE]. On the following day, [DATE], the door had not been yet checked at the time of elopement incident. Further interview revealed, post incident, the northeast door alarm was found to have failed. Additional interview revealed staff was posted on each door until all were checked and that he supervised the northeast door, then rotated with assistants in his department until the door was repaired, as well as changed the door codes. Review of the facility's door alarm logs confirmed pass checks, including on the northeast door, which was checked and passed after repair. Review of the supervision log confirmed that the northeast door was covered throughout the day until the alarm was repaired. Review of documentation from Enterprise Technical Solutions LLC revealed the repairs were completed on [DATE]. Observation of door alarm checks and Wander Guard checks revealed all were currently in working order, while review of the logs revealed continued checks on a daily basis. 6. Interviews on [DATE] with the Administrator at 12:14 PM, the DON at 11:56 PM, the UM at 11:24 AM and the MDS nurse at 09:00 AM revealed the Signature Care Consultant provided education to the Administrator, Staff Development Coordinator (SDC), DON, UM's and MDS nurse on [DATE] on the Elopement/missing person policy, care of a wandering resident policy, and comprehensive care plan update related to elopement risk residents and behavior changes. 7. Interview with the DON on [DATE] at 11:56 PM revealed that she and the SDC provided re-education to all staff beginning on [DATE] for Elopement/Missing Resident, Elopement/Wandering Resident, Care of Wandering Residents, and care plans. Continued interview with DON and with the UM on [DATE] at 11:24 AM revealed that specific re-education also began on Comprehensive Care plans for nurses, detailing what to include, door alarms, door codes, use of entrances and exits, behavior management of residents at risk for elopement and the Wander Guard test box system and the necessity to place elopement concerns on the 24-hour report. Additional interview revealed that all staff working on [DATE] and [DATE] were educated on those days, and the remainder were educated before they next worked. Interview with the Administrator and DON revealed that this training will be included in orientation training for all new staff. Interviews with CNA #5 at [DATE] at 12:35 PM, LPN #1 on [DATE] at 8:45 PM, LPN #7 on [DATE] at 8:57 PM, CNA #11 on [DATE] at 1:59 PM, Hospitality Aide (HA) #1 on [DATE] at 2:11 PM, HA #2 on [DATE] at 2:31 PM, RN #3 on [DATE] at 3:17 PM, HA #3 on [DATE] at 3:31 PM, CNA #1 on [DATE] at 3:54 PM, CNA #13 on [DATE] at 4:21 PM, CNA #2 on [DATE] at 4:48 PM, CNA #2 on [DATE] at 4:48 PM, LPN #4 on [DATE] at 8:45 PM, LPN #9 on [DATE] at 10:40 PM, Environmental Services (EVS) #1 on [DATE] at 9:00 AM, Physical Therapist (PT) #1 on [DATE] at 9:43 AM, Occupational Therapist (OT) #1 on [DATE] at 09:45 AM, Dietary Manager (DM) on [DATE] at 10:00 AM and Cook #1 on [DATE] at 10:15 PM all revealed they had received such education and were able to define the content of education. Interview with the SSD on [DATE] at 11:40 AM revealed that care plan responsibility falls across disciplines and that her contact information is available at the nurse stations in the event of needing assistance with adding to a care plan after hours. Review of in-service documents confirmed delivery of education by content and dates. Review of Resident #1's care plan revealed that it had been updated to reflect more specific interventions for elopement prevention and review of MAR/TAR revealed that it reflected completed tasks for placement and function checks each day. Review of care plans for the residents in the Elopement Book revealed appropriate interventions for prevention and completed tasks in the MAR/TAR. 8. Interviews with the Administrator on [DATE] at 12:14 PM and the DON on [DATE] at 11:56 AM revealed drills were being conducted and they were monitoring the drills. Interview with the DPO on [DATE] at 11:49 AM revealed he was responsible for conducting the drills. Interviews with CNA #5 at [DATE] at 12:35 PM, LPN #1 on [DATE] at 8:45 PM, LPN #7 on [DATE] at 8:57 PM, CNA #11 on [DATE] at 1:59 PM, HA #1 on [DATE] at 2:11 PM, HA #2 on [DATE] at 2:31 PM, RN #3 on [DATE] at 3:17 PM, HA #3 on [DATE] at 3:31 PM, CNA #1 on [DATE] at 3:54 PM, CNA #13 on [DATE] at 4:21 PM, CNA #2 on [DATE] at 4:48 PM, CNA #2 on [DATE] at 4:48 PM, LPN #4 on [DATE] at 8:45 PM, LPN #9 on [DATE] at 10:40 PM, Environmental Services (EVS) #1 on [DATE] at 9:00 AM, PT #1 on [DATE] at 9:43 AM, OT #1 on [DATE] at 9:45 AM, DM on [DATE] at 10:00 AM and Cook #1 on [DATE] at 10:15 PM revealed the DPO had conducted many elopement drills since [DATE], on both shifts and at varying times. Observation of an elopement drill on [DATE] at 11:15 AM revealed process consistent with interviews and revealed successful location of a resident who was hiding in a small office within minutes. Review of documentation on [DATE], confirmed such, with completed [TRUNCATED]

Based on observation, interview, record review, review of manufacturer's user guides, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of seventeen (17) sampled residents (Resident #1). Resident #1's Admission Elopement Risk Evaluation (ERE), dated [DATE], the day of admission, revealed he/she was at low risk for elopement. However, after Resident #1's new onset of exit seeking behaviors, on [DATE], a repeat ERE assessed him/her to be at high risk for elopement. Resident #1's care plan was revised for this risk, with the addition of the interventions of monitoring for tailgating (following an individual exiting the facility to try and exit as well) and using redirection and diversionary activities. On the evening of [DATE], Resident #1 was in a wheelchair and pushed the northwest door open, with his/her feet through the doorway before staff returned him/her inside and redirected the resident. On [DATE], a follow-up ERE confirmed Resident #1 was at risk of elopement. Another intervention done was to apply a Wander Guard bracelet, a tracking device designed to prevent persons at risk for wandering from leaving the facility unaccompanied. The Wander Guard bracelet would sound an alarm when the resident went through a doorway with a Wander Guard receiver in place. There was no documented evidence the facility otherwise increased Resident #1's level of supervision. Subsequently, on [DATE], Resident #1 exited the building without staff knowledge. The delayed egress door alarm failed, and no Wander Guard receiver was in place on that door. Resident #1 exited the northeast door of the facility at 7:57 AM, and was found by Physical Therapist (PT) #1, who happened to be arriving to work, in the rear parking lot, and was returned to the building at 7:59 AM. The exit door was found to have loose wiring on the delayed egress controller. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657, Care Plan Timing and Revision at a Scope and Severity (S/S) of a J and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency (SSA) validated removal of the IJ, on [DATE], as alleged, prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Elopement/Wandering, last reviewed [DATE], revealed an elopement/wandering assessment would be completed upon admission and quarterly thereafter. Continued review revealed that any resident displaying significant wandering behaviors would be assessed for elopement/wandering risk and care planned appropriately. Additional review revealed that care plans and individual behavior plans would address wandering as a specific problem, with approaches formulated, patterns identified if any, and the causes determined. Further review revealed that a wandering/elopement notebook containing pictures and pertinent demographic information would be maintained by social services and kept at nurses' stations and the receptionist desk with quarterly updates. Review of the facility's policy titled, Elopement/Missing Resident, effective date [DATE], revealed elopement drills were conducted a minimum of twice per year and documented accordingly. Further review revealed that staff should remain alert and follow re-direction techniques if a wandering resident gained access to any exit areas. Continued review revealed that staff shall request help if a wandering resident could not be redirected easily and that staff would be routinely alerted by the Director of Nursing (DON) of residents identified to be at risk. Additional review revealed service plans would reflect interventions for resident safety, that routine safety checks would be made by staff and that, in the event a resident continued to unsafely wander or exit seek, more appropriate placement might be required. Review of The Equipment Lifecycle System (TELS) instructions for magnetic lock and exit doors revealed these doors should be checked daily. Further review revealed detailed instructions for checking the operation of the magnetic door locks and the delayed egress operation. The instructions detailed that checking magnetic door locks required inspecting the door lock mounting and the operation and panic hardware on egress doors. Per the instructions, this inspection included verifying the resident transmitter to make sure the door stayed locked and the alarm sounded if a resident with a transmitter device attempted to exit the door. The instructions also described checking the delayed egress operation by pushing the door release hard for a fraction of a second, which should not allow the door to open, and the alarm should not sound. The instructions stated to then apply pressure to the door release for the pre-determined nuisance period setting of one (1) to three (3) seconds, then the door should go into an irreversible unlocking sequence that sounded the alarm and opened the door in less than fifteen (15) seconds. The instructions further stated to close the door and reset the alarm. Continued review of the instructions revealed the facility must ensure that signs were placed on doors adjacent to the release device that read, Keep pushing. Door will unlock after 15 seconds. The instructions concluded by stating, after the doors and hardware were tested for proper operation and condition, the results should be documented in a logbook. Review of the Secure Care 430 KHz Advantage Series Non-ID Resident Transmitter with Strap User Guide (for the Wander Guard device) revealed that the resident transmitter must be applied to an unelevated ankle. Further review of the guide revealed that the aide responsible for the care of the resident utilizing the Secure Care System must ensure that the transmitter was in place at each shift change. Additional review revealed that each transmitter should be tested daily to ensure it was working properly, and a documented test of each transmitter at the facility must be made each day. Review of TELS logs, on [DATE], revealed each exit door locked and both doors with Wander Guard capability had passed testing on a daily basis for the past thirty (30) days, from [DATE] to [DATE]. Review of Resident #1's Electronic Medical Record (EMR) revealed the facility admitted the resident, on [DATE], with diagnoses that included Non-Hodgkin's Lymphoma, Unspecified, Spleen; Unspecified Dementia with Behavioral Disturbance; Altered Mental Status, Unspecified; and Syncope and Collapse. Review of Resident #1's Brief Interview for Mental Status (BIMS), on [DATE], revealed a score of five (5) of fifteen (15), indicating severely impaired cognition. Subsequently, in the Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident's BIMS' score was fifteen (15) of fifteen (15), indicating intact cognitive ability. Review of Resident #1's additional BIMS assessments, done by the Social Services Director (SSD) revealed, on [DATE], a score of fourteen (14); on [DATE], a score of thirteen (13); and on [DATE], a score of fifteen (15); all of these indicated intact cognition. The SSD also documented a BIMS assessment, after Resident #1's elopement, on [DATE] at 12:32 PM, which revealed a score of eleven (11), indicating moderate cognitive impairment. However, review of Resident #1's Progress Note, on [DATE], by the Speech Therapist, revealed she also conducted a BIMS assessment for Resident #1 at 1:15 PM, with a score of three (3), which indicated severe cognitive impairment. Review of Resident #1's care plan, dated [DATE], revealed the addition of the new problem of Elopement, on [DATE], with interventions of adding the resident to the Elopement Book, to monitor Resident #1 for tailgating, and using diversionary activities as well as cues for redirection. Further review revealed no additions or revisions until [DATE], [DATE], and then [DATE], when new orders to check placement and function of the Wander Guard were added. Review of Resident #1's initial ERE, dated [DATE], revealed he/she was at low risk for elopement. In addition, the initial ERE indicated Resident #1 was not cognitively impaired and was not independently mobile. However, Resident #1's Admission Note, dated [DATE] and written by Registered Nurse (RN) #3 reflected he/she was forgetful and had a short-term memory problem. Review of the second ERE, dated [DATE], reflected Resident #1 was at risk for elopement, but there was no evidence of such in Resident #1's Progress Notes. Review of Resident #1's Progress Notes (PN), in the EMR, revealed the resident first exhibited aggressive behaviors the nights of [DATE] and [DATE]. Further review revealed, on [DATE], Licensed Practical Nurse (LPN) #8 found Resident #1 going toward an exit door stating that he/she wanted to go home that night. The SSD note, on [DATE] at 3:03 PM, reflected no exit seeking behavior. Continued review of Resident #1's PN's revealed an exit attempt, on [DATE] at 8:00 PM, during which he/she was able to get his/her feet through the threshold. At that time, the resident stated he/she was looking for his/her children. Per the notes, the resident was moved inside the building and redirected to his/her room. Additional review revealed the Attending Nurse reported the event to Unit Manager (UM) #2, and the following day UM #2 conducted the third ERE, which confirmed that Resident #1 was a high risk for elopement. Per the notes, UM #2 applied a Wander Guard resident transmitter to Resident #1's ankle. Continued review of the PN's revealed Resident #1 exhibited exit seeking behavior with redirection given, on [DATE], and again, on [DATE], when he/she was able to trigger the door alarms. Review of Resident #1's Physician's Orders revealed new orders, on [DATE], for laboratory tests, a psychiatric consult, and to encourage Resident #1 to be out of bed and engaged in activity. These orders were given subsequent to verbal altercations with Resident #1's roommate, which occurred on [DATE] and [DATE]. Additional review revealed an order, dated [DATE], for Macrobid (an antibiotic used for urinary tract infections) daily for seven (7) days and Depakote (an anti-convulsant which could be used to treat certain psychiatric disorders) twice daily, with no end date, added on [DATE]. Further review revealed no order for the Wander Guard, for placement and function checks, until [DATE]. Review of Resident #1's Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed staff had only documented Wander Guard placement and function checks on each shift beginning [DATE]. Review of the facility's security camera video recording, viewed on [DATE] at 1:51 PM, revealed Resident #1 advanced in a wheelchair to the northeast door, by the resident library, on [DATE] at 7:56:54 AM. He/she was at the door, alternating pushing on the door and looking back down the hall, for forty (40) seconds before exiting through the door. The next image revealed Resident #1 returning through the door with Physical Therapist (PT) #1 pushing his/her wheelchair at 7:59:56 AM. Interview with the Director of Plant Operations (DPO), on [DATE] at 1:51 PM, revealed the security camera was triggered by a motion sensor, so it recorded when there was motion in range of the camera. The security camera recorded no images between Resident #1's exit and his/her return. Further, the DPO stated he tested the northeast door immediately after the elopement, and the alarm was not functional, in spite of passing the test the previous day. Additionally, he stated he examined the control box and realized the repair was beyond what the facility could complete independently and, in turn, called the regional DPO who provided instruction for the source of the repair service. The DPO further stated he and his assistants rotated supervision on the door until the repairers came around 2:30 PM, on [DATE]. Observation of the elopement route, on [DATE] at 1:10 PM, with the State Survey Agency (SSA) Surveyor and the DPO, revealed the measurement of the elopement route was seventy (70) feet. Per the observation, the area leading from the northeast exit to the rear parking lot began with a small flat stoop and then continued with a sloping sidewalk to the asphalt parking lot. Also measured, at this time, was the distance from the location in the parking lot where PT #1 met Resident #1 to the street, which was one-hundred eighteen and seven-tenths (118.7) feet. Further observation of the facility revealed five (5) of seven (7) doors were not outfitted with the sensor for Wander Guard and the northeast door where Resident #1 exited did not have the Wander Guard sensor. Interview with Resident #1, on [DATE] at 1:40 PM, revealed the resident was resting in bed and he/she did not remember leaving the building, nor did the resident recall any reason he/she might have attempted to leave. Per the interview, the resident stated he/she felt safe at the facility. Observation at this time revealed the resident had a one-to-one (1:1) staff member assigned. Additional interview with Resident #1, on [DATE] at 3:15 PM, revealed again that he/she had no recollection of exiting the facility, nor a plan to leave. Also, the resident could not state the date, day of week, month, or year. Interview with PT #1, on [DATE] at 2:14 PM, revealed she was in the rear parking lot, on [DATE] around 8:00 AM, having arrived for the workday. She stated she observed Resident #1 rolling down the ramp to the parking lot from the northeast door. PT #1 stated the resident got as far as the fourth parked car, where she met the resident. PT #1 stated the resident asked PT #1 if she was going to take him/her home. PT #1 also stated Resident #1 did not appear to be upset at going back in the building. She stated she was aware Resident #1 was typically confused. Interview with Certified Nursing Assistant (CNA) #8, on [DATE] at 3:11 PM, revealed she had arrived at the facility, on [DATE] around 8:00 AM, and parked in the rear parking lot where she did not notice anyone else out in the area. Further interview revealed she entered the facility, stowed her belongings, and then went to the north side desk. She stated she then observed PT #1 pushing Resident #1, saying she found him/her outside, and the alarm was not sounding. Per the interview, CNA #8 stated she asked Resident #1 where he/she was going, with his/her response, Oh, I was just going home. CNA #8 stated she reminded Resident #1 that he/she lived here now, to which the resident responded that he/she did not. She stated the resident was calmed after learning that his/her son was coming to visit. Interview with CNA #6, on [DATE] at 1:29 PM, revealed the day before the elopement, on [DATE], Resident #1 was antsy, stating he/she wanted to leave and was looking for the door. She stated she was on light duty, so she was walking around with Resident #1, trying to redirect and occupy the resident's time. CNA #6 further stated that while wandering, Resident #1 was sitting by the northwest door, pushed on the door, and the alarm sounded. She stated she and CNA #7 responded to the door alarm, redirected Resident #1 to the dining area, and settled him/her for dinner. She stated she reported this to the Director of Nursing (DON), who asked her to stay with the resident until the end of the shift for the resident's safety. CNA #6 further stated Resident #1 had been anxious about his/her glasses being broken and was calmed when the DON was able to repair them. She stated she gave report to the oncoming staff about Resident #1's wandering. After dinner, CNA #6 stated Resident #1 roamed the dining room after dinner and was reading instructions on the door about egress and the fifteen (15) second wait when doors opened, but was not close enough to trigger the Wander Guard door alarm. CNA #6 stated she had never observed Resident #1 to be exit seeking prior to [DATE]. Additional interview with CNA #6, on [DATE] at 4:07 PM, clarified her instructions to the oncoming shift, on [DATE], related to Resident #1, were to keep an eye on him/her, and specifically, stay with the resident and divert him/her from exit doors. Interview with CNA #7, on [DATE] at 2:49 PM, revealed after morning shift change, on [DATE], LPN #6 had asked her to check on Resident #1 due to a concern for falling. She further stated she found Resident #1 sitting up on the side of the bed, demanding to be taken to the kitchen. When reminded that he/she did not have his/her own kitchen, Resident #1 wanted to make a grocery list, and in turn, CNA #7 placed the overbed table in front of him/her and offered a word search book with a suggestion to find what was needed for the list there. CNA #7 also stated Resident #1 was content and occupied, so she went to deliver breakfast trays, returning after a few minutes to check on him/her. When finding Resident #1 still occupied with the word search, CNA #7 stated she returned to delivering trays. She stated the next thing she knew, PT #1 was pushing Resident #1 up the hall, saying he/she had been in the parking lot. Further interview revealed she then learned that Licensed Practical Nurse (LPN) #6 had transferred him/her to the chair and then positioned him/her in the sitting area by the nurses' station. She stated staff was either administering medications or delivering trays at the time of exit, and the door alarm never sounded. She stated she had received elopement training via the online training system, and the facility had a door alarm drill, but not until after this elopement event. CNA #7 stated she had not observed exit seeking behaviors prior to the incident and had no report of exit seeking during shift report for Resident #1. Interview with LPN #6, on [DATE] at 9:29 PM, revealed she was new to the building, and she did not recall from whom she received report on [DATE]. She further revealed she could not be sure, but she did not recall receiving information that Resident #1 had exit seeking behavior. LPN #6 stated she just knew that Resident #1 was sitting on the edge of the bed, and she was afraid the resident might try to get up by himself/herself and fall. She further stated Resident #1 was somewhat unsteady on her feet, and since she was caring for another resident, she asked CNA #7 to check on Resident #1. She stated she transferred Resident #1 to a wheelchair about 7:30 AM and moved him/her to the sitting area across from the North Wing nurses' station so that someone would have eyes on him/her all the time. Per the interview, she stated Resident #1 could propel himself/herself pretty well. LPN #6 stated she did not see Resident #1 rolling down the hall and nobody reported to her that they had seen the resident going down the hall either. She also stated that the door alarm did not sound when Resident #1 pushed the door open and exited the building. Interview with CNA #1, on [DATE] at 3:10 PM, revealed she had been working today and yesterday providing one-to-one (1:1) supervision for Resident #1. She stated the resident had been confused but pleasant and cooperative, which appeared to be the resident's baseline demeanor. She stated when she was with Resident #1 yesterday, the resident wandered the facility but did not exhibit exit seeking behavior, but acknowledged the resident asked if doors were used to go out. Interview with CNA #3, on [DATE] at 3:52 PM, revealed Resident #1 had dementia and that he/she should be on a dementia unit as he/she is constantly wandering, always. She stated that she had worked the night shift prior to Resident #1's elopement incident, and he/she had been wandering during the night. She further stated that Resident #1 was at the door over and over but did not push on it long enough to trigger the alarm. CNA #3 stated the resident was very persistent on pursuing getting to the door, having stated that he/she had to get up and go to work at the store. She stated that Resident #1 was determined to get out the door, but finally got tired, was helped to bed, and then slept the remainder of the night. Interview with LPN #2, on [DATE] at 8:20 PM, revealed when she first met Resident #1, he/she was able to make needs known, could ambulate to the bathroom, knew his/her name, and knew he/she was in a nursing home. LPN #2 stated Resident #1 became more confused and agitated after a room change due to issues with the roommate. LPN #2 stated Resident #1 had been exit seeking before, pushing the doors, and setting off alarms. She stated, when that happened, she redirected the resident, put the code in to cancel the alarm, and then called maintenance for assistance. She stated that happened within the last week. Additional interview with Resident #1, on [DATE] at 3:16 PM, revealed the resident could not recall the date, day of week, month, or year. Further interview revealed Resident #1 had five (5) children; and could only call one (1) child by name. The resident stated he/she had been in the facility for two (2) weeks and was going home today. However, Resident #1 could not state why or how he/she was getting home, but just stated he/she wanted to go home. Interview with CNA #1, on [DATE] at 11:05 AM, revealed Resident #1 was sleeping, and had slept until 11:45 AM, and then got up for lunch. She stated Resident #1 was wandering and agitated yesterday about her touching the resident's chair or following the resident. CNA #1 stated Resident #1 was often more oriented earlier in the day after awakening; then his/her orientation declined around 4:00 PM and continued the rest of the day. Interview with CNA #5, on [DATE] at 12:35 PM, revealed she observed no wandering or exit seeking behavior with Resident #1 until he/she was moved to the North Wing after difficulty with his/her roommate, after which she noticed increased wandering by Resident #1. CNA #5 stated Resident #1 might be in a good mood one day, then not so much on another day; but she never observed exit seeking until the resident was placed on the South Wing after the elopement. CNA #5 stated, since the elopement, Resident #1 had continued to seek doors/exits and talked frequently of going home. Interview with the Assistant Director of Nursing (ADON) #2, on [DATE] at 1:29 PM, revealed Resident #1 had been infected with the COVID-19 virus, as evidenced by a positive test on [DATE]. ADON stated the Interdisciplinary Team (IDT, which included the DON, the Unit Manager (UM), the ADON, the SSD, the Activities Director (AD) and Therapy had considered whether this could have been a precipitating factor to his/her behavior changes, including exit seeking. She further reported that the ERE in [DATE] occurred in response to overt exit seeking, to include getting feet over the door threshold, and that a Wander Guard bracelet was applied in response to this event. Further interview revealed that she was able to make the decision to apply the Wander Guard bracelet and then take it to IDT for review. She explained she did not necessarily need a Physician's Order, though the staff would notify the Physician with the change of condition anyway. ADON #2 stated that in response to any resident who was exit seeking, the nurse was expected to notify the DON, who would in turn inform the UM. She stated the DON could also give the instructions to apply the Wander Guard bracelet, start fifteen (15) minute checks, or whatever was necessary for the situation. ADON #2 stated that her expectation was that staff observing exit seeking behavior would notify leaders, would keep closer observation on the resident, and would give report to the receiving nurse/CNA upon transfer of care or at shift change. She stated that shift change was a high risk time, which made shift report all the more important as well as rounding with purpose. Interview with the DON (Director of Nursing), on [DATE] at 3:42 PM, revealed she had been in the position since [DATE]. Further interview revealed that she had observed Resident #1 wandering with glasses in hand during the late afternoon, before dinner on [DATE], and that she fixed the glasses for him/her. Since CNA #6 was on light duty, she stated she asked her to keep an eye on Resident #1 due to agitation. She stated the instructions given to CNA #6 were to stay with the resident, keep him/her company, and help the resident avoid exit doors. Continued interview revealed that the DON made no assignment of one-to-one (1:1) supervision for the night because even though the resident was wandering, exit seeking behavior was not observed. Continued interview with the DON, on [DATE] at 3:42 PM, revealed she was not aware of exit seeking behavior prior to the elopement, and if that had happened, the nurse should have notified the DON or placed Resident #1 on the 24 Hour Report, a document that detailed significant events that have occurred in the past twenty-four (24) hours on a given unit. The DON also stated her expectation was that this would also be carried forward in report from shift to shift. The DON stated the placement of Wander Guard door alarms on only the central doors was a decision made before she came to the facility. She stated she suspected this was because the central doors were in eyesight of the administrative staff during the day, but less so during the night. She also stated the distant doors were under the eyesight of direct care staff at any given time. The DON explained, at the time of elopement, the staff would have been delivering breakfast trays, assisting with feeding, or for nurses, administering morning medications. She stated, because of these tasks, staff was moving up and down the hall a lot at that time. Interview with the Administrator, on [DATE] at 2:12 PM and on [DATE] at 4:11 PM, revealed she had been in her position for almost a year. She stated the Wander Guard sensors were on two (2) doors only, and the decision was made at the corporate level before she was hired. Continued interview revealed her belief that it might be because the staff do not really use the other doors. She stated it had been discussed among the facility's leadership whether to add the Wander Guard sensor to all doors or to remove them altogether. She stated she was aware of Resident #1's increased exit seeking but had personally observed that he/she was able to be redirected easily prior to this incident. She stated she had not been aware of the details of changes in Resident #1's behaviors due to the time of day or any specific precipitating factor. She also stated her expectation was that any staff member's observation of exit seeking by a resident would be reported to leadership. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE] that alleged removal of the IJ on [DATE]. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On [DATE], Resident #1 was placed on one-to-one (1:1) supervision immediately upon being brought back into the facility. One on one was provided by the Unit Manager (UM) and then she was replaced by a Certified Nurse Assistant (CNA). Resident #1 was assisted to his/her room and received a head-to-toe assessment by UM LPN. No new concerns. Vital signs were obtained by UM: BP ,d+[DATE], HR 74, RR 20, Temp 97.4, O2 saturation was 98%. No concerns noted. A pain Assessment was completed, the Wander Guard was tested , and the Physician and family were notified by the UM. No concerns were noted. 2. On [DATE], prior Residents reviewed that had been identified to be an elopement risk and validation was completed that their Wander Guard was working, not expired, and was monitored for function and placement. Further review revealed elopement binders were up to date; elopement assessments and care plans were updated by the Social Worker (SSD), Director of Nursing (DON), Plant Director, and Minimum Data Set (MDS) Nurse. 3. Elopement risk evaluations were completed on 100% of residents on [DATE] by the DON, UM, ADON and Regional Nurse. All residents had been assessed. 4. An audit was completed on [DATE] of the care plans of current residents who were at risk for exit seeking/elopement behavior and the care plans and the CNA's Point of Care Plans were revised by the DON, UM, ADON and Regional Nurse. No other elopement issues were identified that were not on the care plans. 5. On [DATE], Maintenance checked all doors and alarms and changed door codes. The door in question was malfunctioning and the alarm was not sounding when the release bar was held for 15 seconds. The Plant Operations Director (DOP) monitored this door and rotated out with both plant operations assistants until it could be repaired. Maintenance immediately requested servicing to come and inspect the malfunctioning alarm. The delayed egress controller was found to have an internal faulty wire which caused the door to not alarm, per the technician. The Administrator reviewed the past 30-day door checks completed by the Plant Director and found no concerns. All facility doors with and without Wander Guards will be checked Monday-Friday by maintenance and the same checks will be completed on Saturday and Sunday by the facility's Manager on Duty. 6. Signature Care Consultant educated the Administrator, Staff Development Coordinator (SDC), DON, UM's and MDS Nurse on [DATE] on the following Elopement/Missing Person Policy, care of a wandering resident policy, comprehensive care plan update related to elopement risk residents and changes in behaviors. 7. Re-education was restarted on [DATE] and was completed by [DATE] on Elopement/Missing Resident, Elopement/Wandering Residents, Care of Wandering Resident, and Revision of the Comprehensive Care Plans by the SDC for all staff and nurses for comprehensive care plans, and what to include, door alarms and door codes, use of entrances and exits, behavior management of residents at risk for elopement and wandering, and the wander guard test box system. All stakeholders working [DATE] were educated on that day and all the other stakeholders were educated from then on, before they worked. As of midnight, on [DATE], 36 of 75 stakeholders had been educated. Agency staff were educated before they worked per the schedule by the Staff Development Coordinator. Stakeholders who have not received the re-education by start of shift [DATE] will be expected to complete the education prior to the next shift they work. The education will be given by the Administrator, DON and SDC. This education will also be included in orientation for all new staff. Any elopement concerns by nursing will be placed on the 24-hour shift report. 8. Elopement drills were conducted daily starting on [DATE] and going through [DATE]. Elopement drills were completed by Plant Operations. Following the elopement drills for five (5) days, then elopement drills will be conducted three (3) times per week on different shifts for thirty (30) days and two (2) times per week for the next thirty (30) days and one (1) time per week for the next thirty (30) days. Any issues identified will be [NAME] [TRUNCATED]

Based on interview, record review, and review of facility Policy, it was determined the facility staff failed to ensure the Physician/Medical Provider was notified when there was an accident involving the resident which results in injury or a need to alter treatment significantly for one (1) of four (4) sampled residents (Resident #1). On 12/13/19, Resident #1 received a [MEDICATION NAME] 5/325 milligrams related to right hip pain at 8:30 PM due to a [DIAGNOSES REDACTED]. On 12/13/19, at approximately 10:35 PM, Resident #1 sustained a fall from the bed while the bed was in high position and was found lying in the prone position, partially on his/her left hip. Although the resident complained of left hip pain after the fall, which was horrible and intense directly after the fall, as per the Fall Event Report dated 12/14/19, Registered Nurse (RN) #1 failed to notify the Advanced Registered Nurse Practitioner (ARNP) of the fall and left hip pain until 12/13/19 at 11:37 PM, approximately one (1) hour after the fall. An X-Ray was ordered which revealed the resident sustained [REDACTED].#1 received the X-Ray results on 12/14/19 at 2:00 AM, she failed to notify the ARNP of the Left [MEDICAL CONDITION] due to incorrectly reading the X-Ray findings. Resident #1 continued to complain of left hip pain, and received [MEDICATION NAME] 5/325 mg again at 2:30 AM. Staff interviews revealed the resident continued to complain of pain after receiving the 2:30 AM pain medication; however, there was no documented evidence the ARNP was notified of the continued pain or the Left [MEDICAL CONDITION] until 12/14/19, at 7:45 AM, after RN #2 identified the [MEDICAL CONDITION] from the X-Ray findings. Resident #1 was then transferred to the hospital on [DATE] at approximately 8:00 AM, and admitted with a [DIAGNOSES REDACTED]. Resident #1 required Open Reduction Internal Fixation (ORIF) due to the Left [MEDICAL CONDITION], on 12/15/19. (Refer to F-655, F-658, F-689, and F-697) The facility's failure to have an effective system in place to ensure notification to the Physician when there is a significant change in condition has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2020 and was determined to exist on 12/13/19. The findings include: Review of the facility's Change of Condition Policy, revised 11/06/19, revealed the facility will evaluate and document changes in a resident's health in an efficient and effective manner to include: a significant change in the resident's physical, mental or psychosocial status; a need to alter treatment; a decision to transfer or discharge the resident from the facility; and an accident which results in injury and/or has the potential for requiring physician intervention. Further review revealed documentation will be completed in the Situation, Background, Assessment, Recommendation (SBAR) in the Electronic Medical Record (EMR) and an Incident Report, as needed. The nurse will document notification to the Physician, ARNP, Physician Assistant (PA) and Resident's Representative, consistent with his or her authority, of resident changes immediately. Review of the facility's Fall Policy, revised 06/01/15, revealed if a fall occurs the resident will be assessed including neurological checks, pain, and range of motion, skin, joint, extremities, and vital signs. Further review revealed the Physician and family are to be notified. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 12/11/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Note, dated 12/11/19 at 3:21 PM, revealed the resident was admitted from an Acute Care Hospital and transferred via ambulance with spouse in attendance. According to the Note, the resident was alert and oriented x 2 (alert to person and place) with occasional confusion and could verbalize needs. Further review revealed the resident had a [DIAGNOSES REDACTED]. Continued review revealed the resident was occasionally incontinent of bowel and bladder, and required assistance with Activities of Daily Living (ADLs). Review of Resident #1's physician's orders [REDACTED]. The facility did not complete an Admission Minimum Data Set (MDS) Assessment due to the resident being a new admission. However, review of Resident #1's Brief Interview for Mental Status (BIMS), dated 12/12/19, revealed the facility assessed the resident as having a score of six (6) out of fifteen (15) indicating severe cognition impairment. Review of Resident #1's Fall Event Report, revealed a fall occurred on 12/13/19 at 10:35 PM, and the resident had severe pain (horrible intense) of the left hip. Range of Motion (ROM) painful/limited in lower extremity (did not specify which extremity) and no rotation/deformity/shortening noted of extremities. Additional review of the Report revealed check marks in the boxes to indicate: Neurological checks completed; alert and responds appropriately to stimuli; strong facial muscle movement; strong upper left and right upper extremity grasps; strong left and right lower extremity movement; and left and right eye pupil size 3 millimeters and round and brisk pupil movement. Continued review revealed the resident had raised the bed in the highest position and fell from the bed. Resident #1 was then placed in the wheelchair and brought to the nurse's station. Notifications included the DON and the Administrator. Per the Report, the ARNP was notified on 12/13/19 at 11:30 PM, and a left hip X-Ray was ordered. The Fall Event Report was completed on 12/14/19 at 8:17 AM, by RN #1. Review of the facility's Phone Message Record dated 12/13/19, revealed the ARNP was notified at 11:37 by RN #1, that Resident #1 sustained a fall from his/her bed at 10:35 PM and was complaining of hip pain (left or right hip was not specified). RN #1 requested follow-up orders on the voice message. Review of the Mobile Diagnostic Services X-Ray Report, dated 12/14/19, which was received at the facility on 12/14/19 at 2:00 AM, revealed significant findings of left hip, unilateral views of the pelvis. Per the Report, there was a non-displaced intertrochanteric [MEDICAL CONDITION] femur. Review of the Situation Background Assessment Recommendation (SBAR) Communication Form, revealed on 12/13/19, the resident had a change in condition and worsening pain in the left hip with a pain level of ten (10), with ten (10) being the worst pain on a pain scale of one (1) to ten (10). Further, vital signs were obtained which were stable, and neuro checks were completed with no changes observed. Continued review revealed there was new pain in the left hip and wincing with movement. Additionally, an X-Ray was completed which showed a new [MEDICAL CONDITION] of the left hip and the Medical Provider was notified on 12/14/19 at 7:45 AM. Resident #1 was then transferred to the emergency room (ER) for evaluation and the resident's representative was notified on 12/14/19 at 7:50 AM. There was no signature on this document and no date of completion. Post survey interview with RN #1, on 01/15/2020, at 8:45 AM, revealed she completed the SBAR after the resident was transferred to the Hospital ER, on 12/14/19. Review of the Discharge MDS Assessment, dated 12/14/19, revealed Resident #1 was discharged to an Acute Care Hospital. Review of Resident #1's Hospital History and Physical, dated 12/14/19, revealed the resident's chief complaint was left hip pain status [REDACTED]. Further review revealed ROM was not assessed due to complaint of left hip pain per the resident, and external rotation and shortening of the left leg noted. Review of the Hospital Discharge Summary, dated 12/28/19, revealed Resident #1 was admitted on [DATE], after a fall in the nursing home resulting in an Intertrochanteric [MEDICAL CONDITION] Hip. Additional [DIAGNOSES REDACTED]. Per the Discharge Summary, upon admission Resident #1 was confused and not responding to questions appropriately. When admitted to the ER Resident #1 was complaining of severe left hip pain which was made worse by movement. Further review of the Discharge Summary, revealed the resident underwent [REDACTED]. Post-op course was without complication except for pain management and agitation. Per the Discharge Summary, Resident #1 was discharged to a Skilled Nursing Facility and would follow up with Family Medicine. Review of the facility's Fall Investigation, revealed Resident #1 had been assessed to be at high risk for falls with contributing factor to include impulsive behavior. The resident had been up and down during the 7:00 PM to 7:00 AM shift on 12/13/19 to 12/14/19 at the nursing station. The resident requested to go to bed and SRNA #1 put Resident #1 back to bed. Soon after, SRNA #1 heard the resident fall in the room (with no specified time of the fall). Per the Investigation, the resident was evaluated by the nurse and taken to the nurse's station. The ARNP was notified at 11:30 PM, and a new order was obtained for an X-Ray. The X-Ray was misread by RN #1 on the night shift. However, RN #2, who was the day shift nurse, reviewed the X-Ray and found a new [MEDICAL CONDITION] hip, and the Physician was then notified. The resident was transferred to the Hospital ER. Per the Investigation, the root cause of the fall was fall from bed, and the contributing factors were impulsive behavior. This Investigation was signed by the Director of Nursing (DON) on 12/16/19. Interview on 12/30/19 at 5:38 PM, with SRNA #1, revealed she was assigned to Resident #1 on 12/13/19 from 7:00 PM until 7:00 AM, on 12/14/19. Per interview, while checking on the resident she noticed the resident raised the bed up in high position and put the head of the bed straight up using the hand held bed control, and SRNA #1 had to readjust the bed to the low position. Per interview, the resident also persisted in trying to get up without assistance and RN #1 was made aware of the resident's behavior. Additional interview revealed she had toileted Resident #1, and assisted him/her back to bed, and a short time later, about 10:30 PM, she heard a noise. Per interview, when she entered Resident #1's room the resident was on the floor and the bed was in the high position. She stated she notified RN #1 of the fall, and RN #1 checked on the resident, but she did not remember the nurse completing an assessment of the resident. SRNA #1 stated she and RN #1 lifted the resident back to the bed, and the resident complained of pain. Per interview, the resident continued to complain of pain throughout the night, but did not specify where he/she was hurting. Per interview, she sat with the resident about thirty (30) minutes after the fall, and then Resident #1 was positioned at the nurse's station for close monitoring and continued to complain of pain. Interview on 12/30/19 at 3:25 PM, with SRNA #2, revealed she did not provide care to Resident #1 accept to help pull him/her up in the bed on 12/13/19 during the evening shift through the morning of 12/14/19. She stated she did remember the resident verbalizing he/she was having pain, but the resident did not verbalize where the pain was located. She stated she did not know anything about the fall except she was told the resident fell . Interview with RN #4, on 12/30/19 at 3:53 PM, revealed she was working South Hall on 12/13/19, the night Resident #1 sustained the fall, and RN #1 was working the North Hall. Per interview, RN #4 sat with the resident for a few minutes after the fall which occurred at approximately 10:30 PM, while the SRNAs were completing their rounds on other residents. RN #4 stated while she was sitting with the resident, he/she was very restless, trying to get out of bed and was confused. Per interview, she did not notice any non-verbal signs of pain such as moaning, grimacing or guarding. However, she stated the resident did complain of pain once up in the wheelchair after the fall while sitting across from the nurse's station, and that was when RN #1 made the phone call to get the X-Ray, which was about 11:30 PM. Interview on 12/24/19 at 8:00 AM, and post survey interview on 01/15/2020 at 8:45 AM, with RN #1, revealed when she arrived on the unit 12/13/19, Resident #1 was in bed and the resident's spouse inquired about pain medication for the resident. Per interview, she administered [MEDICATION NAME] 5/325 mg to the resident at 8:30 PM. She stated Resident #1 kept trying to get out of bed unassisted after 8:30 PM and kept raising the bed up into the