Every finding on record at Menifee Meadows Nursing & Rehab LLC

Based on observation, interview, record review and facility policy, the facility failed to review and revise the comprehensive care plan for 2 of 13 sampled Residents (R). (R14 and R26). Review of the facility policy titled Comprehensive Care Plans not dated, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical nursing, and mental and psychosocial needs and all services that were identified in the resident's comprehensive assessment and meet professional standards of quality.Observation on 03/03/2026 at 11:49AM revealed Resident (R) 14 wearing a soft helmet, that strapped under the chin.Review of R14's face sheet revealed Resident was admitted on [DATE] with diagnoses of Dementia with behavioral disturbance, major depression, and anxiety.Review of R14's Quarterly Minimum Data Set with as Assessment Reference Date (ARD) of 02/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated R14 was severely cognitively impaired.Review of R14's Care plan revealed a focused care area for falls, initiated on 01/14/2022 and last revised on 01/08/2026 for Physical Therapy but no intervention that included use of the soft helmet or interventions for maintenance of the soft helmet.During an interview on 03/04/2026 at 10:30 AM with R26, she stated she was upset during her shower on 03/03/2026 because it took longer than normal and she became short of breath. She further stated her regular State Registered Nurse Aide (SRNA) was very fast and could take her to the shower without taking the oxygen with her.Review of R26's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia and anxiety. Review of R26's Physician Orders revealed an order dated 03/04/2026 for Oxygen at three liters per minute (LPM) per nasal cannula, continuous, may use humification for comfort every shift.Review of R26's Kardex revealed no direction for Oxygen use for the SRNA's to follow.Review of R26's Care plan revealed a focus area for altered respiratory status and oxygen to be applied as ordered but no specific interventions for times when/if oxygen could be removed.During an interview on 03/05/2026 at 1:39 PM with SRNA 3 he stated he was the staff who bathed R26 on 03/03/2026. He stated he did not recall R26 stating she felt short of air. SRNA 3 further stated he did not take any portable oxygen in the shower room during the shower but stated if R26 had told him she was short of air he would have went to storage and gotten a portable tank of oxygen. During an interview on 03/05/2026 at 3:43 PM with the Director of Nursing (DON) she stated she was responsible for updating resident care plans. She stated she had failed to add the intervention on R14's care plan for the padded helmet as well as specific times if any that R26 could be without her oxygen that was ordered around the clock. The DON stated R26 should have a portable oxygen tank available at all times even when in the shower room. She further stated the padded helmet was not required to have a physician order due to it was a nursing intervention. During an interview on 03/05/2026 at 2:55 PM with Licensed Practical Nurse (LPN) 1 she stated R26 should not go without her oxygen ever. She further stated the oxygen was ordered at all times. LPN stated the oxygen should be available at all times and while in the shower room the portable oxygen should be available.During an interview on 03/05/2026 at 4:00 PM with the Nurse Practitioner (NP) she stated her expectation was for R26 to have oxygen available and near her at all times. NP stated she was aware R26 removed her oxygen at will, but with the diagnoses of R26 the oxygen should be near at all times.

Based on observation, interview, record review and facility policy, it was determined the facility failed to keep portable Oxygen available for a Resident that required continuous Oxygen during the shower. Resident 26 stated she became short of breath and upset during her shower on 03/03/2026. No portable tank was available in the shower room.Review of the facility policy titled Oxygen Administration, not dated, revealed Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further stated Oxygen is administered under orders of a physician, except in the case of and emergency. Review of R 26's face sheet revealed she was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute on Chronic Respiratory Failure with Hypoxia, and Congestive Heart Failure. Review of R26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2026 revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated R26 had moderate cognitive impairment. Review of R26's Physician Orders revealed an order dated 03/04/2026 for Oxygen at 3 Liters per minute (LPM) every shift.Review of R26's Care Plan revealed a Focus for Altered Respiratory status related to COPD. Respiratory failure, and shortness of breath, initiated on 08/03/2023. The goal indicated R26 would maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date of 02/26/2026. Interventions included applying oxygen as ordered, revised on 05/02/2025. Review of R26's Kardex revealed no documentation or direction for the Skilled Registered Nurse Aide's (SRNA's) regarding oxygen.During an interview on 03/03/2026 at 10:30 AM with Resident (R) 26 she stated she became upset during her shower earlier in am. R26 further stated the shower took longer than usual and she became short of breath. She stated there was no portable oxygen available in the shower room for use.During an interview on 03/05/2026 at 1:39 PM with Skilled Registered Nurse Aide (SRNA)3 he stated he was the staff that showered R26 on 03/03/2026, he stated he did not notice R26 short of air and does not require her saying she was short of air. SRNA3 further stated if R26 had stated she was short of air he would have obtained a portable oxygen tank that she could utilize during the shower. Additionally, SRNA3 stated he was not aware of how the oxygen was specifically ordered for R26.During an interview on 03/05/2025 at 3:43 PM with the Director of Nursing (DON) she stated if the physician order was for oxygen continuous every shift, then the resident should keep the oxygen on at all times. She stated her expectation was for the staff to have the oxygen readily available and encourage resident to use at all times.During an interview on 03/05/2026 at 4:00 PM with the Nurse Practitioner she stated her expectation was for R26 to wear the oxygen at all times. NP stated she did realize R26 was very independent and refused to keep oxygen on at times while ambulating to the bathroom but expected the oxygen be available at all times near R26.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food in a sanitary manner and in accordance with professional standards for food service safety. During initial tour, Cook1 was observed prepping food and moving about in the kitchen production area without wearing a proper beard protector to ensure complete coverage of his facial hair. Continued observation during the tour revealed dietary equipment such as the stove top surface/back-splash, grease trap, and convection oven were dirty/soiled and in need of cleaning. This failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's [NAME] Report, last updated 12/15/2024, revealed 52 of 52 residents received their food from the kitchen. 1. Review of the facility's Prevention of Foodborne Illness/Infection Control policy, revised date on 02/14/2024, revealed it is the policy of the facility that the Food and Nutrition Department observe strict procedures to prevent foodborne illness and the spread of infectious disease. The purpose of the policy was to ensure that staff were aware of their responsibility such as with personal hygiene to prevent the spread of foodborne illness and utilize the required infection control practices in all food service areas to maintain a clean and sanitary condition. Per the policy, hair nets and beard nets must be worn at all times. Further, per the policy, education and in-service training of food and nutrition staff at a minimum included topics such as personal hygiene and proper hand washing, causes of foodborne illness, cleaning of equipment and utensils, sources and transmission of infections and the use of plastic gloves were required to be included in annual training. a. During initial tour with the Dietary Manager (DM) on 12/17/2024 at 10:39 AM, A Shift Cook1 (SC1) was observed prepping food and moving about in the kitchen production area without wearing a proper beard protector to ensure complete coverage of his facial hair. b. During observation of the kitchen on 12/17/2024 at 10:54 AM, the Maintenance Director was observed standing beside SC1 at the prep station without wearing proper mustache/beard protector. During an interview on 12/17/2024 at 10:40 AM, with SC1, he stated it would be important to cover all hair, including facial/beard hair to prevent contamination of hair from getting into the food. During an interview on 12/17/2024 at 10:55 AM, the Maintenance Director stated he was aware that beards must be covered and protected, but not a mustache. However, he felt it would be important to ensure all facial hair was covered to prevent cross contamination and hair particles from getting into the food. During interview on 12/17/2024 at 11:00 AM, the Dietary Manager (DM) stated staff were to have all hair covered, when staff entered the kitchen and all their hair was to be secured under the hairnet throughout the kitchen and in the food production area. She stated it was important to wear a hairnet to prevent contamination from occurring with the food. 2. Review of the facility's Kitchen/Food Service Area Cleaning and Sanitary Standards policy, revised on 02/14/2024, revealed it is the purpose of the facility to practice sanitation standards as set forth for the delivery of food and nutrition services. Per the policy, general cleaning revealed the food and nutrition staff would use the Dietary Cleaning Schedule (Attachment #1) for general cleaning of the kitchen area. Further, per the policy, tasks were assigned on specific days of the week and staff were required to sign the schedule as tasksweare performed. Tasks assigned to the Dietary [NAME] included to wipe down all surfaces which included tables (tops and bottom); shelves, sinks, serving line and microwave oven, after each use and at the end of each shift. In addition, Grill [NAME] tasks included to follow a cleaning schedule on a daily basis. The grill cook was also assigned to clean doors and windows in the dietary department. a. During initial tour of the kitchen on 12/16/2024 at 10:58 AM, the stove top surface was dirty with grease stains and the back splash was noted with blackened grease-stained smears and dried food particles. Continued observation revealed two large areas of burnt, dried food substance and particles with scattered debris in the grease trap. b. Continued observation during the initial kitchen tour, on 12/16/2024 at 11:06 AM, revealed the convection oven glass double doors contained a thick blackened