high position using the bed control. Further, the resident was toileted several times as he/she kept verbalizing the need to go to the bathroom, even though he/she was just taken to the toilet. Per interview, SRNA #1 was checking on the resident every fifteen (15) minutes, but this was not documented. Continued interview with RN #1, revealed she was called to Resident #1's room by SRNA #1, on 12/13/19 at 10:35 PM, and the resident was observed to be on the floor in the prone position lying partly on his/her left side. Per interview, she did not check the resident's Range of Motion (ROM), or perform a comprehensive neuro check after the fall, even though she documented that she did. She stated she did do a visual assessment of the resident who seemed to be okay, and vital signs were obtained. Per interview, the resident did complain of pain in the left hip after the fall, but she and SRNA #1 were able to lift the resident under his/her arms and stand the resident to his/her feet and then assist the resident to bed. She stated the resident verbalized increased pain during this transfer. Per interview, once in bed the resident kept trying to get out of bed unassisted and was very confused, and she decided to position the resident in the wheelchair across from the nurse's station in order to keep a closer eye on him/her. RN #1 stated while the resident was sitting in the wheelchair after the fall, he/she kept complaining of pain in the left hip, but it was not time for pain medication. Per interview, at 11:37 PM, she notified the ARNP of the resident's fall due to the resident's continued complaints of pain and an order was obtained for an X-Ray of the resident's hips and pelvis. Additional interview with RN #1, revealed the X-Ray results were received by her at 2:00 AM, when the X-Ray report was faxed to the facility; however, she did not notify the ARNP of the left [MEDICAL CONDITION] when she received the results. Per interview, she did not accurately read the X-Ray report findings and was unaware Resident #1 had a new left [MEDICAL CONDITION] due to thinking the fracture on the X-Ray was the same fracture acquired prior to admission. Per interview, the resident was not medicated again for pain until 12/14/19 at 2:30 AM when she administered [MEDICATION NAME] 5 mg/325 mg. Furthermore, RN #1 stated the resident continued to complain of pain, but she did not notify the ARNP concerning Resident #1's continued pain after the first call on 12/13/19 at 11:37 PM because the resident was always complaining of pain. Per interview, the resident was assisted back to bed for thirty (30) minutes from approximately 3:00 AM until 3:30 AM, but was assisted to the wheelchair and remained in the wheelchair from 3:30 AM until 5:30 AM, when the resident was assisted back to bed and fell asleep. Per interview, RN #2 arrived and reviewed the X-Ray report findings during shift change at 7:30 AM on 12/14/19, which was nine (9) hours after the fall and five and a half (5.5) hours after the X-Ray report was originally available to the facility. Per interview, the ARNP was then notified of the X-Ray results. Interview with RN #2, on 12/27/19 at 12:01 PM, she took report during shift change from RN #1 the morning of 12/14/19, and was informed Resident #1 had a fall from his/her bed and an X-Ray had been obtained. Per interview, she was informed by RN #1 the results of the X-Ray indicated a [MEDICAL CONDITION] hip, which the resident had been admitted with after a surgical repair. Per interview, RN #2 reviewed the X-Ray report findings, and identified the resident had sustained new Left [MEDICAL CONDITION]. Per interview, she informed RN #1 of this and the ARNP was notified of the Left [MEDICAL CONDITION] on 12/14/19 at 7:30 AM. RN #2 stated the resident's family was then notified of the injury and the resident was transferred sent to the Hospital ER. Interview with the Unit Manager, on 12/27/19 at 2:00 PM, revealed she was not aware until 12/17/19, Resident #1 sustained a fall from the bed and fractured his/her left hip because she had been off work. However, she stated she would expect the nurses to provide the Physician with all the information needed to make an appropriate [DIAGNOSES REDACTED]. Further interview revealed it was her expectation the nurses complete a thorough assessment after the resident sustains a fall and immediately notify the Physician of the fall and any obvious injuries after the assessment. Continued interview revealed it was her expectation nurses notify the Physician of any increased or new pain after a fall, and notify the Physician if pain medication was ineffective. Interview on 12/23/19 at 12:24 PM, with Resident #1's spouse, revealed he/she received a call the morning of 12/14/19 at 1:30 AM, related to the resident sustaining a fall and was informed an X-Ray was to be done. Per interview, an hour later he/she received a call from a nurse at 2:30 AM, informing him/her the X-ray report was negative and they were keeping the resident at the nurse's station due to the resident being restless and raising the bed in high position. Further interview revealed on 12/14/19 at 8:00 AM, the spouse received a call explaining there was a mistake, and the resident's hip was indeed broken. Interview with the ARNP, on 12/30/19 at 3:33 PM, revealed she was in bed on 12/13/19, when she received a call around 11:30 PM related to Resident #1 sustaining a fall and complaining of hip pain. Per interview, she ordered a Stat X-Ray of the Left Hip, but did not want to order any further pain medication at the time of the call. She stated she wanted the resident's pain managed with the medication that was already ordered until the X-Ray results came back, which usually took a few hours if ordered Stat. Further interview with the ARNP, revealed she did not hear back from the nurse related to the X-Ray results or related to the resident's pain until 12/14/19 about 6:00 AM or 6:30 AM. Additional interview revealed if a resident sustained [REDACTED]. In addition, she stated she would expect the nurse to immediately inform her of accurate X-Ray results and to inform her if a resident's pain was not managed with current pain medication. Continued interview revealed if she had been notified of accurate X-Ray results in a timely manner for Resident #1, she would have given orders to send the resident to the Hospital ER because a resident with a [MEDICAL CONDITION] would need to be evaluated by an orthopedic surgeon. Interview with the Director of Nursing (DON), on 12/27/19 at 2:36 PM, 01/02/2020 at 3:15 PM, and post survey interview on 01/16/2020 at 12:06 PM, revealed a prudent nurse would thoroughly assess any resident after a fall to include neuro checks, ROM, pain, skin check, and vital signs and immediately notify the Medical Provider of the assessment findings and any new or increased pain. Additional interview revealed a prudent nurse would have reviewed Resident #1's X-Ray findings and accurately notified the Medical Provider of the results, which was not done for Resident #1. Per interview, it was also her expectation the Medical Provider be notified if a resident's pain was not effectively relieved. Interview with the Administrator, on 01/02/2020 at 3:51 PM, and post survey interview on 01/16/2020 at 1:53 PM, revealed it was her expectation residents be thoroughly assessed after a fall and the Physician be notified immediately after the fall, especially if there was increased or new pain related to a fall. Per interview, RN #1 should have notified the ARNP immediately after the fall on 12/13/19. Further interview revealed Resident #1's X-Ray results should have been communicated accurately to the ARNP after RN #1 received the results the morning of 12/14/19, in order for the ARNP to make an informed decision related to necessary treatment. Further interview revealed the ARNP should have been notified when the resident's pain was not relieved after receiving the ordered pain medication after the fall, in order to ensure the resident's pain was managed. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/19/2020 alleging removal of the Immediate Jeopardy on 12/31/19. Review of the AoC revealed the facility implemented the following: 1. Resident #1 did not return to the facility after discharge to the hospital on [DATE]. 2. On 12/14/19, the Director of Nursing (DON) provided Registered Nurse (RN) #1 re-education related to falls, Physician notification, pain assessments, proper handling of X-ray results and completing fall investigations. 3. Beginning 12/23/19 through 12/30/19, the DON, Unit Managers (UMs), Minimum Data Set (MDS) Nurse and Signature Clinical Coordinator (SCC) completed a review of fall investigations, pain evaluations, fall risk assessments, fall prevention Care Plans, and State Registered Nurse Aide (SRNA) Care Plans for all residents who sustained a fall during the previous 30 (thirty) days. 4. Beginning 12/23/19 through 12/30/19, the DON, UMs, MDS Nurse and SCC conducted a review of all residents' electronic medical records (EMR) including the Medication Administration Record [REDACTED]. Any issues found were immediately addressed with the Physician. 5. Beginning 12/23/19 through 12/30/19, all residents were assessed for pain with the MatricCare Pain Evaluation Data Assessment Tool and the MatricCare Pain Assessment in Advanced Dementia Scale Tool by the DON, UMs, SCC, and MDS Nurses. Any pain identified was immediately addressed with the Physician and the resident's Care Plan was updated to meet the resident's needs. 6. On 12/23/19, the Quality Assurance Performance Improvement (QAPI) committee met to discuss current findings, and the development and execution of plans in place, and consulted with the Medical Director for any further recommendation. Those in attendance included the Administrator, DON, UMs, MDS Nurse, SCC, Dietary Manager, Social Manager, Infection Control Nurse, Medical Director and Regional Vice President. After this meeting, there was to be weekly QAPI meetings held to review and evaluate the plan. 7. Beginning 12/23/19 through 12/30/19, all Baseline Care Plans and SRNA Care Plans were audited by the DON, MDS Nurses, Social Services, SCC, Center Executive Officer (CEO) and Staff Development Nurse (SDN) from another Signature Home for the last thirty (30) days to assure Baseline Care Plans, and State Registered Nurse Aide (SRNA) Care Plans reflected current resident care needs and goals. Any concerns noted were immediately corrected by updating Care Plans and SRNA Care Plans to reflect current resident care needs. 8. Beginning 12/23/19 though 12/30/19, all residents had a fall risk assessment completed by the DON, MDS, UMs, and SCC. 9. Beginning 12/23/19, all reported resident falls will be called into the DON ongoing until the QAPI team determines this process can be changed. 10. Beginning 12/23/19 through 12/30/19, the DON, UMs and SCC provided re-education to licensed nurses and SRNAs regarding appropriate documentation of Physician notification as part of the change in condition policy, accidents/incidents, X-ray and lab results, pain policy, abuse and neglect policy, Baseline/Care Plan policy, and following Care Plans with a one hundred percent (100%) competency test. A 100% passing score was required to show competency before the nurses and SRNAs could work. All fifty-six (56) nurses and SRNAs received the education prior to 12/30/19. Re-education was required by 12/30/19, prior to staff working their next shift. Any new nurses and SRNAs will receive the education in orientation by the SDC . The facility does not use agency staff. 11. Beginning 12/24/19, falls will be reviewed in the daily clinical meeting by the Interdisciplinary Team (IDT) and the SCC for compliance with falls, pain and Physician notification policies. This will include a review to ensure pain management, neuro checks completed if required, X- ray reports completed and communicated, thorough investigation conducted with witness statements, and Baseline Care Plans revised with interventions. This will be ongoing until the QAPI team determines the process can be changed. 12. Beginning 12/24/19 through 01/13/2020, the DON, UM and MDS Nurse reviewed daily the Twenty-four (24) Hour Reports, Progress Notes, and Event Manager for Physician notification and changes in residents' condition. This review will be ongoing daily until QAPI determines this process could be changed. 13. Beginning 12/26/19 through 01/13/2020, the UMs and MDS Nurse checked daily to validate pain assessments were completed by nursing staff. 14. Beginning 12/28/19 through 01/13/2020, the IDT validated fall prevention interventions were in place by conducting random audits of 20 (twenty) residents. 15. Beginning 12/31/19 through 01/13/2020, the MDS Nurse and the UMs validated that pain medication was appropriately signed out by nursing staff. 16. Beginning 12/31/19 through 01/13/2020, the Staff Development Coordinator (SDC) randomly tested a minimum of ten (10) nursing staff on education they received. 17. Beginning 12/31/19 through 01/13/2020, the Baseline Care Plans were monitored by MDS staff related to initial goals of care, safety needs, risks for accidents, therapy, dietary, social services, completion in forty-eight (48) hours and fall risk assessments. Any concerns identified would be addressed immediately and reported to the DON to address with nursing staff to include re-education and/or disciplinary action. 18. On 12/30/19, a QAPI Meeting was held to review audits related to fall investigations, Physician notification, pain, Baseline Care Plans/ SRNA Care Plans, and pain medication monitoring results. In addition, the meeting validated all staff had received education as per the AoC. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's medical record revealed on 12/27/19 at 7:54 AM, the facility's Administrator documented she initiated telephone contact with the resident's husband to inquire on the status of the resident's condition at the hospital and to see if or when the resident would be returning to the facility. The Administrator documented Resident #1's husband stated, My attorney has advised me not to talk with you, goodbye. Interview on 02/21/2020 at 11:00 AM, with the facility's DON, revealed Resident #1 sustained a fall with a fracture on 12/13/19, and the resident was transported to the hospital on [DATE]. Per interview, the resident's family decided they did not want the resident to return to the facility. 2. Review of the email dated 12/26/19 at 2:49 PM, from the DON to the Administrator, revealed RN #1 was educated by the DON related to any diagnostic reports were to be read word for word to the Physician or Nurse Practitioner. Further, she educated the nurse to notify the Physician of any falls immediately, and evaluate any resident for pain or injury immediately after a fall. In addition, the DON educated the nurse related to administering pain medications as ordered and evaluating effectiveness of the pain medication afterward. Continued review revealed she educated RN #1 related to completing Fall Assessments after any fall, and updating the Care Plan with interventions. Interview on 02/21/2020 at 11:00 AM, with the DON, revealed she provided education to RN#1 on 12/14/19 regarding the events of Resident #1's fall that resulted in a fracture on 12/13/19. Per interview, she educated the nurse related to the need to ready word for word any diagnostic reports to the Physician or Nurse Practitioner. Further, she educated the nurse to notify the Physician of any falls immediately; evaluate any resident for pain or injury immediately after a fall; and administer pain medications as ordered and evaluate effectiveness of the pain medication afterward. In addition, she stated she educated the nurse related to the need to complete a Fall Assessment after any fall, and update the Care Plan with fall interventions. Interview conducted on 02/21/2020 at 2:50 PM, with the facility's Regional Vice President (RVP), revealed on 12/30/19, the Medical Director agreed with the governing body to terminate RN #1 for performance failure. 3. Review of the 30 (thirty) Day Falls Audit, conducted 12/23/19 through 12/30/19, revealed all facility residents who were documented as sustaining a fall from 11/23/19 through 12/23/19, were reviewed by the DON, UMs, MDS Nurses and the SCC to include a review of fall investigations, pain evaluations, fall risk assessments, fall prevention Care Plans, and SRNA Care Plans. Twenty (20) residents sustained falls during this time frame and of the twenty (20) residents reviewed, fourteen (14) residents were identified by the facility as not having their Care Plans updated after the falls. Interview on 02/21/2020 at 11:00 AM, with the DON, revealed an audit was conducted 12/23/19 through 12/30/19, for residents who sustained a fall in the facility from 11/23/19 through 12/23/19. The DON stated a checklist was maintained for each of those residents reviewed. Per interview, the residents were reviewed to ensure a fall investigation had been completed, pain issues were addressed, fall risk assessments were completed and fall prevention care plans were updated for those residents. Further interview revealed the audit indicated several residents did not have their Care Plans updated after their falls and the Care Plans were updated during the review. Interview with UM #1, on 02/21/2020 at 1:10 PM, revealed she participated in the review conducted 12/23/19 through 12/30/19, for all residents who sustained a fall from 11/23/19 through 12/23/19. Per interview, the residents were reviewed to ensure a fall investigation had been completed,

Based on interview, record review and review of the facility Baseline Care Plan Process, it was determined the facility failed to develop/revise and implement the Baseline Care Plan to provide effective and person centered care of the resident for one (1) of four (4) sampled residents (Resident #1). On 12/11/19, the facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 12/12/19, the resident sustained [REDACTED]. According to the Fall Investigation completed related to this fall, the new intervention to prevent further falls of the same nature was to toilet the resident before and after meals and at night. However, there was no documented evidence the Baseline Care Plan was revised to include this intervention. Additionally, on 12/13/19, at 8:30 PM, Resident #1 received a [MEDICATION NAME] 5/325 milligram for right hip pain. Staff interviews revealed after receiving the medication, the resident was restless and kept repeatedly raising the bed into the high position with the bed control, and attempting to get out of bed unassisted. However, the Baseline Care Plan was not developed/revised with interventions for supervision consistent with the resident's needs and staff left the resident in the bed unsupervised. Resident #1 sustained a fall from the bed resulting in new and horrible intense pain to the left hip at approximately 10:35 AM. However, after the fall, the Baseline Care Plan was not implemented related to pain management as Registered Nurse (RN) #1 did not notify the Advanced Registered Nurse Practitioner (ARNP) of the fall and complaints of left hip pain until 12/13/19 at 11:37 PM, approximately one (1) hour after the fall. An X-Ray of the left hip was ordered after the notification, and RN #1 received the X-Ray results on 12/14/19 at 2:00 AM. However, RN #1 did not review the X-Ray findings accurately and did not inform the ARNP of the results of the X-Ray which revealed a Left [MEDICAL CONDITION]. Although Resident #1 continued to complain of pain and received another [MEDICATION NAME] 5/325 mg on 12/14/19, at 2:30 AM, there was no documented evidence a pain assessment was completed prior to or after administration of the medication. Staff interviews revealed the resident continued to complain of pain after receiving the 2:30 AM pain medication; however there was no documented evidence the ARNP was notified of the continued pain or the Left [MEDICAL CONDITION] until 12/14/19 at 7:45 AM, after RN #2 reviewed the X-Ray results. Resident #1 was transferred to the hospital on [DATE] at approximately 8:00 AM, and admitted with [DIAGNOSES REDACTED]. Resident #1 underwent Open Reduction Internal Fixation (ORIF) due to the Left [MEDICAL CONDITION], on 12/15/19. (Refer to F-580, F-658, F-689 and F-697) The facility's failure to have an effective system in place to develop/revise and implement the Baseline Care Plan related to instructions needed to provide effective and person centered care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2020 and was determined to exist on 12/13/19. The findings include: Review of the facility Baseline Care Plan Process dated 07/19/18, revealed the purpose of the process was to ensure care needs are met, utilizing a person centered focus, for newly admitted and/or readmitted residents. 1) The Charge Nurse admits the resident to the facility and completes all assessments including the Nursing Admission Evaluation and other ancillary evaluations, as needed; and medications and orders are reconciled. 2) Create a Baseline Care Plan, high risk residents must be care planned within twenty-four (24) hours. It will include Admission Nursing Evaluation and ancillary evaluations which are triggered. i.e. Falls, Diabetes. It will include: dietary orders, goals for discharge, goals based on admission orders [REDACTED]. Further review revealed the Baseline Care Plan will be a working tool for the first forty-eight (48) hours. The Baseline Care Plan is finalized during the first forty-eight (48) hours after admission utilizing input from all disciplinary team members along with the resident and/or the resident's Power of Attorney (POA) or family. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 12/11/19 from an acute care hospital with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment was not completed due to the resident being newly admitted . However, review of Resident #1's Brief Interview for Mental Status (BIMS), dated 12/12/19, revealed the facility assessed the resident as having a score of six (6) out of fifteen (15) indicating severe cognition impairment. Review of the physician's orders [REDACTED]. Review of the Baseline Care Plan, initiated 12/12/19, revealed Resident #1 had the potential for falls related to a history of falls as per the resident's fall risk score. The goal stated the resident would not sustain an injury related to falls over the next thirty (30) days. Interventions initiated 12/12/19, included assisting the resident with toileting and transfers every shift; assist for toileting and transfers as needed; cue for safety awareness; keep the environment safe; place the call within easy reach; and use safety device(s). Additional review of the Baseline Care Plan, initiated 12/12/19, revealed the resident was not a candidate for bowel and bladder retraining with a goal stating the resident would receive assistance to be kept clean, dry, and comfortable. Interventions included checking the resident every two (2) to three (3) hours and as needed for incontinence episodes every shift; and providing incontinence care after each incontinent episode. Further review of the Baseline Care Plan, initiated 12/12/19, revealed Resident #1 was admitted with right hip pain post operatively, with a goal stating the resident would have relief or reduction of pain intensity within one (1) hour after receiving interventions over the next thirty (30) days. The interventions included administer pain medications as per physician's orders [REDACTED]. Review of Resident #1's Certified Nursing Assistant (CNA) Record (Nurse Aide Care Plan), dated 12/12/19, revealed the resident was alert, confused, verbal and/or alert, oriented, and verbal. Interventions included assistance of one (1) staff with full weight bearing as tolerated on the left and right side for transfers and ambulation; non-skid socks; one quarter (1/4) side rails on the left and right side; toileting with the assistance of one (1) staff and encourage toileting before and after meals. An additional intervention was added on 12/13/19, to provide the resident with diversion at the nursing station and provide snacks. Review of Resident #1's Fall Investigation, revealed on 12/12/19 (time not documented), Resident #1 was in the wheelchair in the room attempting to transfer self to the bathroom and fell . The call light was not in use at the time of the fall, but was in reach. The resident had no signs of injury, and denied pain. Continued review revealed the root cause was determined to be the resident attempted to use the bathroom. Per this Investigation, the resident was assisted to the bathroom and then brought to sit in front of the nurse's station. Further review revealed the new intervention was to toilet the resident before and after meals and at night. This Investigation was signed by the Director of Nursing (DON) and dated 12/16/19. However, further review of the Baseline Care Plan, revealed there was no documented evidence it reflected changes to approaches as necessary or was developed/revised with interventions for toileting the resident before and after meals and at night as a corrective intervention after the fall sustained on 12/12/19 fall. Review of the Controlled Drug Record (CDR), revealed Resident #1 received [MEDICATION NAME] 5/325 mg on 12/13/19 at 8:30 PM, and on 12/14/19 at 2:30 AM. However, review of the Medication Administration Record [REDACTED]. In addition, there was no documented evidence on the MAR indicated [REDACTED]. Review of Resident #1's Progress Notes, revealed no documentation for the shift of 12/13/19 from 7:00 PM through 12/14/19 at 7:00 AM, even though staff interviews revealed after 8:30 PM on 12/13/19, the resident exhibited behaviors which included raising the bed in the high position, attempting to get out of bed unassisted, and asking to go to the bathroom frequently. Additionally, there was no documented evidence the Baseline Care Plan reflected changes to approaches as necessary or was revised with interventions for increased supervision necessary to keep the resident safe. (An entry was made to the Baseline Care Plan on 12/17/19, after the resident was discharged to provide diversion at the nurse's station). Review of the Phone Message Record dated 12/13/19 at 11:37, revealed the ARNP was notified by RN #1, that Resident #1 fell from his/her bed at 10:35 PM and was complaining of hip pain which was unspecified on the message. RN #1 requested follow-up orders per the voice message. Review of Resident #1's Fall Event Report, revealed a fall occurred on 12/13/19 at 10:35 PM, and the resident had severe pain (horrible intense) of the left hip. Resident #1 had raised the bed in the highest position and fell from the bed. Resident #1 was then placed in the wheelchair and brought to the nurse's station. Notifications included the DON and the Administrator. The ARNP was notified on 12/13/19 at 11:30 PM, and a left hip X-Ray was ordered. This Fall Event Report was completed on 12/14/19 at 8:17 AM, by RN #1. Review of the Mobile X-Ray report, dated 12/14/19, received by the facility on 12/14/19 at 2:00 AM, revealed there was a non-displaced intertrochanteric [MEDICAL CONDITION] femur. Additional review revealed status [REDACTED]. Review of the Situation Background Assessment Recommendation (SBAR) Communication Form, revealed on 12/13/19, the resident had a change in condition and worsening pain in the left hip with a pain level of ten (10), with ten (10) being the worst on a pain scale of one (1) to ten (10). Vital signs were obtained which were stable, and neuro checks were completed with no changes observed. Further, there was new pain in the left hip and wincing with movement. An X-Ray was completed which showed a new [MEDICAL CONDITION] of the left hip and the Medical Provider was notified on 12/14/19 at 7:45 AM. Resident #1 was transferred to the emergency room (ER) and the resident's representative was notified on 12/14/19 at 7:50 AM. There was no signature to this SBAR document and no date of completion. Post survey interview with RN #1, on 01/15/2020, at 8:45 AM, revealed she completed this SBAR after the resident was sent to the Hospital emergency room (ER), on 12/14/19. Review of Resident #1's Discharge MDS Assessment, dated 12/14/19, revealed the resident was discharged to an Acute Care Hospital. Review of the Hospital Discharge Summary, dated 12/28/19, revealed Resident #1 was admitted on [DATE], after sustaining a fall in the nursing home resulting in an Intertrochanteric [MEDICAL CONDITION] Hip. Other admission [DIAGNOSES REDACTED]. Per the Discharge Summary, when admitted to the ER Resident #1 was confused and complaining of severe left hip pain made worse by movement. Further review of the Discharge Summary, revealed the resident underwent [REDACTED]. The resident tolerated the procedure and his/her post-op course was without complication with the exception of pain management and agitation. Resident #1 was discharged to a Skilled Nursing Facility and would follow up with Family Medicine. Continued review of the Discharge Summary, revealed instructions for Activity as Tolerated; Weight bearing as tolerated; and no formal hip precautions. Review of Resident #1's Fall Investigation, revealed the resident had been up and down during the 7:00 PM to 7:00 AM shift on 12/13/19 to 12/14/19 at the nursing station. After the resident requested to go to bed, State Registered Nurse Aide (SRNA) #1 put Resident #1 back to bed and soon afterward heard the resident fall in the room (with no specified time of the fall). Resident #1 was evaluated by the nurse and taken to the nurse's station. The ARNP was notified at 11:30 PM, and a new order was given for an X-Ray. However, this X-Ray was misread by RN #1 on the night shift, and RN #2, who was the day shift nurse, reviewed the X-Ray and found a new [MEDICAL CONDITION] hip. The Physician was then notified and the resident was sent to the Hospital ER. Per this Fall Investigation, the root cause of the fall was fall from bed, and the contributing factors were impulsive behavior. The Fall Investigation was signed by the DON on 12/16/19. Interview on 12/30/19 at 5:38 PM, with SRNA #1, revealed she was assigned to Resident #1 on 12/13/19 from 7:00 PM until 7:00 AM, on 12/14/19. Per interview, after the resident's spouse left about 8:30 PM on 12/13/19, the resident kept trying to climb out of the bed and she had to repeatedly assist the resident to the bathroom. Further interview revealed she sat in the room with Resident #1 from about 8:30 PM until 9:00 PM, after the resident received pain medication for complaints of right hip pain. Continued interview with SRNA #1, revealed on 12/13/19 about 9:00 PM, she went to check on her other residents, but checked on Resident #1 at least every thirty (30) minutes. She stated while checking on Resident #1 she observed the resident raised the bed up in high position and put the head of the bed straight up using the hand held bed control, and SRNA #1 had to readjust the bed to the low position. SRNA #1 further stated the resident also persisted in trying to get up out of bed without assistance. Further, when the resident was in the bed, SRNA #1 would continuously have to lower the bed to the lowest position and pull the resident back up towards the head of the bed and RN #1 was made aware of the resident's behavior. Further interview with SRNA #1, revealed she had toileted the resident, and assisted him/her back to bed, and a short time later, about 10:30 PM, she heard a noise and entered Resident #1's room and noted the resident was on the floor and the bed was in the high position. Per interview, she notified RN #1 of the fall, and after RN #1 checked on the resident, she and RN #1 lifted the resident back to the bed. SRNA #1 stated she sat with the resident about thirty (30) minutes after the fall, and then he/she was positioned at the nurse's station for close monitoring. Per interview, after the fall the resident continued to complain of pain throughout the night, but he/she did not specify where he/she was hurting. Additional interview with SRNA #1, revealed after the fall, Resident #1 was assisted back to bed for an X-Ray on 12/14/19 about 1:30 AM, which took about thirty (30) minutes at the most. She stated the resident was then positioned at the nurse's station in the wheelchair in order for staff to monitor him/her for safety until 5:30 AM, when the resident was assisted back to bed and went to sleep. Further interview revealed if Resident #1 had someone to sit with him/her during the shift when he/she was so restless, this may have prevented the fall. However, she stated she was not directed to give the resident one on one (1:1) supervision or given further instructions related to increased monitoring and supervision of the resident that night prior to the fall. Interview on 12/24/19 at 8:00 AM, and post survey interview on 01/15/2020 at 8:45 AM, with RN #1, revealed she just started at the facility on 12/11/19, and 12/13/19 was her first night out of orientation working on the North hall as the only nurse for the hall. She stated she administered [MEDICATION NAME] 5/325 mg at 8:30 PM to Resident #1 for right hip pain on 12/13/19, at the resident's spouse's request. She further stated the resident kept trying to get out of bed unassisted after his/her spouse left which was around 8:30 PM. Per interview, the resident was also raising the bed up into the high position using the bed control. Further, the resident was toileted several times as he/she kept verbalizing the need to go to the bathroom, even though he/she was just taken to the toilet. She stated SRNA #1 kept checking on him/her every fifteen (15) minutes, although this was not documented. She further stated she was aware the resident was continuously attempting to get out of bed, continuously raising the bed up into the high position, and frequently verbalizing the need to be toileted. However, she stated she did not develop/revise the Baseline Care Plan with interventions for increased supervision and monitoring. She stated she should have called the DON and asked for a staff member to sit one on one (1:1) with the resident as the resident was not safe left alone in his/her room during this timeframe due to his/her behaviors. Continued interview with RN #1, revealed SRNA #1 called her to Resident #1's room on 12/13/19 at 10:35 PM, and the resident was observed to be on the floor in the prone position lying partly on his/her left side. Per interview, the resident did complain of pain in the left hip after the fall, but she and SRNA #1 were able to lift the resident under his/her arms and stand the resident to his/her feet and then assist the resident to bed. Per interview, once the resident was in bed, he/she kept trying to get out of bed unassisted and was very confused. RN #1 stated she made the decision to position the resident in the wheelchair across from the nurse's station in order to keep a closer eye on him/her. Per interview, while sitting in the wheelchair, Resident #1 resident kept complaining of pain in the left hip, and at 11:37 PM the ARNP was notified of the resident's fall and continued complaints of pain with an order obtained for an X-Ray of the resident's hips and pelvis. Further interview with RN #1, revealed Resident #1 was assisted back to bed for an X-Ray on 12/14/19, at approximately 1:30 AM, and then assisted back up to the wheelchair for close monitoring. Per interview, the X-Ray results were received by her at 2:00 AM, after the X-Ray report was faxed to the facility. However, she stated she did not accurately read the X-Ray report results and was not aware Resident #1 had a new left [MEDICAL CONDITION] due to thinking the fracture on the X-Ray was the same fracture acquired prior to admission. She stated the resident received another [MEDICATION NAME] 5/325 mg on 12/14/19 at 2:30 AM, for continued complaints of pain and then was assisted back to bed for thirty (30) minutes from approximately 3:00 AM until 3:30 AM. However, she stated she did not complete a pain assessment prior to or after administration of the medication, but just observed the resident for signs and symptoms of pain. She further stated the resident was then assisted back to the wheelchair at 3:30 PM due to attempting to get out of bed unassisted, and remained in the wheelchair from 3:30 AM until 5:30 AM, when the resident was assisted back to bed and fell asleep due to exhaustion. Per interview, during shift change the morning of 12/14/19, RN #2 read the X-Ray report findings at 7:30 AM which was nine (9) hours after the fall and five and a half (5.5) hours after the X-Ray report was originally available to the facility. She stated the ARNP was then notified of the X-Ray results. Further interview with RN #1, revealed Resident #1's Baseline Care Plan was not implemented related to pain management. She stated she should have notified the ARNP related to the resident's new left hip pain immediately after the fall, and she should have notified the ARNP of the resident's continued pain throughout the night of 12/13/19 and the morning of 12/14/19 after the fall, as per the Baseline Care Plan. Further, she should have observed the resident for effectiveness of pain medication and reported to the Physician when the resident did not experience reduction in pain after receiving pain medication on 12/13/19 and 12/14/19. Interview with the DON, on 12/27/19 at 2:36 PM, 01/02/2020 at 3:15 PM, and post survey interview on 01/16/2020 at 12:06 PM, revealed it was her expectation that staff develop, revise, and implement the Baseline Care Plan related to supervision to minimize the risk of falls and for pain management. Per interview, the nurse assigned to the resident would be responsible for developing, updating the Baseline Care Plan as needed. She stated Resident #1's Baseline Care Plan should have been developed/revised after the fall on 12/12/19 to include toileting the resident before and after meals and at night as per the interventions noted as corrective action on the Fall Investigation which she signed on 12/16/19. Continued interview with the DON, revealed during the investigation of Resident #1's 12/13/19 fall, she identified the resident was restless and attempting to get out of bed unassisted and also raising the bed in high position prior to the fall. She stated RN #1 should have revised the Baseline Care Plan as needed in an attempt to prevent the resident from sustaining a fall. However, she stated she did think extra supervision was provided for the resident prior to the fall as staff provided frequent monitoring of the resident, even though this was not documented. Further interview with the DON, revealed Resident #1's Baseline Care Plan should have been implemented related to pain management to include observing effectiveness of pain medication, providing comfort measures and reporting to the Physician if the resident did not experience reduction in pain. Per interview, pain assessments were not completed on the MAR for the evening of 12/13/19 and the morning of 12/14/19 for this resident before or after administration of medication. Further, it would have been her expectation the ARNP be notified immediately after the fall of the resident's new and severe left hip pain, and again when the resident was exhibiting continued pain. Interview with the Administrator, on 01/02/2020 at 3:51 PM, and post survey interview on 01/16/2020 at 1:53 PM, revealed it was up to nursing to decide which interventions would need to be developed and implemented on the Care Plan to keep a resident safe as that was not her area of expertise. Continued interview revealed Resident #1's Baseline Care Plan should have been revised with new interventions to prevent falls after the 12/12/19 fall by the interdisciplinary Team according to corrective interventions on the Fall Investigation. Further interview revealed Resident #1's Baseline Care Plan should have been developed/revised by RN #1 with interventions to supervise the resident in an attempt to keep him/her from climbing out of the bed, on the evening of 12/13/19, and these interventions should have been implemented to prevent the fall. Additional interview revealed Resident #1's Baseline Care Plan should have been implemented related to pain management prior to and after the fall on 12/13/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/19/2020 alleging removal of the Immediate Jeopardy on 12/31/19. Review of the AoC revealed the facility implemented the following: 1. Resident #1 did not return to the facility after discharge to the hospital on [DATE]. 2. On 12/14/19, the Director of Nursing (DON) provided Registered Nurse (RN) #1 re-education related to falls, Physician notification, pain assessments, proper handling of X-ray results and completing fall investigations. 3. Beginning 12/23/19 through 12/30/19, the DON, Unit Managers (UMs), Minimum Data Set (MDS) Nurse and Signature Clinical Coordinator (SCC) completed a review of fall investigations, pain evaluations, fall risk assessments, fall prevention Care Plans, and State Registered Nurse Aide (SRNA) Care Plans for all residents who sustained a fall during the previous 30 (thirty) days. 4. Beginning 12/23/19 through 12/30/19, the DON, UMs, MDS Nurse and SCC conducted a review of all residents' electronic medical records (EMR) including the Medication Administration Record [REDACTED]. Any issues found were immediately addressed with the Physician. 5. Beginning 12/23/19 through 12/30/19, all residents were assessed for pain with the MatricCare Pain Evaluation Data Assessment Tool and the MatricCare Pain Assessment in Advanced Dementia Scale Tool by the DON, UMs, SCC, and MDS Nurses. Any pain identified was immediately addressed with the Physician and the resident's Care Plan was updated to meet the resident's needs. 6. On 12/23/19, the Quality Assurance Performance Improvement (QAPI) committee met to discuss current findings, and the development and execution of plans in place, and consulted with the Medical Director for any further recommendation. Those in attendance included the Administrator, DON, UMs, MDS Nurse, SCC, Dietary Manager, Social Manager, Infection Control Nurse, Medical Director and Regional Vice President. After this meeting, there was to be weekly QAPI meetings held to review and evaluate the plan. 7. Beginning 12/23/19 through 12/30/19, all Baseline Care Plans and SRNA Care Plans were audited by the DON, MDS Nurses, Social Services, SCC, Center Executive Officer (CEO) and Staff Development Nurse (SDN) from another Signature Home for the last thirty (30) days to assure Baseline Care Plans, and State Registered Nurse Aide (SRNA) Care Plans reflected current resident care needs and goals. Any concerns noted were immediately corrected by updating Care Plans and SRNA Care Plans to reflect current resident care needs. 8. Beginning 12/23/19 though 12/30/19, all residents had a fall risk assessment completed by the DON, MDS, UMs, and SCC. 9. Beginning 12/23/19, all reported resident falls will be called into the DON ongoing until the QAPI team determines this process can be changed. 10. Beginning 12/23/19 through 12/30/19, the DON, UMs and SCC provided re-education to licensed nurses and SRNAs regarding appropriate documentation of Physician notification as part of the change in condition policy, accidents/incidents, X-ray and lab results, pain policy, abuse and neglect policy, Baseline/Care Plan policy, and following Care Plans with a one hundred percent (100%) competency test. A 100% passing score was required to show competency before the nurses and SRNAs could work. All fifty-six (56) nurses and SRNAs received the education prior to 12/30/19. Re-education was required by 12/30/19, prior to staff working their next shift. Any new nurses and SRNAs will receive the education in orientation by the SDC . The facility does not use agency staff. 11. Beginning 12/24/19, falls will be reviewed in the daily clinical meeting by the Interdisciplinary Team (IDT) and the SCC for compliance with falls, pain and Physician notification policies. This will include a review to ensure pain management, neuro checks completed if required, X- ray reports completed and communicated, thorough investigation conducted with witness statements, and Baseline Care Plans revised with interventions. This will be ongoing until the QAPI team determines the process can be changed. 12. Beginning 12/24/19 through 01/13/2020, the DON, UM and MDS Nurse reviewed daily the Twenty-four (24) Hour Reports, Progress Notes, and Event Manager for Physician notification and changes in residents' condition. This review will be ongoing daily until QAPI determines this process could be changed. 13. Beginning 12/26/19 through 01/13/2020, the UMs and MDS Nurse checked daily to validate pain assessments were completed by nursing staff. 14. Beginning 12/28/19 through 01/13/2020, the IDT validated fall prevention interventions were in place by conducting random audits of 20 (twenty) residents. 15. Beginning 12/31/19 through 01/13/2020, the MDS Nurse and the UMs validated that pain medication was appropriately signed out by nursing staff. 16. Beginning 12/31/19 through 01/13/2020, the Staff Development Coordinator (SDC) randomly tested a minimum of ten (10) nursing staff on education they received. 17. Beginning 12/31/19 through 01/13/2020, the Baseline Care Plans were monitored by MDS staff related to initial goals of care, safety needs, risks for accidents, therapy, dietary, social services, completion in forty-eight (48) hours and fall risk assessments. Any concerns identified would be addressed immediately and reported to the DON to address with nursing staff to include re-education and/or disciplinary action. 18. On 12/30/19, a QAPI Meeting was held to review audits related to fall investigations, Physician notification, pain, Baseline Care Plans/ SRNA Care Plans, and pain medication monitoring results. In addition, the meeting validated all staff had received education as per the AoC. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's medical record revealed on 12/27/19 at 7:54 AM, the facility's Administrator documented she initiated telephone contact with the resident's husband to inquire on the status of the resident's condition at the hospital and to see if or when the resident would be returning to the facility. The Administrator documented Resident #1's husband stated, My attorney has advised me not to talk with you, goodbye. Interview on 02/21/2020 at 11:00 AM, with the facility's DON, revealed Resident #1 sustained a fall with a fracture on 12/13/19, and the resident was transported to the hospital on [DATE]. Per interview, the resident's family decided they did not want the resident to return to the facility. 2. Review of the email dated 12/26/19 at 2:49 PM, from the DON to the Administrator, revealed RN #1 was educated by the DON related to any diagnostic reports were to be read word for word to the Physician or Nurse Practitioner. Further, she educated the nurse to notify the Physician of any falls immediately, and evaluate any resident for pain or injury immed (TRUNCATED)