stained appearance inside and out. Observation of the inside stove revealed an approximate one-fourth inch thick, build-up of a gritty-greased, blackened substance that covered the entire bottom shelf. Review of the facility's Attachment #1 Daily Dietary Cleaning Schedule revealed the A shift cook dietary staff was required to ensure equipment such as the stovetop was clean, and the B shift cook was also to ensure equipment such as the stovetop was clean. However, the cleaning schedule did not include that the stove top backsplash, grease trap, and/or convection oven were scheduled to be cleaned. During an interview on 12/17/2024 at 11:10 AM, the A Shift Aide (SA1), stated she thought she cleaned the stove top, backsplash, and grease trap off yesterday; however, it sure didn't look like it today. SA1 could not recall the last time the oven had been cleaned and checked off. During an interview on 12/17/2024 at 11:12 AM, with the DM, she stated all the heavy equipment was to be cleaned throughout the day on both shifts and after each use. However, the DM was not able to convey a past cleaning schedule for the heavy equipment such as the stove and convection oven. The DM stated that due to its appearance, the DM felt it had not been cleaned per the facility's cleaning schedule. The DM asked SA1 during the survey team's observation of the kitchen as to when the last time she had cleaned the stove and grease trap, and SA1 stated she thought yesterday, but was not definite. During an interview on 12/18/2024 at 11:48 AM, with Shift [NAME] 2 (SC2), she stated it was important to sanitize the kitchen area, as well as all the cooking equipment to prevent residents and staff from getting sick and to prevent cross contamination. SC2 also stated she was not sure the last time the oven had been cleaned. Continued interview on 12/19/2024 at 2:35 PM, with the DM (who toured with the survey team), revealed each kitchen staff member was responsible for cleaning the kitchen areas which included the heavy equipment such as the stove and oven to include the entire surfaces, handwashing station, prep stations, surfaces, and floors between equipment, under the equipment and around the equipment in their work area every day and after each meal. Continued interview revealed she recently, just this week, initiated an updated Shift A/B cleaning schedule that included heavy equipment such as the stove and convection oven for all staff; however, she indicated the need to start a closer tracking system to monitor and audit the checklist and the equipment to ensure staff were cleaning the cooking equipment after each meal service and shift. Per interview, she relied on all dietary staff to ensure the kitchen was clean, sanitary and a safe environment.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure each resident's environment was free from accident hazards as possible and each resident received adequate supervision to prevent accidents for two (2) of five (5) sampled residents (Residents #5 and #25). 1.On 06/03/2023, Resident #5 lowered his/her bed and had fallen onto the floor and told staff he/she did not want to bother staff. Review of the resident's Comprehensive Care Plan, revised 08/22/2018, revealed staff were to monitor the resident frequently for safety needs as the resident frequently attempted to get up per self. Review of the resident's Electronic Medical Record revealed no documentation to support the resident was provided increased supervision, to monitor for his/her safety needs. Subsequently, on 07/15/2023 Resident #5 was found on the floor with a large amount of blood by his/her head. The resident was transferred to the Hospital emergency room (ER) and was treated for a C1 spinal fracture, head laceration, and a displaced fracture of the proximal left index phalangeal. 2. On 07/14/2023 at 4:25 PM, Resident #25 had an unwitnessed fall. The resident was care planned for staff to provide increased supervision and know the whereabouts of the resident. Staff failed to implement the resident's care plan and the resident experienced a second (2nd) unwitnessed fall on the same day at 6:54 PM, which resulted in an abrasion on both resident's knees and a red area to the bony prominence of the resident's right shoulder. Additionally, the facility failed to monitor for the effectiveness of the interventions that were previously care planned, as per the facility's falls policy, to prevent the reoccurrence of falls. (Refer to F656) The findings include: Review of the facility's policy titled, Accidents and Supervision, revised on 01/28/2023, revealed the resident's environment would remain as free of accident hazards as possible and each resident would receive adequate supervision and assistive devices to prevent accidents. Continued review revealed this would include identifying hazard(s) and risk(s), evaluating and analyzing hazards(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for the effectiveness and modifying interventions when necessary. Review of the facility's policy titled, Fall Prevention Management, last reviewed on 03/07/2023, revealed it was the facility's policy to minimize the risk of serious injury, recognize the risk/causes of falls, and implement fall prevention management interventions to achieve best practice standards of care. Further review of the policy revealed a fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface. A continued review of the policy revealed necessary interventions would be added to prevent the recurrence of a fall. Further, the facility would determine the root cause of the fall using the five (5) Whys Tool for Determining the Root Cause Analysis. The policy further stated staff was to complete the incident report under risk management, complete each section of event documentation (associated vital signs, orders, additional progress notes, etc.), and update the plan of care as needed. 1. Review of Resident #5's Admission Record revealed the facility admitted the resident on 08/08/2018 with diagnoses to include: Parkinson's Disease, Hypertension, Seizures, and Chronic Pain Syndrome. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required one (1) person for physical assist with supervision and oversight. Continued review revealed the resident was not steady, only able to stabilize with human assistance, when surface-to-surface transfer between bed, chair, or wheelchair. An additional review of the MDS revealed the resident had one (1) fall with no injury, since admission or prior assessment. Review of Resident #5's Falls Care Plan, initiated on 03/08/2018 revealed the resident required twenty-four (24) hour supervised/assisted care related to a history of falls: Parkinson's Disease, Alert with episodes of increased confusion noted at times, and Macular Degeneration. The goal was for the resident to maintain his/her highest level of functional ability within a safe environment. The interventions included: keep the environment free of obstruction, monitor frequently for safety needs (frequently attempts to get up per self); alert with confusion, oriented to name only-reorient to place and time; low bed placed in room [ROOM NUMBER]/28/2018; keep call light within reach; encourage to ring for assistance as needed; provide cues/reminders to enhance safety awareness, remind the resident to refrain from getting up by himself/herself; Reacher device provided 03/02/2021; resident educated to ring for assist and not to lean over to pick items up out of the floor; initiated 05/12/2023, per therapy recommendation, resident may have a pillow behind his/her right shoulder as needed, per resident request initiated. Review of Resident #5's post-fall Morse Fall Scale assessment dated [DATE] completed by LPN #4 revealed the facility assessed the resident to be a Moderate Risk for falls. Review of Resident #5's Nursing Progress Note dated 06/03/2023 at 8:50 PM, by Licensed Practical Nurse (LPN) #4 revealed he was called to Resident #5's room by housekeeping staff. Per the Note, the LPN noted the resident was observed sitting on his/her bedside mat, digging through his/her dresser drawers. Upon entering the resident's room, LPN #4 noted that the resident was sitting on the bedside mat with his/her back against his/her bed with multiple coloring books spread out in front of him/her. The resident stated he/she lowered his/her bed down to get to the floor easier. The LPN noted that the resident's call light was pinned to his/her shirt. The LPN added the intervention to reeducate the resident to utilize his/her call light for assistance; however, the LPN failed to implement the resident's care plan which would require staff to monitor the resident frequently for the resident's safety needs, due to the resident's attempts to get up on his/her own. Review of the facility's Fall Review assessment dated [DATE] at 4:50 PM completed by the Resident Care Coordinator (RCC) revealed Resident #5 was found lying on the floor on his/her back. A continued review of the fall review assessment revealed the resident stated he/she leaned too far out of his/her wheelchair. Review of Resident #5's Annual Morse Fall Scale assessment dated [DATE] completed by the Director of Nursing (DON) revealed the resident was assessed to be a High Risk for falls. Review of Resident #5's Nursing Progress Note, dated 07/15/2023 at 6:54 PM, documented by LPN #15 revealed staff called the nurse to the resident's room. The resident was found lying on his/her back on the floor. Further, LPN #15 noted a large amount of blood observed beside the resident. LPN #15 noted she immediately called emergency services. Per the Note, the resident was observed to have sustained a laceration to the left side of his/her forehead. Further, the resident's right knee was swollen, red and abraised, and his/her left knee was observed to be red and abraised. The resident complained of stiffness in his/her neck and pain to the back of his/her neck. Continued review of the Note revealed the resident was alert and vocalized what happened and was aware of his/her situation. Review of Resident #5's Hospital emergency room (ER) Medical Record, dated 07/15/2023 at 6:14 PM, revealed the resident complained of a fall from his/her wheelchair resulting in head and neck trauma. Continued review of the record revealed the resident stated he/she fell while positioning himself /herself in his/ her wheelchair, landing on his/ her head, neck, and bilateral knees. Continued review revealed the resident mainly expressed neck pain, bilateral shoulder pain, and left ear pain. The resident denied having any syncope prior to his/her fall. Further review of the record revealed the resident was diagnosed with a C1 spinal fracture, head laceration, and a displaced fracture of the proximal left index phalangeal fracture. The hospital ER Medical Record revealed the resident was transferred to another hospital on 07/16/2023 for a neurological consult. Review of Hospital #2's Medical Record Summary, dated 07/17/2023, revealed the resident was transferred for a neurosurgical