Based on interview, record review, review of facility Policy, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) it was determined the facility failed to ensure services being provided meet professional standards of quality for one (1) of four (4) sampled residents (Resident #1). On 12/13/19, at approximately 10:35 PM, Resident #1 sustained a fall from the bed while the bed was in high position and was found lying in the prone position, partially on his/her left hip. Resident #1 complained of horrible and intense left hip pain directly after the fall, as per the Fall Event Report dated 12/14/19. However, RN #1 did not notify the Advanced Registered Nurse Practitioner (ARNP) of the fall and left hip pain until 12/13/19 at 11:37 PM. An X-Ray was obtained which revealed the resident sustained [REDACTED].#1 received the X-Ray results on 12/14/19 at 2:00 AM, she failed to notify the ARNP of the Left [MEDICAL CONDITION] due to incorrectly reading the X-Ray results. Resident #2 had received [MEDICATION NAME] 5/325 milligram (mg) on 12/13/19 at 8:30 PM, and after the fall, received [MEDICATION NAME] 5/325 mg again at 2:30 AM. However, staff interviews revealed the resident continued to complain of pain through the night. There was no documented evidence the ARNP was notified of the Left [MEDICAL CONDITION] until 12/14/19, at 7:45 AM, after RN #2 identified the [MEDICAL CONDITION] from the X-Ray findings. Resident #1 was transferred to the hospital on [DATE] at approximately 8:00 AM, and admitted with a [DIAGNOSES REDACTED]. Resident #1 required Open Reduction Internal Fixation (ORIF) due to the Left [MEDICAL CONDITION], on 12/15/19. (Refer to F-580, F-655, F-689, and F-697) The facility's failure to have an effective system in place to ensure services being provided meet professional standards of quality has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/12/2020 and was determined to exist on 12/13/19. The findings include: Review of the facility's Change of Condition Policy, revised 11/06/19, revealed the facility will evaluate and document changes in a resident's health in an efficient and effective manner to include: a significant change in the resident's physical, mental or psychosocial status; a need to alter treatment; a decision to transfer or discharge the resident from the facility; and an accident which results in injury and/or has the potential for requiring physician intervention. Further review revealed documentation will be completed in the Situation, Background, Assessment, Recommendation (SBAR) in the Electronic Medical Record (EMR) and an Incident Report, as needed. The nurse will document notification to the Physician, ARNP, Physician Assistant (PA) and Resident's Representative, consistent with his or her authority, of resident changes immediately. Review of the KBN, AOS #19, revised 10/2019, revealed nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing, and requires licensees to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice and be evidenced based. Nurse are held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders. Nurse are responsible to clearly and effectively communicate with everyone involved in health care. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 12/11/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Note, dated 12/11/19 at 3:21 PM, revealed Resident #1 was admitted from an Acute Care Hospital and transferred per ambulance. Further, the resident was alert and oriented x 2 (alert to person and place) with occasional confusion and could verbalize needs. Continued review revealed the resident had a [DIAGNOSES REDACTED]. Additional review revealed the resident was occasionally incontinent of bowel and bladder, and required assistance with Activities of Daily Living (ADLs). Review of the physician's orders [REDACTED]. The facility had not yet completed an Admission Minimum Data Set (MDS) Assessment due to the resident being a new admission. However, review of the Brief Interview for Mental Status (BIMS), dated 12/12/19, revealed the facility assessed Resident #1 as having a score of six (6) out of fifteen (15) indicating severe cognition impairment. Review of the Fall Event Report, revealed Resident #1 sustained a fall on 12/13/19 at 10:35 PM, and the resident had severe pain (horrible intense) of the left hip. Range of Motion (ROM) painful/limited in lower extremity (did not specify which extremity) and no rotation/deformity/shortening noted of the extremities. Additional review of the Report revealed check marks in the boxes to indicate: Neurological checks completed; alert and responds appropriately to stimuli; strong facial muscle movement; strong upper left and right upper extremity grasps; strong left and right lower extremity movement; and left and right eye pupil size 3 millimeters and round and brisk pupil movement. Continued review revealed the resident had raised the bed in the highest position and fell from the bed. Resident #1 was then placed in the wheelchair and brought to the nurse's station. Notifications included the DON and the Administrator. Per the Report, the ARNP was notified on 12/13/19 at 11:30 PM, and a left hip X-Ray was ordered. The Fall Event Report was completed on 12/14/19 at 8:17 AM, by RN #1. Review of the facility's Phone Message Record dated 12/13/19, revealed the ARNP by RN #1 at 11:37, that Resident #1 sustained a fall from his/her bed at 10:35 PM and was complaining of hip pain (left or right hip was not specified). RN #1 requested follow-up orders per the voice message. Review of the Mobile X-Ray Report, dated 12/14/19, received at the facility on 12/14/19 at 2:00 AM, revealed significant findings of left hip, unilateral views of the pelvis. According to the Report, there was a non-displaced intertrochanteric [MEDICAL CONDITION] femur. Review of Resident #1's Situation Background Assessment Recommendation (SBAR) Communication Form, revealed on 12/13/19, the resident had a change in condition and worsening pain in the left hip with a pain level of ten (10), with ten (10) being the worst pain on a pain scale of one (1) to ten (10). Further review revealed vital signs were obtained which were stable, and neuro checks were completed with no changes observed. There was new pain in the left hip and wincing with movement. An X-Ray was completed which showed a new [MEDICAL CONDITION] of the left hip and the Medical Provider was notified on 12/14/19 at 7:45 AM. Resident #1 was then transferred to the emergency room (ER) for evaluation and the resident's representative was notified on 12/14/19 at 7:50 AM. There was no signature on this document and no date of completion. Post survey interview with RN #1, on 01/15/2020, at 8:45 AM, revealed she completed the SBAR after the resident was transferred to the Hospital ER, on 12/14/19. Review of the Discharge MDS Assessment, dated 12/14/19, revealed Resident #1 was discharged to an Acute Care Hospital. Review of the Hospital Discharge Summary, dated 12/28/19, revealed Resident #1 was admitted on [DATE], after a fall in the nursing home resulting in an Intertrochanteric [MEDICAL CONDITION] Hip. Additional [DIAGNOSES REDACTED]. Per the Discharge Summary, upon admission Resident #1 was confused and not responding to questions appropriately. When admitted to the ER Resident #1 was complaining of severe left hip pain which was made worse by movement. Further review of the Discharge Summary, revealed the resident underwent [REDACTED]. Post-op course was without complication except for pain management and agitation. According to the Discharge Summary, Resident #1 was discharged to a Skilled Nursing Facility and would follow up with Family Medicine. Review of Resident #1's facility's Fall Investigation, revealed Resident #1 had been assessed as at high risk for falls with contributing factors to include impulsive behavior. The resident had been up and down during the 7:00 PM to 7:00 AM shift on 12/13/19 to 12/14/19 at the nursing station. The resident requested to go to bed and SRNA #1 put Resident #1 back to bed. Soon after, SRNA #1 heard the resident fall in the room (with no specified time of the fall). According to the Investigation, the resident was evaluated by the nurse and taken to the nurse's station. The ARNP was then notified at 11:30 PM, and a new order was obtained for an X-Ray. The X-Ray was then misread by RN #1 on the night shift. However, RN #2, who was the day shift nurse, reviewed the X-Ray and identified a new [MEDICAL CONDITION] hip, and the Physician was notified. The resident was transferred to the Hospital ER. Further, the root cause of the fall was fall from bed, and the contributing factors were impulsive behavior. This Investigation was signed by the Director of Nursing (DON) on 12/16/19. Interview on 12/30/19 at 5:38 PM, with SRNA #1, revealed she was assigned to Resident #1 on 12/13/19 from 7:00 PM until 7:00 AM, on 12/14/19. Per interview, the resident persisted in trying to get up without assistance and RN #1 was made aware of the resident's behavior. Additional interview revealed she had toileted Resident #1, and assisted him/her back to bed, and a short time later, about 10:30 PM, she heard a noise in the resident's room. Per interview, when she entered Resident #1's room she observed the resident on the floor and the bed was in the high position. Per interview, she notified RN #1 of the fall, and RN #1 checked on the resident. She stated then she (SRNA #1) and RN #1 lifted the resident back to the bed, and the resident complained of pain. She further stated the resident continued to complain of pain throughout the night, but did not specify where he/she was hurting. Additional interview revealed she sat with the resident about thirty (30) minutes after the fall, and then Resident #1 was positioned at the nurse's station for close monitoring. Interview on 12/24/19 at 8:00 AM, and post survey interview on 01/15/2020 at 8:45 AM, with RN #1, revealed on 12/13/19, she administered [MEDICATION NAME] 5/325 mg to the resident at 8:30 PM for right hip pain, which was ordered every six (6) hours PRN (as needed) for pain. Per interview, Resident #1 kept trying to get out of bed unassisted after 8:30 PM and kept raising the bed up into the high position using the bed control. Further interview revealed the resident was toileted several times as he/she kept verbalizing the need to go to the bathroom, even though he/she was just taken to the toilet. RN #1 stated SRNA #1 was checking on the resident every fifteen (15) minutes, but this was not documented. Continued interview with RN #1, revealed she was called to Resident #1's room by SRNA #1, on 12/13/19 at 10:35 PM, and the resident was observed to be on the floor in the prone position lying partly on his/her left side. She stated the resident did complain of pain in the left hip after the fall, but she only did a visual assessment of the resident, who seemed to be okay except for the pain. She further stated she did not complete thorough neuro checks or ROM as documented in the Event Report. Further, once the resident was transferred to the bed he/she kept trying to get out of bed unassisted and was very confused, and she decided to position the resident in the wheelchair across from the nurse's station in order to keep a closer eye on him/her. Per interview, while the resident was sitting in the wheelchair after the fall, he/she kept complaining of pain in the left hip and at 11:37 PM, she notified the ARNP of the resident's fall due to the resident's continued complaints of pain and an order was obtained for an X-Ray of the resident's left hip. Continued interview with RN #1, revealed the X-Ray results were received by her at 2:00 AM, when the X-Ray report was faxed to the facility; however, she did not notify the ARNP of the left [MEDICAL CONDITION] when she received the results because she thought the results were negative. She stated she did not accurately read the X-Ray report findings and was unaware Resident #1 had a new left [MEDICAL CONDITION] due to thinking the fracture on the X-Ray was the same fracture acquired prior to admission. Per interview, the resident continued to complain of pain, but was not medicated again for pain until 12/14/19 at 2:30 AM, when she administered [MEDICATION NAME] 5 mg/325 mg. Per interview, when RN #2 arrived she reviewed the X-Ray report findings during shift change at 7:30 AM on 12/14/19, which was nine (9) hours after the fall and five and a half (5.5) hours after the X-Ray report was originally available to the facility. RN #1 stated the ARNP was then notified of the X-Ray results. Interview with RN #2, on 12/27/19 at 12:01 PM, she took report during shift change from RN #1 the morning of 12/14/19, and was informed Resident #1 had a fall from the bed and an X-Ray had been obtained. Per interview, during shift report she was informed by RN #1, the results of the X-Ray indicated a [MEDICAL CONDITION] hip, which the resident had been admitted with after a surgical repair. Further interview revealed RN #2 reviewed the X-Ray report findings, and identified the resident had sustained a new Left [MEDICAL CONDITION]. Per interview, she informed RN #1 of the injury and the ARNP was notified of the Left [MEDICAL CONDITION] on 12/14/19 at 7:30 AM. RN #2 stated the resident's family was then notified of the injury and the resident was transferred to the Hospital ER. Interview with the Unit Manager, on 12/27/19 at 2:00 PM, revealed she was notified on 12/17/19, Resident #1 sustained a fall from the bed and fractured his/her left hip because she had been off work until that date. She stated she would expect the nurses to provide the Medical Provider with all the information needed to make an appropriate [DIAGNOSES REDACTED]. Interview on 12/23/19 at 12:24 PM, with Resident #1's spouse, revealed he/she received a call the morning of 12/14/19 at 1:30 AM, related to the resident sustaining a fall and was informed an X-Ray was to be done. Per interview, an hour later he/she received a call from a nurse at 2:30 AM, informing him/her the X-ray report was negative and they were keeping the resident at the nurse's station due to the resident being restless and raising the bed in high position. Further interview revealed on 12/14/19 at 8:00 AM, the spouse received a call explaining there was a mistake, and the resident's hip was indeed broken. Interview with the ARNP, on 12/30/19 at 3:33 PM, revealed on 12/13/19, she received a call at approximately 11:30 PM related to Resident #1 sustaining a fall and complaining of hip pain. Per interview, she ordered a Stat X-Ray of the Left Hip, but did not order any further pain medication at the time of the call. She stated she wanted the resident's pain managed with the medication that was already ordered until the X-Ray results came back, which usually only took a few hours if ordered Stat. Additional interview with the ARNP, revealed she did not hear back from the nurse related to the X-Ray results or related to the resident's pain until 12/14/19 about 6:00 AM or 6:30 AM. She stated she would expect the nurse to immediately inform her of accurate X-Ray results. The ARNP stated if she had been notified of accurate X-Ray results in a timely manner for Resident #1, she would have given orders to send the resident to the Hospital ER because a resident with a [MEDICAL CONDITION] would need to be evaluated by an orthopedic surgeon. Interview with the Director of Nursing (DON), on 12/27/19 at 2:36 PM, 01/02/2020 at 3:15 PM, and post survey interview on 01/16/2020 at 12:06 PM, revealed a prudent nurse would have reviewed Resident #1's X-Ray findings and accurately notified the Medical Provider of the results, which was not done for Resident #1. Interview with the Administrator, on 01/02/2020 at 3:51 PM, and post survey interview on 01/16/2020 at 1:53 PM, revealed it was her expectation care and services be provided for the residents according to accepted standards of clinical practice. Per interview, Resident #1's X-Ray results should have been communicated accurately to the ARNP after RN #1 received the results the morning of 12/14/19, in order for the ARNP to make an informed decision related to necessary treatment. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/19/2020 alleging removal of the Immediate Jeopardy on 12/31/19. Review of the AoC revealed the facility implemented the following: 1. Resident #1 did not return to the facility after discharge to the hospital on [DATE]. 2. On 12/14/19, the Director of Nursing (DON) provided Registered Nurse (RN) #1 re-education related to falls, Physician notification, pain assessments, proper handling of X-ray results and completing fall investigations. 3. Beginning 12/23/19 through 12/30/19, the DON, Unit Managers (UMs), Minimum Data Set (MDS) Nurse and Signature Clinical Coordinator (SCC) completed a review of fall investigations, pain evaluations, fall risk assessments, fall prevention Care Plans, and State Registered Nurse Aide (SRNA) Care Plans for all residents who sustained a fall during the previous 30 (thirty) days. 4. Beginning 12/23/19 through 12/30/19, the DON, UMs, MDS Nurse and SCC conducted a review of all residents' electronic medical records (EMR) including the Medication Administration Record [REDACTED]. Any issues found were immediately addressed with the Physician. 5. Beginning 12/23/19 through 12/30/19, all residents were assessed for pain with the MatricCare Pain Evaluation Data Assessment Tool and the MatricCare Pain Assessment in Advanced Dementia Scale Tool by the DON, UMs, SCC, and MDS Nurses. Any pain identified was immediately addressed with the Physician and the resident's Care Plan was updated to meet the resident's needs. 6. On 12/23/19, the Quality Assurance Performance Improvement (QAPI) committee met to discuss current findings, and the development and execution of plans in place, and consulted with the Medical Director for any further recommendation. Those in attendance included the Administrator, DON, UMs, MDS Nurse, SCC, Dietary Manager, Social Manager, Infection Control Nurse, Medical Director and Regional Vice President. After this meeting, there was to be weekly QAPI meetings held to review and evaluate the plan. 7. Beginning 12/23/19 through 12/30/19, all Baseline Care Plans and SRNA Care Plans were audited by the DON, MDS Nurses, Social Services, SCC, Center Executive Officer (CEO) and Staff Development Nurse (SDN) from another Signature Home for the last thirty (30) days to assure Baseline Care Plans, and State Registered Nurse Aide (SRNA) Care Plans reflected current resident care needs and goals. Any concerns noted were immediately corrected by updating Care Plans and SRNA Care Plans to reflect current resident care needs. 8. Beginning 12/23/19 though 12/30/19, all residents had a fall risk assessment completed by the DON, MDS, UMs, and SCC. 9. Beginning 12/23/19, all reported resident falls will be called into the DON ongoing until the QAPI team determines this process can be changed. 10. Beginning 12/23/19 through 12/30/19, the DON, UMs and SCC provided re-education to licensed nurses and SRNAs regarding appropriate documentation of Physician notification as part of the change in condition policy, accidents/incidents, X-ray and lab results, pain policy, abuse and neglect policy, Baseline/Care Plan policy, and following Care Plans with a one hundred percent (100%) competency test. A 100% passing score was required to show competency before the nurses and SRNAs could work. All fifty-six (56) nurses and SRNAs received the education prior to 12/30/19. Re-education was required by 12/30/19, prior to staff working their next shift. Any new nurses and SRNAs will receive the education in orientation by the SDC . The facility does not use agency staff. 11. Beginning 12/24/19, falls will be reviewed in the daily clinical meeting by the Interdisciplinary Team (IDT) and the SCC for compliance with falls, pain and Physician notification policies. This will include a review to ensure pain management, neuro checks completed if required, X- ray reports completed and communicated, thorough investigation conducted with witness statements, and Baseline Care Plans revised with interventions. This will be ongoing until the QAPI team determines the process can be changed. 12. Beginning 12/24/19 through 01/13/2020, the DON, UM and MDS Nurse reviewed daily the Twenty-four (24) Hour Reports, Progress Notes, and Event Manager for Physician notification and changes in residents' condition. This review will be ongoing daily until QAPI determines this process could be changed. 13. Beginning 12/26/19 through 01/13/2020, the UMs and MDS Nurse checked daily to validate pain assessments were completed by nursing staff. 14. Beginning 12/28/19 through 01/13/2020, the IDT validated fall prevention interventions were in place by conducting random audits of 20 (twenty) residents. 15. Beginning 12/31/19 through 01/13/2020, the MDS Nurse and the UMs validated that pain medication was appropriately signed out by nursing staff. 16. Beginning 12/31/19 through 01/13/2020, the Staff Development Coordinator (SDC) randomly tested a minimum of ten (10) nursing staff on education they received. 17. Beginning 12/31/19 through 01/13/2020, the Baseline Care Plans were monitored by MDS staff related to initial goals of care, safety needs, risks for accidents, therapy, dietary, social services, completion in forty-eight (48) hours and fall risk assessments. Any concerns identified would be addressed immediately and reported to the DON to address with nursing staff to include re-education and/or disciplinary action. 18. On 12/30/19, a QAPI Meeting was held to review audits related to fall investigations, Physician notification, pain, Baseline Care Plans/ SRNA Care Plans, and pain medication monitoring results. In addition, the meeting validated all staff had received education as per the AoC. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's medical record revealed on 12/27/19 at 7:54 AM, the facility's Administrator documented she initiated telephone contact with the resident's husband to inquire on the status of the resident's condition at the hospital and to see if or when the resident would be returning to the facility. The Administrator documented Resident #1's husband stated, My attorney has advised me not to talk with you, goodbye. Interview on 02/21/2020 at 11:00 AM, with the facility's DON, revealed Resident #1 sustained a fall with a fracture on 12/13/19, and the resident was transported to the hospital on [DATE]. Per interview, the resident's family decided they did not want the resident to return to the facility. 2. Review of the email dated 12/26/19 at 2:49 PM, from the DON to the Administrator, revealed RN #1 was educated by the DON related to any diagnostic reports were to be read word for word to the Physician or Nurse Practitioner. Further, she educated the nurse to notify the Physician of any falls immediately, and evaluate any resident for pain or injury immediately after a fall. In addition, the DON educated the nurse related to administering pain medications as ordered and evaluating effectiveness of the pain medication afterward. Continued review revealed she educated RN #1 related to completing Fall Assessments after any fall, and updating the Care Plan with interventions. Interview on 02/21/2020 at 11:00 AM, with the DON, revealed she provided education to RN#1 on 12/14/19 regarding the events of Resident #1's fall that resulted in a fracture on 12/13/19. Per interview, she educated the nurse related to the need to ready word for word any diagnostic reports to the Physician or Nurse Practitioner. Further, she educated the nurse to notify the Physician of any falls immediately; evaluate any resident for pain or injury immediately after a fall; and administer pain medications as ordered and evaluate effectiveness of the pain medication afterward. In addition, she stated she educated the nurse related to the need to complete a Fall Assessment after any fall, and update the Care Plan with fall interventions. Interview conducted on 02/21/2020 at 2:50 PM, with the facility's Regional Vice President (RVP), revealed on 12/30/19, the Medical Director agreed with the governing body to terminate RN #1 for performance failure. 3. Review of the 30 (thirty) Day Falls Audit, conducted 12/23/19 through 12/30/19, revealed all facility residents who were documented as sustaining a fall from 11/23/19 through 12/23/19, were reviewed by the DON, UMs, MDS Nurses and the SCC to include a review of fall investigations, pain evaluations, fall risk assessments, fall prevention Care Plans, and SRNA Care Plans. Twenty (20) residents sustained falls during this time frame and of the twenty (20) residents reviewed, fourteen (14) residents were identified by the facility as not having their Care Plans updated after the falls. Interview on 02/21/2020 at 11:00 AM, with the DON, revealed an audit was conducted 12/23/19 through 12/30/19, for residents who sustained a fall in the facility from 11/23/19 through 12/23/19. The DON stated a checklist was maintained for each of those residents reviewed. Per interview, the residents were reviewed to ensure a fall investigation had been completed, pain issues were addressed, fall risk assessments were completed and fall prevention care plans were updated for those residents. Further interview revealed the audit indicated several residents did not have their Care Plans updated after their falls and the Care Plans were updated during the review. Interview with UM #1, on 02/21/2020 at 1:10 PM, revealed she participated in the review conducted 12/23/19 through 12/30/19, for all residents who sustained a fall from 11/23/19 through 12/23/19. Per interview, the residents were reviewed to ensure a fall investigation had been completed, pain issues were addressed, fall risk assessments were completed and fall prevention care plans were updated for those residents. Per interview, any concerns identified were immediately addressed. Interview on 02/21/19 at 3:10 PM, with the SCC, revealed she participated in the review conducted 12/23/19 through 12/30/19, for all residents who sustained a fall from 11/23/19 through 12/23/19. Interview conducted on 02/21/2020 at 1:50 PM, with the MDS Nurse, revealed she did conduct a review of residents who sustained a fall between 11/23/19 and 12/23/19. The MDS Nurse stated she reviewed the facility's Event Manager to see which residents had sustained falls, and used the census sheet to keep track of the identified residents who were reviewed for falls. Per interview, for those residents who sustained a fall, she reviewed their fall investigations, pain evaluations, fall risk assessments, fall care plan and SRNA care plan. 4. Review of the facility's Daily Census Sheet, dated 12/23/19, revealed the facility had a total census of eighty-five (85) residents on that day and there was documentation on the Sheet indicating the DON, North UM, MDS Nurse, and the SCC reviewed all residents' electronic medical records on that date. Interview on 02/21/2020 at 11:00 AM, with the DON, revealed all facility residents who were current residents on 12/23/19, had their medical records reviewed for the previous 30 (thirty) days including Event Manager, X-ray reports, and laboratory findings to ensure appropriate notification to the Physician or Nurse Practioner related to any change in condition. Per interview, the review was also to ensure the Medical Provider was notified of any pain not addressed, any concerns with medications, or any concerns with X-rays and labs. Further, any issues identified were immediately addressed with the Physician. Interview conducted on 02/21/2020 at 1:50 PM, with the MDS Nurse, revealed she participated in the review of each resident's medical record to check on the accuracy of their progress notes, Medication Administration Record [REDACTED]. Per interview, she did not recall finding any discrepancies or concerns related to the EMRs. 5. Review of the Pain Audits, revealed from 12/23/19 through 12/30/19, all residents were assessed for pain using the MarticCare Pain Evaluation Data Assessment Tool and the MatricCare Pain Assessment in Advanced Dementia Scale Tool, by the DON, UMs, SCC, and MDS Nurses. Per the Audits and record review, pain identified was addressed with the Physician and the resident's Care Plan was updated to meet the resident's needs. Interview with the DON on 02/21/2020 at 11:00 AM, revealed she did participate in assessing residents using the MatricCare Pain Evaluation Data Assessment Tool and the MatricCare Pain Assessment in Advanced Dementia Scale Tool. Per interview, she did identify one (1) resident (Resident #2) who needed his/her pain control addressed and followed through to ensure the resident's pain was addressed and care plan was updated. 6. Review of the facility's QAPI Sign In Sheet, dated 12/23/19, revealed the facility's Administrator, DON, UM, MDS Nurse, SCC, Dietary Manager, Social Services Manager, Infection Control Nurse, Medical Director and Regional Vice President (RVP) were present at the meetings. Discussion included review of possible Immediate Jeopardy (IJ) AoC and potential deficiencies. Further review revealed the RVP and SCC were present to provide oversite related to IDT daily meeting reviews. 7. Review of the Audit sheets revealed from 12/23/19 through 12/30/19, Baseline Care Plans and SRNA Care Plans were audited by the DON, MDS Nurses, Social Services, SCC, Center Executive Officer (CEO) and SDN from another Signature Home for the previous thirty (30) days to assure Baseline Care Plans, and SRNA Care Plans reflected current resident care needs and goals. Interview with the MDS Coordinator on 02/21/2020, revealed she participated in the review of resident care plans from 12/23/19 through 12/30/19 a (TRUNCATED)

Based on interview, record review, and review of facility Policies, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of four (4) sampled residents (Resident #1). On 12/11/19, the facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 12/13/19, after the resident's spouse left at 8:30 PM, the resident received [MEDICATION NAME] 5/325 milligram (narcotic pain medication) for pain, but after this became restless. Staff interviews revealed the resident repeatedly raised the bed into the high position with the bed control, and attempted to get out of bed unassisted. Staff interviews further revealed the resident repeatedly requested to be toileted, even though he/she had just been toileted. Although staff sat with the resident at intervals or checked on the resident at intervals during the night on 12/13/19, the facility failed to ensure supervision consistent with the resident's needs and left the resident in the bed unsupervised. On 12/13/19, at approximately 10:35 PM, the resident sustained [REDACTED]. Although Resident #1 complained of left hip pain after the fall, interview with Registered Nurse (RN) #1 revealed she did not complete a thorough assessment of the resident to include neuro checks or Range of Motion after the fall, but lifted the resident under the arms and pulled him/her to his/her feet, and then assisted the resident to bed with the assistance of State Registered Nurse Assistant (SRNA) #1. SRNA #1 sat with the resident about thirty (30) minutes after the fall, and then staff assisted the resident into the wheelchair in order to monitor him/her at the nurse's station. On 12/13/19 at 11:37 PM, approximately one (1) hour after the fall, the Advanced Registered Nurse Practioner (ARNP) was notified of the fall and the resident's complaint of left hip pain. An X-Ray was ordered which revealed a Left [MEDICAL CONDITION]. However, when RN #1 received the X-Ray results on 12/14/19 at 2:00 AM, she did not inform the ARNP of the Left [MEDICAL CONDITION] due to incorrectly reading the X-Ray results. Resident #1 continued to complain of pain and received another [MEDICATION NAME] 5/325 mg on 12/14/19, at 2:30 AM. Staff interviews revealed after the resident sustained [REDACTED]./19 at approximately 1:30 AM, and a rest period on 12/14/19 from approximately 3:00 AM until 3:30 AM. In addition, staff interviews revealed the resident was toileted several times after the fall at the resident's request which required weight bearing. On 12/14/19, at approximately 7:15 AM, RN #2 reviewed the X-Ray results and the ARNP was then notified of the Left [MEDICAL CONDITION]. Resident #1 was transferred to the hospital on [DATE] at approximately 8:00 AM, and admitted with [DIAGNOSES REDACTED]. Resident #1 underwent Open Reduction Internal Fixation (ORIF) due to the Left [MEDICAL CONDITION], on 12/15/19. Furthermore, review of the facility's Investigation related to Resident #1's fall, revealed there was no documented evidence of a thorough Root Cause Analysis, in an attempt to evaluate causal factors leading to the resident's fall, determine what could have contributed to the fall and address risk factors for the fall. The Root Cause according to the Investigation, was fell from bed. In addition, there was no documented evidence the facility obtained witness Statements related to Resident #1's fall until the State Agency Representative entered the building, which was ten (10) days after the fall. (Refer to F-580, F-655, F-658, and F-697) The facility's failure to have an effective system in place to ensure each resident receives adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020 and was determined to exist on 12/13/19. The findings include: Review of the facility's Falls Policy, revised 06/01/15, revealed it is the intent of the facility to provide residents with assistance and supervision in an effort to minimize risk of falls and fall related injuries. Further review revealed all residents will have a comprehensive fall risk assessment on admission and with a significant change of condition. Appropriate interventions will be implemented and evaluated as indicated by the assessment. A Comprehensive Care Plan will be implemented based on the fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall and with a significant change. The following actions will take place, assessment of the resident, including neurological checks, pain, Range of Motion (ROM), skin, joints, extremities, and vital signs. The Physician and family will be notified. Pain will be evaluated every shift for seventy-two (72) hours. The assessment would be documented, with pertinent facts in the Event Manager. An investigation will be implemented, and the Interdisciplinary (IDT) will determine the root-cause of the fall if possible and the care plan will be updated. Review of the facility's Accident and Incident Investigating Reporting Policy, revised 11/06/19, revealed accidents or incidents involving residents, occurring on the facility premises shall be investigated and reported to the administrator and/or Director of Nursing (DON). The incident will be recorded in the Electronic Medical Record (EMR) with be the date and time of the accident or incident and the nature of the injury and circumstances surrounding the incident. The documentation will also include where the incident occurred, name of the witnesses and their account. In addition, documentation will include the time the injured person's Attending Physician was notified, as well as, the time the Physician responded and his/her instructions. Documentation will include the date/time the family was notified and by whom, and the condition of the injured resident and the disposition of the resident along with any corrective action. Review of Resident #1's closed medical record revealed the facility admitted the resident on 12/11/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Note, dated 12/11/19 at 3:21 PM, revealed the resident was admitted from an Acute Care Hospital transferred via ambulance with spouse in attendance. Per the Note, the resident was alert and oriented x 2 (alert to person and place) with occasional confusion and could verbalize needs. Further review of the Note, revealed the resident had a [DIAGNOSES REDACTED]. Further, the resident was occasionally incontinent of bowel and bladder, and required assistance with Activities of Daily Living (ADLs) secondary to pain and decreased strength. Review of Resident #1's John's Hopkins Fall Risk Assessment Tool, dated 12/11/19, revealed the resident scored a twenty-one (21), indicating the resident was at high risk for falls. The risk factors included history of one (1) or more falls within the previous six (6) months; urgency/frequency and incontinence; receiving two (2) or more high risk medications; requires assistance or supervision for mobility, transfer, or ambulation; unsteady gait; and impulsive behavior. The facility did not complete an Admission Minimum Data Set (MDS) Assessment due to the resident being a new admission. However, review of Resident #1's Brief Interview for Mental Status (BIMS), dated 12/12/19, revealed the facility assessed the resident as having a score of six (6) out of fifteen (15) indicating severe cognition impairment. Review of the Physical Therapy Evaluation and Plan of Treatment Note, dated 12/12/19, revealed the resident presented with functional mobility deficits as a result of his/her recent [MEDICAL CONDITION] and subsequent hospitalization . Per the Note, the resident had deficits in transfers and gait, had poor balance, had decreased activity tolerance and generalized strength deficits, and would require physical therapy services. Per the Note, the resident would need to be safe at a supervised level to return home. Further review of the Note, revealed due to documented physical impairments and associated functional deficits, the resident was at risk for further decline in function and falls. Review of Resident #1's Fall Investigation, revealed on 12/12/19 (time not documented), Resident #1 was in the wheelchair in the room attempting to transfer self to the bathroom and fell . Per the Investigation, the resident had no signs of injury, and denied pain. The call light was not in use at the time of the fall, but was in reach. Further review revealed the root cause was determined to be the resident attempted to use the bathroom. Per the Investigation, the resident was assisted to the bathroom and then brought to sit in front of the nurse's station. Further, the new intervention was to toilet the resident before and after meals and at night. This Investigation was signed by the DON and dated 12/16/19. Review of the Baseline Care Plan, initiated 12/12/19, revealed the resident had the potential for falls related to a history of falls as per the resident's fall risk score. The goal stated the resident would not sustain an injury related to falls over the next thirty (30) days. Interventions included assisting the resident with toileting and transfers every shift; assist for toileting and transfers as needed; cue for safety awareness; keep the environment safe; place the call within easy reach; and use safety device(s). (Safety devices to be utilized were not listed on the care plan). All interventions were initiated, on 12/12/19. Further review of the Baseline Care Plan, initiated 12/12/19, revealed the resident was not a candidate for bowel and bladder retraining with a goal stating the resident would receive assistance to be kept clean, dry, and comfortable. Interventions included check resident every two (2) to three (3) hours and as needed for incontinence episodes every shift; and provide incontinence care after each incontinent episode. However, there was no documented evidence the Baseline Care Plan was revised with interventions for toileting the resident before and after meals and at night as a corrective intervention after the 12/12/19 fall. (Refer to F-655) Continued review of the Baseline Care Plan, initiated 12/12/19, revealed Resident #1 was admitted with right hip pain post operatively. The goal stated the resident would have relief or reduction of pain intensity within one (1) hour after receiving interventions over the next thirty (30) days. Interventions included administer pain medications as per physician's orders [REDACTED]. (Refer to F-655) Review of Resident #1's Certified Nursing Assistant (CNA) Record (Nurse Aide Care Plan), dated 12/12/19, revealed the resident was alert, confused, verbal and/or alert, oriented, and verbal. Interventions included assistance of one (1) staff with full weight bearing as tolerated on the left and right side for transfers and ambulation; non-skid socks; one quarter (1/4) side rails on the left and right side; toileting with the assistance of one (1) staff and encourage toileting before and after meals. An additional intervention was added on 12/13/19, to provide the resident with diversion at the nursing station and provide snacks. Review of Resident #1's Progress Note, dated 12/12/19 at 1:53 AM, revealed the resident attempted to sit on the edge of the bed and staff encouraged and educated the resident about safety and to utilize the call light to ask staff for assistance related to safety measures. Review of the subsequent Progress Note, dated 12/13/19 at 2:47 AM, revealed the resident continued to adjust to the new facility. Per the Note, the resident was calling out for help and complaining of hip pain. Further review revealed pain medication was given as ordered and the resident was instructed to use the call light for assistance. Review of Resident #1's Progress Notes, revealed no documentation for the shift of 12/13/19 from 7:00 PM through 12/14/19 at 7:00 AM, even though staff interviews revealed after 8:30 PM on 12/13/19, the resident exhibited behaviors including raising the bed in the high position, attempting to get out of bed unassisted, and asking to go to the bathroom frequently. In addition, there was no documented evidence the Baseline Care Plan was revised related to these behaviors with interventions for increased supervision necessary to keep the resident safe. An entry was made to the Baseline Care Plan on 12/17/19, after the resident was discharged to provide diversion at the nurse's station. (Refer to F-655) Review of the Controlled Drug Record (CDR), revealed the resident received [MEDICATION NAME] 5/325 mg on 12/13/19 at 8:30 PM, and on 12/14/19 at 2:30 AM. However, review of the Medication Administration Record [REDACTED]. (Refer to F-697) Review of the Fall Event Report, revealed a fall occurred on 12/13/19 at 10:35 PM, and the resident had severe pain (horrible intense) of the left hip. Range of Motion (ROM) painful/limited in lower extremity (did not specify which extremity) and no rotation/deformity/shortening noted of extremities. Further review of the Report revealed check marks in the boxes to indicate: Neurological checks completed; alert and responds appropriately to stimuli; strong facial muscle movement; strong upper left and right upper extremity grasps; strong left and right lower extremity movement; and left and right eye pupil size 3 millimeters and round and brisk pupil movement. Further review revealed the resident had raised the bed in the highest position and fell from the bed. Resident #1 was then placed in the wheelchair and brought to the nurse's station. Notifications included the DON and the Administrator. Per the Report, the ARNP was notified on 12/13/19 at 11:30 PM, and a left hip X-Ray was ordered. The Fall Event Report was completed on 12/14/19 at 8:17 AM, by RN #1. Review of the facility's Phone Message Record dated 12/13/19 at 11:37, revealed the ARNP was notified by RN #1, that Resident #1 had fell from his/her bed at 10:35 PM and was complaining of hip pain which was unspecified on the message. RN #1 requested follow-up orders on the voice message. Review of the Mobile X-Ray report, dated 12/14/19, received at the facility on 12/14/19 at 2:00 AM, revealed significant findings of left hip, unilateral views of the pelvis. The bones were noted to be osteoporotic, and there was a non-displaced intertrochanteric [MEDICAL CONDITION] femur. Further review revealed status [REDACTED]. Review of the Situation Background Assessment Recommendation (SBAR) Communication Form, revealed on 12/13/19, the resident had a change in condition and worsening pain in the left hip with a pain level of ten (10), with ten (10) being the worst on a pain scale of one (1) to ten (10). Per the SBAR, vital signs were obtained which were stable, and neuro checks were completed with no changes observed. Further, there was new pain in the left hip and wincing with movement. Additional review revealed an X-Ray was completed which showed a new [MEDICAL CONDITION] of the left hip and the Medical Provider was notified on 12/14/19 at 7:45 AM. Resident #1 was transferred to the emergency room (ER) for evaluation and the resident's representative was notified on 12/14/19 at 7:50 AM. There was no signature to this document and no date of completion. Post survey interview with RN #1, on 01/15/2020, at 8:45 AM, revealed she completed this SBAR Form after the resident was sent to the Hospital emergency room (ER), on 12/14/19. Review of the Progress Note, dated 12/14/19 at 9:03 AM, revealed Resident #1's spouse was notified of new orders to send the resident to the emergency room (ER) and the resident was being sent via ambulance. Per the Note, the ambulance was called and report was called to the Hospital ER. Further review of the Note, revealed Emergency Medical Technicians (EMTs) arrived and transferred the resident to the stretcher per a three (3) man lift. The Note was signed by RN #2. Review of the Discharge MDS Assessment, dated 12/14/19, revealed the resident was discharged to an Acute Care Hospital. Review of the Hospital History and Physical, dated 12/14/19, revealed Resident #1's chief complaint was left hip pain status [REDACTED]. ROM was not assessed due to complaint of left hip pain per the resident, and external rotation and shortening of the left leg noted. Review of the Hospital Discharge Summary, dated 12/28/19, revealed Resident #1 was admitted on [DATE], after sustaining a fall in the nursing home resulting in an Intertrochanteric [MEDICAL CONDITION] Hip. Additional [DIAGNOSES REDACTED]. Per the Summary, upon admission Resident #1 was confused and not responding to questions appropriately. When admitted to the ER Resident #1 was complaining of severe left hip pain made worse by movement. Further review of the Summary, revealed the resident underwent [REDACTED]. The resident tolerated the procedure and his/her post-op course was without complication except for pain management and agitation. Per the Summary, Resident #1 was discharged to a Skilled Nursing Facility and would follow up with Family Medicine. Continued review of the Summary, revealed instructions for Activity as Tolerated; Weight bearing as tolerated; and no formal hip precautions. Review of Resident #1's Fall Investigation, revealed the resident had been assessed to be at high risk for falls with contributing factor to include impulsive behavior. Further review revealed the resident had been up and down during the 7:00 PM to 7:00 AM shift on 12/13/19 to 12/14/19 at the nursing station. The resident requested to go to bed and State Registered Nurse Aide (SRNA) #1 put Resident #1 back to bed. Soon after, SRNA #1 heard the resident fall in the room (with no specified time of the fall). The resident was evaluated by the nurse and taken to the nurse's station. The ARNP was notified at 11:30 PM, and a new order was given for an X-Ray. The X-Ray was misread by RN #1 on the night shift. RN #2, who was the day shift nurse, reviewed the X-Ray and found a new [MEDICAL CONDITION] hip, and the Physician was then notified. The resident was sent to the Hospital ER. Per the Fall Investigation, the root cause of the fall was fall from bed, and the contributing factors were impulsive behavior. This Investigation was signed by the DON on 12/16/19. However, there was no documented evidence of a thorough Root Cause Analysis, in an attempt to evaluate causal factors leading to the resident's fall, determine what could have contributed to the fall, and address risk factors for the fall. In addition, there was no documented evidence witness Statements from staff involved when Resident #1 sustained the fall were obtained by the facility, until after the State Agency Representative entered the building, ten (10) days after the fall. Review of SRNA #1's written Statement, dated 12/24/19, revealed the night Resident #1 fell out of bed, she had just assisted the resident to bed per the nurse's request. Further, SRNA #1 then completed rounds and checked on Resident #1 again after her rounds. Per the Statement, the resident's bed was in the lowest position and the resident was in bed and by the time she made it to the nurse's station, she heard a loud noise and took off running down the hall. Continued review of the Statement, revealed Resident #1 was in the floor and the bed was extended up in the air. SRNA #1 yelled for RN #1 who came to the room and RN #1 and SRNA #1 picked the resident up off the floor and put him/her in the bed. Per the Statement, RN #1 and SRNA #1 then put the resident in the wheelchair and took him/her to the nurse's station. Interview on 12/30/19 at 5:38 PM, with SRNA #1, revealed she was assigned to Resident #1 on 12/11/19, and 12/12/19, and during the evening/night shift the resident would occasionally try to scoot and sit on the side of the bed and needed to be redirected for safety. Per interview, she was also assigned to the resident on 12/13/19 from 7:00 PM until 7:00 AM, on 12/14/19. Per interview, the resident's spouse was in the resident's room until 8:30 PM on 12/13/19, and after the spouse left the resident kept trying to climb out of the bed and she had to repeatedly assist the resident to the bathroom. Further interview revealed for a short time she sat in the room with Resident #1 from about 8:30 PM until 9:00 PM, after the resident was medicated for complaints of right hip pain. Additional interview with SRNA #1, revealed about 9:00 PM, she went to check on her other residents, and continued to check on Resident #1 at least every thirty (30) minutes. Per interview, while checking on the resident she noticed the resident raised the bed up in high position and put the head of the bed straight up using the hand held bed control, and SRNA #1 had to readjust the bed to the low position. SRNA #1 further stated the resident also persisted in trying to get up without assistance. Per interview, when the resident was in the bed, SRNA #1 would continuously have to lower the bed to the lowest position and pull the resident back up towards the head of the bed with the help of SRNA #2. Per interview, RN #1 was made aware of the resident's behavior. Further interview with SRNA #1, revealed she had toileted the resident, and assisted the resident back to bed, and a short time later, about 10:30 PM, she heard a noise and entered Resident #1's room and noted the resident was on the floor and the bed was in the high position. Per interview, she notified RN #1 of the fall, and RN #1 checked on the resident, but she did not recall the nurse completing an assessment of the resident. SRNA #1 stated she and RN #1 lifted the resident back to the bed. Continued interview revealed SRNA #1 sat with the resident about thirty (30) minutes after the fall, and then Resident #1 was positioned at the nurse's station for close monitoring. Per interview, after the fall the resident continued to complain of pain throughout the night, but did not specify where he/she was hurting. Additional interview with SRNA #1, revealed after the fall, the resident was assisted back to bed for an X-Ray on 12/14/19 about 1:30 AM, which took about thirty (30) minutes at the most, then the resident was again positioned at the nurse's station in the wheelchair in order for staff to monitor him/her for safety. Further, the resident was positioned in the wheelchair at the nurse's station until 5:30 AM, when the resident was assisted back to bed and went to sleep. Additional interview revealed she was the only aide for the group which included Resident #1 on the North Hall that night. Continued interview revealed if Resident #1 had someone to sit with him/her during the shift when he/she was so restless, this may have prevented the fall. Per interview, she was unable to give the resident one on one (1:1) supervision nor was she directed to give the resident one on one (1:1) supervision that night because she would have been unable to care for other residents assigned to her. Review of SRNA #2's written Statement dated 12/25/19, revealed on 12/13/19 on the 7:00 PM to 7:00 AM shift, Resident #1 repeatedly threw his/her legs out of the bed and each time he/she was repositioned and pulled up in the bed. Per the Statement, after she went on a bathroom break she found out the resident fell , and she did not assist after the fall as she was working on the other end of the unit. Interview on 12/30/19 at 3:25 PM, with SRNA #2, revealed she did not provide care to Resident #2 accept to help pull him/her up in the bed on 12/13/19 during the evening shift through the morning of 12/14/19. She stated she did recall the resident verbalizing he/she was having pain, but the resident did not verbalize where the pain was located. Further interview with SRNA #2, revealed the resident was up and down throughout the night trying to get out of bed, and the resident was periodically placed at the nurse's station for closer observation. She stated she did not know anything about the fall except she was told the resident fell . Interview with RN #4, on 12/30/19 at 3:53 PM, revealed she was working South Hall on 12/13/19, the night Resident #1 fell , and RN #1 was working the North Hall. Per interview, RN #4 sat with the resident for a few minutes after the fall which occurred at approximately 10:30 PM, while the SRNAs were completing their rounds. Per interview, while she was sitting with the resident, he/she was very restless, trying to get out of bed and was confused. She stated when the SRNAs finished their rounds they still were unable to keep the resident in bed and the resident was positioned across from the nurse's station for closer monitoring. Per interview, she did not notice any non-verbal signs of pain such as moaning, grimacing or guarding. However, the resident did complain of pain once up in the wheelchair after the fall while sitting across from the nurse's station, and that was when RN #1 made the phone call to get the X-Ray, which was about 11:30 PM. Review of RN #1's written Statement, dated 12/24/19, revealed Resident #1 was constantly trying to get out of bed the evening of 12/13/19, after his/her spouse left the unit. SRNA #1 was the aide assigned and was checking on the resident frequently as he/she was impulsive. Resident #1's bed control was placed out of his/her reach by the SRNAs, but he/she pulled on the cord until he/she as able to obtain it and he/she raised his/her bed up to the highest position. SRNA #1 heard a thud and immediately ran to the resident's room and then informed RN #1 of the resident's fall. Resident #1 was lying on the floor in the prone position, more on his/her left side. The resident was then assisted to his/her feet and then back in bed. Resident #1 continued to attempt to climb out of the bed so he/she was placed in the wheelchair and brought out to the desk. The time of the fall was 10:35 PM. Per the Statement, the resident did complain of left hip pain, but always complained of pain. At 11:45 PM, when the resident was still complaining of pain, RN #1 notified the Physician about possibly sending the resident out. The ARNP on call ordered a Stat X-Ray of the left hip. The family and DON were notified of the fall and of the X-Ray ordered and pending. Further review of RN #1's written Statement, revealed when the X-Ray results came back RN #1 immediately looked it over, but accidentally overlooked the fact that the results showed a left [MEDICAL CONDITION]. Resident #1 was receiving [MEDICATION NAME] every six (6)hours as needed, and when it was due RN #1 gave it. The resident was kept at the nurse's station most of the night due to him/her being compulsive and to keep him/her safe. When RN #4 went on break, she offered to sit outside the resident's door and keep an eye on him/her. Resident #1 continued to attempt to get out of the bed multiple times and was then brought out to the nurse's station again. When RN #1 gave report the next morning to RN #2, she showed her the X-Ray report, and RN #2 immediately picked up on the fact that the resident had a left [MEDICAL CONDITION]. RN #1 immediately called the on call ARNP and obtained an order to send Resident #1 to the ER. RN #2 called the ambulance and the resident was transported to the Hospital. Interview on 12/24/19 at 8:00 AM, and post survey interview on 01/15/2020 at 8:45 AM, with RN #1, revealed she just started at the facility on 12/11/19. Per interview, 12/13/19 was her first night out of orientation working on the North hall as the only nurse for the hall. She stated when she arrived on the unit 12/13/19, Resident #1 was in bed and the resident's spouse came to find her to ask about pain medication. Per interview, the resident's spouse left at about 8:30 PM, and that was when she administered [MEDICATION NAME] 5/325 mg to the resident for right hip pain. She further stated Resident #1 kept trying to get out of bed unassisted after 8:30 PM and kept raising the bed up into the high position using the bed control. Per interview, the resident was toileted several times as he/she kept verbalizing the need to go to the bathroom, even though he/she was just taken to the toilet. Further interview revealed SRNA #1 kept checking on him/her every fifteen (15) minutes, although this was not documented. Continued interview with RN #1, revealed she was called to Resident #1's room by SRNA #1, on 12/13/19 at 10:35 PM, and the resident was noted to be on the floor in the prone position lying partly on his/her left side. Per interview, she did not check the resident's ROM, or do a comprehensive neuro check after the fall, even though she may have documented that she did. She stated she did a visual assessment of the resident who seemed to be okay, and vital signs were obtained. She further stated the resident did complain of pain in the left hip after the fall, but she and SRNA #1 were able to lift the resident under his/her arms and stand the resident to his/her feet and then assist the resident to bed. Per interview, the resident did complain of increased pain with this transfer. She stated once in bed the resident kept trying to get out of bed unassisted and was very confused, and she made the decision to position the resident in the wheelchair across from the nurse's station in order to keep a closer eye on him/her. Per interview, while sitting in the wheelchair, the resident kept complaining of pain in the left hip, and at 11:37 PM the ARNP was notified of the resident's fall and continued complaints of pain. She stated an order was obtained for an X-Ray of the resident's hips and pelvis. Additional interview with RN #1, revealed Resident #1 was assisted back to bed for an X-Ray on 12/14/19, at approximately 1:30 AM, and then assisted back up to the wheelchair as the resident continued to try to climb out of bed. Per interview, the X-Ray results were received by her at 2:00 AM, when the X-Ray report was faxed to the facility. However, she stated she did not accurately read the X-Ray report findings and was not aware Resident # (TRUNCATED)

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure pain management is provided to residents who require such services for one (1) of four (4) sampled residents (Resident #1). On 12/11/19, the facility admitted Resident #1 from an Acute Care Hospital status [REDACTED]. Per the Controlled Drug Record, the resident received a [MEDICATION NAME] 5/325 mg tablet on 12/13/19 at 8:30 PM; however, there was no documented evidence of an assessment prior to or after administration of the pain medication in order to evaluate if the medication was effective. On 12/13/19, at approximately 10:35 PM, Resident #1 sustained a fall from the bed while the bed was in high position and was found lying in the prone position, partially on his/her left hip. Although the Fall Event Report, dated 12/14/19 at 8:17 AM, revealed Registered Nurse (RN) #1 documented the resident's pain was horrible and intense directly after the fall on 12/13/19, RN #1 and State Registered Nurse Aide (SRNA) #1 lifted the resident under the arms and pulled him/her to his/her feet, and transferred the resident to bed for approximately thirty (30) minutes, and then assisted the resident to the wheelchair to be monitored at the nurse's station. Although Resident #1 continued to complain of left hip pain, RN #1 did not notify the Advanced Registered Nurse Practitioner (ARNP) of the fall and complaints of left hip pain until 12/13/19 at 11:37 PM, approximately one (1) hour after the fall. An X-Ray of the left hip was obtained and RN #1 received the X-Ray results on 12/14/19 at 2:00 AM. However, RN #1 did not review the X-Ray findings accurately and did not inform the ARNP of the results of the X-Ray which revealed a Left [MEDICAL CONDITION]. Resident #1 continued to complain of pain and received another [MEDICATION NAME] 5/325 mg on 12/14/19, at 2:30 AM, with no documented pain assessment prior to or after administration of the medication. Staff interviews revealed the resident continued to complain of pain after receiving the 2:30 AM pain medication; however there was no documented evidence the ARNP was notified of the continued pain or the Left [MEDICAL CONDITION] until 12/14/19 at 7:45 AM, after RN #2 reviewed the X-Ray results and identified the Left [MEDICAL CONDITION]. Resident #1 was transferred to the hospital on [DATE] at approximately 8:00 AM, and admitted with [DIAGNOSES REDACTED]. Resident #1 underwent Open Reduction Internal Fixation (ORIF) due to the Left [MEDICAL CONDITION], on 12/15/19. (Refer to F-580, F-655, F-658, and F-689) The facility's failure to have an effective system in place to ensure pain management is provided to residents who require such services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020 and was determined to exist on 12/13/19. The findings include: Review of the facility's Pain Management Policy, revised 02/15/18, revealed upon admission and re-admission the Pain Evaluation will be completed for each resident to include pain assessment, name of pain medication, dosage, frequency and effectiveness's and appropriate diagnosis; history of pain; pain characteristics including intensity, location, frequency and location; factors such as activities that exacerbate the pain. Use a pain scale to describe the severity of the pain and also for the evaluation of pain relief achieved after treatment has been administered. Pain scale of zero (0) to ten (10) can be used with residents who understand this concept, and for residents who cannot understand a numerical scale, a visual scale may be used using Wong-Baker faces to aid in determining the severity level of pain. Residents will have ongoing assessments, a monitoring system, and a comprehensive person centered plan of care to address pain management to include the resident's goals and preferences. Further review revealed staff was to recognize when the resident has pain and circumstances when pain can be anticipated; evaluate the existence of pain; and manage or prevent pain consistent with professional standards of care and in accordance with the plan of care. Continue review of the Policy, revealed documentation of the administration of pain medication shall be completed on the EZMAR (Electronic Medication Administration Record). A pain evaluation is completed each shift on all residents and documented in EZMAR. Whenever the results of pain assessments reveal the resident's pain is not under control, the Attending Physician/Medical Provider shall be notified. If PRN (as needed) pain medication is utilized, monitoring of effectiveness and documentation will occur. If the pain medication is ineffective the pain will be evaluated and the Situation Background Assessment Recommendation (SBAR) will be completed prior to calling the physician for notification of unrelieved pain. Interview with the Director of Nursing (DON) on 12/23/19 at 2:47 AM, revealed staff was to utilize the Medication Administration Record [REDACTED]. Further, staff was to reassess the resident's pain level after administration of the medication for effectiveness and document the pain level on the MAR. Review of Resident #1's closed medical record revealed the facility admitted the resident on 12/11/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Note, dated 12/11/19 at 3:21 PM, revealed Resident #1 was admitted from an Acute Care Hospital transferred via ambulance. Per the Note, the resident was alert and oriented x 2 (alert to person and place) with occasional confusion and was able to verbalize needs. Further review of the Note, revealed the resident had a [DIAGNOSES REDACTED]. Additional review of the Nurse's Note, revealed pain was not addressed. Review of the Observation Report, dated 12/11/19 at 5:57 PM, completed by RN #2, revealed the resident was assessed as oriented to person and place, and having clear speech. Review of the Pain Assessment section of the Report, revealed the resident had frequent pain in the right hip, morning, afternoon and night; and described his/her pain during this assessment as a seven (7) on a scale of one (1) to ten (10) with ten (10) being the worst pain. Further review revealed [MEDICATION NAME] therapy (pain medication) made the pain better and bending and changing positions made the pain worse. Interview with RN #2, on 12/27/19 at 12:01 PM, revealed she admitted the resident on 12/11/19, after surgical repair for a right [MEDICAL CONDITION]. Per interview, the resident was confused on admission, but knew his/her own name and knew his/her spouse. Per interview the resident was not in pain, but was restless on admission. Review of physician's orders [REDACTED]. The Admission Minimum Data Set (MDS) Assessment was not completed due to the resident being newly admitted . Review of Resident #1's Brief Interview for Mental Status (BIMS), dated 12/12/19, revealed the facility assessed the resident to score a six (6) out of fifteen (15) which indicated severe cognition impairment. Review of the Baseline Care Plan, initiated 12/12/19, revealed the resident was admitted with right hip pain post operatively. The goal stated the resident would have relief or reduction of pain intensity within one (1) hour after receiving interventions over the next thirty (30) days. Interventions included administer pain medications as per physician's orders [REDACTED]. However there was no documented evidence this Baseline Care Plan was implemented for on 12/13/19 from 7:00 PM through the morning of 12/14/19. (Refer to F-655) Review of Resident #1's Progress Notes, revealed no documentation for the shift of 12/13/19 from 7:00 PM through 12/14/19 at 7:00 AM, even though staff interviews revealed after 8:30 PM on 12/13/19, the resident exhibited behaviors including raising the bed in the high position, attempting to get out of bed unassisted, and requesting to go to be assisted to the bathroom frequently. [MEDICATION NAME] 5-325 mg one (1) tablet was signed out on the Controlled Drug Record (CDR) on 12/13/19 at 8:30 PM. However, review of the Medication Administration Record [REDACTED]. In addition, there was no documented evidence on the MAR indicated [REDACTED]. Review of Resident #1's Fall Event Report, revealed a fall event occurred on 12/13/19 at 10:35 PM, and the resident had severe pain (horrible intense) of the left hip. Range of Motion (ROM) painful/limited in lower extremity (did not specify which extremity) and no rotation/deformity/shortening noted of extremities. Further review revealed check marks in the boxes to indicate: Neurological checks completed; alert and responds appropriately to stimuli; strong facial muscle movement; strong upper left and right upper extremity grasps; strong left and right lower extremity movement; and left and right eye pupil size 3 millimeters and round and brisk pupil movement. Continued review revealed the resident had raised the bed in the highest position and fell from the bed. Resident #1 was then placed in the wheelchair and brought to the nurse's station. Notifications included the DON and the Administrator. Per the Report, the ARNP was notified on 12/13/19 at 11:30 PM, and a left hip X-Ray was ordered. The Fall Event Report was completed on 12/14/19 at 8:17 AM, by RN #1. Review of the facility's Phone Message Record dated 12/13/19, revealed the ARNP was notified at 11:37 by RN #1, Resident #1 sustained a fall from his/her bed at 10:35 PM and was complaining of hip pain (left or right hip was not specified). RN #1 requested follow-up orders on the voice message. Review of the Mobile X-Ray report, dated 12/14/19, received at the facility on 12/14/19 at 2:00 AM, revealed there was significant findings of the left hip, unilateral views of the pelvis. The bones were osteoporotic, and there was a non-displaced intertrochanteric [MEDICAL CONDITION] femur. Additional review revealed status [REDACTED]. [MEDICATION NAME] 5-325 mg one (1) tablet was signed out on the CDR on 12/14/19 at 2:30 AM. However, review of the MAR, revealed no documented evidence [MEDICATION NAME] was administered on 12/13/19 at 2:30 PM. In addition, there was no documented evidence on the MAR indicated [REDACTED]. Review of Resident #1's Situation Background Assessment Recommendation (SBAR) Communication Form, revealed on 12/13/19, the resident had a change in condition and worsening pain in the left hip with a pain level of ten (10), with ten (10) being the worst on a pain scale of one (1) to ten (10). Vital signs were obtained which were stable, and neuro checks were completed with no changes observed. Further review revealed there was new pain in the left hip and wincing with movement. An X-Ray was completed which showed a new [MEDICAL CONDITION] of the left hip and the Medical Provider was notified on 12/14/19 at 7:45 AM. Resident #1 was then transferred to the emergency room (ER) for evaluation and the resident's representative was notified on 12/14/19 at 7:50 AM. This document was not signed and had no date of completion. Post survey interview with RN #1, on 01/15/2020, at 8:45 AM, verified she completed this SBAR Form after the resident was sent to the Hospital emergency room (ER), on 12/14/19. Review of the Progress Note, dated 12/14/19 at 9:03 AM, revealed Resident #1's spouse was notified of new orders to send the resident to the emergency room (ER) and the resident was being sent via ambulance. Per the Note, the ambulance was called and report was called to ER. The resident continued to complain of pain with movement. Further review of the Note, revealed Emergency Medical Technicians (EMTs) arrived and transferred the resident to the stretcher per a three (3) man lift. The Note was signed by RN #2. Review of the Discharge MDS Assessment, dated 12/14/19, revealed the facility discharged the resident to an Acute Care Hospital. Review of the Hospital History and Physical, dated 12/14/19, revealed Resident #1's chief complaint was left hip pain status [REDACTED]. Range of Motion (ROM) was not assessed due to complaint of left hip pain per the resident, and external rotation and shortening of the left leg noted. Review of the Hospital Discharge Summary, dated 12/28/19, revealed Resident #1 was admitted on [DATE], after a fall in the nursing home resulting in an Intertrochanteric [MEDICAL CONDITION] Hip. Additional admission [DIAGNOSES REDACTED]. Per the Summary, upon admission Resident #1 was confused and did not respond to questions appropriately. When admitted to the ER Resident #1 complained of severe left hip pain made worse by movement. Continued review of the Summary, revealed the resident underwent [REDACTED]. Per the Summary, the resident tolerated the procedure and his/her post-op course was without complication except for pain management and agitation. According to the Summary, Resident #1 was discharged to a Skilled Nursing Facility and would follow up with Family Medicine. Instructions included Activity as Tolerated; Weight bearing as tolerated; and no formal hip precautions. Review of Resident #1's Fall Investigation, revealed the resident had been assessed to be at high risk for falls with contributing factor to include impulsive behavior. The resident had been up and down during the 7:00 PM to 7:00 AM shift on 12/13/19 to 12/14/19, at the nurse's station. After the resident requested to go to bed, and SRNA #1 put Resident #1 back to bed. Soon afterward, SRNA #1 heard the resident fall in the room (with no specified time of the fall). Resident #1 was evaluated by the nurse and taken to the nurse's station. The ARNP was notified at 11:30 PM, and a new order was received for an X-Ray. The X-Ray was misread by RN #1 on the night shift. RN #2, who was the day shift nurse, reviewed the X-Ray and found a new [MEDICAL CONDITION] hip, and the Physician was notified. Resident #1 was transferred to the Hospital ER. Per the Fall Investigation, the root cause of the fall was fall from bed, and the contributing factor was impulsive behavior. This Fall Investigation was signed by the DON on 12/16/19. Interview on 12/30/19 at 5:38 PM, with SRNA #1, revealed she was assigned to Resident #1 on 12/13/19 from 7:00 PM until 7:00 AM, on 12/14/19. SRNA #1 stated after the resident's spouse left about 8:30 PM on 12/13/19, the resident kept trying to climb out of the bed and she had to repeatedly assist the resident to the bathroom. Continued interview revealed she sat in the room with Resident #1 from about 8:30 PM until 9:00 PM, after the resident was medicated for complaints of right hip pain. Further interview with SRNA #1, revealed about 9:00 PM, she went to check on her other residents, and checked on Resident #1 at least every thirty (30) minutes. Per interview, while checking on the resident she noticed the resident raised the bed up in high position and put the head of the bed straight up using the hand held bed control, and SRNA #1 had to readjust the bed to the low position. SRNA #1 further stated the resident also kept trying to get up without assistance. Per interview, when the resident was in the bed, SRNA #1 would have to lower the bed to the lowest position and pull the resident back up towards the head of the bed with the help of SRNA #2. SRNA #1 stated RN #1 was made aware of the resident's behavior. Additional interview with SRNA #1, revealed she had toileted the resident, and assisted the resident back to bed, and a short time later, about 10:30 PM, she heard a noise. She stated she entered Resident #1's room, and observed the resident was on the floor and the bed was in the high position. Per interview, she notified RN #1 of the fall, and RN #1 checked on the resident, but she could not recall the nurse completing an assessment of the resident. SRNA #1 further stated she and RN #1 lifted the resident back to the bed. SRNA #1 stated she sat with the resident about thirty (30) minutes after the fall, and then Resident #1 was positioned at the nurse's station for close monitoring. Additional interview with SRNA #1, revealed after the fall, Resident #1 was assisted back to bed for an X-Ray on 12/14/19 about 1:30 AM, which took about thirty (30) minutes at the most, then the resident was again positioned at the nurse's station in the wheelchair in order for staff to monitor him/her closely for safety. Per interview, after the fall the resident continued to complain of pain throughout the night, but did not specify where he/she was hurting. Further interview revealed the resident was positioned in the wheelchair at the nurse's station until 5:30 AM, when the resident was assisted back to bed and went to sleep. Interview on 12/30/19 at 3:25 PM, with SRNA #2, revealed she did not provide care to Resident #2 accept to assist with pulling him/her up in the bed on 12/13/19 during the evening shift through the morning of 12/14/19. She stated she did remember the resident verbalizing he/she was having pain, but the resident did not verbalize where the pain was located. Additional interview with SRNA #2, revealed the resident was up and down throughout the night trying to get out of bed, and the resident was periodically placed at the nurse's station for closer observation. Interview with RN #4, on 12/30/19 at 3:53 PM, revealed she was working South Hall on 12/13/19, the night Resident #1 fell , while RN #1 was working the North Hall. Per interview, RN #4 sat with the resident for a few minutes after the fall which occurred at approximately 10:30 PM, while the SRNAs were completing their rounds on other residents. Per interview, during the time she was sitting with the resident, he/she was very restless, trying to get out of bed and was confused. She stated when the SRNAs finished their rounds they still were unable to keep the resident in bed and he/she was positioned across from the nurse's station for closer monitoring. She stated she did not notice any non-verbal signs of pain such as moaning, grimacing or guarding. However, she further stated the resident did complain of pain once up in the wheelchair after the fall while sitting across from the nurse's station, and that was when RN #1 made the phone call to get the X-Ray, which was about 11:30 PM. Interview on 12/24/19 at 8:00 AM, and post survey interview on 01/15/2020 at 8:45 AM, with RN #1, revealed she just started working at the facility on 12/11/19, and 12/13/19 was her first night out of orientation working on the North hall as the only nurse for the hall. She stated when she arrived on the unit 12/13/19, Resident #1 was in bed and the resident's spouse asked if the resident could have pain medication. Per interview, the resident's spouse left at about 8:30 PM, and at that time she administered [MEDICATION NAME] 5/325 mg to the resident for right hip pain. She stated she did assess the resident for pain prior to administration of the medication, and the resident's pain was in the right hip, although she did not recall the intensity of the pain. Per interview, she was unaware she had failed to document administration of the pain medication, or the resident's pain level prior to and after administration of the medication on the MAR. She stated she did not utilize the pain scale of one (1) to ten (10), nor did she use a visual scale of faces to determine the resident's pain level. She further stated she just observed the resident for signs and symptoms of pain to ensure the pain medication was effective. Per interview, the resident's pain seemed to be at baseline after receiving the medication as the resident was always in pain. Further interview revealed Resident #1 kept trying to get out of bed unassisted after 8:30 PM and kept raising the bed up into the high position using the bed control. Per interview, the resident was toileted several times as he/she kept verbalizing the need to go to the bathroom, even though he/she was just taken to the toilet. Further interview revealed SRNA #1 kept checking on him/her every fifteen (15) minutes, although this was not documented. Continued interview with RN #1, revealed she was called to Resident #1's room by SRNA #1, on 12/13/19 at 10:35 PM, and the resident was noted to be on the floor in the prone position lying partly on his/her left side. RN #1 stated she did not assess the resident's ROM, or do a comprehensive neuro check after the fall, even though she may have documented that she did. She further stated she did a visual assessment of the resident who seemed to be okay, and vital signs were obtained. Per interview, after assessing the resident he/she seemed to be okay. RN #1 stated the resident did complain of pain in the left hip after the fall, but she and SRNA #1 were able to lift the resident under his/her arms and stand the resident to his/her feet and then assist the resident to bed. Per interview, the resident did complain of increased pain with this transfer. She stated once in bed the resident kept trying to get out of bed unassisted and was very confused, and she decided to position the resident in the wheelchair across from the nurse's station in order to keep a closer eye on him/her. Per interview, while sitting in the wheelchair, the resident kept complaining of pain in the left hip, and at 11:37 PM the ARNP was notified of the resident's fall and continued complaints of pain. She stated an order was obtained for an X-Ray of the resident's hips and pelvis. Additional interview with RN #1, revealed Resident #1 was assisted back to bed for an X-Ray on 12/14/19, at approximately 1:30 AM, and then assisted back up to the wheelchair as the resident continued to try to climb out of bed. Per interview, the X-Ray results were received by her at 2:00 AM, when the X-Ray report was faxed to the facility. However, she stated she did not accurately read the X-Ray report findings and was not aware Resident #1 had a new left [MEDICAL CONDITION] due to thinking the fracture on the X-Ray was the same fracture acquired prior to admission. Per interview, the resident received another [MEDICATION NAME] 5/325 mg on 12/14/19 at 2:30 AM, when it was time for the medication which could be administered every six (6) hours and then he/she was assisted back to bed for thirty (30) minutes from approximately 3:00 AM until 3:30 AM. She stated she was unaware she failed to document administration of the [MEDICATION NAME] on the MAR indicated [REDACTED]. Per interview, she again did not use the pain scale, nor did she use a visual scale of faces to determine the resident's pain, but just observed the resident for signs and symptoms of pain before and after administration of the 2:30 AM [MEDICATION NAME]. When questioned if the pain medication at 2:30 PM was effective to relieve the resident's pain, she stated the resident did continue to complain of pain. However, continued interview with RN #1, revealed she did not notify the ARNP concerning Resident #1's continued pain after the first call on 12/13/19 at 11:37 PM because the resident was always complaining of pain. Per interview, the resident was assisted back to the wheelchair from 3:30 AM for close monitoring, and was assisted back to bed at 5:30 AM, when the resident fell asleep due to exhaustion. Per interview, RN #2 arrived and read the X-Ray report findings during shift change at 7:30 AM on 12/14/19, which was nine (9) hours after the resident sustained [REDACTED]. RN #1 stated the ARNP was then notified of the X-Ray results. Additional interview with RN #1, revealed after the resident sustained [REDACTED]. Interview with RN #2, on 12/27/19 at 12:01 PM, revealed during shift change she received report from RN #1 the morning of 12/14/19, and was told Resident #1 had a fall from his/her bed and there had been an X-Ray done. Further, she was informed by RN #1 the results of the X-Ray indicated a [MEDICAL CONDITION] hip, which the resident had been admitted with after a surgical repair. Per interview, RN #2 reviewed the X-Ray report findings, and identified there was a new Left [MEDICAL CONDITION]. RN #2 stated she informed RN #1 of this and the ARNP was notified of the Left [MEDICAL CONDITION] on 12/14/19 at 7:30 AM. RN #2 further stated the resident's family, and the DON were notified, and the resident was transferred to the Hospital emergency room . Interview on 12/23/19 at 12:24 PM, with Resident #1's spouse, revealed on the evening of 12/13/19, the resident was a little confused, but together they discussed the resident's need to receive rehabilitation in the nursing home due to recent hip surgery. Further interview revealed the spouse received a call the morning of 12/14/19 at 1:30 AM, regarding the resident sustaining a fall and an X-Ray was to be done. Per interview, an hour later the spouse received a call from a nurse at 2:30 AM, stating the X-ray report indicated everything was fine and they were keeping the resident at the nurse's station due to the resident being restless and raising the bed in high position. Further interview revealed on 12/14/19 at 8:00 AM, the spouse received a call explaining there was a mistake, and the resident's hip was indeed broken. Per interview, the spouse stated he/she thought, Oh my God, {he/she} fell and broke {his/her} hip and was kept up at the nurse's station. Additional interview with Resident #1's spouse, revealed the resident had developed serious confusion since his/her left hip surgery, and now had two (2) broken hips and was receiving narcotic pain medication in the form of pills as well as [MEDICATION NAME] injections. Per interview, Resident #1 was calm after the pain medication, but after it wore off he/she was in agony. Resident #1's spouse further stated, I feel {he/she} was warehoused, stuck in a room, therapy in the morning, and then good luck. Interview with the ARNP, on 12/30/19 at 3:33 PM, revealed she received a call around 11:30 PM on 12/13/19 related to Resident #1 sustaining a fall and complaining of hip pain. She stated she ordered a Stat X-Ray of the Left Hip, but did not want to order any further pain medication at the time of the call. Per interview, she wanted the resident's pain managed with the medication that was already ordered until the X-Ray results came back, which usually took a few hours if ordered Stat. Additional interview with the ARNP, revealed she did not hear back from the nurse related to the X-Ray results or related to the resident's pain until 12/14/19 about 6:00 AM or 6:30 AM. Further interview revealed if a resident sustained [REDACTED]. In addition, the ARNP stated she would expect the nurse to immediately inform her of accurate X-Ray results and to inform her if a resident's pain was not managed with current pain medication. The ARNP stated if she had been notified of accurate X-Ray results in a timely manner for Resident #1, she would have given orders to send the resident to the Hospital ER because a resident with a [MEDICAL CONDITION] would need to be evaluated by an orthopedic surgeon. Interview with the DON, on 12/27/19 at 2:36 PM, 01/02/2020 at 3:15 PM, and post survey interview on 01/16/2020 at 12:06 PM, revealed a prudent nurse would thoroughly assess a resident after a fall to include neuro checks, ROM, pain, skin check, and vital signs in order to check for abnormalities and injuries. Per interview, if Resident #1 had new pain or pain in a different area after the 12/13/19 fall, the ARNP should have been notified of the fall and the pain immediately, instead of waiting for an hour. Further interview revealed failure of RN #1 to accurately review and report Resident #1's X-Ray findings to the ARNP related to the [MEDICAL CONDITION] delayed the resident being sent to the Hospital for treatment and further pain management. Further interview revealed bearing weight for toileting after the fall could have caused further injury and increased pain. Further, having the resident sit in the wheelchair after the fall could have contributed to the resident's pain level. Additional interview revealed it was her expectation staff follow facility policy and document administration of pain medications on the MAR indicated [REDACTED]. Interview with the Administrator, on 01/02/2020 at 3:51 PM, and post survey interview on 01/16/2020 at 1:53 PM, revealed it was her expectation residents be thoroughly assessed by the nurse after a fall and the Physician be notified immediately if there was increased pain or new pain after a fall. Further interview revealed RN #1 should have read Resident #1's X-Ray findings to the ARNP accurately in order for the resident to receive timely necessary treatment and pain management. Additional interview revealed she could not say if sitting up in the wheelchair or being toileted which required weight bearing after sustaining the new left [MEDICAL CONDITION] contributed to the resident's pain that night; however, nursing staff should be able to identify circumstances that contribute to increased pain. Further, she stated it was her expectation staff assess residents for pain and document the pain assessments as well as notify the Physician if pain was not relieved with current pain medications or interventions. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/19/2020 alleging removal of the Immediate Jeopardy on 12/31/19. Review of the AoC revealed the facility implemented the following: 1. Resident #1 did not return to the facility after discharge to the hospital

Based on observation, interview, record review, review of applicable Safety Data Sheets (SDS), and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the environment remained as free from accidents and hazards as possible. Observations on 03/14/17 and 03/15/17 revealed the medication cart on the South Hall was left unlocked and unattended. Additionally on 03/14/17, a vial of insulin and three (3) medication cups containing loose narcotic pain pills were left on top of the cart, accessible to any resident who approached the cart. Continued observation during the initial facility tour on 03/14/17 and on 03/16/17 revealed a medication cart unlocked and unattended in the North Hall nurses station. Interview revealed the facility had a total of fourteen (14) residents who were independently mobile in a wheelchair and assessed by the facility as cognitively impaired. Also, observation during the initial facility tour on 03/14/17 revealed the South Hall shower room door was left open. Continued observation inside the shower room revealed the following items were unsecured and accessible to residents: two (2) containers of Germicidal Clorox wipes and a bar of Dove soap; a bottle of shampoo; and shampoo and body wash, deodorant, mouth wash and hand sanitizer in a plastic storage bin. Additionally, the shower room floor was wet. The facility's failure to have an effective system in place to ensure the environment remained as free from accidents and hazards as possible, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were identified on 03/15/17, and determined to exist on 03/14/17. The facility was notified of the Immediate Jeopardy on 03/15/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 alleging removal of the Immediate Jeopardy on 03/17/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/22/17, prior to exit on 03/22/17, with remaining non-compliance at a Scope and Severity of an E, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Accident Prevention policy, dated January 2005, revealed employees were to keep the work environment safe and accident free. Review of the facility's Medication Administration policy, dated 2007, revealed during administration of the medications, the medication cart was to be kept closed and locked when out of sight of the medication nurse, no medications were to be kept on top of the cart, and the cart must be clearly visible to the personnel administering medications when unlocked. 1. Observation on the South Hall, on 03/14/17 at 5:07 PM, revealed the medication cart was unlocked and unattended. Further observation of the medication cart revealed a bottle of insulin and three (3) unlabeled medication cups, each containing a single unidentified pill, were on top of the cart and accessible to anyone who walked by. Continued observation revealed RN #1 returned to the cart at 5:13 PM. Interview with RN #1, on 03/14/17 at 5:13 PM, revealed she left the cart unlocked and unattended when a resident called out and she went to assist the resident. RN #1 acknowledged she left the unlabeled medications on top of the cart, and stated she should have locked the cart before walking away and should not have left narcotic medications on top of the cart. Continued interview revealed leaving medications on top of the cart made them accessible to anyone in the area, and they were a danger because anyone could have gotten hold of them. Subsequent observation on the South Hall, on 03/15/17 at 2:45 PM, revealed the medication cart had again been left unlocked and unattended. Continued observation revealed RN #1 returned to the cart at 2:50 PM. Interview with RN #1 at the time of the observation revealed she thought she had locked the cart before walking away. The facility provided a Roster Matrix with all residents who were mobile, either independently ambulatory or mobile by wheelchair, highlighted in yellow. In addition, each highlighted resident was further characterized by their BIMS score. Review of the list with the DON revealed fourteen (14) residents in the facility were mobile and were assessed by the facility to have a BIMS score less than eight (8), which indicated they were cognitively impaired. Eight (8) of those fourteen (14) residents lived on the South Hall. Interview with Licensed Practical Nurse (LPN) #4, on 03/15/17 at 3:15 PM, revealed she was the South Hall Unit Manager. She stated the medication carts should be kept locked at all times when unattended and out of sight of the nurse, and medications should not be stored on top of the cart. 2. Observation on the North Hall during the initial facility tour, on 03/14/17, at 10:07 AM, revealed an unlocked and unattended medication cart was located in the nurses station. Interview with LPN #2, on 03/14/17 at 10:10 AM, revealed she was the Unit Manager for the North Hall. She stated the medication cart should not have been left unlocked and unattended, for reasons of resident safety. Further observation on the North Hall, on 03/16/17 at 8:00 AM, revealed the medication cart was unlocked and unattended on the resident hall. Continued observation revealed LPN #1 returned to the cart at 8:05 AM. Further review of the Roster Matrix indicating which residents were mobile and cognitively impaired revealed six (6) of the fourteen (14) residents resided on the North Hall. Interview with LPN #1 at that time revealed she had locked the cart prior to leaving it. Continued interview revealed the cart had been serviced a week or so ago for a faulty lock and must have broke again. She stated an unlocked medication cart was potentially dangerous if a resident opened the drawers and ingested a medication which caused an adverse reaction. Interview with the Director of Plant Operations, on 03/16/17 at 8:30 AM, revealed the lock on the medication cart gets caught sometimes. He stated the cart was serviced by the facility's contracted pharmacy about a week and a half ago, and he was not aware there had been any other problems until the cart was found to be unlocked by the State Survey Agency. He further stated the pharmacy had again been contacted to service the faulty lock. Interview with the facility's contracted pharmacy Cart Maintenance Supervisor, on 03/16/17 at 1:50 PM, revealed he had serviced the medication cart about a week and a half ago for the lock and thought the cart had been repaired. Interview with the Director of Nursing (DON), on 03/16/17 at 4:53 PM, and review of the facility's list of wandering residents with the DON, revealed there were sixteen (16) wanderers who resided in the facility. The DON stated unlocked and unattended medication carts placed wandering residents at risk for potential harm. She stated it was the nurses' responsibility to ensure the medication carts were locked when not attended or out of the their direct line of vision. She further stated medications were not to be kept on top of the carts. 