evaluation. Further review revealed no acute neurosurgical intervention was warranted. Continued review of the medical record, revealed the resident obtained a C1 spinal fracture and a left index finger fracture. The resident was to wear a cervical collar, left upper extremity in a gutter splint, non-weight bearing left upper extremity. Resident #5 was discharged back to the facility on [DATE]. Observation of Resident #5 on 07/24/2023 at 1:30 PM revealed Resident #5 was lying in bed. Continued observations revealed the resident had a cervical collar in place, and his/her left forehead had a dried blood area with sutures. Further observations revealed the resident's forehead had greenish/brownish bruising. The resident's left arm was observed to have a splint and an ace wrap from his/her elbow to the tips of his/her fingers. Further observation revealed the resident had on bilateral heel protector boots and no fall mat was noted in the resident's room. During an interview with Resident #5, on 07/26/2023 at 3:50 PM, he/she stated that the day he/she fell , on 07/15/2023, he/she could not recall reaching for an item off the floor. Per the interview, the resident stated that his/her Reacher was on his/her table and within reach. The resident stated he/she thought about his/her fall and was uncertain how the fall occurred. During an interview with Licensed Practical Nurse (LPN) #11, on 07/28/2023 at 9:12 PM, she stated that she observed Resident #5, the day before the fall. She stated she witnessed Resident #5 leaning forward trying to get her Reacher and crayons. LPN #11 stated that the resident normally used his/her Reacher but had pushed himself/herself away from the table and could not reach it that day. Further, she stated the resident's call light was on the bed and unreachable. However, there was no documentation to support the LPN implemented the resident's care plan to provide increased monitoring for the safety of the resident and ensured the resident's call light was within reach, to prevent the resident's reoccurrence of falls. In an interview, on 07/25/2023 at 1:48 PM, with State Registered Nurse Assistant (SRNA) #22, she stated that on the day Resident #5 fell on [DATE]. The SRNA stated she was working on another hall and did not witness the fall. Per the interview, she stated she had taken care of Resident #5 in the past and the resident was known to come close to falling out of his/her wheelchair due to leaning forward often to retrieve items off the floor. Further, the CNA stated the resident did not utilize his/her call light but yelled for assistance. During an interview on 07/24/2023 at 2:40 PM and 07/27/2023 at 12:00 PM with SRNA #26, she stated she was assigned to work with Resident #5 on 07/15/2023, the day he/she fell from his/her wheelchair. She stated that she was passing trays between 4:30 PM-5:00 PM. The SRNA stated she had gone down the hall to assist residents to the community area for dinner when she noted Resident #5 lying on the floor. SRNA #26 stated she went into Resident #5's room and noted a pool of blood on the floor. She stated she immediately yelled for the nurse and went back to the resident. The SRNA stated she stayed with the resident until the nurse arrived. Per the interview, she stated emergency services were called and the ambulance came to transport the resident to the emergency room (ER). The SRNA stated Resident #5 had been sitting in his/her wheelchair earlier that day. She stated she was not aware the resident had previous falls; however, stated that prior to the resident's fall, Resident #5 required two (2) assist to go to the bathroom and could feed himself/herself with set-up. SRNA #26 stated Resident #5 had a history of attempting to get up out of his/her wheelchair without assistance. She stated the resident did not ring his/her call light often. Licensed Practical Nurse (LPN) #15, in an interview on 07/25/2023 at 2:06 PM, stated she worked with a staffing agency. LPN #15 stated that on 07/15/2023 she was at the nurse's station on the south hall when she heard a SRNA (SRNA #26) yell from the doorway for assistance. When LPN #15 entered the room of Resident #5, she stated the resident was observed lying on her/his back on the floor, with a pool of blood next to his/her head. She stated Resident #5 was awake and responded appropriately. LPN #15 stated she asked Resident #5 what had happened, and the resident stated, I'm a klutz. LPN #15 stated she kept Resident #5 talking to her and checked his/her blood pressure only. She stated Resident #5 was very shaky. LPN #15 stated Resident #5 could not recall how he/she fell . At the time of the fall, LPN #15 stated the resident was noted to have a small laceration to his/her left forehead, and his/her knees were red and abraised. The LPN stated the resident was transported to the hospital by way of an ambulance. Review of the facility's Falls investigation, untitled and undated, revealed the resident's fall was on 07/15/2023 at 4:50 PM. Continued review revealed staff were in the process of passing out dinner trays when the resident was observed on the floor of his/her room. Further review of the investigation revealed the root cause of the resident's fall was that he/she was leaning forward in his/her wheelchair and weakness. Immediate interventions that were put in place were to re-educate the resident to use his/her call light, notify staff to assist with picking items from the floor, and to use his/her Reacher as needed. The interventions, however, were care planned for the resident on 03/08/2018 and 03/02/2021. The facility failed to monitor for the effectiveness of the resident's comprehensive care plan to prevent the reoccurrence of falls. Interview on 07/27/2023 at 11:27 AM, LPN #4 stated he completed the fall incident report on 07/15/2023; however, he stated Resident #5's fall happened before he reported to work. LPN #4 stated he received report from LPN #15, who informed him of Resident #15's fall. LPN #4 stated LPN #15 reported to him that Resident #5 fell on [DATE], sometime around 5:00 PM. LPN #4 stated he called the hospital and was informed the resident received a C1 spinal fracture from his/her fall. He stated he contacted the Administrator and the Director of Nursing (DON), at around 10:30 PM on 07/15/2023, and was told to complete an incident report related to the resident's fall. LPN#4 stated it was not unusual for Resident #5 to drop items and lean to pick them up. Per the interview, he stated that on 06/03/2023, one of the housekeepers found Resident #5 on the floor and Resident #5 told him he/she was crawling over to get coloring books and did not want to bother the staff. LPN #4 stated the resident's bed was observed to be in the lowest position with his/her floor mat in place. LPN #4 stated the resident sustained no injuries with that fall, on 06/03/2023. Review of Resident #5's Person-Centered Comprehensive Care Plan revealed the LPN failed to ensure the resident's care plan was implemented to include increased monitoring for the safety of the resident when the resident was found on the floor on 06/03/2023, to prevent the reoccurrence of falls. Further interview with Licensed Practical Nurse (LPN) #4, on 07/27/2023 at 11:27 AM, he stated that Resident #5 had occasional confusion about the days of the week sometimes, but most of the time was alert and oriented. LPN #4 stated the resident's interventions were appropriate for Resident #5. He further stated that staff checked on the residents every hour and every two hours for check and change. LPN #4 stated that ordinarily with a fall during the day, the fall team completed the fall report. Per the interview, LPN #4 stated the protocol was to assess the resident and figure out what happened, determine the root cause, and review the interventions in place. LPN #4 further stated that when an unwitnessed fall occurred, staff must assume the resident hit his/her head. Further, he stated it was the nurse's responsibility to determine the initial root cause of the resident's fall. During an interview with the Director of Rehabilitation, on 07/25/2023 at 1:00 PM, she stated she had been employed with the facility since April of 2023. Per the interview, the Director of Rehabilitation stated Resident #5 had not had a fall since she had started and had been intensively working with the resident, utilizing different devices and techniques to develop his/her skills to allow the resident to become more independent. She stated Resident #5 was in a regular wheelchair with a mid-range back tilt so that the resident's feet could still touch the floor. She stated she had worked on several positioning devices over the past few months to get the resident into a mid-line position. Per the interview, she stated Resident #5's choice was for his/her feet to touch the floor so that he/she was independent with mobility. Further interview with the Director of Rehabilitation, on 07/25/2023 at 1:00 PM, she stated that prior to the resident's fall on 07/15/2023, the resident's activity items (coloring book, sewing items, etc.) were placed at arm's reach. Further, she stated the resident was provided a Reacher in case items were dropped on the floor. The Director of Rehabilitation stated Resident #5 typically leaned to the right side since having a right shoulder injury prior to admission to the facility. She stated Resident #5 had a great deal of difficulty leaning forward and tended to lean back, to his/her right side. Further, she stated she discussed the use of a lap belt with the Interdisciplinary Team (IDT) and facility management but was informed that the use of the lap belt was prohibited as the facility was restraint free. Additionally, the Director of Rehabilitation stated that prior to the resident's fall, the staff utilized a pillow in the resident's wheelchair and placed it on the resident's right side to keep him/her in alignment while sitting. 2. Review of Resident #25's Admission Record revealed the facility admitted the resident on 04/12/2018 with diagnoses of Alzheimer's Disease, Unspecified Dementia with other Behavioral, Psychotic Disorders with Delusions due to known physiological conditions, Adjustment Disorder with Mixed disturbance of emotions and conduct. Review of Resident #25's Annual Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of zero-zero (00), which indicated the resident was cognitively impaired. Further review of the MDS revealed the resident had one (1) fall with injury (except major injury) since Admission and the previous MDS was completed on 03/06/2023. Review of Resident #25's care plan, revised on 07/10/2023, revealed a focus related to the resident's impaired cognitive function/dementia or impaired thought processes related to Dementia. Interventions included: to provide needed assistance with one-to-one activities daily as needed for redirection; and diversion such as read to, talk to, sing to, talk about his/her children or family; increased/close supervision related to diagnosis of Dementia; staff was to monitor for increased supervision/whereabouts; and fifteen (15) minute checks. Review of Resident #25's Nursing Progress Note, documented by Licensed Practical Nurse (LPN) #11, dated 07/14/2023 at 2:26 PM revealed the State Registered Nurse (SRNA) had reported to the LPN that Resident #25 was laying on the floor in a supine position with his/her feet placed in his/her wheelchair seat. Further review revealed the SRNA placed the resident in his/her wheelchair and brought the resident to the nurse's station where the resident continued to lean forward in his/her wheelchair. There was no documentation to support the facility implemented the resident's care plan to know the whereabouts of the resident and increase supervision as the resident had an unwitnessed fall. Review of Resident #25's Nurses Progress Note, dated 07/14/2023 at 4:55 PM, documented by Licensed Practical Nurse (LPN) #15 revealed Resident #25 was found lying on the floor next to the dining room door. A review of the Note revealed an abrasion was noted on both resident's knees and a red area to the bony prominence of the resident's right shoulder. Continued review revealed staff assisted the resident to bed. Interview on 07/25/2023 at 1:48 PM with SRNA #22, on 07/10/2023, she stated she did not witness either incident with Resident #25. The SRNA stated she would only have documented on the fifteen-minute check sheet if the incident happened at that time. The SRNA stated she was checking on the resident every fifteen (15) minutes but stated a lot of things can happen in fifteen (15) minutes. Per the interview, she stated she had other job duties, which included passing trays and assisting other residents with showers. The State Registered Nurse Aide (SRNA) #22 stated she re-directs Resident #25 three to four times daily. SRNA stated she did not believe the fifteen (15) minute checks were working for Resident #25. She stated other interventions that may work for the resident would be to provide one-to-one (1:1) supervision. During an interview on 07/27/2023 at 11:27 AM with Licensed Practical Nurse (LPN) #4 he stated he had done some of the checks on Resident #25. LPN #4 stated every fifteen-minute checks, were not adequate for Resident #25. Per the interview, LPN #4 stated everyone knows to keep an eye on the resident and he/she roams in his/her wheelchair all the time. . During an interview with the Director of Nursing (DON) on 07/28/2023 at 4:50 PM, she stated the facility was a physical restraint-free facility and had been for years. Per the interview, she stated the use of a lap buddy, pelvic belt, seat belt, and chair alarms, were considered restraints and were not considered interventions for Resident #5. Further, she stated the Quality Assurance Performance Improvement (QAPI) Committee met and interventions were discussed with each resident. The DON; however, stated she could not recall specific interventions discussed. The DON stated the facility was working with health care consultants to assist with care plans and appropriate interventions. During an interview with the Interim Administrator, on 07/28/2023 at 10:30 PM, she stated it was her expectation that the nurses, Social Service Director (SSD), and Director of Nursing (DON) would complete the root cause analysis related to the resident's falls. Further, she stated she reviewed all the fall analyses and provided oversight by continuously asking the staff questions regarding any other interventions that could be put into place to prevent the reoccurrence of the resident's falls. She stated the Interdisciplinary Team (IDT) went over further interventions with the Medical Director (MD). A continued interview with the Interim Administrator stated she could not restrain residents, so the discussions have been ongoing about different interventions for wandering residents. The Administrator stated the facility staff discussed engaging the residents with more activities, which would increase the ability of staff to monitor the residents, to keep up with the residents. Regarding Resident #25, the Interim Administrator stated the resident was currently on fifteen (15) minute checks. Per the interview, she stated she would not know what to do for Resident #25, other than increasing the resident's level of supervision to 1:1, adding, I don't know if that would help.

Based on observation, interview, record review, review of the facility's policy, it was determined the facility failed to implement the residents' Comprehensive Care Plan to prevent falls for two (2) of five (5) sampled residents (Resident #5 and #25). 1. On 06/03/2023, Resident #5 lowered his/her bed and had an unwitnessed fall onto the floor and told staff he/she did not want to bother staff. Review of the resident's Comprehensive Care Plan, revised 08/22/2018, revealed staff were to monitor the resident frequently for safety needs as the resident frequently attempted to get up per self. Record Review and interviews with staff revealed they were aware of the resident's behaviors to attempt to get up without staff assistance; however, the resident required the assistance of staff for most of his/her care. The facility failed to ensure the resident's care plan was implemented to provide increased supervision, to monitor for the resident's safety needs. As a result, on 07/15/2023 Resident #5 was found on the floor with a large amount of blood by his/her head. The resident was transferred to the Hospital emergency room (ER) and was diagnosed to have a C1 spinal fracture, head laceration, and a displaced fracture of the proximal left index phalangeal. 2. On 07/14/2023 at 4:25 PM, Resident #25 had an unwitnessed fall. The resident was care planned for staff to provide increased supervision and know the whereabouts of the resident. The resident was care planned for staff to check on the resident every fifteen (15) minutes; however, interviews with staff revealed it was difficult to follow the resident's care plan and they could not always check on the resident within his/her fifteen (15) minute checks. As a result, the resident experienced a second (2nd) unwitnessed fall on the same day at 6:54 PM, which resulted in an abrasion on both resident's knees and a red area to the bony prominence of the resident's right shoulder. (Refer to F689) The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 01/23/2023, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Review of the facility policy titled Accidents and Supervision revised 01/28/2023 revealed: The resident's environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. This would include identifying hazard(s) and risk(s), evaluating, and analyzing hazards(s) and risk(s), implementing interventions to reduce hazard(s), and risk(s), and monitoring for the effectiveness and modifying interventions when necessary. 1. Review of Resident #5's Admission Record revealed the facility admitted the resident on 08/08/2018 with diagnoses to include: Parkinson's Disease, Hypertension, Seizures, and Chronic Pain syndrome. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of Resident #5's Falls Care Plan, initiated on 03/08/2018 revealed the resident required twenty-four (24) hour supervised/assisted care related to a history of falls: Parkinson's Disease, Alert with episodes of increased confusion noted at times, and Macular Degeneration. The goal was for the resident to maintain his/her highest level of functional ability within a safe environment. The interventions included: keep the environment free of obstruction, monitor frequently for safety needs (frequently attempts to get up per self); alert with confusion, oriented to name only-reorient to place and time; low bed placed in room [ROOM NUMBER]/28/2018; keep call light within reach; encourage to ring for assistance as needed; provide cues/reminders to enhance safety awareness, remind the resident to refrain from getting up by himself/herself; and Reacher device provided 03/02/2021. Review of Resident #5's Nursing Progress Note dated 06/03/2023 at 8:50 PM, documented by Licensed Practical Nurse (LPN) #4 revealed he was called to Resident #5's room by housekeeping staff. The LPN noted the resident was observed sitting on his/her bedside mat, digging through his/her dresser drawers. Upon entering the resident's room, LPN #4 noted that the resident was sitting on the bedside mat with his/her back against his/her bed with multiple coloring books spread out in front of him/her. The resident stated he/she lowered his/her bed down to get to the floor easier. Per the note, the resident's call light was pinned to his/her shirt. Review of the resident's Comprehensive Care Plan; however, revealed the LPN failed to implement the resident's care plan which would require staff to monitor the resident frequently for the resident's safety needs, due to the resident's attempts to get up on his/her own. Review of Resident #5's Nursing Progress Note, dated 07/15/2023 at 6:54 PM, documented by LPN #15 revealed staff called the nurse to the resident's room. The resident was found lying on his/her back on the floor. Further, LPN #15 noted a large amount of blood beside the resident. LPN #15 noted she immediately called emergency services. The LPN noted the resident was observed to have sustained a laceration to the left side of his/her forehead. Further, the resident's right knee was swollen, red and abraised, and his/her left knee was observed to be red and abraised. The resident complained of stiffness in his/her neck and pain to the back of his/her neck. Review of Hospital #2's Medical Record Summary, dated 07/17/2023, revealed the resident was transferred for a neurosurgical evaluation. Further review revealed no acute neurosurgical intervention was warranted. Continued review of the medical record, revealed the resident obtained a C1 spinal fracture and a left index finger fracture. The resident was to wear a cervical collar, left upper extremity in a gutter splint, non-weight bearing left upper extremity. Resident #5 was discharged back to the facility on [DATE]. During an interview with Resident #5, on 07/26/2023 at 3:50 PM, he/she stated that the day he/she fell , on 07/15/2023, he/she could not recall reaching for an item off the floor. Per the interview, the resident stated that his/her Reacher was on his/her table and within reach. The resident stated he/she thought about his/her fall and was uncertain how the fall occurred. Interview on 07/25/2023 at 1:48 PM with State Registered Nurse Aide (SRNA) #22 , she stated Resident #5 fell while she was working another hall. The SRNA stated she had taken care of Resident #5 in the past and the resident had come close to falling due to leaning forward often to get items of the floor. SRNA #22 stated Resident #5 did not ring his/her call light often and would yell out for assistance. During an interview with Licensed Practical Nurse (LPN) #11, on 07/28/2023 at 9:12 PM, she stated that she observed Resident #5, the day before the fall. She stated she witnessed Resident #5 leaning forward trying to get