3. Observation during the facility tour, on 03/14/17 at 10:15 AM, revealed State Registered Nurse Aide (SRNA) #1 exited the shower room located on the South Hall and left the door opened. Continued observation inside the shower room revealed two (2) containers of Germicidal Clorox wipes sitting on the whirlpool tub, a bottle of shampoo lying in the whirlpool tub, and a bar of Dove soap on the edge of the whirlpool tub. Further observation revealed shampoo and body wash, deodorant, mouth wash and hand sanitizer were observed stored in an unsecured plastic storage bin. Additional observation revealed the shower room floor was wet. Review of the SDS revealed Micro Kill Bleach Germicidal Wipes could cause eye tearing, redness, and discomfort. Review of the SDS revealed April Fresh Alcohol Free Mouthwash could cause eye and skin irritation. Review of the SDS revealed Epi-Clenz Hand Sanitizer could cause eye irritation, could be harmful if swallowed, and could cause an allergic skin reaction. Review of the SDS revealed Fragrance Shampoo and Body Wash could cause moderate eye irritation and could be harmful if swallowed. Review of the SDS revealed Medspa Deodorant could cause eye and skin irritation, and could be harmful if ingested. Continued review revealed the following precautions: keep out of reach of children, and do not use on broken skin. Review of the SDS revealed Dove Bar Soap could cause eye irritation. Further review revealed the following: if ingested, do not induce vomiting, seek medical attention. Interview with SRNA #1, on 03/16/17 at 8:45 AM, revealed the shower room door should be kept closed and locked at all times so residents could not get in there and fall on the wet floor or hurt themselves with items that were stored in the shower room. Continued interview revealed SRNA #1 had left the door open but should have shut and locked it when she exited. Interview with LPN #8, on 03/14/17 at 10:20 AM, revealed she worked on the South Hall. She stated the shower room door should be closed when not in use to protect the safety of the residents. She further stated the wet floor could cause a resident to fall and the personal hygiene products stored in the plastic bin and on the whirlpool tub could be hazardous to residents. Additional interview with LPN #4/South Hall Unit Manager, on 03/15/17 at 3:15 PM, revealed the shower room door should be closed and locked to protect residents from potentially harmful substances if ingested, and injury if a resident fell on the wet floor. Further interview with the DON, on 03/16/17 at 5:43 PM, revealed all doors with a keypad lock, including the shower room, should be kept closed and locked at all times to protect residents from potential harm. The DON stated her expectation for all staff to follow the facility's Accident Prevention policy. Interview with the Administrator, on 03/16/17 at 6:00 PM, revealed he expected staff to follow the facility's Accident Prevention policy. He further stated he expected staff to keep shower room doors closed and locked to protect residents from potential injury from a fall due to the wet floor, or from potentially hazardous substances that were stored in the shower room. Additionally, the Administrator stated he expected the nurses to follow the facility's Medication Administration Policy when administering medications to ensure medications were securely stored and the carts were locked when unattended. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/17/17. Review of the AOC revealed the facility implemented the following: 1. On 03/15/17, the Regional Nurse Consultant educated the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UMs) regarding a safe environment for residents, medication storage, medication administration policy and procedure, and administering care to ensure the highest practical physical, mental and psychosocial well-being of each resident, and to maintain acceptable professional standards and practices. 2. On 03/16/17, the Director of Operations (DO) educated the Administrator, DON, SDC, Health Information Manager (HIM), Quality of Life Director, Social Services Director, Minimum Data Set (MDS) Nurse, Maintenance Director, Dietary Manager, Business Office Manager (BOM) and Regional Nurse Consultant on the facility's quality assurance (QA) process and policy. Administrative oversight of the facility would be completed by the Director of Operations or Designee weekly to ensure audit compliance until the removal of the Immediate Jeopardy. All audits would be presented at the weekly QA meeting. Any areas found to be out of compliance will result in actions including, but not limited to re-education, with disciplinary action up to and including termination. 3. On 03/15/17, the DON, SDC, and the UMs conducted walking round audits on both units (North Hall and South Hall) to ensure all medication carts, medication rooms, and treatment carts were locked and all medications, including narcotics, were secured. In addition, the DON and the SDC audited all medication carts to ensure medications were in the secured pharmacy packs. On 03/15/17, a locked cabinet was placed in each shower room for the purpose of storing cleaning supplies. To avoid cross contamination and infection control issues, the shower rooms will not be used for storing residents' personal items. On 03/16/17, a sign was placed in each shower room stating, No Storing of Personal Items. 4. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services and post-tests to all licensed nurses regarding securing medication carts and medications, including narcotic medications. The proper securing of treatment carts was also addressed. In addition, the training included proper storage of germicidal items, residents' personal items, and hand sanitizer. Twenty-six (26) of the twenty-eight (28) licensed nurses employed by the facility were educated by 03/16/17. The facility does not utilize agency staff or Kentucky Medication Aides. Nurses were also in-serviced on pre-filling medications and following the five (5) rights of medication administration. In addition, the in-service included the Kentucky Board of Nursing (KBN) Professional Standards of Practice regarding medication, medications carts, and proper storage of those medications. Also included in the mandatory in-service was the requirement to ensure the medications were under the direct observation of the person administering the medications, or were locked in the medication storage area/cart. Any licensed staff not educated by 03/16/17 would not be permitted to work until the in-service and post-test were completed. Furthermore, all licensed nurses will receive this training during new-hire orientation. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services to all staff on handling and storage of chemicals and making sure resident personal care items are not stored in the shower rooms. No staff were permitted to work until the in-service and post-test were completed. Ninety-three (93) of one hundred one (101) stakeholders employed by the facility received the education and completed a post-test related to the storage of germicidal agents and personal care items in shower rooms. Any stakeholder that did not receive the educations by 03/16/17 was not permitted to work until they completed the training and post-test. Furthermore, the training topic was added for all staff to receive during new-hire orientation. 5. On 03/15/17, the DON, SDC, Weekend Supervisor, and UMs began daily audits, at random times on both units, six (6) times per day, to ensure medication carts were locked and all medications/narcotics were secured. In addition, daily audits of the shower rooms were initiated on 03/15/17, to be completed by the Administrator, DON, UMs, Weekend Supervisor, BOM, Assistant BOM (ABOM), Admissions Coordinator, HIM, Housekeeping Manager, Dietary Manager, Quality of Life Director, Social Services Director, MDS nurse, and the Maintenance Director. The audits were to be conducted six (6) times daily, at random times on both units, to ensure no residents' personal items were stored in the shower rooms, germicidal cleaners were locked in the cabinets in the shower rooms, and shower room doors were closed. 6. A QA meeting was held on 03/15/17 and 03/16/17. In attendance were the Medical Director, Administrator, DON, SDC, HIM and a nurse. All audits were to be reviewed weekly in a QA meeting. 7. The Administrator and the DON were to function in a manner that enabled the use of effective and efficient resources to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Job Description and expectations of the Administrator's role were reviewed with the Administrator by the DO on 03/16/17. The DO would hold weekly meetings with the Administrator and the DON to validate the facility's Allegation of Compliance. These weekly meeting will continue until the immediacy of jeopardy has been lifted. The Administrator and the DON received education on 03/16/17 from the DO regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. An additional ad hoc QAPI meeting was held via phone, on 03/16/17 with the Medical Director, Administrator, DON, SDC, HIM, and Regional Nurse Consultant. Discussion included the outcome of the recent survey and the issuance by the State Agency of the 2 additional IJ deficiencies related to QA and Administrative oversight. The audit tools and education were reviewed with the Medical Director, who had no further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the In-service Attendance Record, dated 03/15/17, revealed the Regional Nurse Consultant provided education to the administrative staff related to a safe environment for residents, medication storage. the medication administration policy, all to ensure the highest practical physical, mental, and psychosocial well-being of each resident and to maintain acceptable professional standards of practice. The in-service addressed storage of chemical agents in the shower room, a mandate that no residents' personal items would be stored in the shower room, and shower doors would remain closed. Interview with the Regional Nurse Consultant, on 03/22/17 at 2:05 PM, revealed she conducted the in-service for Administration on 03/15/17. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, the Weekend Supervisor at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM, and the Administrator at 1:35 PM, revealed all had received instruction from the Regional Nurse Consultant on 03/15/17 concerning a safe environment for residents, medication storage, the and the medication administration policy in order to maintain acceptable standards of practice. In addition, the in-service covered the storage of chemicals in the shower room, the prohibition against storing residents' personal items in the shower rooms, and the requirement to ensure the shower room doors were kept closed at all times. 2. Review of training records revealed the DO in-serviced the administrative team on the facility QAPI program on 03/16/17, and reviewed the AOC with the team on 03/17/17. Review of the facility form titled Administrative Oversight completed by Director of Operations or Designee revealed the DO had signed for completing the oversight for the week of 03/13/17 through 03/17/17. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he reviewed the facility's QA process and provided training to the QAPI leadership team. Continued interview revealed he reviewed and provided oversight of the facility's implementation of the AOC weekly. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, South UM at 10:25 AM, Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed all attended the in-service conducted by the Regional Nurse Consultant on 03/15/17 and were trained on the QAPI process. Continued interview revealed the interviewees attended the weekly QAPI meetings on 03/15/17 and 03/22/17. 3. Review of the facility's audit tool titled Med Cart Audit and Medication Package Audit revealed the DON and the UMs for both the South unit and the North unit, documented completion of initial rounds on 03/15/17 at 7:00 PM with observations that the medication carts were locked, all medications including narcotics were secured, and the treatment carts were locked and secured. Review of the facility audit tool titled Shower Room Audit revealed the DON and UMs for both units completed initial rounds on 03/15/17 at 7:00 PM with observations to ensure no residents' personal items left out, germicidal cleaners were locked in cabinets, and the shower room doors were closed. Observations on the South Unit on 03/21/17 at 9:15 AM, 9:42 AM, 11:40 AM, 11:43 AM, 4:01 PM, and 5:00 PM, and on 03/22/17 at 8:00 AM, of the South Unit revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Observations on the North Unit on 03/21/17 at 9:45 AM, 9:50 AM, 11:45 AM, 1:15 PM, 1:20 PM, 3:20 PM, and 5:05 PM, and on 03/22/17 at 8:11 AM, 9:52 AM and 11:16 AM, revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the South Unit medication carts and shower rooms on 03/15/17. Interview with the North UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the North Unit medication carts and shower rooms on 03/15/17. Interviews on 03/22/17 with the SDC at 1:05 PM, and the DON at 1:20 PM, revealed they assisted in walking rounds on 03/15/17, and observed all medications were secured and carts were locked, and all items in the shower rooms were secured. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he purchased locking cabinets to hold chemical supplies for the two (2) shower rooms on 03/15/17, and placed signs in the shower rooms stating No Storing of Personal Items. 4. Review of the facility's mandatory training records revealed all licensed nurses were educated on 03/15/17 and 03/16/17 by the SDC related to the facility's medication policy, including the five rights of medication administration, and Standards of Practice. All nurses were in-serviced in person or by phone interview. Continued review revealed the training included a post-test to test staff understanding of the educational topics. Interviews on 03/21/17 with RN #3 at 8:00 AM, LPN #9 at 9:02 AM, RN #2 at 9:59 AM, LPN #9, LPN #1 10:00 AM, LPN #10 at 10:39 with, LPN #4 and 11:45 AM, and on 03/22/17 with LPN #12 at 7:00 AM, LPN #11 at 7:08 AM, LPN #3 at 7:11 AM, RN #4 at 7:15 AM, LPN #14 at 7:25 AM, LPN #13 at 7:30 AM, LPN #5 at 9:05 AM, and LPN #15 at 9:11 AM, revealed all had received in-service training by the SDC, in person or by phone interview, related to the facility's policy for medication administration, securing medications and ensuring carts were locked, and Standards of Practice for administration of medications. In addition, the nurses reported training included safe practices of never leaving medications unattended, and only preparing medications at the time of administration. The nurses further reported the training included safe storage of germicidal chemicals in the shower rooms, prohibition of storing resident personal items in the shower rooms, and keeping the shower room door closed. Continued interview revealed all completed a post-test to evaluate their understanding of the education. Interview further revealed the nursing staff could state correct administration practice and the five rights of medication administration (right medication, right dose, right time, right route and right resident). Further review of facility's mandatory in-service training records revealed all staff were educated by the SDC, with the assistance of the Administrator, DON, Unit Managers and Department Heads on 03/15/17 and 03/16/17 related to proper storage of germicidal agents, storage of residents' personal items, and ensuring the shower room doors were kept closed. In addition, the training records included completed post-tests to ensure staff understanding of the training topics. Interviews on 03/21/17 with State Registered Nursing Assistant (SRNA) #7 at 10:10 AM, SRNA #3 at 10:15 AM, SRNA #8 at 10:25 AM, SRNA #9 at 10:30 AM, SRNA #10 at 10:55 AM, SRNA #11 at 11:00 AM, SRNA #1 at 11:05 AM, SRNA #12 at 3:15 PM, SRNA #13 at 3:20 PM, SRNA #5 at 3:22 PM, SRNA #14 at 3:49 PM, and SRNA #4 at 3:52 PM, and on 03/22/17 with SRNA #18 at 7:20 AM, SRNA #16 at 7:21 AM, SRNA #15 at 7:30 AM, SRNA #17 at 8:00 AM, SRNA #19 at 8:05 AM, and SRNA #20 at 8:40 AM, revealed all were in-serviced on 03/15/17 or 03/16/17 concerning proper storage of germicidal agents and residents' personal items, and ensuring the shower room was kept closed at all times. Continued interview revealed they completed a post-test after the training. The staff further stated if they made any observations of items not stored correctly or the shower room door left open, they were to report immediately to the nurse on that unit. Interviews on 03/21/17 with Cook #1 at 3:50 PM, Cook #2/Assistant Manager at 4:00 PM, Dietary Aide #1 at 4:05 PM, Dietary Manager at 4:15 PM, and on 03/22/17 with Cook #4 at 8:45 AM, and with Cook #3 at 8:52 AM, revealed all were instructed by the SDC, Administrator and/or Dietary Manager concerning the proper storage of germicidal agents and residents' personal care items. In addition, the training included the requirement for shower room doors to be kept closed at all times. All interviewed reported completing a post-test after being educated. The interviewees further stated if they made any observations of items not stored correctly or the shower room doors open, they were to report immediately to the nurse on that unit. Interview with the Director of Plant Operations on 03/21/17 at 4:12 PM, and with the Assistant Director of Plant Operations on 03/22/17 at 7:40 AM, revealed they received training by the Administrator concerning proper storage of germicidal agents and residents' personal care items. Both reported they completed a post-test of their understanding of the education. Interview with Laundry Aide #1 on 03/21/17 at 4:55 PM, and with the Housekeeping Manager on 03/22/17 at 8:30 AM, revealed they were in-serviced by the Administrator related to proper storage of germicidal agents and residents' personal care items. Both reported they were required to complete a post-test after receiving the education to ensure their understanding of the topics. Interviews on 03/22/17 with the Social Worker at 9:39 AM, the Occupation Therapist at 10:21 AM, and with the Physical Therapist at 10:42 AM, revealed they had been trained by Administrator and the SDC regarding the proper storage of germicidal agents and residents' personal care items, and on the requirement for the shower room doors to be kept closed at all times. Those interviewed they completed a post-test. All stated if they made any observations of items not stored correctly, or a shower room door left open, they were to report immediately to the nurse on that unit. Interview with the ABOM, on 03/22/17 at 12:35 PM, revealed she was educated by the BOM concerning the proper storage of germicidal agents and residents' personal care items, and on observing to ensure the shower room doors were closed. She stated she completed a post-test related to the topics presented. Interview with the BOM, on 03/22/17 at 12:53 PM, revealed had educated the ABOM and administered the post-test. 5. Review of the facility's forms titled Every Shift Audit, Med Cart Checklist, and Shower Room Checklist revealed the audits were conducted six (6) times per day from 03/16/17 through 03/21/17. The South and North unit audits included monitoring for locked medication carts, ensuring no medications were left on top of the carts, and ensuring all medications, including narcotics, were secured. In addition, the shower rooms were audited for proper storage of germicidal agents/chemicals in locked cabinets, no resident personal items stored in the shower rooms, and doors kept closed. Continued review of the audit forms revealed no concerns noted by staff during the daily rounds. Interview with the Director of Plant Operations on 03/21/17 at 4:45 PM, and with Maintenance Staff #1 on 03/22/17 at 7:40 AM, revealed they were assigned to observe the shower room doors throughout the day to ensure they were kept closed. Interview with the North UM, on 03/22/17 at 10:15 AM, revealed she checked the North medication cart and shower room six (6) times daily and documented on the audit form. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she checked the South medication cart and the shower room six (6) times daily and documented on the audit form. Interview with the RN Weekend Supervisor, on 03/22/17 at 10:20 AM, revealed she checked the medication carts and shower rooms six (6) times daily on both units over the weekend. Interview on 03/22/17 with the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, and the SDC at 1:05 PM, revealed all assisted with daily rounds to ensure medication carts were locked, no medications were left unsecured, and shower room doors were kept closed. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she checked the audit sheets daily to ensure they were complete. She stated she continued to make random checks of the medication carts and the shower rooms. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he reviewed the audit forms for completeness and to identify any continued concerns related to the medication carts/medication security and the shower rooms. 6. Review of the attendance record revealed the ad hoc QAPI meeting on 03/15/17 was attended by the Administrator, DON, SDC, South UM, and the Director of Health Information. Continued review revealed the Medical Director was present by phone. Interviews on 03/21/17 with the SDC at 3:31 PM, and on 03/22/17 with the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they attended an ad hoc QAPI meeting on 03/15/17, with the Medical Director present by phone. Continued interview they also attended a meeting on 03/16/17 to discuss the concerns identified during the State Agency survey. All those interviewed reported a discussion related to the Immediate Jeopardy and removing the immediacy, and more discussion related to deficiencies regarding Administration. Interview with the Medical Director, on 03/22/17 at 11:07 AM, revealed he was contacted by the facility on 03/15/17 and on 03/16/17 to discuss the Immediate Jeopardy related to unlocked and unattended medication carts, and narcotics left unsecured on top of the cart. Continued interview revealed the second call was a concentration on the Administrative deficiencies. He stated he was in agreement with the facility's plan to correct the concerns and did not have additional recommendations. Interview on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, the South UM at 10:25 AM, the Director of Health I

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure medication carts were locked at all times when unattended, and all drugs and biologicals were labeled, dated, and stored securely in locked compartments. Observation on the South Hall on [DATE] revealed the medication cart was unlocked and unattended on the resident hall. Continued observation revealed a bottle of insulin and three (3) unlabeled, unidentified pills were in cups on top of the cart, accessible to any person who approached the cart. Interview with Registered Nurse (RN) #1 revealed after looking at the Narcotic Book to recall which residents she had signed pills out for, she identified the pills as narcotic pain medications intended for Residents #8, C, and D. Subsequent observation on [DATE] revealed the same medication cart on the South resident hall was again unlocked and unattended. In addition, observations revealed a medication cart was left unlocked and unattended at the North Hall nurses station on [DATE] and on the North Resident Hall on [DATE]. Also, observation of the refrigerator in the South Hall medication storage room on [DATE] revealed an opened multi-dose vial of Tubersol Purified Protein Derivative (PPD - used for TB skin testing) which was not labeled indicating the date the vial was opened. The facility's failure to have an effective system in place to ensure drugs and biological's were labeled appropriately and stored safely and securely in locked compartments has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of an E, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Medication Administration policy, dated 2007, revealed during administration of the medications, the medication cart was to be kept closed and locked when out of sight of the medication nurse, no medications were to be kept on top of the cart, and the cart must be clearly visible to the personnel administering medications when unlocked. Further review of the policy revealed when a multi-dose medication is first opened, the nurse should place a date opened sticker on the medication, and write the date it was opened. 1. Observation of the South Hall medication cart, on [DATE] at 5:07 PM, revealed it was left in the resident hall, unlocked and unattended. Continued observation of the medication cart revealed a bottle of insulin and three (3) unlabeled medication cups, each containing a single uncovered and unidentified pill, were lying on top of the cart. Further observation revealed RN #1 returned to the cart at 5:13 PM. RN #1 identified the pills as follows: an Oxycodone ,[DATE] milligram (mg) tablet signed out for Resident D; a Hydrocodone ,[DATE] mg tablet signed out to Resident C; and a Norco 7XXX,[DATE] mg tablet signed out to Resident #8. (Oxycodone, Hydrocodone and Norco are narcotic pain medications.) Interview with RN #1, on [DATE] at 5:13 PM, revealed she had left the cart unlocked and unattended while she assisted a resident who called out. She stated the cart was out of her sight while she was in the resident's room. RN #1 further stated she should have locked the cart before walking away, and should not have left narcotic medications on top of the cart and accessible to anyone who was in the area. Continued interview revealed it could have been dangerous if a resident other than the ones the medications were intended for had obtained them. Per interview, RN #1 stated she had been a nurse for twenty-four (24) years and had been trained on the facility's medication administration policy. Subsequent observation of the South Hall medication cart, on [DATE] at 2:45 PM, revealed it was again left unlocked and unattended on the resident hall. Continued observation revealed RN #1 returned to the cart at 2:50 PM. Interview with RN #1 at that time revealed she thought she had locked the cart before walking away. Interview with the South Hall Unit Manager, on [DATE] at 3:15 PM, revealed the medication carts should be kept locked when unattended and out of sight of the nurse, and medications should not be store on top of the medication cart. Observation of the North Hall nurses station, on [DATE] at 10:07 AM and on [DATE] at 8:00 AM, revealed the medication cart was unlocked and unattended. On [DATE], observation revealed LPN #1 returned to the cart at 8:05 AM. Interview with LPN #1 at that time revealed she had locked the cart prior to leaving it. She stated the cart lock had not worked about a week and a half ago, and had been serviced. She further stated if the lock was not engaged, anyone could access the medications by opening any of the drawers. Further interview revealed an unlocked medication cart was potentially dangerous if a resident ingested a medication which caused an adverse reaction. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 10:10 AM, revealed she was the Unit Manager for the North Hall. She stated the medication cart should not have been left unlocked and unattended, for reasons of resident safety. Interview with the Cart Maintenance Supervisor for the facility's contracted pharmacy, on [DATE] at 1:50 PM, revealed he had recently serviced the medication cart and thought it had been repaired until notified again on [DATE] by the facility. 2. Observation with the Unit Manager of the refrigerator in the South Hall medication room, on [DATE] at 2:45 PM, revealed one (1) opened and partially used multi-dose vial of Tubersol PPD, which was not labeled with the date when it was opened. Interview with the South Hall Unit Manager, on [DATE] at 3:15 PM, revealed upon opening a multi-dose medication vial, such as the PPD, nurses should indicate the date the medication was opened and the initials of the person who opened it. She stated without the date, it was impossible to know how long the medication had been open; therefore, it could not be determined when the solution expired and was no longer considered safe or effective for use. Interview with the Director of Nursing (DON), on [DATE] at 4:53 PM, revealed she expected nurses to ensure the medication carts were locked when not attended or out of their direct line of sight in order to to prevent resident and visitor access to the medications being stored in the medication cart. The DON further stated multi-dose medications were to be dated with the date they were opened so the nurses would know when to discard the medication. Interview with the Administrator, on [DATE] at 6:00 PM, revealed he expected nursing staff to ensure resident safety by making sure medication carts remained locked when not in use. Per interview, leaving the medication carts unlocked and unattended could cause harm to anyone who accessed the drugs in the cart. Continued interview revealed his expectation that all medications be labeled and stored securely according to the facility's Medication Administration Policy. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Regional Nurse Consultant educated the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UMs) regarding a safe environment for residents, medication storage, medication administration policy and procedure, and administering care to ensure the highest practical physical, mental and psychosocial well-being of each resident, and to maintain acceptable professional standards and practices. 2. On [DATE], the Director of Operations (DO) educated the Administrator, DON, SDC, Health Information Manager (HIM), Quality of Life Director, Social Services Director, Minimum Data Set (MDS) Nurse, Maintenance Director, Dietary Manager, Business Office Manager (BOM) and Regional Nurse Consultant on the facility's quality assurance (QA) process and policy. Administrative oversight of the facility would be completed by the Director of Operations or Designee weekly to ensure audit compliance until the removal of the Immediate Jeopardy. All audits would be presented at the weekly QA meeting. Any areas found to be out of compliance will result in actions including, but not limited to re-education, with disciplinary action up to and including termination. 3. On [DATE], the DON, SDC, and the UMs conducted walking round audits on both units (North Hall and South Hall) to ensure all medication carts, medication rooms, and treatment carts were locked and all medications, including narcotics, were secured. In addition, the DON and the SDC audited all medication carts to ensure medications were in the secured pharmacy packs. On [DATE], a locked cabinet was placed in each shower room for the purpose of storing cleaning supplies. To avoid cross contamination and infection control issues, the shower rooms will not be used for storing residents' personal items. On [DATE], a sign was placed in each shower room stating, No Storing of Personal Items. 4. On [DATE] at 6:30 PM, the SDC initiated mandatory in-services and post-tests to all licensed nurses regarding securing medication carts and medications, including narcotic medications. The proper securing of treatment carts was also addressed. In addition, the training included proper storage of germicidal items, residents' personal items, and hand sanitizer. Twenty-six (26) of the twenty-eight (28) licensed nurses employed by the facility were educated by [DATE]. The facility does not utilize agency staff or Kentucky Medication Aides. Nurses were also in-serviced on pre-filling medications and following the five (5) rights of medication administration. In addition, the in-service included the Kentucky Board of Nursing (KBN) Professional Standards of Practice regarding medication, medications carts, and proper storage of those medications. Also included in the mandatory in-service was the requirement to ensure the medications were under the direct observation of the person administering the medications, or were locked in the medication storage area/cart. Any licensed staff not educated by [DATE] would not be permitted to work until the in-service and post-test were completed. Furthermore, all licensed nurses will receive this training during new-hire orientation. On [DATE] at 6:30 PM, the SDC initiated mandatory in-services to all staff on handling and storage of chemicals and making sure resident personal care items are not stored in the shower rooms. No staff were permitted to work until the in-service and post-test were completed. Ninety-three (93) of one hundred one (101) stakeholders employed by the facility received the education and completed a post-test related to the storage of germicidal agents and personal care items in shower rooms. Any stakeholder that did not receive the educations by [DATE] was not permitted to work until they completed the training and post-test. Furthermore, the training topic was added for all staff to receive during new-hire orientation. 5. On [DATE], the DON, SDC, Weekend Supervisor, and UMs began daily audits, at random times on both units, six (6) times per day, to ensure medication carts were locked and all medications/narcotics were secured. In addition, daily audits of the shower rooms were initiated on [DATE], to be completed by the Administrator, DON, UMs, Weekend Supervisor, BOM, Assistant BOM (ABOM), Admissions Coordinator, HIM, Housekeeping Manager, Dietary Manager, Quality of Life Director, Social Services Director, MDS nurse, and the Maintenance Director. The audits were to be conducted six (6) times daily, at random times on both units, to ensure no residents' personal items were stored in the shower rooms, germicidal cleaners were locked in the cabinets in the shower rooms, and shower room doors were closed. 6. A QA meeting was held on [DATE] and [DATE]. In attendance were the Medical Director, Administrator, DON, SDC, HIM and a nurse. All audits were to be reviewed weekly in a QA meeting. 7. The Administrator and the DON were to function in a manner that enabled the use of effective and efficient resources to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Job Description and expectations of the Administrator's role were reviewed with the Administrator by the DO on [DATE]. The DO would hold weekly meetings with the Administrator and the DON to validate the facility's Allegation of Compliance. These weekly meeting will continue until the immediacy of jeopardy has been lifted. The Administrator and the DON received education on [DATE] from the DO regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. An additional ad hoc QAPI meeting was held via phone, on [DATE] with the Medical Director, Administrator, DON, SDC, HIM, and Regional Nurse Consultant. Discussion included the outcome of the recent survey and the issuance by the State Agency of the 2 additional IJ deficiencies related to QA and Administrative oversight. The audit tools and education were reviewed with the Medical Director, who had no further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the In-service Attendance Record, dated [DATE], revealed the Regional Nurse Consultant provided education to the administrative staff related to a safe environment for residents, medication storage. the medication administration policy, all to ensure the highest practical physical, mental, and psychosocial well-being of each resident and to maintain acceptable professional standards of practice. The in-service addressed storage of chemical agents in the shower room, a mandate that no residents' personal items would be stored in the shower room, and shower doors would remain closed. Interview with the Regional Nurse Consultant, on [DATE] at 2:05 PM, revealed she conducted the in-service for Administration on [DATE]. Interviews on [DATE] with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, the Director of Plant Operations at 4:45 PM, and on [DATE] with the North UM at 10:15 AM, the Weekend Supervisor at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM, and the Administrator at 1:35 PM, revealed all had received instruction from the Regional Nurse Consultant on [DATE] concerning a safe environment for residents, medication storage, the and the medication administration policy in order to maintain acceptable standards of practice. In addition, the in-service covered the storage of chemicals in the shower room, the prohibition against storing residents' personal items in the shower rooms, and the requirement to ensure the shower room doors were kept closed at all times. 2. Review of training records revealed the DO in-serviced the administrative team on the facility QAPI program on [DATE], and reviewed the AOC with the team on [DATE]. Review of the facility form titled Administrative Oversight completed by Director of Operations or Designee revealed the DO had signed for completing the oversight for the week of [DATE] through [DATE]. Interview with the DO, on [DATE] at 1:50 PM, revealed he reviewed the facility's QA process and provided training to the QAPI leadership team. Continued interview revealed he reviewed and provided oversight of the facility's implementation of the AOC weekly. Interviews on [DATE] with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on [DATE] with the North UM at 10:15 AM, RN #2 at 10:20 AM, South UM at 10:25 AM, Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed all attended the in-service conducted by the Regional Nurse Consultant on [DATE] and were trained on the QAPI process. Continued interview revealed the interviewees attended the weekly QAPI meetings on [DATE] and [DATE]. 3. Review of the facility's audit tool titled Med Cart Audit and Medication Package Audit revealed the DON and the UMs for both the South unit and the North unit, documented completion of initial rounds on [DATE] at 7:00 PM with observations that the medication carts were locked, all medications including narcotics were secured, and the treatment carts were locked and secured. Review of the facility audit tool titled Shower Room Audit revealed the DON and UMs for both units completed initial rounds on [DATE] at 7:00 PM with observations to ensure no residents' personal items left out, germicidal cleaners were locked in cabinets, and the shower room doors were closed. Observations on the South Unit on [DATE] at 9:15 AM, 9:42 AM, 11:40 AM, 11:43 AM, 4:01 PM, and 5:00 PM, and on [DATE] at 8:00 AM, of the South Unit revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Observations on the North Unit on [DATE] at 9:45 AM, 9:50 AM, 11:45 AM, 1:15 PM, 1:20 PM, 3:20 PM, and 5:05 PM, and on [DATE] at 8:11 AM, 9:52 AM and 11:16 AM, revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Interview with the South UM, on [DATE] at 10:25 AM, revealed she assisted with the initial tour of the South Unit medication carts and shower rooms on [DATE]. Interview with the North UM, on [DATE] at 10:25 AM, revealed she assisted with the initial tour of the North Unit medication carts and shower rooms on [DATE]. Interviews on [DATE] with the SDC at 1:05 PM, and the DON at 1:20 PM, revealed they assisted in walking rounds on [DATE], and observed all medications were secured and carts were locked, and all items in the shower rooms were secured. Interview with the Administrator, on [DATE] at 1:35 PM, revealed he purchased locking cabinets to hold chemical supplies for the two (2) shower rooms on [DATE], and placed signs in the shower rooms stating No Storing of Personal Items. 4. Review of the facility's mandatory training records revealed all licensed nurses were educated on [DATE] and [DATE] by the SDC related to the facility's medication policy, including the five rights of medication administration, and Standards of Practice. All nurses were in-serviced in person or by phone interview. Continued review revealed the training included a post-test to test staff understanding of the educational topics. Interviews on [DATE] with RN #3 at 8:00 AM, LPN #9 at 9:02 AM, RN #2 at 9:59 AM, LPN #9, LPN #1 10:00 AM, LPN #10 at 10:39 with, LPN #4 and 11:45 AM, and on [DATE] with LPN #12 at 7:00 AM, LPN #11 at 7:08 AM, LPN #3 at 7:11 AM, RN #4 at 7:15 AM, LPN #14 at 7:25 AM, LPN #13 at 7:30 AM, LPN #5 at 9:05 AM, and LPN #15 at 9:11 AM, revealed all had received in-service training by the SDC, in person or by phone interview, related to the facility's policy for medication administration, securing medications and ensuring carts were locked, and Standards of Practice for administration of medications. In addition, the nurses reported training included safe practices of never leaving medications unattended, and only preparing medications at the time of administration. The nurses further reported the training included safe storage of germicidal chemicals in the shower rooms, prohibition of storing resident personal items in the shower rooms, and keeping the shower room door closed. Continued interview revealed all completed a post-test to evaluate their understanding of the education. Interview further revealed the nursing staff could state correct administration practice and the five rights of medication administration (right medication, right dose, right time, right route and right resident). Further review of facility's mandatory in-service training records revealed all staff were educated by the SDC, with the assistance of the Administrator, DON, Unit Managers and Department Heads on [DATE] and [DATE] related to proper storage of germicidal agents, storage of residents' personal items, and ensuring the shower room doors were kept closed. In addition, the training records included completed post-tests to ensure staff understanding of the training topics. Interviews on [DATE] with State Registered Nursing Assistant (SRNA) #7 at 10:10 AM, SRNA #3 at 10:15 AM, SRNA #8 at 10:25 AM, SRNA #9 at 10:30 AM, SRNA #10 at 10:55 AM, SRNA #11 at 11:00 AM, SRNA #1 at 11:05 AM, SRNA #12 at 3:15 PM, SRNA #13 at 3:20 PM, SRNA #5 at 3:22 PM, SRNA #14 at 3:49 PM, and SRNA #4 at 3:52 PM, and on [DATE] with SRNA #18 at 7:20 AM, SRNA #16 at 7:21 AM, SRNA #15 at 7:30 AM, SRNA #17 at 8:00 AM, SRNA #19 at 8:05 AM, and SRNA #20 at 8:40 AM, revealed all were in-serviced on [DATE] or [DATE] concerning proper storage of germicidal agents and residents' personal items, and ensuring the shower room was kept closed at all times. Continued interview revealed they completed a post-test after the training. The staff further stated if they made any observations of items not stored correctly or the shower room door left open, they were to report immediately to the nurse on that unit. Interviews on [DATE] with Cook #1 at 3:50 PM, Cook #2/Assistant Manager at 4:00 PM, Dietary Aide #1 at 4:05 PM, Dietary Manager at 4:15 PM, and on [DATE] with Cook #4 at 8:45 AM, and with Cook #3 at 8:52 AM, revealed all were instructed by the SDC, Administrator and/or Dietary Manager concerning the proper storage of germicidal agents and residents' personal care items. In addition, the training included the requirement for shower room doors to be kept closed at all times. All interviewed reported completing a post-test after being educated. The interviewees further stated if they made any observations of items not stored correctly or the shower room doors open, they were to report immediately to the nurse on that unit. Interview with the Director of Plant Operations on [DATE] at 4:12 PM, and with the Assistant Director of Plant Operations on [DATE] at 7:40 AM, revealed they received training by the Administrator concerning proper storage of germicidal agents and residents' personal care items. Both reported they completed a post-test of their understanding of the education. Interview with Laundry Aide #1 on [DATE] at 4:55 PM, and with the Housekeeping Manager on [DATE] at 8:30 AM, revealed they were in-serviced by the Administrator related to proper storage of germicidal agents and residents' personal care items. Both reported they were required to complete a post-test after receiving the education to ensure their understanding of the topics. Interviews on [DATE] with the Social Worker at 9:39 AM, the Occupation Therapist at 10:21 AM, and with the Physical Therapist at 10:42 AM, revealed they had been trained by Administrator and the SDC regarding the proper storage of germicidal agents and residents' personal care items, and on the requirement for the shower room doors to be kept closed at all times. Those interviewed they completed a post-test. All stated if they made any observations of items not stored correctly, or a shower room door left open, they were to report immediately to the nurse on that unit. Interview with the ABOM, on [DATE] at 12:35 PM, revealed she was educated by the BOM concerning the proper storage of germicidal agents and residents' personal care items, and on observing to ensure the shower room doors were closed. She stated she completed a post-test related to the topics presented. Interview with the BOM, on [DATE] at 12:53 PM, revealed had educated the ABOM and administered the post-test. 5. Review of the facility's forms titled Every Shift Audit, Med Cart Checklist, and Shower Room Checklist revealed the audits were conducted six (6) times per day from [DATE] through [DATE]. The South and North unit audits included monitoring for locked medication carts, ensuring no medications were left on top of the carts, and ensuring all medications, including narcotics, were secured. In addition, the shower rooms were audited for proper storage of germicidal agents/chemicals in locked cabinets, no resident personal items stored in the shower rooms, and doors kept closed. Continued review of the audit forms revealed no concerns noted by staff during the daily rounds. Interview with the Director of Plant Operations on [DATE] at 4:45 PM, and with Maintenance Staff #1 on [DATE] at 7:40 AM, revealed they were assigned to observe the shower room doors throughout the day to ensure they were kept closed. Interview with the North UM, on [DATE] at 10:15 AM, revealed she checked the North medication cart and shower room six (6) times daily and documented on the audit form. Interview with the South UM, on [DATE] at 10:25 AM, revealed she checked the South medication cart and the shower room six (6) times daily and documented on the audit form. Interview with the RN Weekend Supervisor, on [DATE] at 10:20 AM, revealed she checked the medication carts and shower rooms six (6) times daily on both units over the weekend. Interview on [DATE] with the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, and the SDC at 1:05 PM, revealed all assisted with daily rounds to ensure medication carts were locked, no medications were left unsecured, and shower room doors were kept closed. Interview with the DON, on [DATE] at 1:20 PM, revealed she checked the audit sheets daily to ensure they were complete. She stated she continued to make random checks of the medication carts and the shower rooms. Interview with the Administrator, on [DATE] at 1:35 PM, revealed he reviewed the audit forms for completeness and to identify any continued concerns related to the medication carts/medication security and the shower rooms. 6. Review of the attendance record revealed the ad hoc QAPI meeting on [DATE] was attended by the Administrator, DON, SDC, South UM, and the Director of Health Information. Continued review revealed the Medical Director was present by phone. Interviews on [DATE] with the SDC at 3:31 PM, and on [DATE] with the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they attended an ad hoc QAPI meeting on [DATE], with the Medical Director present by phone. Continued interview they also attended a meeting on [DATE] to discuss the concerns identified during the State Agency survey. All those interviewed reported a discussion related to the Immediate Jeopardy and removing the immediacy, and more discussion related to deficiencies regarding Administration. Interview with the Medical Director, on [DATE] at 11:07 AM, revealed he was contacted by the facility on [DATE] and on [DATE] to discuss the Immediate Jeopardy related to unlocked and unattended medication carts, and narcotics left unsecured on top of the cart. Continued interview revealed the second call was a concentration on the Administrative deficiencies. He stated he was in agreement with the facility's plan to correct the concerns and did not have additional recommendations. Interview on [DATE] with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on [DATE] with the North UM at 10:15 AM, RN #2 at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they have been active in all QAPI process meetings and activities since the Immediate Jeopardy was called. 7. Interview with the DO, on [DATE] at 1:50 PM, revealed he conducted a training session on [DATE] with the Administrator and the DON regarding their job descriptions. Interview with the DON, on [DATE] at 1:20 PM, revealed she met with the DO on [DATE] to discuss her job description and responsibilities. Interview with the Administrator, on [DATE] at 1:35 PM, revealed he met with the DO to review his job description and the expectations for his role in the facility.