her Reacher and crayons. LPN #11 stated that the resident normally used his/her Reacher but had pushed himself/herself away from the table and could not reach it that day. Further, she stated the resident's call light was on the bed and unreachable. However, there was no documentation to support the LPN implemented the resident's care plan to ensure the resident's call light was within reach and that staff was aware the resident leaned forward attempting to reach his/her Reacher and crayons, which would have been a fall risk for the resident and required increased monitoring. During an interview with the Director of Rehabilitation, on 07/25/2023 at 1:00 PM, she stated prior to the resident's fall on 07/15/2023, the resident's activity items (coloring book, sewing items, etc.) were placed at arm's reach. Further, she stated the resident was provided a Reacher in case items were dropped on the floor. The Director of Rehabilitation stated Resident #5 typically leaned to the right side since having a right shoulder injury prior to admission to the facility. She stated Resident #5 had a great deal of difficulty leaning forward and tended to lean back, to his/her right side. Further, she stated she discussed the use of a lap belt with the Interdisciplinary Team (IDT) and facility management but was informed that the use of the lap belt was prohibited as the facility was restraint free. 2. Review of Resident #25's Admission Record revealed the facility admitted the resident on 04/12/2018 with diagnoses of Alzheimer's Disease, Unspecified Dementia with other Behavioral, Psychotic Disorders with Delusions due to known physiological conditions, Adjustment Disorder with Mixed disturbance of emotions and conduct. Review of Resident #25's Annual Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of zero-zero (00), which indicated the resident was cognitively impaired. Review of Resident #25's care plan, revised on 07/10/2023, revealed a focus related to the resident's impaired cognitive function/dementia or impaired thought processes related to Dementia. Interventions included: to provide needed assistance with one-to-one activities daily as needed for redirection; and diversion such as read to, talk to, sing to, talk about his/her children or family; increased/close supervision related to diagnosis of Dementia; staff was to monitor for increased supervision/whereabouts; and fifteen (15) minute checks. Review of Resident #25's Nursing Progress Note, documented by Licensed Practical Nurse (LPN) #11, dated 07/14/2023 at 2:26 PM revealed the State Registered Nurse (SRNA) had reported to the LPN that Resident #25 was laying on the floor in a supine position with his/her feet placed in his/her wheelchair seat. Further review revealed the SRNA placed the resident in his/her wheelchair and brought the resident to the nurse's station where the resident continued to lean forward in his/her wheelchair. Interviews with staff revealed it was difficult to monitor the whereabouts of the resident and complete his/her fifteen (15) minute checks, as care planned. Review of Resident #25's Nurses Progress Note, dated 07/14/2023 at 4:55 PM, documented by Licensed Practical Nurse (LPN) #15 revealed Resident #25 was found lying on the floor next to the dining room door. A review of the Note revealed an abrasion was noted on both resident's knees and a red area to the bony prominence of the resident's right shoulder. Interview on 07/25/2023 at 1:48 PM with SRNA #22, on 07/10/2023, she stated she did not witness either incident with Resident #25. The SRNA stated she would only have documented on the fifteen-minute check sheet if the incident happened at that time. The SRNA stated she was checking on the resident every fifteen (15) minutes but stated a lot of things can happen in fifteen (15) minutes. Per the interview, she stated she had other job duties, which included passing trays and assisting other residents with showers. The State Registered Nurse Aide (SRNA) #22 stated she re-directs Resident #25 three to four times daily. SRNA stated she did not believe the fifteen (15) minute checks were working for Resident #25. During an interview on 07/27/2023 at 11:27 AM with Licensed Practical Nurse (LPN) #4 he stated he had done some of the checks on Resident #25. LPN #4 stated every fifteen-minute checks, were not adequate for Resident #25. Per the interview, LPN #4 stated everyone knows to keep an eye on the resident and he/she roams in his/her wheelchair all the time. During an interview with the Director of Nursing (DON) on 07/28/2023 at 4:50 PM, she stated the Quality Assurance Performance Improvement (QAPI) Committee met and interventions were discussed regarding the care of each. The DON; however, stated she could not recall specific interventions discussed. The DON stated the facility was working with health care consultants to assist with care plans. During an interview with the Interim Administrator, on 07/28/2023 at 10:30 PM, she stated it was her expectation the facility staff would discuss engaging the residents with more activities, which would increase the ability of staff to monitor the residents, to keep up with the residents. Regarding Resident #25, the Interim Administrator stated the resident was currently on fifteen (15) minute checks. Per the interview, she stated she would not know what to do for Resident #25, other than increasing the resident's level of supervision to 1:1, adding, I don't know if that would help.

Based on observation, interview, record review, and the facility's abuse policy, it was determined the facility failed to protect three (3) of five (5) sampled residents from abuse. (Residents #25, #28, and #29). On 07/10/2023, at approximately 2:00 PM, Resident #25 entered Resident #28's room and tried to take Resident#28's baby doll. Resident #28 screamed get out and they began slapping each other. On 07/18/2023, at approximately 2:28 PM, Resident #25 hit Resident #29 in the arm three to four times. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 07/13/2023 revealed, it was the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The definition of abuse per policy was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which included: staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Further review revealed physical abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. Furthermore, the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieved; the identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. 1. Review of the Resident #25's Admission Record revealed the facility admitted Resident #25 on 04/12/2018 with diagnoses that included Alzheimer's Disease, Unspecified Dementia with other behavioral disturbance Psychotic Disorder with Delusions due to known physiological condition, adjustment disorder with mixed disturbance of emotions and conduct. Review of Resident #25's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) which indicated the facility was unable to assess the resident's cognition. Review of Section E. revealed behaviors of physical symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Further review revealed verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), which occurred four to six days of the past fourteen days. Review of Resident #25's care plan revealed a focus of; The resident had impaired cognitive function/dementia or impaired thought processes related to Dementia. Resident #25 had a history of hitting/swatting at other residents at times. The goal was that Resident #25 would maintain his/her current level of cognitive function over the next 90 days. Interventions included: resident needed assistance with one-to-one activities daily as needed for redirection, and diversion such as read to, talk to, sing to, talk about his/her children or family. Further review revealed interventions initiated on 08/04/2020 included: Resident required increased/close supervision related to diagnosis of Dementia. Initiated on 03/05/2023; Resident #25 was placed on 15-minute checks related to an altercation with another resident, staff were to monitor for increased supervision/whereabouts. Interventions initiated on 06/27/2023: Administer medications as ordered; and initiated on 07/10/2023; monitor for safety needs on hourly rounds. Record review revealed on 07/10/2023, Resident #25 entered Resident #28's room and tried to take Resident #28's baby doll. Resident #28 screamed get out and they began slapping each other. Review of the facility's investigation dated 07/10/2023 revealed that SRNA (State Registered Nurse Aide) heard Resident #28 yelling, upon entering the room she noted Resident #25 swatting at Resident #28. Skin assessments were completed by the nurse on both residents with no injuries noted. Resident #28 denied pain. Resident #25 placed on 15- minute checks. The Medical Director (MD) and Power of Attorney (POA) were notified. Review of Resident #25's care plan revealed a focus of; the resident had impaired cognitive function/dementia or impaired thought processes related to Dementia. Resident #25 had a history of hitting/swatting at other residents at times. 07/10/2023, Resident #25 swatted at a resident and hit another resident on the arm. The goal was that Resident #25 would maintain his/her current level of cognitive function over the next 90 days. Interventions included, resident needed assistance with one-to-one activities daily as needed for redirection, and diversion such as read to, talk to, sing to, talk about his/her children or family. Interventions initiated on 08/04/2020 included: Resident required increased/close supervision related to diagnosis of Dementia; on 03/05/2023, Resident #25 was placed on 15-minute checks related to an altercation with another resident, staff were to monitor for increased supervision/whereabouts; on 06/27/2023, Administer medications as ordered and on 07/10/2023; monitor for safety needs on hourly rounds. Review of Resident #28's admission record revealed the facility admitted the resident on 07/10/2019 with diagnoses of dementia without behaviors, anxiety disorder, and mood disorder. Review of Resident #28's Quarterly MDS revealed a BIMS score of 11 which indicated the facility assessed the resident to have moderately impaired cognition. Review of Resident #28's Behavior Care Plan revealed a focus of Resident at risk for altered mood/behavior related to diagnosis of anxiety. Resident has had episodes of being short tempered and episodes of verbal/physical abuse, stating he/she wanted to go home, with periods of agitation. The goal for this focus was that the resident would display a stable mood over the next ninety (90) days. Interventions included administer medication as ordered, monitor for adverse reactions to medication, report abnormal signs/symptoms to MD (Medical Doctor). Assess, monitor, and document any displayed mood/behaviors (i.e., sad effect, restlessness, tearfulness, irritability); Pharmacy to review psychotropic medication use quarterly and as needed; Psych evaluation as needed initiated on 