Based on observation, interview, record review, review of the Administrator's Job Description, review of the facility's Plan of Correction for the 04/07/16 Standard Survey, and review of the facility's policies and procedures, it was determined the facility's Administration failed to have an effective system in place to ensure the facility was administered effectively to ensure identified deficiencies were corrected. (Refer to F431 and F441) Observations on 03/14/17, 03/15/17 and 03/16/17 revealed medication carts were left unlocked and unattended in the nurses' station and on the resident halls. In addition, on 03/14/17, unlabeled and unidentified narcotic pain medications and a bottle of insulin were left on top of the cart, accessible to any resident who approached the unsecured cart. Also, observation of the refrigerator in the South Hall medication storage room on 03/16/17 revealed an open multi-dose vial of [MEDICATION NAME] Purified Protein Derivative (PPD - used for TB skin testing) which was not labeled indicating the date the vial was opened. Observations on both the North Hall and the South Hall during the initial facility tour on 03/14/17 revealed infection control concerns related to multiple unbagged and unlabeled resident items stored in shared bathrooms with the potential to adversely affect residents by cross-contamination in eight (8) resident rooms. The facility's failure to have an effective Administrative system in place to ensure the facility's policies were implemented, and the Plan of Correction for identified deficiencies was effective, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 03/15/17 and determined to exist on 03/14/17. The facility was notified of the Immediate Jeopardy on 03/15/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 alleging removal of the Immediate Jeopardy on 03/17/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/22/17, prior to exit on 03/22/17, with remaining non-compliance at a Scope and Severity of an E, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Administrator, dated December 2011, revealed it was the Administrator's job to direct the overall operations of the facility in accordance with government regulations and company policies. Continued review revealed the Administrator would verify that the building and grounds were maintained appropriately and that equipment and work areas were clean, safe and orderly, and any hazardous conditions were addressed. Further review revealed he was to oversee regular rounds to monitor delivery of nursing care. Review of the facility's Accident Prevention policy, dated January 2005, revealed employees were responsible for ensuring the work environment was safe and accident-free. Review of the facility's Medication Administration policy, dated 2007, revealed the medication cart was to be kept closed and locked when out of sight of the medication nurse, no medications were to be kept on top of the cart, and the cart must be clearly visible to the personnel administering medications when unlocked. 1. Review of the Plan of Correction for F431 for the Standard Survey of 04/07/16 revealed actions to be implemented to correct the cited deficiency included re-education of all licensed nursing staff related to storage and labeling of medications and QA audits of the medication carts and storage rooms. Observation on 03/14/17 revealed the South Hall medication cart was unlocked and no staff were in the vicinity. A bottle of insulin and three (3) unidentified pills were on top of the cart and accessible to any resident who approached the cart. In addition, on 03/15/17, the medication cart was again unlocked and unattended on the South resident hall. Furthermore, the North Hall medication cart was observed to be unlocked and unattended in the nurses' station on 03/14/17, and unlocked and unattended on the North resident hall on 03/16/17. Interview with Registered Nurse #1, on 03/14/17 at 5:13 PM, revealed she had been trained on the proper handling, labeling and storage of medications. She acknowledged she should not have left the medications unsecured on top of the cart, and should have locked the cart before she walked away. Interview with the Staff Development Coordinator (SDC), on 03/16/17 at 11:08 AM, revealed she could not explain how the facility's POC had failed. She stated as part of the Management Team, she had been involved in staff education and audits to ensure compliance. She further stated in the past ten (10) months, she had only had to re-educate staff maybe once or twice when a medication cart was found unlocked. Continued interview revealed the Administrator had occasionally told the SDC he had found a medication cart unlocked and had re-educated the nurse responsible at the time. The SDC reported the on-the-spot education that was provided was not documented in education records. Interview with the Director of Nursing (DON), on 03/16/17 at 5:43 PM, revealed she and the Unit Managers (UMs) had educated the nursing staff on medication administration, medication storage, and proper destruction of medications. She stated no ongoing concerns were identified based on periodic audits related to the deficient practice, and she could not say how the system had failed. Continued interview revealed any discrepancies noted on audit were handled individually with the staff responsible at the time. No documented evidence was provided related to any individual training or competencies. 2. Review of the Plan of Correction for F441 Infection Control, dated 04/07/16, revealed the facility's QA plan included re-education of all staff related to proper labeling and storage of personal items, and audits by administrative staff to ensure the plan was implemented effectively. Observations on both the North Hall and the South Hall during the initial facility tour on 03/14/17 revealed repeated infection control concerns in shared resident bathrooms, related to unlabeled and unbagged bedpans, bathpans, and toothbrush, with the potential for cross-contamination affecting residents in eight (8) rooms. Interview with the Administrator, on 03/16/17 at 6:00 PM, revealed he did not know why the facility's system had failed. He stated the nursing staff had been educated on medication administration and storage, and audits of the medication carts and storage rooms were ongoing. He stated he had been involved in writing the POC for the 04/07/16 survey, and had heard audit results presented at monthly QAPI meetings. Additional interview revealed the Administrator was responsible for ensuring the POC was effective, but had not become aware of any ongoing concerns which warranted a revision of the plan. Continued interview revealed the facility's action plan would have to be re-evaluated and revised, based on the findings of the State Agency. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/17/17. Review of the AOC revealed the facility implemented the following: 1. On 03/15/17, the Regional Nurse Consultant educated the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UMs) regarding a safe environment for residents, medication storage, medication administration policy and procedure, and administering care to ensure the highest practical physical, mental and psychosocial well-being of each resident, and to maintain acceptable professional standards and practices. 2. On 03/16/17, the Director of Operations (DO) educated the Administrator, DON, SDC, Health Information Manager (HIM), Quality of Life Director, Social Services Director, Minimum Data Set (MDS) Nurse, Maintenance Director, Dietary Manager, Business Office Manager (BOM) and Regional Nurse Consultant on the facility's quality assurance (QA) process and policy. Administrative oversight of the facility would be completed by the Director of Operations or Designee weekly to ensure audit compliance until the removal of the Immediate Jeopardy. All audits would be presented at the weekly QA meeting. Any areas found to be out of compliance will result in actions including, but not limited to re-education, with disciplinary action up to and including termination. 3. On 03/15/17, the DON, SDC, and the UMs conducted walking round audits on both units (North Hall and South Hall) to ensure all medication carts, medication rooms, and treatment carts were locked and all medications, including narcotics, were secured. In addition, the DON and the SDC audited all medication carts to ensure medications were in the secured pharmacy packs. On 03/15/17, a locked cabinet was placed in each shower room for the purpose of storing cleaning supplies. To avoid cross contamination and infection control issues, the shower rooms will not be used for storing residents' personal items. On 03/16/17, a sign was placed in each shower room stating, No Storing of Personal Items. 4. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services and post-tests to all licensed nurses regarding securing medication carts and medications, including narcotic medications. The proper securing of treatment carts was also addressed. In addition, the training included proper storage of germicidal items, residents' personal items, and hand sanitizer. Twenty-six (26) of the twenty-eight (28) licensed nurses employed by the facility were educated by 03/16/17. The facility does not utilize agency staff or Kentucky Medication Aides. Nurses were also in-serviced on pre-filling medications and following the five (5) rights of medication administration. In addition, the in-service included the Kentucky Board of Nursing (KBN) Professional Standards of Practice regarding medication, medications carts, and proper storage of those medications. Also included in the mandatory in-service was the requirement to ensure the medications were under the direct observation of the person administering the medications, or were locked in the medication storage area/cart. Any licensed staff not educated by 03/16/17 would not be permitted to work until the in-service and post-test were completed. Furthermore, all licensed nurses will receive this training during new-hire orientation. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services to all staff on handling and storage of chemicals and making sure resident personal care items are not stored in the shower rooms. No staff were permitted to work until the in-service and post-test were completed. Ninety-three (93) of one hundred one (101) stakeholders employed by the facility received the education and completed a post-test related to the storage of germicidal agents and personal care items in shower rooms. Any stakeholder that did not receive the educations by 03/16/17 was not permitted to work until they completed the training and post-test. Furthermore, the training topic was added for all staff to receive during new-hire orientation. 5. On 03/15/17, the DON, SDC, Weekend Supervisor, and UMs began daily audits, at random times on both units, six (6) times per day, to ensure medication carts were locked and all medications/narcotics were secured. In addition, daily audits of the shower rooms were initiated on 03/15/17, to be completed by the Administrator, DON, UMs, Weekend Supervisor, BOM, Assistant BOM (ABOM), Admissions Coordinator, HIM, Housekeeping Manager, Dietary Manager, Quality of Life Director, Social Services Director, MDS nurse, and the Maintenance Director. The audits were to be conducted six (6) times daily, at random times on both units, to ensure no residents' personal items were stored in the shower rooms, germicidal cleaners were locked in the cabinets in the shower rooms, and shower room doors were closed. 6. A QA meeting was held on 03/15/17 and 03/16/17. In attendance were the Medical Director, Administrator, DON, SDC, HIM and a nurse. All audits were to be reviewed weekly in a QA meeting. 7. The Administrator and the DON were to function in a manner that enabled the use of effective and efficient resources to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Job Description and expectations of the Administrator's role were reviewed with the Administrator by the DO on 03/16/17. The DO would hold weekly meetings with the Administrator and the DON to validate the facility's Allegation of Compliance. These weekly meeting will continue until the immediacy of jeopardy has been lifted. The Administrator and the DON received education on 03/16/17 from the DO regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. An additional ad hoc QAPI meeting was held via phone, on 03/16/17 with the Medical Director, Administrator, DON, SDC, HIM, and Regional Nurse Consultant. Discussion included the outcome of the recent survey and the issuance by the State Agency of the 2 additional IJ deficiencies related to QA and Administrative oversight. The audit tools and education were reviewed with the Medical Director, who had no further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the In-service Attendance Record, dated 03/15/17, revealed the Regional Nurse Consultant provided education to the administrative staff related to a safe environment for residents, medication storage. the medication administration policy, all to ensure the highest practical physical, mental, and psychosocial well-being of each resident and to maintain acceptable professional standards of practice. The in-service addressed storage of chemical agents in the shower room, a mandate that no residents' personal items would be stored in the shower room, and shower doors would remain closed. Interview with the Regional Nurse Consultant, on 03/22/17 at 2:05 PM, revealed she conducted the in-service for Administration on 03/15/17. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, the Weekend Supervisor at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM, and the Administrator at 1:35 PM, revealed all had received instruction from the Regional Nurse Consultant on 03/15/17 concerning a safe environment for residents, medication storage, the and the medication administration policy in order to maintain acceptable standards of practice. In addition, the in-service covered the storage of chemicals in the shower room, the prohibition against storing residents' personal items in the shower rooms, and the requirement to ensure the shower room doors were kept closed at all times. 2. Review of training records revealed the DO in-serviced the administrative team on the facility QAPI program on 03/16/17, and reviewed the AOC with the team on 03/17/17. Review of the facility form titled Administrative Oversight completed by Director of Operations or Designee revealed the DO had signed for completing the oversight for the week of 03/13/17 through 03/17/17. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he reviewed the facility's QA process and provided training to the QAPI leadership team. Continued interview revealed he reviewed and provided oversight of the facility's implementation of the AOC weekly. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, South UM at 10:25 AM, Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed all attended the in-service conducted by the Regional Nurse Consultant on 03/15/17 and were trained on the QAPI process. Continued interview revealed the interviewees attended the weekly QAPI meetings on 03/15/17 and 03/22/17. 3. Review of the facility's audit tool titled Med Cart Audit and Medication Package Audit revealed the DON and the UMs for both the South unit and the North unit, documented completion of initial rounds on 03/15/17 at 7:00 PM with observations that the medication carts were locked, all medications including narcotics were secured, and the treatment carts were locked and secured. Review of the facility audit tool titled Shower Room Audit revealed the DON and UMs for both units completed initial rounds on 03/15/17 at 7:00 PM with observations to ensure no residents' personal items left out, germicidal cleaners were locked in cabinets, and the shower room doors were closed. Observations on the South Unit on 03/21/17 at 9:15 AM, 9:42 AM, 11:40 AM, 11:43 AM, 4:01 PM, and 5:00 PM, and on 03/22/17 at 8:00 AM, of the South Unit revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Observations on the North Unit on 03/21/17 at 9:45 AM, 9:50 AM, 11:45 AM, 1:15 PM, 1:20 PM, 3:20 PM, and 5:05 PM, and on 03/22/17 at 8:11 AM, 9:52 AM and 11:16 AM, revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the South Unit medication carts and shower rooms on 03/15/17. Interview with the North UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the North Unit medication carts and shower rooms on 03/15/17. Interviews on 03/22/17 with the SDC at 1:05 PM, and the DON at 1:20 PM, revealed they assisted in walking rounds on 03/15/17, and observed all medications were secured and carts were locked, and all items in the shower rooms were secured. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he purchased locking cabinets to hold chemical supplies for the two (2) shower rooms on 03/15/17, and placed signs in the shower rooms stating No Storing of Personal Items. 4. Review of the facility's mandatory training records revealed all licensed nurses were educated on 03/15/17 and 03/16/17 by the SDC related to the facility's medication policy, including the five rights of medication administration, and Standards of Practice. All nurses were in-serviced in person or by phone interview. Continued review revealed the training included a post-test to test staff understanding of the educational topics. Interviews on 03/21/17 with RN #3 at 8:00 AM, LPN #9 at 9:02 AM, RN #2 at 9:59 AM, LPN #9, LPN #1 10:00 AM, LPN #10 at 10:39 with, LPN #4 and 11:45 AM, and on 03/22/17 with LPN #12 at 7:00 AM, LPN #11 at 7:08 AM, LPN #3 at 7:11 AM, RN #4 at 7:15 AM, LPN #14 at 7:25 AM, LPN #13 at 7:30 AM, LPN #5 at 9:05 AM, and LPN #15 at 9:11 AM, revealed all had received in-service training by the SDC, in person or by phone interview, related to the facility's policy for medication administration, securing medications and ensuring carts were locked, and Standards of Practice for administration of medications. In addition, the nurses reported training included safe practices of never leaving medications unattended, and only preparing medications at the time of administration. The nurses further reported the training included safe storage of germicidal chemicals in the shower rooms, prohibition of storing resident personal items in the shower rooms, and keeping the shower room door closed. Continued interview revealed all completed a post-test to evaluate their understanding of the education. Interview further revealed the nursing staff could state correct administration practice and the five rights of medication administration (right medication, right dose, right time, right route and right resident). Further review of facility's mandatory in-service training records revealed all staff were educated by the SDC, with the assistance of the Administrator, DON, Unit Managers and Department Heads on 03/15/17 and 03/16/17 related to proper storage of germicidal agents, storage of residents' personal items, and ensuring the shower room doors were kept closed. In addition, the training records included completed post-tests to ensure staff understanding of the training topics. Interviews on 03/21/17 with State Registered Nursing Assistant (SRNA) #7 at 10:10 AM, SRNA #3 at 10:15 AM, SRNA #8 at 10:25 AM, SRNA #9 at 10:30 AM, SRNA #10 at 10:55 AM, SRNA #11 at 11:00 AM, SRNA #1 at 11:05 AM, SRNA #12 at 3:15 PM, SRNA #13 at 3:20 PM, SRNA #5 at 3:22 PM, SRNA #14 at 3:49 PM, and SRNA #4 at 3:52 PM, and on 03/22/17 with SRNA #18 at 7:20 AM, SRNA #16 at 7:21 AM, SRNA #15 at 7:30 AM, SRNA #17 at 8:00 AM, SRNA #19 at 8:05 AM, and SRNA #20 at 8:40 AM, revealed all were in-serviced on 03/15/17 or 03/16/17 concerning proper storage of germicidal agents and residents' personal items, and ensuring the shower room was kept closed at all times. Continued interview revealed they completed a post-test after the training. The staff further stated if they made any observations of items not stored correctly or the shower room door left open, they were to report immediately to the nurse on that unit. Interviews on 03/21/17 with Cook #1 at 3:50 PM, Cook #2/Assistant Manager at 4:00 PM, Dietary Aide #1 at 4:05 PM, Dietary Manager at 4:15 PM, and on 03/22/17 with Cook #4 at 8:45 AM, and with Cook #3 at 8:52 AM, revealed all were instructed by the SDC, Administrator and/or Dietary Manager concerning the proper storage of germicidal agents and residents' personal care items. In addition, the training included the requirement for shower room doors to be kept closed at all times. All interviewed reported completing a post-test after being educated. The interviewees further stated if they made any observations of items not stored correctly or the shower room doors open, they were to report immediately to the nurse on that unit. Interview with the Director of Plant Operations on 03/21/17 at 4:12 PM, and with the Assistant Director of Plant Operations on 03/22/17 at 7:40 AM, revealed they received training by the Administrator concerning proper storage of germicidal agents and residents' personal care items. Both reported they completed a post-test of their understanding of the education. Interview with Laundry Aide #1 on 03/21/17 at 4:55 PM, and with the Housekeeping Manager on 03/22/17 at 8:30 AM, revealed they were in-serviced by the Administrator related to proper storage of germicidal agents and residents' personal care items. Both reported they were required to complete a post-test after receiving the education to ensure their understanding of the topics. Interviews on 03/22/17 with the Social Worker at 9:39 AM, the Occupation Therapist at 10:21 AM, and with the Physical Therapist at 10:42 AM, revealed they had been trained by Administrator and the SDC regarding the proper storage of germicidal agents and residents' personal care items, and on the requirement for the shower room doors to be kept closed at all times. Those interviewed they completed a post-test. All stated if they made any observations of items not stored correctly, or a shower room door left open, they were to report immediately to the nurse on that unit. Interview with the ABOM, on 03/22/17 at 12:35 PM, revealed she was educated by the BOM concerning the proper storage of germicidal agents and residents' personal care items, and on observing to ensure the shower room doors were closed. She stated she completed a post-test related to the topics presented. Interview with the BOM, on 03/22/17 at 12:53 PM, revealed had educated the ABOM and administered the post-test. 5. Review of the facility's forms titled Every Shift Audit, Med Cart Checklist, and Shower Room Checklist revealed the audits were conducted six (6) times per day from 03/16/17 through 03/21/17. The South and North unit audits included monitoring for locked medication carts, ensuring no medications were left on top of the carts, and ensuring all medications, including narcotics, were secured. In addition, the shower rooms were audited for proper storage of germicidal agents/chemicals in locked cabinets, no resident personal items stored in the shower rooms, and doors kept closed. Continued review of the audit forms revealed no concerns noted by staff during the daily rounds. Interview with the Director of Plant Operations on 03/21/17 at 4:45 PM, and with Maintenance Staff #1 on 03/22/17 at 7:40 AM, revealed they were assigned to observe the shower room doors throughout the day to ensure they were kept closed. Interview with the North UM, on 03/22/17 at 10:15 AM, revealed she checked the North medication cart and shower room six (6) times daily and documented on the audit form. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she checked the South medication cart and the shower room six (6) times daily and documented on the audit form. Interview with the RN Weekend Supervisor, on 03/22/17 at 10:20 AM, revealed she checked the medication carts and shower rooms six (6) times daily on both units over the weekend. Interview on 03/22/17 with the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, and the SDC at 1:05 PM, revealed all assisted with daily rounds to ensure medication carts were locked, no medications were left unsecured, and shower room doors were kept closed. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she checked the audit sheets daily to ensure they were complete. She stated she continued to make random checks of the medication carts and the shower rooms. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he reviewed the audit forms for completeness and to identify any continued concerns related to the medication carts/medication security and the shower rooms. 6. Review of the attendance record revealed the ad hoc QAPI meeting on 03/15/17 was attended by the Administrator, DON, SDC, South UM, and the Director of Health Information. Continued review revealed the Medical Director was present by phone. Interviews on 03/21/17 with the SDC at 3:31 PM, and on 03/22/17 with the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they attended an ad hoc QAPI meeting on 03/15/17, with the Medical Director present by phone. Continued interview they also attended a meeting on 03/16/17 to discuss the concerns identified during the State Agency survey. All those interviewed reported a discussion related to the Immediate Jeopardy and removing the immediacy, and more discussion related to deficiencies regarding Administration. Interview with the Medical Director, on 03/22/17 at 11:07 AM, revealed he was contacted by the facility on 03/15/17 and on 03/16/17 to discuss the Immediate Jeopardy related to unlocked and unattended medication carts, and narcotics left unsecured on top of the cart. Continued interview revealed the second call was a concentration on the Administrative deficiencies. He stated he was in agreement with the facility's plan to correct the concerns and did not have additional recommendations. Interview on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they have been active in all QAPI process meetings and activities since the Immediate Jeopardy was called. 7. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he conducted a training session on 03/16/17 with the Administrator and the DON regarding their job descriptions. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she met with the DO on 03/16/17 to discuss her job description and responsibilities. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he met with the DO to review his job description and the expectations for his role in the facility.

Based on observation, interview, record review, and review of the facility's policies and the facility's Plan of Correction (POC) for the Recertification Survey of 04/07/16, it was determined the facility's Quality Assurance (QA) Program failed to develop an effective plan of action for deficiencies identified, as evidenced by repeat deficiencies related to unsecured and improperly labeled medications. (Refer to F431) Observation revealed the medication cart was unlocked and unattended on the South resident hall on 03/14/17. Continued observation revealed a bottle of insulin and three (3) unlabeled, unidentified pills were in cups on top of the cart, accessible to any resident or other unauthorized person who was in the vicinity of the cart. When Registered Nurse (RN) #1 returned to the cart, she identified the pills as narcotic pain medications for specific residents, but only after looking in the Narcotic Book to recall who she had signed medications out for. Furthermore, the South Hall medication cart was again unlocked and unattended on the resident hall on 03/15/17. Also, observations revealed a medication cart was left unlocked and unattended at the North Hall nurses station on 03/14/17 and on the North Resident Hall on 03/16/17. In addition, repeat deficiencies were identified related to infection control when the facility failed to ensure resident items with the potential for cross-contamination were properly labeled and stored. (Refer to F441) The facility's failure to have an effective system in place to maintain an effective Quality Assurance (QA) Program that was structured to identify quality issues with the potential for negatively affecting residents, and to develop and implement appropriate plans to correct identified deficient practices has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 03/15/17 and determined to exist on 03/14/17. The facility was notified of the Immediate Jeopardy on 03/15/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 alleging removal of the Immediate Jeopardy on 03/17/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/22/17, prior to exit on 03/22/17, with remaining non-compliance at a Scope and Severity of an E, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Administrator, dated December 2011, revealed it was the Administrator's job to direct the overall operations of the facility in accordance with government regulations and company policies, and he was responsible for the facility's QA Program. Review of the Quality Assurance Performance Improvement (QAPI) Plan, not dated, revealed it was the intent of the facility to conduct an ongoing QAPI program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. Continued review revealed sources used to address areas of concern included State Agency survey results. Further review revealed the QAPI program was responsible for designing and implementing corrective action plans as needed to resolve resident care/service problems. Review of the Plan of Correction for F431 for the Standard Survey of 04/07/16 revealed the facility would audit the medication cart and medication rooms twice weekly times four (4) weeks, then monthly ongoing to ensure there were no undated or expired medications. Additionally, the facility would complete six (6) observations of medication administration weekly times three (3) weeks, then once a week for three (3) weeks to ensure medications were administered according to facility policy. Further review revealed the Quality Assessment/Process Improvement (QAPI) Committee, including the Administrator, would review audit results at monthly meetings and make revisions to the plan as indicated. Observation, on 03/14/17 at 5:07 PM, revealed the medication cart on the South resident hall was unlocked and unattended, and a bottle of insulin and three (3) unidentified pills were on top of the cart and accessible to any resident who approached the cart. Subsequent observation, on 03/15/17 at 2:45 PM, revealed the medication cart was again unlocked and unattended on the South resident hall. In addition, the North Hall medication cart was observed to be unlocked and unattended in the nurses' station on 03/14/17, and again observed unlocked and unattended on the North resident hall on 03/16/17. Review of the Plan of Correction for F441 Infection Control, for the standard survey conducted on 04/07/16, revealed the facility's QA plan included the following: re-education of all staff related to proper labeling and storage of personal items; and audits by administrative staff to ensure the plan was implemented effectively. Continued review revealed the Unit Managers would do a daily room round for two (2) week, then once weekly for ten (10) weeks to ensure all toothbrushes, bedpans and urinals were labeled and bagged appropriately. Observations on the North and South Halls during the initial facility tour on 03/14/17 revealed infection control concerns in shared resident bathrooms, including unlabeled and unbagged bedpans, bathpans, a bedside commode bucket, a Continuous Passive Motion (CPM) Device and a toothbrush. These items had the potential to cause cross-contamination affecting residents in eight (8) rooms. Interview with the Director of Nursing, on 03/16/17 at 5:43 PM, revealed she did not know why the facility's QA program had failed in these areas. Per interview, audits for effectiveness of the POC were ongoing and the DON stated the team had not identified a continuing problem. She stated the audits included observations of the medications carts and storage rooms, and opened medications for dates. She further stated the SDC conducted audits of equipment in resident rooms and had not identified an ongoing problem. Interview with the Administrator, on 03/16/17 at 6:00 PM, revealed he did not know why the QA process failed. He stated ongoing audits for effectiveness of the POC had not identified any continued problems. Per interview, had he been made aware of any concerns based on audit results, he would have re-evaluated and revised the QA process to address them. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/17/17. Review of the AOC revealed the facility implemented the following: 1. On 03/15/17, the Regional Nurse Consultant educated the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UMs) regarding a safe environment for residents, medication storage, medication administration policy and procedure, and administering care to ensure the highest practical physical, mental and psychosocial well-being of each resident, and to maintain acceptable professional standards and practices. 2. On 03/16/17, the Director of Operations (DO) educated the Administrator, DON, SDC, Health Information Manager (HIM), Quality of Life Director, Social Services Director, Minimum Data Set (MDS) Nurse, Maintenance Director, Dietary Manager, Business Office Manager (BOM) and Regional Nurse Consultant on the facility's quality assurance (QA) process and policy. Administrative oversight of the facility would be completed by the Director of Operations or Designee weekly to ensure audit compliance until the removal of the Immediate Jeopardy. All audits would be presented at the weekly QA meeting. Any areas found to be out of compliance will result in actions including, but not limited to re-education, with disciplinary action up to and including termination. 3. On 03/15/17, the DON, SDC, and the UMs conducted walking round audits on both units (North Hall and South Hall) to ensure all medication carts, medication rooms, and treatment carts were locked and all medications, including narcotics, were secured. In addition, the DON and the SDC audited all medication carts to ensure medications were in the secured pharmacy packs. On 03/15/17, a locked cabinet was placed in each shower room for the purpose of storing cleaning supplies. To avoid cross contamination and infection control issues, the shower rooms will not be used for storing residents' personal items. On 03/16/17, a sign was placed in each shower room stating, No Storing of Personal Items. 4. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services and post-tests to all licensed nurses regarding securing medication carts and medications, including narcotic medications. The proper securing of treatment carts was also addressed. In addition, the training included proper storage of germicidal items, residents' personal items, and hand sanitizer. Twenty-six (26) of the twenty-eight (28) licensed nurses employed by the facility were educated by 03/16/17. The facility does not utilize agency staff or Kentucky Medication Aides. Nurses were also in-serviced on pre-filling medications and following the five (5) rights of medication administration. In addition, the in-service included the Kentucky Board of Nursing (KBN) Professional Standards of Practice regarding medication, medications carts, and proper storage of those medications. Also included in the mandatory in-service was the requirement to ensure the medications were under the direct observation of the person administering the medications, or were locked in the medication storage area/cart. Any licensed staff not educated by 03/16/17 would not be permitted to work until the in-service and post-test were completed. Furthermore, all licensed nurses will receive this training during new-hire orientation. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services to all staff on handling and storage of chemicals and making sure resident personal care items are not stored in the shower rooms. No staff were permitted to work until the in-service and post-test were completed. Ninety-three (93) of one hundred one (101) stakeholders employed by the facility received the education and completed a post-test related to the storage of germicidal agents and personal care items in shower rooms. Any stakeholder that did not receive the educations by 03/16/17 was not permitted to work until they completed the training and post-test. Furthermore, the training topic was added for all staff to receive during new-hire orientation. 5. On 03/15/17, the DON, SDC, Weekend Supervisor, and UMs began daily audits, at random times on both units, six (6) times per day, to ensure medication carts were locked and all medications/narcotics were secured. In addition, daily audits of the shower rooms were initiated on 03/15/17, to be completed by the Administrator, DON, UMs, Weekend Supervisor, BOM, Assistant BOM (ABOM), Admissions Coordinator, HIM, Housekeeping Manager, Dietary Manager, Quality of Life Director, Social Services Director, MDS nurse, and the Maintenance Director. The audits were to be conducted six (6) times daily, at random times on both units, to ensure no residents' personal items were stored in the shower rooms, germicidal cleaners were locked in the cabinets in the shower rooms, and shower room doors were closed. 6. A QA meeting was held on 03/15/17 and 03/16/17. In attendance were the Medical Director, Administrator, DON, SDC, HIM and a nurse. All audits were to be reviewed weekly in a QA meeting. 7. The Administrator and the DON were to function in a manner that enabled the use of effective and efficient resources to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Job Description and expectations of the Administrator's role were reviewed with the Administrator by the DO on 03/16/17. The DO would hold weekly meetings with the Administrator and the DON to validate the facility's Allegation of Compliance. These weekly meeting will continue until the immediacy of jeopardy has been lifted. The Administrator and the DON received education on 03/16/17 from the DO regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. An additional ad hoc QAPI meeting was held via phone, on 03/16/17 with the Medical Director, Administrator, DON, SDC, HIM, and Regional Nurse Consultant. Discussion included the outcome of the recent survey and the issuance by the State Agency of the 2 additional IJ deficiencies related to QA and Administrative oversight. The audit tools and education were reviewed with the Medical Director, who had no further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the In-service Attendance Record, dated 03/15/17, revealed the Regional Nurse Consultant provided education to the administrative staff related to a safe environment for residents, medication storage. the medication administration policy, all to ensure the highest practical physical, mental, and psychosocial well-being of each resident and to maintain acceptable professional standards of practice. The in-service addressed storage of chemical agents in the shower room, a mandate that no residents' personal items would be stored in the shower room, and shower doors would remain closed. Interview with the Regional Nurse Consultant, on 03/22/17 at 2:05 PM, revealed she conducted the in-service for Administration on 03/15/17. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, the Weekend Supervisor at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM, and the Administrator at 1:35 PM, revealed all had received instruction from the Regional Nurse Consultant on 03/15/17 concerning a safe environment for residents, medication storage, the and the medication administration policy in order to maintain acceptable standards of practice. In addition, the in-service covered the storage of chemicals in the shower room, the prohibition against storing residents' personal items in the shower rooms, and the requirement to ensure the shower room doors were kept closed at all times. 2. Review of training records revealed the DO in-serviced the administrative team on the facility QAPI program on 03/16/17, and reviewed the AOC with the team on 03/17/17. Review of the facility form titled Administrative Oversight completed by Director of Operations or Designee revealed the DO had signed for completing the oversight for the week of 03/13/17 through 03/17/17. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he reviewed the facility's QA process and provided training to the QAPI leadership team. Continued interview revealed he reviewed and provided oversight of the facility's implementation of the AOC weekly. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, South UM at 10:25 AM, Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed all attended the in-service conducted by the Regional Nurse Consultant on 03/15/17 and were trained on the QAPI process. Continued interview revealed the interviewees attended the weekly QAPI meetings on 03/15/17 and 03/22/17. 3. Review of the facility's audit tool titled Med Cart Audit and Medication Package Audit revealed the DON and the UMs for both the South unit and the North unit, documented completion of initial rounds on 03/15/17 at 7:00 PM with observations that the medication carts were locked, all medications including narcotics were secured, and the treatment carts were locked and secured. Review of the facility audit tool titled Shower Room Audit revealed the DON and UMs for both units completed initial rounds on 03/15/17 at 7:00 PM with observations to ensure no residents' personal items left out, germicidal cleaners were locked in cabinets, and the shower room doors were closed. Observations on the South Unit on 03/21/17 at 9:15 AM, 9:42 AM, 11:40 AM, 11:43 AM, 4:01 PM, and 5:00 PM, and on 03/22/17 at 8:00 AM, of the South Unit revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Observations on the North Unit on 03/21/17 at 9:45 AM, 9:50 AM, 11:45 AM, 1:15 PM, 1:20 PM, 3:20 PM, and 5:05 PM, and on 03/22/17 at 8:11 AM, 9:52 AM and 11:16 AM, revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the South Unit medication carts and shower rooms on 03/15/17. Interview with the North UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the North Unit medication carts and shower rooms on 03/15/17. Interviews on 03/22/17 with the SDC at 1:05 PM, and the DON at 1:20 PM, revealed they assisted in walking rounds on 03/15/17, and observed all medications were secured and carts were locked, and all items in the shower rooms were secured. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he purchased locking cabinets to hold chemical supplies for the two (2) shower rooms on 03/15/17, and placed signs in the shower rooms stating No Storing of Personal Items. 4. Review of the facility's mandatory training records revealed all licensed nurses were educated on 03/15/17 and 03/16/17 by the SDC related to the facility's medication policy, including the five rights of medication administration, and Standards of Practice. All nurses were in-serviced in person or by phone interview. Continued review revealed the training included a post-test to test staff understanding of the educational topics. Interviews on 03/21/17 with RN #3 at 8:00 AM, LPN #9 at 9:02 AM, RN #2 at 9:59 AM, LPN #9, LPN #1 10:00 AM, LPN #10 at 10:39 with, LPN #4 and 11:45 AM, and on 03/22/17 with LPN #12 at 7:00 AM, LPN #11 at 7:08 AM, LPN #3 at 7:11 AM, RN #4 at 7:15 AM, LPN #14 at 7:25 AM, LPN #13 at 7:30 AM, LPN #5 at 9:05 AM, and LPN #15 at 9:11 AM, revealed all had received in-service training by the SDC, in person or by phone interview, related to the facility's policy for medication administration, securing medications and ensuring carts were locked, and Standards of Practice for administration of medications. In addition, the nurses reported training included safe practices of never leaving medications unattended, and only preparing medications at the time of administration. The nurses further reported the training included safe storage of germicidal chemicals in the shower rooms, prohibition of storing resident personal items in the shower rooms, and keeping the shower room door closed. Continued interview revealed all completed a post-test to evaluate their understanding of the education. Interview further revealed the nursing staff could state correct administration practice and the five rights of medication administration (right medication, right dose, right time, right route and right resident). Further review of facility's mandatory in-service training records revealed all staff were educated by the SDC, with the assistance of the Administrator, DON, Unit Managers and Department Heads on 03/15/17 and 03/16/17 related to proper storage of germicidal agents, storage of residents' personal items, and ensuring the shower room doors were kept closed. In addition, the training records included completed post-tests to ensure staff understanding of the training topics. Interviews on 03/21/17 with State Registered Nursing Assistant (SRNA) #7 at 10:10 AM, SRNA #3 at 10:15 AM, SRNA #8 at 10:25 AM, SRNA #9 at 10:30 AM, SRNA #10 at 10:55 AM, SRNA #11 at 11:00 AM, SRNA #1 at 11:05 AM, SRNA #12 at 3:15 PM, SRNA #13 at 3:20 PM, SRNA #5 at 3:22 PM, SRNA #14 at 3:49 PM, and SRNA #4 at 3:52 PM, and on 03/22/17 with SRNA #18 at 7:20 AM, SRNA #16 at 7:21 AM, SRNA #15 at 7:30 AM, SRNA #17 at 8:00 AM, SRNA #19 at 8:05 AM, and SRNA #20 at 8:40 AM, revealed all were in-serviced on 03/15/17 or 03/16/17 concerning proper storage of germicidal agents and residents' personal items, and ensuring the shower room was kept closed at all times. Continued interview revealed they completed a post-test after the training. The staff further stated if they made any observations of items not stored correctly or the shower room door left open, they were to report immediately to the nurse on that unit. Interviews on 03/21/17 with Cook #1 at 3:50 PM, Cook #2/Assistant Manager at 4:00 PM, Dietary Aide #1 at 4:05 PM, Dietary Manager at 4:15 PM, and on 03/22/17 with Cook #4 at 8:45 AM, and with Cook #3 at 8:52 AM, revealed all were instructed by the SDC, Administrator and/or Dietary Manager concerning the proper storage of germicidal agents and residents' personal care items. In addition, the training included the requirement for shower room doors to be kept closed at all times. All interviewed reported completing a post-test after being educated. The interviewees further stated if they made any observations of items not stored correctly or the shower room doors open, they were to report immediately to the nurse on that unit. Interview with the Director of Plant Operations on 03/21/17 at 4:12 PM, and with the Assistant Director of Plant Operations on 03/22/17 at 7:40 AM, revealed they received training by the Administrator concerning proper storage of germicidal agents and residents' personal care items. Both reported they completed a post-test of their understanding of the education. Interview with Laundry Aide #1 on 03/21/17 at 4:55 PM, and with the Housekeeping Manager on 03/22/17 at 8:30 AM, revealed they were in-serviced by the Administrator related to proper storage of germicidal agents and residents' personal care items. Both reported they were required to complete a post-test after receiving the education to ensure their understanding of the topics. Interviews on 03/22/17 with the Social Worker at 9:39 AM, the Occupation Therapist at 10:21 AM, and with the Physical Therapist at 10:42 AM, revealed they had been trained by Administrator and the SDC regarding the proper storage of germicidal agents and residents' personal care items, and on the requirement for the shower room doors to be kept closed at all times. Those interviewed they completed a post-test. All stated if they made any observations of items not stored correctly, or a shower room door left open, they were to report immediately to the nurse on that unit. Interview with the ABOM, on 03/22/17 at 12:35 PM, revealed she was educated by the BOM concerning the proper storage of germicidal agents and residents' personal care items, and on observing to ensure the shower room doors were closed. She stated she completed a post-test related to the topics presented. Interview with the BOM, on 03/22/17 at 12:53 PM, revealed had educated the ABOM and administered the post-test. 5. Review of the facility's forms titled Every Shift Audit, Med Cart Checklist, and Shower Room Checklist revealed the audits were conducted six (6) times per day from 03/16/17 through 03/21/17. The South and North unit audits included monitoring for locked medication carts, ensuring no medications were left on top of the carts, and ensuring all medications, including narcotics, were secured. In addition, the shower rooms were audited for proper storage of germicidal agents/chemicals in locked cabinets, no resident personal items stored in the shower rooms, and doors kept closed. Continued review of the audit forms revealed no concerns noted by staff during the daily rounds. Interview with the Director of Plant Operations on 03/21/17 at 4:45 PM, and with Maintenance Staff #1 on 03/22/17 at 7:40 AM, revealed they were assigned to observe the shower room doors throughout the day to ensure they were kept closed. Interview with the North UM, on 03/22/17 at 10:15 AM, revealed she checked the North medication cart and shower room six (6) times daily and documented on the audit form. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she checked the South medication cart and the shower room six (6) times daily and documented on the audit form. Interview with the RN Weekend Supervisor, on 03/22/17 at 10:20 AM, revealed she checked the medication carts and shower rooms six (6) times daily on both units over the weekend. Interview on 03/22/17 with the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, and the SDC at 1:05 PM, revealed all assisted with daily rounds to ensure medication carts were locked, no medications were left unsecured, and shower room doors were kept closed. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she checked the audit sheets daily to ensure they were complete. She stated she continued to make random checks of the medication carts and the shower rooms. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he reviewed the audit forms for completeness and to identify any continued concerns related to the medication carts/medication security and the shower rooms. 6. Review of the attendance record revealed the ad hoc QAPI meeting on 03/15/17 was attended by the Administrator, DON, SDC, South UM, and the Director of Health Information. Continued review revealed the Medical Director was present by phone. Interviews on 03/21/17 with the SDC at 3:31 PM, and on 03/22/17 with the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they attended an ad hoc QAPI meeting on 03/15/17, with the Medical Director present by phone. Continued interview they also attended a meeting on 03/16/17 to discuss the concerns identified during the State Agency survey. All those interviewed reported a discussion related to the Immediate Jeopardy and removing the immediacy, and more discussion related to deficiencies regarding Administration. Interview with the Medical Director, on 03/22/17 at 11:07 AM, revealed he was contacted by the facility on 03/15/17 and on 03/16/17 to discuss the Immediate Jeopardy related to unlocked and unattended medication carts, and narcotics left unsecured on top of the cart. Continued interview revealed the second call was a concentration on the Administrative deficiencies. He stated he was in agreement with the facility's plan to correct the concerns and did not have additional recommendations. Interview on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they have been active in all QAPI process meetings and activities since the Immediate Jeopardy was called. 7. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he conducted a training session on 03/16/17 with the Administrator and the DON regarding their job descriptions. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she met with the DO on 03/16/17 to discuss her job description and responsibilities. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he met with the DO to review his job description and the expectations for his role in the facility.

Based on observation, interview, record review, review of the Kentucky Board of Nursing (KBN) Scope of Practice Determination Guidelines, review of the KBN Advisory Opinion Statements, review of the American Nurses Association (ANA) Scope and Standards of Practice, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure services provided or arranged by the facility met professional standards of quality related to labeling and administration of medications. Observation on the South resident hall, on 03/14/17 revealed a vial of insulin and three unlabeled, unidentified pills were noted unsecured in cups on top of the medication cart. Furthermore on 03/14/17, when the nurse returned to the cart, she was unable to say what the pills were or to whom they belonged until she looked in the Narcotic Book to recall what pills she had signed out. She stated the pills were narcotic pain medications. Without further verifying the pills or for whom they were prescribed, the nurse proceeded to administer one of the pills to Unsampled Resident D. The facility's failure to have an effective system in place to ensure services provided or arranged by the facility met professional standards of quality has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 03/15/17 and determined to exist on 03/14/17. The facility was notified of the Immediate Jeopardy on 03/15/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 alleging removal of the Immediate Jeopardy on 03/17/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/22/17, prior to exit on 03/22/17, with remaining non-compliance at a Scope and Severity of an D, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the ANA's Scope and Standards of Practice, 3rd edition, revealed the Registered Nurse (RN) would employ strategies to promote a safe environment. Continued review revealed the RN contributes to quality nursing practice by ensuring that nursing practice is safe, effective, efficient, equitable, timely, and patient-centered. Review of the KBN Registered Nurse/Licensed Practical Nurse Scope of Practice Determination Guidelines, revised June 2015, revealed the administration of medications would be consistent either with ANA Standards of Practice, or with standards of practice established by other nationally accepted organizations of registered nurses. Continued review revealed components of medication administration included the preparation and giving of medications. Review of the KBN Advisory Opinion Statement titled The Role of Nurses in the Administration of Medications via Various Routes, revised October 2014, revealed nurses were responsible and accountable for making decisions that were based upon current clinical competencies in nursing. Continued review revealed nursing practice was to be consistent with established standards of practice, for example the ANA Standards of Practice. Review of the facility's Medication Administration policy, dated 2007, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices. Continued review revealed medications were to be administered at the time they were prepared. In addition, licensed personnel were to verify the medication three (3) times before administration - when pulling the medication package from the cart; when preparing the dose; and before administering the dose. Further review of the policy revealed during administration of medications, no medications were to be kept on top of the cart. Observation on the South resident hall, on 03/14/17 at 5:07 PM, revealed a bottle of insulin and three (3) unlabeled medication cups, each containing a single unpackaged pill, were unsecured on top of the unattended medication cart. Continued observation revealed Registered Nurse (RN) #1 returned to the medication cart at 5:13 PM, but was unable to say who the medications belonged to. After looking at the Narcotic Book, RN #1 determined which residents she had signed pills out to, and identified them as follows: an [MEDICATION NAME] 5/325 milligram (mg) tablet belonging to Resident D; a [MEDICATION NAME] 5/325 mg tablet belonging to Resident C; and a [MEDICATION NAME] 7.5/325 mg tablet for Resident #8. ([MEDICATION NAME] and [MEDICATION NAME] are narcotic pain medications.) Additional observation revealed RN #1 proceeded to administered the pill she had identified to be [MEDICATION NAME] to Resident D, without further verifying the right pill at the right dose for the right resident, according to the facility's policy and ANA standards of practice which ensure safe, effective, efficient, equitable, timely, and patient-centered care. Interview with RN #1, on 03/14/17 at 5:13 PM, revealed medications should be prepared and administered using the five rights: the right resident; the right medication; the right dose; the right route; and, the right time of administration. Furthermore, RN #1 stated each medication should have been administered immediately after being prepared to avoid giving the wrong medication to a resident. Regarding the pill RN #1 identified as [MEDICATION NAME] belonging to Resident D, she explained she routinely administered the medications to the residents on the South Hall and she just knew to whom they belonged. Per interview, she had pulled the pills and placed them in the medication cups herself, even though she had to look back at the Narcotic Book to see for whom she had pulled pills. Interview with Licensed Practical Nurse (LPN) #4, on 03/15/17 at 3:15 PM, revealed she was the South Hall Unit Manager. She stated medications should not be stored on top of the medication cart. Continued interview revealed nurses administering medications should prepare each resident's medications and administer them immediately after preparation. Interview with the Director of Nursing (DON), on 03/16/17 at 4:53 PM, revealed she expected staff to follow professional standards and the facility's policy on administering medications. The DON stated medications were not to be kept on top of the medication carts, and medications were to be administered immediately after they were prepared using the five rights of identification (right medication, right dose, right time, right route and right resident) to prevent potential medication errors. Continued interview revealed nurses were trained on the correct medication administration process upon hire, annually, and any time the facility identified a concern. Interview with the Administrator, on 03/16/17 at 5:30 PM, revealed it was his expectation for nursing staff to follow professional standards of practice and the facility's policy related to medication administration. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/17/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/17/17. Review of the AOC revealed the facility implemented the following: 1. On 03/15/17, the Regional Nurse Consultant educated the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UMs) regarding a safe environment for residents, medication storage, medication administration policy and procedure, and administering care to ensure the highest practical physical, mental and psychosocial well-being of each resident, and to maintain acceptable professional standards and practices. 2. On 03/16/17, the Director of Operations (DO) educated the Administrator, DON, SDC, Health Information Manager (HIM), Quality of Life Director, Social Services Director, Minimum Data Set (MDS) Nurse, Maintenance Director, Dietary Manager, Business Office Manager (BOM) and Regional Nurse Consultant on the facility's quality assurance (QA) process and policy. Administrative oversight of the facility would be completed by the Director of Operations or Designee weekly to ensure audit compliance until the removal of the Immediate Jeopardy. All audits would be presented at the weekly QA meeting. Any areas found to be out of compliance will result in actions including, but not limited to re-education, with disciplinary action up to and including termination. 3. On 03/15/17, the DON, SDC, and the UMs conducted walking round audits on both units (North Hall and South Hall) to ensure all medication carts, medication rooms, and treatment carts were locked and all medications, including narcotics, were secured. In addition, the DON and the SDC audited all medication carts to ensure medications were in the secured pharmacy packs. On 03/15/17, a locked cabinet was placed in each shower room for the purpose of storing cleaning supplies. To avoid cross contamination and infection control issues, the shower rooms will not be used for storing residents' personal items. On 03/16/17, a sign was placed in each shower room stating, No Storing of Personal Items. 4. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services and post-tests to all licensed nurses regarding securing medication carts and medications, including narcotic medications. The proper securing of treatment carts was also addressed. In addition, the training included proper storage of germicidal items, residents' personal items, and hand sanitizer. Twenty-six (26) of the twenty-eight (28) licensed nurses employed by the facility were educated by 03/16/17. The facility does not utilize agency staff or Kentucky Medication Aides. Nurses were also in-serviced on pre-filling medications and following the five (5) rights of medication administration. In addition, the in-service included the Kentucky Board of Nursing (KBN) Professional Standards of Practice regarding medication, medications carts, and proper storage of those medications. Also included in the mandatory in-service was the requirement to ensure the medications were under the direct observation of the person administering the medications, or were locked in the medication storage area/cart. Any licensed staff not educated by 03/16/17 would not be permitted to work until the in-service and post-test were completed. Furthermore, all licensed nurses will receive this training during new-hire orientation. On 03/15/17 at 6:30 PM, the SDC initiated mandatory in-services to all staff on handling and storage of chemicals and making sure resident personal care items are not stored in the shower rooms. No staff were permitted to work until the in-service and post-test were completed. Ninety-three (93) of one hundred one (101) stakeholders employed by the facility received the education and completed a post-test related to the storage of germicidal agents and personal care items in shower rooms. Any stakeholder that did not receive the educations by 03/16/17 was not permitted to work until they completed the training and post-test. Furthermore, the training topic was added for all staff to receive during new-hire orientation. 5. On 03/15/17, the DON, SDC, Weekend Supervisor, and UMs began daily audits, at random times on both units, six (6) times per day, to ensure medication carts were locked and all medications/narcotics were secured. In addition, daily audits of the shower rooms were initiated on 03/15/17, to be completed by the Administrator, DON, UMs, Weekend Supervisor, BOM, Assistant BOM (ABOM), Admissions Coordinator, HIM, Housekeeping Manager, Dietary Manager, Quality of Life Director, Social Services Director, MDS nurse, and the Maintenance Director. The audits were to be conducted six (6) times daily, at random times on both units, to ensure no residents' personal items were stored in the shower rooms, germicidal cleaners were locked in the cabinets in the shower rooms, and shower room doors were closed. 6. A QA meeting was held on 03/15/17 and 03/16/17. In attendance were the Medical Director, Administrator, DON, SDC, HIM and a nurse. All audits were to be reviewed weekly in a QA meeting. 7. The Administrator and the DON were to function in a manner that enabled the use of effective and efficient resources to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Job Description and expectations of the Administrator's role were reviewed with the Administrator by the DO on 03/16/17. The DO would hold weekly meetings with the Administrator and the DON to validate the facility's Allegation of Compliance. These weekly meeting will continue until the immediacy of jeopardy has been lifted. The Administrator and the DON received education on 03/16/17 from the DO regarding the facility's Quality Assurance and Performance Improvement (QAPI) plan. An additional ad hoc QAPI meeting was held via phone, on 03/16/17 with the Medical Director, Administrator, DON, SDC, HIM, and Regional Nurse Consultant. Discussion included the outcome of the recent survey and the issuance by the State Agency of the 2 additional IJ deficiencies related to QA and Administrative oversight. The audit tools and education were reviewed with the Medical Director, who had no further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the In-service Attendance Record, dated 03/15/17, revealed the Regional Nurse Consultant provided education to the administrative staff related to a safe environment for residents, medication storage. the medication administration policy, all to ensure the highest practical physical, mental, and psychosocial well-being of each resident and to maintain acceptable professional standards of practice. The in-service addressed storage of chemical agents in the shower room, a mandate that no residents' personal items would be stored in the shower room, and shower doors would remain closed. Interview with the Regional Nurse Consultant, on 03/22/17 at 2:05 PM, revealed she conducted the in-service for Administration on 03/15/17. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, the Weekend Supervisor at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM, and the Administrator at 1:35 PM, revealed all had received instruction from the Regional Nurse Consultant on 03/15/17 concerning a safe environment for residents, medication storage, the and the medication administration policy in order to maintain acceptable standards of practice. In addition, the in-service covered the storage of chemicals in the shower room, the prohibition against storing residents' personal items in the shower rooms, and the requirement to ensure the shower room doors were kept closed at all times. 2. Review of training records revealed the DO in-serviced the administrative team on the facility QAPI program on 03/16/17, and reviewed the AOC with the team on 03/17/17. Review of the facility form titled Administrative Oversight completed by Director of Operations or Designee revealed the DO had signed for completing the oversight for the week of 03/13/17 through 03/17/17. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he reviewed the facility's QA process and provided training to the QAPI leadership team. Continued interview revealed he reviewed and provided oversight of the facility's implementation of the AOC weekly. Interviews on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, South UM at 10:25 AM, Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed all attended the in-service conducted by the Regional Nurse Consultant on 03/15/17 and were trained on the QAPI process. Continued interview revealed the interviewees attended the weekly QAPI meetings on 03/15/17 and 03/22/17. 3. Review of the facility's audit tool titled Med Cart Audit and Medication Package Audit revealed the DON and the UMs for both the South unit and the North unit, documented completion of initial rounds on 03/15/17 at 7:00 PM with observations that the medication carts were locked, all medications including narcotics were secured, and the treatment carts were locked and secured. Review of the facility audit tool titled Shower Room Audit revealed the DON and UMs for both units completed initial rounds on 03/15/17 at 7:00 PM with observations to ensure no residents' personal items left out, germicidal cleaners were locked in cabinets, and the shower room doors were closed. Observations on the South Unit on 03/21/17 at 9:15 AM, 9:42 AM, 11:40 AM, 11:43 AM, 4:01 PM, and 5:00 PM, and on 03/22/17 at 8:00 AM, of the South Unit revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Observations on the North Unit on 03/21/17 at 9:45 AM, 9:50 AM, 11:45 AM, 1:15 PM, 1:20 PM, 3:20 PM, and 5:05 PM, and on 03/22/17 at 8:11 AM, 9:52 AM and 11:16 AM, revealed medication carts were locked with no medications left unattended, no resident personal items were left in the shower rooms, no germicidal cleaners were unsecured, and the locked cabinet in the shower room held a sign stating No Storing of Personal Items. In addition, the shower room door was closed. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the South Unit medication carts and shower rooms on 03/15/17. Interview with the North UM, on 03/22/17 at 10:25 AM, revealed she assisted with the initial tour of the North Unit medication carts and shower rooms on 03/15/17. Interviews on 03/22/17 with the SDC at 1:05 PM, and the DON at 1:20 PM, revealed they assisted in walking rounds on 03/15/17, and observed all medications were secured and carts were locked, and all items in the shower rooms were secured. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he purchased locking cabinets to hold chemical supplies for the two (2) shower rooms on 03/15/17, and placed signs in the shower rooms stating No Storing of Personal Items. 4. Review of the facility's mandatory training records revealed all licensed nurses were educated on 03/15/17 and 03/16/17 by the SDC related to the facility's medication policy, including the five rights of medication administration, and Standards of Practice. All nurses were in-serviced in person or by phone interview. Continued review revealed the training included a post-test to test staff understanding of the educational topics. Interviews on 03/21/17 with RN #3 at 8:00 AM, LPN #9 at 9:02 AM, RN #2 at 9:59 AM, LPN #9, LPN #1 10:00 AM, LPN #10 at 10:39 with, LPN #4 and 11:45 AM, and on 03/22/17 with LPN #12 at 7:00 AM, LPN #11 at 7:08 AM, LPN #3 at 7:11 AM, RN #4 at 7:15 AM, LPN #14 at 7:25 AM, LPN #13 at 7:30 AM, LPN #5 at 9:05 AM, and LPN #15 at 9:11 AM, revealed all had received in-service training by the SDC, in person or by phone interview, related to the facility's policy for medication administration, securing medications and ensuring carts were locked, and Standards of Practice for administration of medications. In addition, the nurses reported training included safe practices of never leaving medications unattended, and only preparing medications at the time of administration. The nurses further reported the training included safe storage of germicidal chemicals in the shower rooms, prohibition of storing resident personal items in the shower rooms, and keeping the shower room door closed. Continued interview revealed all completed a post-test to evaluate their understanding of the education. Interview further revealed the nursing staff could state correct administration practice and the five rights of medication administration (right medication, right dose, right time, right route and right resident). Further review of facility's mandatory in-service training records revealed all staff were educated by the SDC, with the assistance of the Administrator, DON, Unit Managers and Department Heads on 03/15/17 and 03/16/17 related to proper storage of germicidal agents, storage of residents' personal items, and ensuring the shower room doors were kept closed. In addition, the training records included completed post-tests to ensure staff understanding of the training topics. Interviews on 03/21/17 with State Registered Nursing Assistant (SRNA) #7 at 10:10 AM, SRNA #3 at 10:15 AM, SRNA #8 at 10:25 AM, SRNA #9 at 10:30 AM, SRNA #10 at 10:55 AM, SRNA #11 at 11:00 AM, SRNA #1 at 11:05 AM, SRNA #12 at 3:15 PM, SRNA #13 at 3:20 PM, SRNA #5 at 3:22 PM, SRNA #14 at 3:49 PM, and SRNA #4 at 3:52 PM, and on 03/22/17 with SRNA #18 at 7:20 AM, SRNA #16 at 7:21 AM, SRNA #15 at 7:30 AM, SRNA #17 at 8:00 AM, SRNA #19 at 8:05 AM, and SRNA #20 at 8:40 AM, revealed all were in-serviced on 03/15/17 or 03/16/17 concerning proper storage of germicidal agents and residents' personal items, and ensuring the shower room was kept closed at all times. Continued interview revealed they completed a post-test after the training. The staff further stated if they made any observations of items not stored correctly or the shower room door left open, they were to report immediately to the nurse on that unit. Interviews on 03/21/17 with Cook #1 at 3:50 PM, Cook #2/Assistant Manager at 4:00 PM, Dietary Aide #1 at 4:05 PM, Dietary Manager at 4:15 PM, and on 03/22/17 with Cook #4 at 8:45 AM, and with Cook #3 at 8:52 AM, revealed all were instructed by the SDC, Administrator and/or Dietary Manager concerning the proper storage of germicidal agents and residents' personal care items. In addition, the training included the requirement for shower room doors to be kept closed at all times. All interviewed reported completing a post-test after being educated. The interviewees further stated if they made any observations of items not stored correctly or the shower room doors open, they were to report immediately to the nurse on that unit. Interview with the Director of Plant Operations on 03/21/17 at 4:12 PM, and with the Assistant Director of Plant Operations on 03/22/17 at 7:40 AM, revealed they received training by the Administrator concerning proper storage of germicidal agents and residents' personal care items. Both reported they completed a post-test of their understanding of the education. Interview with Laundry Aide #1 on 03/21/17 at 4:55 PM, and with the Housekeeping Manager on 03/22/17 at 8:30 AM, revealed they were in-serviced by the Administrator related to proper storage of germicidal agents and residents' personal care items. Both reported they were required to complete a post-test after receiving the education to ensure their understanding of the topics. Interviews on 03/22/17 with the Social Worker at 9:39 AM, the Occupation Therapist at 10:21 AM, and with the Physical Therapist at 10:42 AM, revealed they had been trained by Administrator and the SDC regarding the proper storage of germicidal agents and residents' personal care items, and on the requirement for the shower room doors to be kept closed at all times. Those interviewed they completed a post-test. All stated if they made any observations of items not stored correctly, or a shower room door left open, they were to report immediately to the nurse on that unit. Interview with the ABOM, on 03/22/17 at 12:35 PM, revealed she was educated by the BOM concerning the proper storage of germicidal agents and residents' personal care items, and on observing to ensure the shower room doors were closed. She stated she completed a post-test related to the topics presented. Interview with the BOM, on 03/22/17 at 12:53 PM, revealed had educated the ABOM and administered the post-test. 5. Review of the facility's forms titled Every Shift Audit, Med Cart Checklist, and Shower Room Checklist revealed the audits were conducted six (6) times per day from 03/16/17 through 03/21/17. The South and North unit audits included monitoring for locked medication carts, ensuring no medications were left on top of the carts, and ensuring all medications, including narcotics, were secured. In addition, the shower rooms were audited for proper storage of germicidal agents/chemicals in locked cabinets, no resident personal items stored in the shower rooms, and doors kept closed. Continued review of the audit forms revealed no concerns noted by staff during the daily rounds. Interview with the Director of Plant Operations on 03/21/17 at 4:45 PM, and with Maintenance Staff #1 on 03/22/17 at 7:40 AM, revealed they were assigned to observe the shower room doors throughout the day to ensure they were kept closed. Interview with the North UM, on 03/22/17 at 10:15 AM, revealed she checked the North medication cart and shower room six (6) times daily and documented on the audit form. Interview with the South UM, on 03/22/17 at 10:25 AM, revealed she checked the South medication cart and the shower room six (6) times daily and documented on the audit form. Interview with the RN Weekend Supervisor, on 03/22/17 at 10:20 AM, revealed she checked the medication carts and shower rooms six (6) times daily on both units over the weekend. Interview on 03/22/17 with the Quality of Life Director at 12:45 PM, the Social Worker at 12:50 PM, and the SDC at 1:05 PM, revealed all assisted with daily rounds to ensure medication carts were locked, no medications were left unsecured, and shower room doors were kept closed. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she checked the audit sheets daily to ensure they were complete. She stated she continued to make random checks of the medication carts and the shower rooms. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he reviewed the audit forms for completeness and to identify any continued concerns related to the medication carts/medication security and the shower rooms. 6. Review of the attendance record revealed the ad hoc QAPI meeting on 03/15/17 was attended by the Administrator, DON, SDC, South UM, and the Director of Health Information. Continued review revealed the Medical Director was present by phone. Interviews on 03/21/17 with the SDC at 3:31 PM, and on 03/22/17 with the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they attended an ad hoc QAPI meeting on 03/15/17, with the Medical Director present by phone. Continued interview they also attended a meeting on 03/16/17 to discuss the concerns identified during the State Agency survey. All those interviewed reported a discussion related to the Immediate Jeopardy and removing the immediacy, and more discussion related to deficiencies regarding Administration. Interview with the Medical Director, on 03/22/17 at 11:07 AM, revealed he was contacted by the facility on 03/15/17 and on 03/16/17 to discuss the Immediate Jeopardy related to unlocked and unattended medication carts, and narcotics left unsecured on top of the cart. Continued interview revealed the second call was a concentration on the Administrative deficiencies. He stated he was in agreement with the facility's plan to correct the concerns and did not have additional recommendations. Interview on 03/21/17 with the SDC at 3:31 PM, the Dietary Manager at 4:15 PM, and the Director of Plant Operations at 4:45 PM, and on 03/22/17 with the North UM at 10:15 AM, RN #2 at 10:20 AM, the South UM at 10:25 AM, the Director of Health Information at 11:00 AM, the Social Worker at 12:15 PM, the Quality of Life Director at 12:45 PM, the BOM at 12:53 PM, the MDS Coordinator at 1:00 PM, the DON at 1:20 PM and the Administrator at 1:35 PM, revealed they have been active in all QAPI process meetings and activities since the Immediate Jeopardy was called. 7. Interview with the DO, on 03/21/17 at 1:50 PM, revealed he conducted a training session on 03/16/17 with the Administrator and the DON regarding their job descriptions. Interview with the DON, on 03/22/17 at 1:20 PM, revealed she met with the DO on 03/16/17 to discuss her job description and responsibilities. Interview with the Administrator, on 03/22/17 at 1:35 PM, revealed he met with the DO to review his job description and the expectations for his role in the facility.