07/11/2019; Social services intervention and 1:1 supervision as needed. Continued review revealed Resident #28 had a history of periods of anxiety, cursing staff, stating he/she was going home, stating call my family, making negative statements. Staff was to provide redirection/reassurance as needed to aid in easing anxiety, encourage involvement/visits/phone calls from family members as needed when resident was upset. Revisions were on 02/24/2023. Review of Resident #28's Progress Note dated 07/10/2023 at 3:02 PM by Licensed Practical Nurse (LPN) #14 revealed she was notified at 12:30 PM by State Registered Nurse Aide (SRNA) #22 that Resident #25 had entered Resident #28's room. Continued review revealed when Resident #28 told Resident #25 to leave, Resident #25 hit Resident #28. Resident#25 was immediately removed from the room and the stop sign was placed back across the doorway. During interview on 07/24/2023 at 2:50 PM with SRNA #25, she stated that she had worked at the facility since February 2022. SRNA #25 stated that on 07/10/2023 when walking by Resident #28's room she heard Resident #25 scream no don't touch my baby. SRNA #25 walked into the room and both Resident #25 and Resident #29 were slapping each other. Resident #28 was upset and saying, You are not taking my baby. SRNA #25 stated she immediately removed Resident #25 from the room and reported to the nurse. The SRNA stated Resident #25 was placed on fifteen- minute checks. SRNA #25 stated the incident happened approximately between 2:00 PM to 2:30 PM. She stated Resident 25 was noted on occasion to go into other residents' rooms. The SRNA stated that last week', Resident #25 had to be removed from a couple of residents' rooms. She stated that she looked at the care plan for what interventions were in place and she got her information in report for specifics regarding the resident. The SRNA stated the fifteen- minute checks were done by the Restorative Aide, if there was one present, if not then the SRNAs were responsible for doing the checks and documenting. SRNA #25 stated she had been trained on abuse through 'Relias (an online education system), but she did not remember any recent in-house trainings. 2. Record review of Resident #29's Incident note revealed on 07/18/2023 at 2:16 PM Resident #29 stated that Resident #25 hit Resident #29 in the arm three to four times Review of Resident #29's Progress Note dated 07/18/2023 at 2:29 by Registered Nurse (RN) #4 revealed a resident stopped management on the South Hall and reported that Resident #25 had hit him/her in his/her right arm. Resident #29 stated Resident #25 whacked his/her right arm real hard three or four times. Resident #29 denied hitting Resident #25 back or saying anything to her/him. Resident #29 denied pain or injuries. Review of the facility's investigation, dated 07/18/2023, revealed Resident #29 reported that Resident #25 whacked him three or four times on the right arm while Resident #25 was wheeling down the hall. Skin assessments were performed on both residents, with no injuries noted. Review of Resident #29's Admission Record revealed the facility admitted Resident #29 on 02/17/2020 with diagnoses of schizoaffective disorder (Bipolar type) and borderline intellectual functioning. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of eight (8) of fifteen (15) which indicated moderate cognitive impairment. Review of Section E, revealed the facility assessed the resident to have verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which were present one to three days in the past fourteen days. Review of Resident #29's Behavior Care Plan, dated 07/05/2023, revealed the resident was care planned for fifteen-minute checks to monitor for increased supervision. Interventions included: Administer medication as ordered by Physician; monitor for adverse reactions to medication; notify physician as needed; assess, monitor, and document any displayed mood/behaviors; provide reassurance; redirection as needed; pharmacy to review psychotropic medication use quarterly and as needed; and Psych evaluation as needed. During interview, on 07/25/2023 at 11:00 AM, with the Activities Director (AD) she stated she did activities with residents as a whole. She stated Resident #25 originally would participate in activities at times. The AD stated she attempted every day to do some type of 1:1 activity with Resident #25 such as sensory stimulation. However, Resident #25 would tear up the activities quilt. She stated she also tried reading with the resident. The AD stated that Resident #25 became agitated easily, so she attempted different times a day for activities. Resident #25 was in the Dementia group 6:30-7:30 PM. LPN #11, stated during interview, on 07/28/2023 at 9:12 PM, that she was an agency employee and had been at the facility approximately two months. LPN #11 stated that she had not witnessed Resident #25 have altercations with other residents, but she was aware that Resident #25 would swat at and hit people close to him/her. The LPN stated that every fifteen-minute checks was not enough supervision for Resident #25 because the resident was quicker than a blink of an eye. LPN stated that Resident #25 could hit someone before staff could even know it. LPN #11 stated that Resident #25 hit another one of the SRNAs in the stomach last week but, she could not remember which SRNA. She stated Resident #25 always takes down the stop sign nets from other residents' rooms and puts them in the wheelchair with him/her. During interview with the Social Services Director (SSD) on 07/28/2023 at 2:50 PM, she stated she was the Social Services Director (SSD)/Abuse coordinator. She stated that care plans were updated by Director of Nursing (DON), SSD, and the Charge Nurse. The SSD stated that currently they were doing care plan audits, if anyone updated a care plan in morning meeting, the Resident Care Coordinator (RCC) documented it as being updated. During continued interview with the SSD, on 07/28/2023 at 2:50 PM, she stated she felt that the current interventions were appropriate for Resident #25. She stated Resident #25 was on fifteen-minute checks to provide more supervision. The SSD stated she did not know of other interventions that could prevent further incidents. During interview with the Administrator, on 07/28/2023 at 10:30 PM she stated she had been interim since April 10th, 2023. She stated they have discussed getting the residents more engaged with activities, trying to monitor them more and keep up with them. The Administrator stated that Resident #25 was currently on every fifteen-minute supervision and with Resident #25, short of restraining him/her, she did not know what else to do. During continued interview, she stated they could increase to 1:1 supervision, but I don't know if that would help. She stated when the resident was wheeling in hallway, he/she will hit whatever is in the way. The Administrator stated she did not think 24/7 1:1 intervention would help.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have effective safeguards and systems in place to control, account for, and periodically reconcile controlled medications to ensure all controlled drugs were maintained for one (1) of ninteen (19) sampled residents (Residents #12). On 04/26/2023, Licensed Practical Nurse (LPN) #3 noticed the medication room keys were missing and could not be located. In addition, Resident #12's medications were missing, and the facility was not been able to locate the medications. Per interviews and record review, the facility did not have a system in place to audit the medications to prevent the resident's medications from being diverted. The findings include: Review of the facility's policy titled, Controlled Substance Administration and Accountability, revision date of 10/06/2022, revealed it was the policy of the facility to promote safe, high quality patient (resident) care, compliance with state and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place to prevent loss, diversion or accidental exposure. Further review revealed that; All controlled substances were accounted for in one of the following ways: All controlled substances obtained from a non-automated medication cart or cabinet were recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. All specially compounded or non-stock Schedule II controlled substances from the pharmacy for a specific patient would be recorded on the Controlled Drug Record supplied with the medication. In all cases, the dose noted on the usage form must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or the other facility specified form and placed in the patient's medical record. Review of the facility's policy titled, Narcotic Sign In and Sign Out Protocol/Missing Medication, review date of 10/07/2022, revealed the purpose was to provide a practice that ensured an accurate count of narcotics was maintained. The Kentucky Medication Aide (KMA), or nurse assigned to pass medications from a specific medication cart, shall ensure a correct narcotic count prior to accepting responsibility for those narcotics. Once that count was established, that staff person accepted responsibility for those narcotics and obtained the keys to that medication cart. Both staff members should visually check the number of pills against the quantity noted to remain on the narcotic flow sheet. Ensure all controlled substances were counted. If a medication count was wrong, staff would repeat the count for accuracy. If the count continued to appear incorrect, staff were to contact the Director of Nursing (DON). During interview, on 06/01/2023 at 9:41 AM, with Licensed Practical Nurse (LPN) #4, she stated that during the beginning of his shift, on 04/27/2023 around 6:30 PM, he and State Registered Nurse Aide (SRNA)/KMA #16 were conducting the narcotics count. LPN #4 stated he noted that Resident #12 only had two (2) medications cards in the narcotics drawer of the medication cart. The LPN stated he was familiar with Resident #12's medications and the resident normally had three (3) narcotics cards on the cart. LPN #4 stated upon further inspection, it was noted Resident #12's Oxycodone was missing. LPN #4 stated he then checked the orders to see if the Oxycodone had been discontinued by the Physician and, found there was still an active order for the medication. The LPN stated he immediately contacted the Director of Nursing (DON) to report the missing Oxycodone. He stated he was instructed to search all four (4) medication carts and the medication rooms for the missing medications. LPN #4 stated he and SRNA #16 searched for the medications and could not find the missing Oxycodone. The LPN stated that no other narcotics were noted missing. LPN #4 stated he had recent training on signing out narcotics both on the Narcotic Sign Out Sheet and, on the MAR. LPN #4 stated he had failed to document the medication administration on the MAR sometimes due to the computer being slow, and sometimes because he would get busy and forget to document on the MAR. LPN #4 