Based on record review, interview and review of the facility's policy, it was determined the facility failed to ensure services were provided in accordance with each residents' written Plan of Care for one (1) of four (4) sampled residents (Resident #1). Resident #1's Comprehensive Plan of Care stated the resident had a self- care deficit and required assistance for all Activities of Daily Living (ADLs)with interventions which included one (1) person assistance with meals. Record review revealed Resident #1 was served a meal tray that contained coffee without staff assistance. It was reported to staff by a visitor Resident #1 had spilled his/her coffee which resulted in a burn to the resident's right thigh. (Refer to F-323) The findings include: Review of the facility's policy, titled "Care Plans - Comprehensive", revised October 2010, revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas and risk factors associated with the problem areas. Continued review of the "Care Plan Policy" revealed the Comprehensive Care Plan was to aid in preventing or reducing declines in residents' functional status and functional levels, enhance optimal functioning of each resident; and reflect currently recognized standards of practice for problem areas and conditions. Record review revealed the facility admitted Resident #1 on 02/19/15, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/26/15, revealed the facility assessed the resident to have no Brief Interview for Mental Status (BIMS) score documented. The BIMS score is an indication of the resident's cognitive function. Continued review revealed the facility assessed Resident #1 to be moderately impaired with skills for daily decision making. In addition, Resident #1 was assessed to have poor decision-making skills and to require cues and supervision. Further review of the MDS revealed the facility assessed Resident #1 to require one (1) person physical assist and was totally dependent for eating. Review of Resident #1's Comprehensive Care Plan, dated 02/27/15, revealed the resident had a self-care deficit care plan and required assistance with all ADLs, related to the presence of Tremors, Left Sided [MEDICAL CONDITION] (slight paralysis or weakness of the left or right side of the body) and a [MEDICAL CONDITION] Disorder. Continued review revealed Care Plan interventions included a requirement for one (1) person assist with meals and the provision of adaptive/safety equipment as needed. Further review of the Comprehensive Care Plan revealed Resident #1 had a nutritional risk and required total assistance with eating and drinking. Review of the Nurse's Notes, dated 03/11/15 at 12:30 PM, revealed Resident #1 spilled a hot cup of coffee on his/her right leg. Review of the facility's employee incident investigation statements, undated, related to Resident #1 spilling the hot coffee on his/her leg, revealed a staff member served Resident #1 his/her meal without a staff member being present to assist the resident with the meal. Review of the Wound Care Notes, dated 03/11/15, revealed Resident #1 was assessed to have a burn to the right thigh with blisters forming. Interview with State Registered Nursing Aid (SRNA) #1, on 03/23/15 at 8:10 AM, revealed Resident #1 required physical assistance from staff for eating. Per interview, SRNA #1 arrived to the dining room late and observed Resident #1 was sitting in the dining room on 03/11/15 at a table with another resident and a visitor of that resident. Per interview, Resident #1's meal tray had been passed, and the resident had his/her coffee. Further interview revealed no staff were sitting with or assisting Resident #1. Per interview, SRNA #1 did not know who served Resident #1's meal tray; however, she stated the tray should not have been served to Resident #1 without staff physically present to provide assistance and supervision for the resident. Interview with SRNA #2, on 03/23/15 at 8:50 AM, revealed she was working in the dining room on 03/11/15; however, did not witness the incident with Resident #1. Further interview revealed Resident #1 was assessed to require physical assistance of one (1) staff for meals. Continued interview revealed the meal tray should not have been left at the table without staff assistance and supervision. Further interview revealed the process was to stay with the resident once the tray was served. Interview with Licensed Practical Nurse (LPN) #1, on 0/23/15 at 8:45 AM, revealed the facility's process for a resident requiring staff feeding assistance was for the resident not to be left without supervision and assistance after the tray was served. Interview with the Social Service Director (SSD), on 03/23/15 at 1:53 PM, revealed she delivered Resident #1's noon meal tray on 03/11/15. She stated she was aware Resident #1 required physical assistance of staff for eating; however, no staff were present at the table when she delivered Resident #1's meal tray. She further stated she did not see that she had done anything wrong because she pushed the meal tray with the hot coffee further back on the table, to a point where she thought it was out of the resident's reach. Interview with the Director of Nursing (DON), on 03/23/15 at 1:13 PM, revealed Resident #1 was assessed to require staff assistance with eating. Further interview revealed Resident #1 was care planned for staff to assist the resident with meals. Continued interview revealed the care plan was not followed when Resident #1 was served hot coffee and left without assistance. She stated the meal tray should not have been served to Resident #1 without staff present to assist and supervise, per the facility's policy and Resident #1's care plan. Interview with the Administrator, on 03/24/15 at 3:00 PM, revealed Resident #1 had been assessed to require physical staff assistance for meals. Continued interview revealed Resident #1 was care planned to receive physical assistance of one (1) staff for meals. The Administrator stated Resident #1's care plan was not adhered to, and the resident should not have been served the meal tray without the presence of staff for assistance, per the Care Plan and the facility's policy.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents. The facility failed to have an effective system in place, to monitor and/or ensure hot liquids were at a safe temperature. Resident #1, who the facility had assessed to require physical assist of one (1) staff with meals, was served the noon meal on 03/11/15; however, the resident was not provided the assessed physical assist of one (1) staff. Subsequently, Resident #1 spilled hot coffee on his/her right thigh resulting in burns with blistering (second degree) to the right thigh. The findings include: Review of the facility's policy titled, "Safety and Supervision of Residents", revised December 2007, revealed resident safety and supervision and assistance to prevent accidents were facility-wide priorities. Per the Policy, employees would be trained and inserviced on potential accident hazards, how to identify and report accident hazards, and how to prevent avoidable accidents. Further review revealed implementing interventions to reduce accident risks and hazards should include: communicating specific interventions to all relevant staff; assigning responsibility for carrying out the interventions; providing training for staff; and ensuring interventions were implemented and documented. Review of the facility's policy titled, "Assistance with Meals", revised October 2013, revealed residents would receive assistance with meals in a manner which met the individual needs of each resident. The Policy revealed staff would serve resident trays and help residents who required assistance with eating. Continued review revealed residents who could not feed themselves would be fed with attention to safety, comfort and dignity. Review of the facility's policy titled, "Meal Service - In Dining Room", dated July 2002, revealed the meal tray should be served to the resident whose dietary card was on the meal tray. Per the Policy, residents incapable of feeding themselves were "dependent dined", which indicated staff assistance was required. Continued review revealed should a resident require assistance with eating, staff was to help the resident as necessary. Review of the facility's policy titled, "Food Temperatures", updated October 2008, revealed acceptable serving temperatures for coffee, tea or other hot beverages should be equal to or greater than one hundred forty (140) degrees Farenheit and no higher than one hundred fifty-five (155) degrees Farenheit. Record review revealed the facility admitted Resident #1 on 02/19/15, with [DIAGNOSES REDACTED]. Review of the Nutritional Evaluation, dated 02/19/15, revealed the facility assessed Resident #1 to have difficulty swallowing, inadequate food and fluid intake, and difficulty with chewing and feeding self. Further review revealed Resident #1 had disorganized thinking and memory problems and was dependent on staff for feeding. Review of Resident #1's dietary directive card revealed he/she should sit at table 13 B and required staff assist with eating. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/26/15, revealed the facility assessed the resident to have no Brief Interview for Mental Status (BIMS) score documented. Continued review revealed the facility assessed Resident #1 was moderately impaired with skills for daily decision making, made poor decisions and required cues and supervision. Further review of the MDS revealed the facility assessed Resident #1 to require one (1) person physical assist and to be totally dependent for eating. Review of Resident #1's Comprehensive Care Plan, dated 02/27/15, revealed the resident had a self- care deficit problem and required assistance with all activities of daily living (ADL's) related to Tremors, Left Sided Hemiparesis (slight paralysis or weakness of the left or right side of the body) and a Seizure Disorder. Continued review revealed interventions noting the resident required one (1) person assist with meals and should be provided adaptive/safety equipment as needed. Further review of the Comprehensive Care Plan revealed Resident #1 was a nutritional risk and required total assistance with eating and drinking. Continued record review of a Nurse's Note, dated 03/11/15 at 12:30 PM, revealed during the noon meal Resident #1 spilled a hot cup of coffee on his/her right leg. Review of the facility's employee incident investigation statements, undated, related to Resident #1 spilling the hot coffee on his/her leg, revealed a staff member had served Resident #1 the noon meal without staff being present to assist the resident with the meal. Review of the Wound Care Note, dated 03/11/15 at 12:30 PM, revealed Resident #1 was assessed to have a burn to the right thigh with blisters forming. The Note revealed the initial wound assessment measured 16.6 centimeters (cm) in length by 20.3 cm in width by 0.1 cm in depth for the "right thigh whole burn" area, labeled Wound #1. Continued review revealed the left lower quadrant of Resident #1's abdomen was also assessed to have three (3) newly-identified areas observed with serous fluid filled blisters (Wounds #2, #3 and #4). Further review revealed the wounds were documented as follows: Wound #2 measured 0.5 cm in length by 0.7 cm in width by 0.0 cm depth; Wound #3 measured 0.8 cm in length by 0.7 cm in width by 0.0 cm in depth; and Wound #4 measured 0.4 cm in length by 1.2 cm in width by 0.0 cm in depth. Interview with State Registered Nursing Assistant (SRNA) #1, on 03/23/15 at 8:10 AM, revealed Resident #1 required physical assistance from staff for eating. Per interview, Resident #1 was sitting in the dining room on 03/11/15 at a table with another resident and a visitor of the other resident. Continued interview revealed SRNA #1 observed Resident #1's meal tray had been passed, and the resident had his/her coffee with no staff sitting with or assisting the resident. Continued interview revealed the visitor reported to staff Resident #1 had spilled his/her coffee. According to SRNA #1, she did not know who served Resident #1's meal tray; however, she stated the tray should not have been served to the resident without staff physically being present to provide assistance and supervision for the resident. Interview with SRNA #2, on 03/23/15 at 8:50 AM, revealed she was working in the dining room on 03/11/15. She stated she did not witness the incident involving Resident #1, but explained the facility's process for managing residents who required assistance with eating. SRNA #2 further stated she was aware Resident #1 was assessed to require the physical assistance of one (1) staff person for meals. Continued interview revealed the meal tray should not have been left at Resident #1's table without staff being present to provide assistance and supervision. Further interview revealed the process was for staff to stay with the resident once the tray was served. Interview with SRNA #3, on 03/23/15 at 12:45 PM, revealed she was working in the dining room during the noon meal service on 03/11/15. Further interview revealed she was assisting another resident and had her back to Resident #1 when the incident occurred. Continued interview revealed she observed Resident #1 in the dining room, sitting with another resident and the other resident's visitor. Per interview, SRNA #3 heard the other resident's visitor report Resident #1 had spilled his/her coffee. SRNA #3 stated she transported Resident #1 to his/her room via wheel chair and assisted the resident into the bed and with undressing, for the nurse to assess the resident. Interview with Licensed Practical Nurse (LPN) #1, on 03/23/15 at 8:45 AM, revealed the facility's process for a resident who required staff feeding assistance was for the resident not to be left without supervision and assistance after the tray was served. Interview with the Social Service Director (SSD), on 03/23/15 at 1:53 PM, revealed she had been employed at the facility for approximately six (6) or seven (7) weeks. The SSD revealed she had received basic education upon hire related to meal service and setting up the tray for the resident. Continued interview revealed she delivered Resident #1's noon meal tray on 03/11/15. Per interview, she was aware Resident #1 required physical assistance of staff for eating; however, no staff were present when she delivered Resident #1's meal tray. She stated she did not see that she had done anything wrong because she pushed the meal tray with the hot coffee further back on the table, to a position she thought was out of Resident #1's reach. The SSD further stated she did not know how Resident #1 obtained the hot coffee from the meal tray. Further interview revealed the SSD received education after the incident on 03/11/15 regarding not leaving residents unattended at meals if they had been assessed by the facility to require staff assistance with eating. Interview with the Dietary Manager (DM), on 03/26/15 at 3:26 PM, revealed on 03/11/15 after the incident, the temperature of the coffee was obtained and was noted to be between one hundred fifty-five (155) degrees Farenheit and one hundred sixty (160) degrees Farenheit, an acceptable temperature for coffee. The DM stated the appropriate temperatures for serving coffee should be between one hundred forty (140) degrees Farenheit and one hundred sixty (160) degrees Farenheit. Continued interview revealed the Dietary Department did not have a process in place, prior to the incident, to monitoring to ensure correct serving temperatures for hot beverages. According to the DM, the Dietary Department had since implemented a new process for coffee. Further interview revealed the new process included once the coffee was brewed at the station, it was placed in a holding container and remained in the holding container and cooled until the coffee "temped" at the appropriate temperature. Interview with the Director of Nursing (DON), on 03/23/15 at 1:13 PM, revealed the facility did not have a risk assessment tool for hot beverages. Continued interview revealed a meal tray should not have been served to a resident who required physical assistance of staff without staff present to provide the assistance and supervise the resident, as per the facility policy. The DON stated the appropriate temperature for coffee was between one hundred forty (140) degrees Farenheit and one hundred fifty-five (155) degrees Farenheit. She stated the facility's process was not adhered to on 03/11/15, when staff served a meal tray to Resident #1, who was assessed to require assistance, and the tray was left without ensuring staff were present to assist and supervise the resident. Interview with the Administrator, on 03/24/15 at 3:00 PM, revealed the facility did not have an assessment tool in place for screening residents at risk for hot beverages. Further interview revealed the facility's process included staff assigned to the dining room were to ensure meals were served timely and residents were assisted and supervised per the policy. Further interview revealed management and administrative staff was also scheduled in the dining room to assist and monitor residents. Continued interview revealed Resident #1 had been assessed to require physical staff assistance for meals; however, the facility's policy was not followed. The Administrator stated Resident #1 should not have been served his/her meal tray until staff could be present to assist with eating according to the facility's policy. Further interview revealed her expectation for residents requiring assistance with eating, was they should not be served the meal tray without staff being present to provide the assessed assistance, as per the facility's policy.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure assessment results were used to develop the care plan for one (1) of three (3) sampled residents (Resident #1). Based on the Admission Minimum Data Set (MDS) assessment, Resident #1 required extensive assistance with transfers, ambulation, toileting and hygiene, and was cognitively impaired. The facility failed to develop a care plan that reflected the specific abilities and deficits of the resident with individualized interventions based on the resident's assessment. On 01/18/12, Resident #1 was found lying in the bathroom floor after being left unattended on the toilet. As a result of the fall, Resident #1 sustained a displaced bimalleolar [MEDICAL CONDITION] ankle. The findings include: Review of the facility's "Care Plan" policy, effective December 2010, revealed the care plan provided guidance to all staff caring for the resident. Continued review revealed care was individualized based on identified problems. Review of the clinical record revealed the facility admitted Resident #1 on 12/09/11 with [DIAGNOSES REDACTED]. In addition, the resident was status [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/16/11, revealed the facility assessed Resident #1 to require extensive assistance of two (2) persons for transfers, ambulation, and toileting. Continued review revealed the resident was cognitively impaired, with a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating Resident #1 was severely cognitively impaired. Review of the Comprehensive Care Plan, dated 12/16/11, revealed Resident #1 had a Care Plan for at risk for fall related injury. Interventions included "assist with transfers as needed", "remind resident to request assistance before ambulation and/or transfers" and "assist with ambulation as needed". Further review revealed a Care Plan for Activities of Daily Living (ADL) Self Care Deficit and being at risk for complications related to deficit. Continued review of the Care Plan revealed Resident #1 needed/required assistance with transfers. Interventions included "remind resident to request assistance prior to ambulation and/or transfers" and "staff to assist with transfers as needed". Further review of the Care Plan revealed no documented evidence to reflect the resident's specific abilities or deficits related to transfers, toileting and the use of the call light. Review of the Certified Nursing Assistant (CNA) Care Record, dated January 2012, revealed Resident #1 required the assistance of one (1) person for toileting and the assistance of two (2) persons for ambulation and transfers. Review of the nurse's note, dated 01/18/12 at 2:30 PM, revealed Resident #1 was found on the bathroom floor. The resident's right ankle appeared to be swollen and the decision was made to transfer the resident to the emergency room for an evaluation. Continued review revealed the nurse documented, on 01/19/12 at 6:00 AM, Resident #1 had been admitted to the hospital due to a fractured ankle. Further review of a "Late Entry", dated 01/24/12 (no time noted), revealed the nurse documented a Certified Nursing Assistant (CNA) had taken the resident to the bathroom and instructed him/her to ring the call light when finished. Further review revealed the resident was non-compliant and attempted to return to bed without calling for assistance. A subsequent "Late Entry" note dated 01/24/12 was written by the former Director of Nursing (DON). She documented the resident did not use the call bell in order to prove to everyone he/she could do it alone. The CNA who left the resident on the toilet unattended before the fall on 01/18/12 was identified, but was no longer employed at the facility. Multiple attempts to reach the CNA for interview were unsuccessful. Interview with CNA #1, on 06/20/12 at 1:02 PM, revealed Resident #1 knew how to use the call light and could be left alone and instructed to pull the cord. Further interview revealed CNA #1 responded to the call light in Resident #1's room on 01/18/12 and found the resident in the floor and another CNA was present. He stated he did not know who pulled the call light. He continued to state Resident #1's foot was at an angle and the two (2) CNAs picked the resident up and placed him/her in a wheelchair. Review of the admitting hospital History and Physical, dated 01/19/12, revealed Resident #1 sustained a bimalleolar fracture to the right ankle. The resident was admitted and a surgical consult was obtained. Review of the Operative Report, dated 01/19/12, revealed Resident #1 underwent an Open Reduction and Internal Fixation (ORIF) of the right bimalleolar fracture. (An ORIF is a surgical procedure that includes the use of pins and screws to repair the fractured bone.) Continued record review revealed Resident #1 returned to the facility on [DATE]. Interview with the MDS Coordinator, on 06/28/12 at 3:45 PM, revealed she had completed the admission MDS Assessment for Resident #1. She stated the resident required extensive assistance with transfers, ambulation, toileting and hygiene at the time of the assessment. She further stated the care plan should have been based on the assessment. On further interview, she stated the resident didn't always remember to ring the call light; therefore, an intervention for staff to remind the resident to use the call light was added to the care plan. Continued interview revealed, based on the admission MDS Assessment, the resident should not have been left on the toilet unattended. Review of the care plan with the MDS coordinator revealed it was not specific regarding Resident #1's abilities and deficits, and did not provide clear instructions regarding the amount of assistance and supervision the resident required. The only revision to the care plan prior to the fall on 01/18/12 was related to the addition of bed rails as an enabler.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure adequate supervision for Resident #1 who was assessed to require the assistance of two (2) staff for transfers and toileting. Resident #1's Fall Risk Evaluation indicated he/she was at high risk for falls. On 01/18/12, the resident was found lying in the bathroom floor after being left unattended on the toilet. As a result of the fall, Resident #1 sustained a displaced bimalleolar fracture of the right ankle. The findings include: Review of the facility's Fall Policy, revised February 2009, revealed residents were to be provided with "assistance and supervision in an effort to avoid falls and minimize injury and complications that may result from a resident falling". Review of the clinical record revealed the facility admitted Resident #1 on 12/09/11 with [DIAGNOSES REDACTED]. In addition, the resident was status [REDACTED]. Review of the Fall Risk Evaluation, dated 12/10/11, revealed Resident #1 scored 24, where a value greater than 10 indicated the resident was at risk for falls. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/16/11, revealed the facility assessed Resident #1 to require extensive assistance of two (2) persons for transfers and toileting. Continued review revealed the resident was cognitively impaired, with a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognitive status was severely impaired. Review of the Comprehensive Care Plan, dated 12/16/11, revealed Resident #1 had a Care Plan for at risk for fall related injury. Interventions included "assist with transfers as needed", "remind resident to request assistance before ambulation and/or transfers" and "assist with ambulation as needed". Further review revealed a Care Plan for Activities of Daily Living (ADL) Self Care Deficit and being at risk for complications related to deficit. Continued review of the Care Plan revealed Resident #1 needed/required assistance with transfers. Interventions included "remind resident to request assistance prior to ambulation and/or transfers" and "staff to assist with transfers as needed". Further review of the Care Plan revealed no documented evidence to reflect the resident's specific abilities or deficits related to transfers, toileting and the use of the call light. Interview with the MDS Coordinator, on 06/28/12 at 3:45 PM, revealed she had completed the admission MDS Assessment for Resident #1. She stated the resident required extensive assist with transfers, ambulation, toileting and hygiene at the time of the assessment. She stated the resident didn't always remember to ring the call light; therefore, an intervention for staff to remind the resident to use the call light was added to the care plan. Continued interview revealed, based on the MDS Assessment and the Care Plan, the resident would not be able to sit on the commode alone and it could not be assured the resident would remember to use the call light for assistance. Review of the Occupational Therapy Discharge Summary, dated 01/06/12, revealed Resident #1 had reached his/her maximum potential. Continued review revealed the initial plan for the resident to return to the assisted living facility was no longer practical as the resident continued to require more assistance than that facility could provide. It was determined the resident would remain in the long-term care facility due to the continued need for assistance with activities of daily living (ADLs) and the resident required minimum to close supervision related to problem-solving abilities. Interview, on 06/28/12 at 4:05 PM, with the Occupational Therapist who completed the discharge summary, revealed the resident was discharged from Occupational Therapy due to a lack of continued progression. She stated the resident had "plateaued", i.e. maximum potential had been reached. She clarified, "maximum potential did not mean independent". Continued interview revealed the Therapist had always stayed with the resident in the bathroom, as the resident could be impulsive with standing. Further interview revealed Resident #1 did not always exhibit adequate judgment and safety awareness. The Therapist stated her main concern was the resident's fluctuating cognitive status throughout the day, and from day to day. Review of the Physical Therapy Discharge Summary, dated 01/06/12, revealed Resident #1 was discharged from the service due to "highest practical level achieved". Continued review revealed the resident had no measurable improvement in lower extremity strength after four (4) weeks of therapy. In addition, although the resident increased his/her time to remain standing, balance was only fair with bilateral upper extremity support. Further review of comments related to ambulation revealed the resident dragged her right foot, constantly swayed from the line of progression, and was a high fall risk without assistance. (The line of progression refers to the resident's ability to move forward in a straight line.) Review of the Restorative Nursing Program for Ambulation notes, dated 01/10/12, revealed Resident #1 required minimal assistance during ambulation, including verbal and tactile cues to maintain the line of progression. In addition, the resident was noted to have fair balance. Review of the nursing Weekly Summary, dated 01/11/12, revealed Resident #1 had short- and long-term memory problems and required limited assistance with transfers and toileting. Review of the Daily Skilled Nurses' Notes revealed Resident #1 exhibited impaired decision making and disorganized thinking daily from 01/07/12 through 01/12/12. Continued review revealed the resident exhibited disorganized thinking on 01/13/12 and impaired decision making on 01/14/12. Daily notes for 01/15/12 through 01/18/12 were not present. Review of the nurses' note, dated 01/18/12 at 2:30 PM, revealed Resident #1 was found in the bathroom floor. The resident's right ankle appeared to be swollen and the decision was made to transfer the resident to the emergency room for an evaluation. Continued review revealed the nurse documented, on 01/19/12 at 6:00 AM, the resident had been admitted to the hospital due to a fractured ankle. Further review of a "Late Entry", dated 01/24/12 (no time noted), revealed the nurse documented the Certified Nursing Assistant (CNA) had taken the resident to the bathroom and instructed Resident #1 to ring the call light when finished. The nurse further documented the resident was non-compliant and attempted to return to bed without calling for assistance. A subsequent "Late Entry" note dated 01/24/12 was written by the former Director of Nursing (DON). She documented she sat with the resident after the fall while waiting the arrival of the ambulance. Continued review revealed the resident stated he/she wanted to prove to everyone he/she could do it alone. The CNA who left the resident in the bathroom before the fall on 01/18/12 was identified, but was no longer employed at the facility. Multiple attempts to contact the CNA for interview were unsuccessful. Interview with CNA #3, on 06/20/12 at 1:30 PM, revealed she had left Resident #1 alone in the bathroom before. She further stated the resident could use the call light. Continued interview revealed a CNA, on 01/18/12, had reported Resident #1 was in the bathroom and to watch for him/her. Further interview revealed the aide did not know how long the resident was in the bathroom before she heard a scream coming from the room. She stated she entered to find the resident on the floor and noted the ankle was twisted in a way it shouldn't be. She further stated the resident's call light was not on. Interview with CNA #1, on 06/20/12 at 1:02 PM, revealed Resident #1 knew how to use the call light and could be left alone and instructed to pull the cord. Continued interview revealed the CNA responded to the call light in the resident's bathroom on 01/18/12 and found the resident was in the floor and another CNA was present. He stated he did not know who rang the call light. He further stated the resident's foot was at an angle and the two (2) CNAs and a nurse picked the resident up and placed him/her in the wheelchair. Interview with Licensed Practical Nurse (LPN) #6, on 06/19/12 at 3:05 PM, revealed she did not know how the resident got into the bathroom. She stated she heard one of the aides took the resident. She further stated the aide would have instructed the resident to use the emergency light, but did not know if the resident used it or not. Continued interview revealed the resident stated he/she did not use the call bell and tried to get up without assistance. Interview with the Administrator, on 06/20/12 at 1:25 PM, revealed Resident #1 required one-person assist for transfers and toileting. She stated the resident had improved in physical and cognitive abilities since admission. She further stated an aide assisted the resident to the bathroom and told one of the other aides the resident was on the toilet. Further review of the clinical record revealed the nurses' notes from 01/15/12 to 01/18/12, the day of the fall, could not be located by the facility. In addition, the facility could not provide the incident report, fall investigation or statements from staff related to the fall. Interview with the Administrator, on 06/28/12 at 4:40 PM, revealed the facility had completed the missing documents. She stated she believed all documentation related to the incident were together in a file, which had been misplaced. Review of the admitting hospital History and Physical, dated 01/19/12, revealed Resident #1 sustained a bimalleolar fracture to the right ankle. The resident was admitted and a surgical consult was obtained. Review of the Operative Report, dated 01/19/12, revealed Resident #1 underwent an Open Reduction and Internal Fixation (ORIF) of the right bimalleolar fracture. (An ORIF is a surgical procedure that includes the use of pins and screws to repair the fractured bone.) Further record review revealed Resident #1 returned to the facility on [DATE]. Interview with the Director of Nursing (DON), on 06/28/12 at 6:37 PM, revealed she was not employed by the facility at the time Resident #1 fell , and was not familiar with the resident's physical and cognitive status at that time. She stated she had looked, but been unable to find, the nurse's notes for 01/15 to 01/18/12. Interview with the Administrator, on 06/28/12 at 7:55 PM, revealed Resident #1 had used the call light in the past, before the fall. Continued interview revealed she had been unable to locate the file containing the Daily Skilled Nurse's Notes, incident report, fall investigation and staff interviews obtained after the incident.

Based on observation, interview, and record review (of Centers for Disease Control and Prevention(CDC) guidelines, manufacturer's instructions, and the facility's policy and procedure,) it was determined the facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection as evidenced by the facility's failure to ensure staff properly disinfected shared blood glucose monitors after each use and failed to ensure staff was knowledgeable related to the facility's policy regarding blood glucose monitor cleaning. This affected two (2) sampled residents (Resident #1 and #3) and twenty-one (21) unsampled residents, out of a selected sampled of twenty-three (23) residents. On 01/25/11, facility staff was observed using a blood glucose monitor to test Residents #1 and #3's blood sugar levels without disinfecting the device between each use. The facility identified twenty-three (23) residents, who require blood glucose monitoring for which this failure has a likelihood to affect. Additionally, staff failed to adhere to infection control practices with hand washing for Resident #6. The failure of the facility to ensure proper infection control practices were followed, placed residents in the facility at risk for serious harm, injury, impairment or death. Immediate Jeopardy was identified on 01/25/11 and was removed on 01/27/11, after an acceptable Credible Allegation of Compliance (AoC) was received. Further observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy. The facility remained out of compliance at a lower scope and severity of and "E", a pattern deficiency with potential for more than minimal harm, for all residents with a [DIAGNOSES REDACTED]. The findings include: 1. Review of the Centers for Disease Control and Prevention details if blood glucose meters are shared, the device should be cleaned and disinfected after every use. Review of the facility policy, Glucometer-Cleaning, Cleaning of Equipment in Personal Contact, dated 08/2010, revealed: "clean medical device surfaces when visible blood or bloody fluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material before disinfection; if no visible organic material is present, disinfect the exterior surfaces after each use using a cloth or wipe with either an EPA-registered detergent/germicide with a tuberculoid or HBV/HIV label claim, or a dilute bleach solution of 1:10 to 1:100 concentration; disinfect according to guidelines provided by the manufacturer in relation to product kill time...; wipe dry or allow to air dry between cleaning and between each patient ..." Review of the blood glucose monitor manufacturer's instructions revealed that the blood glucose monitor should be cleaned between each use. Observation, on 01/25/11 at 4:10 PM, revealed Licensed Practical Nurse (LPN) #1 went into the room of Resident #1 and Resident #3 with a caddy that contained a blood glucose monitor, alcohol preps, lancets, cotton balls, and test strips. LPN #1 was observed testing the blood sugar for Resident #1. After she completed the blood sugar testing, she went to Resident #3 and completed a blood sugar test with the same monitor. Observation revealed she did not clean the monitor between Resident #1's test and Resident #3's test. Interview with LPN #1, on 01/25/11 at 4:20 PM, revealed she had completed a total of five (5) residents' blood glucose tests, three other residents prior to the observation of Resident #1 and Resident #3. She stated she cleans the monitor with alcohol after she has completed the glucose tests for all the residents. Interview with LPN #2, on 01/25/11 at 4:05 PM, revealed she used alcohol preps to clean the monitor between resident use. Interview with Registered Nurse (RN) #1 on 01/25/11 at 4:20 PM, revealed she used alcohol preps to clean the monitor between resident use. On 01/25/11 at 4:45 PM, observation of the caddies the facility provided for the blood glucose monitor and supplies on both units revealed no evidence the bleach wipes were available. On 01/25/11 at 4:45 PM, observation of the medication rooms on both units revealed no evidence the bleach wipes were available. Record review revealed the facility trained staff on the Cleaning of Equipment in Personal Contact policy in 09/2010, and the three licensed staff (LPN #1, #2 and RN #1) had attended the training. However, interview and observation revealed staff did not follow the facility's policy as evidenced by not cleaning the device after each resident use and the type of disinfectant used. On 01/25/11 at 4:30 PM, the Director of Nursing revealed it was the facility's policy to clean the monitors between each resident use with bleach wipes. She further stated she was unaware staff was not using the bleach wipes to clean the monitors and was unaware staff was not cleaning the glucose monitors after each use. She stated cleaning the monitors with alcohol was unacceptable. She further revealed the facility had no system in place to monitor staff to ensure they were following the Cleaning of Equipment in Personal Contact policy. 2. Review of the facility's Handwashing/Hand Hygiene policy (revised June 2010) revealed staff were to wash their hands prior to donning gloves and after removing gloves. Review of the Personal Protective Equipment (PPE) -Using Gloves Policy (revised August 2009) revealed sterile gloves were to be used for invasive procedures and to decrease the risk of infection when changing dressings. Review of the the facility's Dressing, Dry/Clean Policy (revised August 2009) revealed staff should clean the bedside stand, establish a clean field, and place clean equiptment on the bedside stand. Wash and dry hands thoroughly, put on clean gloves, remove the soiled dressing then pull glove over dressing and discard into plasic or biohazard bag. Hands should then be washed and dried thoroughly and apply clean gloves prior to cleaning and dressing the wound. Using a separate gauze for each cleansing stroke, the wound was to be cleansed from the least contaminated area to the most contaminated area (usually from the center outward). Dry gauze was to be used to pat the wound dry. Record review revealed Resident #6 was diagnosed with [REDACTED]. Review of the Physicians Orders, dated 01/21/11, revealed dressing changes were to be performed every day. On 01/26/11 at 2:15 PM, observation revealed gowns, gloves, and masks were in the hall, in a container beside the resident's door. Observation of the dressing change and skin assessment for Resident #6, on 01/26/11 at 2:15 PM, revealed Registered Nurse (RN) #2 did not use sterile gloves during the dressing change as per the facility's policy. The nurse poured Normal Saline (NS) into the wound and placed gauze in the wound (2 times, used her hand) to absorb the NS then proceeded to measure the wound without changing gloves. The RN wiped the wound with NS-soaked gauze by holding the gauze in her hand. The RN did not use forceps or separate the gauze for each cleansing stroke. The nurse also did not clean the wound from least contaminated to most contaminated. The RN then held gauze in her hand while they poured Dakins solution on the gauze and packed the wound with the gauze using a Q-tip. The nurse touched the cotton of the Q-tip prior to packing the wound. Interview, on 1/27/11 at 3:30 PM with RN #2, revealed she was unaware that she didn't follow protocol/policy. The nurse then proceeded to explain how she should have performed the dressing change. She stated she thought nurses sometimes forget the proper procedures and thought all nurses there needed to have a refresher course. Interview, on 01/27/11 at 5:20 PM with the Director of Nursing (DON), revealed they will re-educate staff about infectious diseases, dressing changes, proper handwashing, PPE disposal, PPE use, finger sticks, glucometer use. Further interview revealed the facility would audit for compliance with PPE for 1 week and then will perform random audits of PPE compliance. The Administrator and the DON were notified on 01/26/11 at 4:45 PM that Immediate Jeopardy (IJ) was determined to exist. The facility provided an acceptable Credible Allegation of Compliance (AoC) on 01/27/11 at 9:15 AM, that alleged removal of the IJ, effective 01/27/11, based on the following correction: 1) Glucose monitors were cleaned immediately upon identification of the concern per facility policy. 2) The Medical Director was notified of the concern and gave orders to obtain an acute Hepatic Panel and CBC (Complete Blood Count) on all residents who received blood glucose monitoring. 3) The licensed staff identified as not correctly cleaning the monitors were counseled and re-educated by the DON regarding the requirement of appropriate cleaning of the monitors with bleach wipes prior to use, between residents, and after use as per facility policy. 4) Licensed staff, assigned to perform blood glucose monitoring were re-educated on how and when to clean the monitors, by Nursing Administration and performed a return demonstration/competency evaluation. 5) On 01/26/11, Nursing Administration performed a 100% audit (by direct visual observation and utilization of a written audit tool) of the resident population who received blood glucose monitoring for compliance to ensure staff were correctly cleaning the monitors per the facility's policy. 6) The facility placed the bleach wipes in each caddy used for blood glucose monitoring and at each nurses' station. Staff were educated on the location of extra disinfectant as well. 7) To assure compliance with the facility's policy, Nursing Administration would monitor performance through direct observation and supervision daily on all three (3) shifts. 8) A Quality Assurance Committee meeting was held on 01/26/11 regarding the plan to ensure appropriate cleaning of blood glucose monitors. The policy and procedure was reviewed and accepted. On 01/27/11, it was verified the immediacy of the IJ was removed and the facility had implemented corrective actions as alleged in the AoC, effective 01/27/11, based on the following: Observation of the blood glucose monitoring rounds on 01/27/11 at 3:40 PM, revealed LPN #2 cleaned the blood glucose monitor with Dispatch bleach wipes before and after performing the finger stick blood sugar on each resident, as per facility policy. Observation further revealed the Unit Manager observed the rounds for compliance. Interview with LPN #2, on 01/27/11 at 3:45 PM, revealed she was aware of the policy and had been educated on the proper cleaning of the monitors before and after each use with Dispatch bleach wipes. Interview with the Unit Manager, on 01/27/11 at 3:50 PM, revealed she was observing for compliance with the facility's policy on cleaning the monitors with Dispatch bleach wipes before and after each use. She stated she would complete the audit form and report to the Administrator. Observation of the blood glucose monitoring rounds, on 01/27/11 at 4:00 PM, revealed RN #3 cleaned the blood glucose monitor with Dispatch bleach wipes before and after performing the finger stick blood sugar on each resident, as per facility policy. Observation further revealed the DON observed the rounds for compliance. Interview with RN #3, on 01/27/11 at 4:05 PM, revealed she had been educated on the facility policy related to the proper cleaning of the monitors with Dispatch bleach wipes before and after each use. Interview with the DON, on 01/27/11 at 4:10 PM, revealed she was observing for compliance with the facility's policy on cleaning the monitors with Dispatch bleach wipes before and after each use. She stated she would complete the audit forms and report to the Administrator. Observation of the blood glucose monitoring rounds, on 01/27/11 at 10:55 AM, revealed LPN #4 cleaned the blood glucose monitor with Dispatch bleach wipes before and after performing the finger stick blood sugar on each resident, as per facility policy. Observation further revealed the DON observed the rounds for compliance. Interview with LPN #4, on 01/27/11 at 10:55 AM, revealed she had been educated by the facility on proper cleaning of the blood glucose monitors as per the facility's policy. She stated that monitors should be cleaned with Dispatch bleach wipes before and after each use. Interview with the Unit Manager, on 01/27/11 at 11:00 AM, revealed she was observing for compliance with the facility's policy on cleaning the monitors with Dispatch bleach wipes before and after each use. She stated she would complete the audit form and report to the Administrator. Review of the residents' records revealed the Hepatic Panels and CBCs were completed for all residents with Diabetes Mellitus on 01/26/11, as ordered. On 01/27/11, a review of the education documentation revealed the facility had conducted education and competency testing on all licensed staff. A review of the monitoring forms confirmed the facility had conducted monitoring on 01/26/11 and 01/27/11, as planned. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm, for all residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review it was determined the facility failed to administer the infection control program in a manner that maintained an ongoing effective facility-wide infection prevention and control program that 1) provided on going surveillance and monitoring to ensure staff was following the facility's policy, 2) trained staff on preventing the spread of infectious diseases by appropriate cleaning/disinfecting blood glucose monitors, and 3) designated an infection control nurse to conduct process and outcome surveillance system, in monitoring staff practices that related to dressing changes and blood glucose monitor maintenance. The failure of the facility to ensure proper infection control practices were followed, placed residents in the facility at risk for serious harm, injury, impairment or death. Immediate Jeopardy was identified on 01/25/11 and was removed on 01/27/11, after an acceptable Credible Allegation of Compliance (AoC) was received and further observations, in-service record reviews and staff interviews were conducted to verify removal of the jeopardy. The facility remained out of compliance at a lower scope and severity of "E", a pattern deficiency with potential for more than minimal harm, for all residents with a [DIAGNOSES REDACTED]. The findings include: 1. Based on observation, interview, and record review (of Centers for Disease Control and Prevention(CDC) guidelines, manufacturer's instructions, and the facility's policy and procedure,) it was determined the facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection as evidenced by the facility's failure to ensure staff properly disinfected shared blood glucose monitors after each use and failed to ensure staff was knowledgeable related to the facility's policy regarding blood glucose monitor cleaning. This affected two (2) sampled residents (Resident #1 and #3) and twenty-one (21) unsampled residents, out of a selected sampled of twenty-three (23) residents. On 01/25/11, facility staff was observed using a blood glucose monitor to test Residents #1 and #3's blood sugar levels without disinfecting the device between each use. The facility identified twenty-three (23) residents, who require blood glucose monitoring for which this failure has a likelihood to affect. Additionally, staff failed to adhere to infection control practices with hand washing for Resident #6. 2. Review of the Infection Control Policy and Procedure for the facility, revealed the facility should have an Infection Control Coordinator, in conjunction with the Quality Assessment and Assurance Committee to be responsible for keeping the infection control program and practices current. Review of the Infection Control Coordinator Policy revealed the Coordinator was responsible for monitoring of the facility's established infection control policies and practices. Interview with the Director of Nursing (DON)/Infection Control Coordinator, on 01/25/11 at 4:45 PM and again on 01/27/11 at 6:15 PM, revealed she had conducted in-services training for all licensed staff in 09/2010 on the Cleaning of Equipment in Personal Contact policy, to include disinfecting the exterior surfaces of blood glucose monitors with a dilute bleach solution of 1:10 to 1:100 concentration after each use. Interview further revealed she had not conducted any surveillance or monitoring to ensure staff was following the policy and was unaware the bleach wipes were not being utilized by the facility staff during blood glucose monitoring. She further stated the facility could do better on monitoring and should have been conducting audits and competencies for staff. Interview with the Administrator, on 01/27/10 at 7:00 PM, revealed she did not know why the staff was not following the policy because they had been educated in 09/2010. She stated the facility did not have an Infection Control Committee, and even though the DON had conducted education the facility had not completed follow-up and monitoring. She further stated the infection control program needed more focus on prevention and surveillance.