further stated he was not aware of any other incidents of missing narcotics. He stated he was aware of the policy requiring him to document on the narcotics sign out log, as well as the MAR. He stated that he had recent training on the new process for signing out the narcotics that had been administered. Review of the facility's investigation, dated 04/28/2023, and completed by the Director of Nursing (DON) revealed that during the narcotics count at shift change, narcotics, specifically Oxycodone tablets were diverted and could not be accounted for. On 04/27/2023, the DON was notified by phone by LPN #4 of the missing Oxycodone. Witness statements were obtained and drug screenings completed on all staff that had access to the medication carts except for LPN #19 who could not be reached. Review of the Admission record for Resident #12 revealed the facility admitted the resident on 03/05/2021 with diagnoses that included Hereditary Spastic Paraplegia, Dementia, with other behavioral Disturbance, Trochanteric Bursitis and Chronic Venous Hypertension with ulcer of the bilateral lower extremities. Review of Resident #12's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was cognitively intact. Further review of Section B. revealed Resident #12 had behaviors of Inattention and Disorganized think that fluctuated (comes and goes, changes in severity). Review of the MDS, Section E, revealed other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), that had occurred in the past one (1) to three (3) days. Review of Resident #12's Physician Order, dated 12/09/2022 Oxycodone HCl Tablet five (5) milligrams (mg), give 5 mg by mouth every 12 hours as needed for pain. Review of Resident #12's Medication Administration Record (MAR) revealed Oxycodone was administered to Resident #12 on 04/06/2023, 04/12/2023, 04/16/2023,04/19/2023, 04/20/2023, 04/29/2023,04/30/2023, 05/04/2023, 05/05/2023, 05/26/2023, 05/27/2023. However, the Narcotics Sign in and Out Log showed Oxycodone was administered to Resident #12 on 04/1/2023, 04/3/2023, 04/4/2023, 04/5/2023, 04/6/2023, 04/7/2023, 04/8/2023, 04/9/2023, 04/10/2023, 04/11/2023, 04/12/2023, 04/13/2023, 04/14/2023, 04/15/2023, 04/16/2023, 04/18/2023, 04/19/2023. The MAR for May narcotic sign in/out log was missing. Review of the State Police Report, dated 04/28/2023 at 6:17 PM, revealed the following; The facility had no system in place to track medicine, it was not logged, {staff} did not know how much or when the medication was given to the {resident} patient. Continued review of the report revealed the prescription was filled on the nineteenth. The report stated, (the facility) has missing medicine and there was no system in place to track the medicine. It was not logged and they did not know how much or when the medication was given to the {resident} patient. During interview on 05/31/2023 at 5:18 PM with the DON, she stated that she received a phone call from LPN #4 on 04/27/2023 at approximately 7:00 PM regarding missing Oxycodone. The DON stated she instructed LPN #4 to search all medication carts and medication rooms to attempt to find the missing Oxycodone. The DON stated she entered the facility the next morning early and started the investigation. She stated that Pharmacy, the Administrator, and State Police were notified. After the investigation was completed, new locks were put on both medication room doors, cameras were installed in each medication room, and a new sign out process was implemented to ensure a more accurate system to account for all narcotics. The DON stated her expectation was that staff followed the policy and signed both the Narcotic sign out log and the MAR when administering narcotics. She stated after audits of the Narcotic sign out logs were compared to the MAR, she provided written disciplinary actions and further education and training with staff. The DON further stated that audits were on going to prevent further misappropriation of narcotics. During interview on 06/01/2023 at 11:10 AM with SRNA/KMA #16, stated she was counting narcotics with LPN #4 at change of shift when the LPN noted that a card of Oxycodone was missing for Resident #12. SRNA #16 stated she had counted that morning with LPN #3 and had noted that no Oxycodone or sign out log was there for Resident #12 but thought that maybe Resident #12 had ran out of Oxycodone and more had been ordered. SRNA #16 stated that normally if medications were needed or low, night shift was responsible for ordering. SRNA stated that Resident #12 very seldom requested pain medication during the day, therefore she was not familiar with the possible number that could have been missing. SRNA stated that sometimes she forgot to document the narcotics on the MAR due to getting busy and forgetting. SRNA stated she was aware of the policy for documenting on the Narcotics sign out log as well as on the MAR. SRNA further stated that after LPN #4 contacted the DON, she assisted LPN #4 with searching all four (4) medication carts prior to leaving her shift that evening. SRNA #16 stated that she had recent training on the new process for signing out narcotics that had been implemented. Interview on 6/05/2023 at 2:45 PM with the Administrator (ADM) revealed she was made aware of the missing narcotics on 04/28/2023 by the DON. The ADM stated that the DON along with the Abuse Coordinator/Social Services Director (SSD) had started an investigation as well as a further search of the building for the Narcotics. The ADM stated she contacted the State Police, the Board of Directors, and the Medical Director (MD). She stated her expectation was that the staff followed the policy and documented both on the Narcotic sign out log and the MAR. As oversight, the ADM stated she had been doing spot checks and pharmacy did monthly facility audits, and the DON had audit tools in place for oversight also. The ADM stated disciplinary actions were taken with staff that had not followed the policy, and staff had been educated and trained on the new process to follow during the shift change Narcotic count. During interview, on 06/01/2023 at 1:22 PM with the Pharmacist, he stated after he was made aware of the Narcotics diversion on 04/28/2023 by the DON. The Pharmacist stated that he made a report to the Drug Enforcement Agency (DEA). The Pharmacist stated that he went to the facility and conducted a narcotic count for all medication carts, all emergency boxes, all medication rooms, and medication refrigerators. Further interview revealed the Pharmacist found no other discrepancies with the narcotics counts. The Pharmacist replaced the Oxycodone on 04/28/2023 at the facility's expense. Attempts were made on 06/01/2023 at 3:41 PM, and on 06/02/2023 at 9:10 AM to contact LPN #19, with two different numbers provided. The call were unsuccessful, with no return call. During interview on 06/01/2023 at 3:43 PM with the Regional Senior Account Manager Shift-Key Supervisor, he stated LPN #19 was under review and could not work for Shift-key until an appeal was done. He stated he did not have access to that information as to why LPN #19 was on review.

Based on observation, interview, record review, and review of the facility's policy, revealed the facility failed to ensure proper supervision for three (3) of nineteen (19) sampled residents (Resident #27, #9, #18). Review of the facility reported incident from 04/16/2023, revealed the facility failed to provide adequate supervision to Resident #27 to prevent the resident from entering another resident's rooms. On 04/16/2023, Resident #27 entered the room of a resident located on the personal care unit (PCU) unit and kissed him/her. Additionally, Resident #18 wandered into Resident #9's room to grab a snack from his/her table and Resident #9 grabbed the resident by his/her arm and stated no. The facility failed to ensure staff monitored the resident's wandering behaviors to prevent accidents. The findings include: Review of the facility policy titled Accidents and Supervision, revision date on 10/04/2022 revealed the resident environment would remain as free of accident hazards as is possible; and each resident received adequate supervision and assistive devices to prevent accidents. The facility should establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Various sources provide information about hazards and risks in the resident environment, these sources may include, quality assurance, environmental rounds, individual observation. This information is to be documented and communicated across all disciplines. Review of Resident #27's Admission Record revealed the facility admitted the resident on 05/25/2021 with diagnoses to include: Turner's Syndrome, and Depression, Adjustment Disorder with mixed anxiety. Review of Resident #27's Quarterly Minimum Data Set (MDS) Assessment, dated 02/16/2023, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderate cognitive impairment. Further review of the MDS revealed there were no behaviors noted. Review of Resident #27's Comprehensive Care Plan, dated 05/24/2021, revealed the resident was care planned for meeting the resident's emotional, intellectual, physical, and social needs related to the diagnosis of Hypertension, Tremors, Turners Syndrome, Hypothyroidism, history of falling and Malignant Neoplasm of his/her Colon. Goals included the resident would attend/participate in activities of his/her choice three to five (3-5) times weekly by next review date. Interventions included all staff were to converse with the resident while providing care, provide resident with an activities calendar, notify the resident of any changes to the calendar of activities, modify daily schedule, and treatment plan as needed to accommodate activity participation as requested by the resident, resident needed assistance with activities of daily living as required during the activity. Additionally, on 01/17/2022, an intervention was added to encourage the resident not to go into other resident's rooms. Continued review of the resident's care plan revealed on 04/17/2023, the focus was added that the resident was noted to be kissing a PCU Resident. Interventions were added to complete fifteen (15) minute checks, the intervention was resolved on 05/13/2023. Further review of the care plan revealed on 04/17/2023 an additional intervention was added to monitor the resident's whereabouts to ensure he/she was not entering other resident's rooms. The facility; however, failed to ensure the resident's care plan was followed, to ensure the resident's whereabouts and to encourage the resident not to go into other resident's rooms. Review of Resident #27's Psychosocial Note, dated 04/17/2023 at 11:16 AM, documented by the Social Services Director (SSD), revealed the SSD and the Director of Nursing (DON) had spoken to the resident about the alleged incident with the Personal Care Unit (PCU) Resident. Continued review of the note revealed Resident #27 stated he/she was in the PCU Resident's room watching television (TV) and talked about old times. Resident #27 stated that he/she kissed the PCU Resident on the cheek and then they continued to watch TV. The SSD and DON explained to Resident #27 that he/she could not kiss or hug other residents or be in others room. Further, the resident was informed that if he/she wanted to watch TV with the PCU Resident, he/she could watch TV in the lounge. During an interview with Resident #27, on 06/05/2023 at 4:51 PM, he/she stated he/she did not like to lie and did not lie. Resident #27 stated the PCU Resident called him/her honey bunches and hugged and kissed him/her. The resident further stated that while he/she was sneaking back to his/her room someone saw her/him and told on him/her. Interview with the Personal Care Unit (PCU) Resident, on 06/05/2023 at 3:20 PM, he/she stated he/she was siting in his/her room watching television (TV) when Resident #27 came to his/her room and kissed him/her on the lips. Further, the PCU Resident stated Resident #27 was his/her friend. The resident stated he/she did not feel threatened or afraid. He/she stated Resident #27 came into his/her room the other day and kissed him/her again. Further, he/she stated he/she did not have sex with Resident #27. The resident stated he/she did not know initially that Resident #27 was not supposed to be in his/her room but was now aware that he/she cannot be alone with Resident #27 in any area other than in a common area with other persons around. In an interview on 06/06/2023 at 5:05 PM with the Director of Nursing (DON) she stated the care plan meetings were held each Tuesday and Thursday. She stated she and the Social Service Director (SSD) primarily updated the residents' care plans. Further, she stated each resident was monitored hourly unless the resident was on fifteen (15) or every thirty (30) minutes checks. The monitoring included for staff to know the location of the residents and what the resident was doing. Further interview with the DON revealed that at any time even with frequent monitoring that anything had the potential to happen. She stated that when the care plan was updated, a message was sent out to staff, also have medical record communication board that all staff can see in the Electronic Medical Record (EMR). In an interview on 06/05/2023 at 2:45 PM with the Interim Administrator, she stated it was her expectation for increased supervision and to monitor the resident closer. Review of the facility incident report dated 04/13/2023, revealed Resident #18 came into Resident #9's room and grabbed his/her snack on the table. Resident #9 grabbed his/her arm and told him/her that was not his/hers and to put it down. Resident #18 said no. The only witness to the incident was Resident #9's spouse who was also in the room. 2 a). Review of Resident #9's Admission record revealed the facility admitted Resident #9 on 10/14/2021 with a diagnosis of Dementia, Anxiety Disorder, and Hypertension. Review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 03/23/2023, revealed the facility assessed Resident #9 to have a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), which indicated moderate cognitive impairment. Record Review of Resident #9's Comprehensive Care Plan, initiated on 12/14/2021, revealed Resident #9 was care planned to have a stop sign across his/her doorway of his/her room to deter other residents from entering the resident's room without invitation. Interview with Resident #9, on 06/01/2023 at 11:30 AM, he/she stated his/her stop sign was not consistently up. 2 b). Review of Resident #18's Admission record revealed the facility admitted Resident #18 on 09/10/2021 with a diagnosis of Chronic Kidney Disease, Anxiety Disorder, and Pancytopenia. Review of the resident's Quarterly MDS assessment, dated 05/26/2023, revealed the facility assessed the resident to have a BIMS of zero (0) out of fifteen (15), which indicates severe cognitive impairment. Record Review revealed Resident #18 had a wandering care plan initiated on 10/28/2021, and a wander guard initiated on 09/10/2021. Continued review revealed the resident was placed on fifteen (15) minute check documentation for 04/13/2023 to 04/27/2023. During an Interview with Resident #18's spouse on 06/02/2023 5:20 PM, he/she stated Resident #18 was not injured related to the incident. The spouse further stated he visits the resident a few times a week to prevent the resident from wandering into other residents' rooms. During an Interview with Social Service Director (SSD), on 06/05/2023 3:23 PM she stated they do a lot of redirection with Resident #18. She stated the stop signs sometimes deter the resident and other times he/she goes right in. The SSD stated the resident did not sit still long enough for activities, maybe five (5) minutes and he/she would wander again. She stated family comes in about every day to help redirect resident and his/her spouse takes him/her out as much as he can to go on rides to doctors appointment. During an Interview with the Director of nursing (DON), on 05/30/2023 at 5:45 PM she stated interventions were hard to be effective when the resident just wanders. She stated the staff knew to redirect the resident and to observe the resident when he/she goes into other resident's rooms. Further, she stated the resident did not stay in activities for long periods of time.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Person Centered Care Plan was implemented for one (1) of nineteen (19) sampled residents (Resident #27). On 04/16/2023, Resident #27 entered the room of a resident located on the personal care unit (PCU) and kissed him/her. Review of Resident #27's care plan revealed the facility initiated the resident's care plan on 01/17/2022 with an intervention to encourage resident not to enter other resident's rooms. Staff; however, failed to ensure the resident's care plan was implemented. Additionally, on 04/17/2023, the resident was care planned for staff to know the whereabouts of the resident. However, on 05/29/2023, Resident #27 was observed by staff to exit another resident's room, PCU Resident, and Resident #27 reported he/she had sex in the PCU Resident's room. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 11/20/2017, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Review of Resident #27's Admission Record revealed the facility admitted the resident on 05/25/2021 with diagnoses to include: Turner's Syndrome, and Depression, Adjustment Disorder with mixed anxiety. Review of Resident #27's Quarterly Minimum Data Set (MDS) Assessment, dated 02/16/2023, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderate cognitive impairment. Further review of the MDS revealed there were no behaviors noted. Review of Resident #27's Comprehensive Care Plan, dated 05/24/2021, revealed the resident was care planned for meeting the resident's emotional, intellectual, physical, and social needs related to the diagnosis of Hypertension, Tremors, Turners Syndrome, Hypothyroidism, history of falling and Malignant Neoplasm of his/her Colon. Goals included the resident would attend/participate in activities of his/her choice three to five (3-5) times weekly by next review date. Interventions included all staff were to converse with the resident while providing care, provide resident with an activities calendar, notify the resident of any changes to the calendar of activities, modify daily schedule, and treatment plan as needed to accommodate activity participation as requested by the resident, resident needed assistance with activities of daily living as required during the activity, resident needs one to one bedside/ in room visits and activities if unable to attend out of room events, and resident needed assistance/escort to activity functions. On 03/14/2022 an intervention was added that resident had a portable DVD player in her room for movies from the activity department. Additionally, on 01/17/2022 an intervention was added to encourage the resident not to go into other resident's rooms. Continued review of the resident's care plan revealed on 04/17/2023, the focus was added that the resident was noted to be kissing a PCU Resident. Interventions were added to complete fifteen (15) minute checks, the intervention was resolved on 05/13/2023. Further review of the care plan revealed on 04/17/2023 an additional intervention was added to monitor the resident's whereabouts to ensure he/she was not entering other resident's rooms. The facility; however, failed to ensure the resident's care plan was followed. The resident was observed in the PCU Resident's room on 04/16/2023 and 05/25/2023. Review of Resident #27's Psychosocial Note, dated 04/17/2023 at 11:16 AM, documented by the Social Services Director (SSD), revealed the SSD and the Director of Nursing (DON) had spoken to the resident about the alleged incident with the Personal Care Unit (PCU) Resident. Continued review of the note revealed Resident #27 stated he/she was in the PCU Resident's room watching television (TV) and talked about old times. Resident #27 stated that he/she kissed the PCU Resident on the cheek and then they continued to watch TV. The SSD and DON explained to Resident #27 that he/she could not kiss or hug other residents or be in others room. Further, the resident was informed that if he/she wanted to watch TV with the PCU Resident, he/she could watch TV in the lounge. During an interview with Resident #27, on 06/05/2023 at 4:51 PM, he/she stated he/she did not like to lie and did not lie. Resident #27 stated the PCU Resident called him/her honey bunches and hugged and kissed him/her. The resident further stated that while he/she was sneaking back to his/her room someone saw her/him and told on him/her. Interview with the Personal Care Unit (PCU) Resident, on 06/05/2023 at 3:20 PM, he/she stated he/she was siting in his/her room watching television (TV) when Resident #27 came to his/her room and kissed him/her on the lips. Further, the PCU Resident stated Resident #27 was his/her friend. The resident stated he/she did not feel threatened or afraid. He/she stated Resident #27 came into his/her room the other day and kissed him/her again. Further, he/she stated he/she did not have sex with Resident #27. The resident stated he/she did not know initially that Resident #27 was not supposed to be in his/her room but was now aware that he/she cannot be alone with Resident #27 in any area other than in a common area with other persons around. In an interview on 06/06/2023 at 5:05 PM with the Director of Nursing (DON) she stated the care plan meetings were held each Tuesday and Thursday. She stated she and the Social Service Director (SSD) primarily updated the residents' care plans. Further, she stated each resident was monitored hourly unless the resident was on fifteen (15) or every thirty (30) minutes checks. The monitoring included for staff to know the location of the residents and what the resident was doing. Further interview with the DON revealed that at any time even with frequent monitoring that anything had the potential to happen. She stated that when the care plan was updated, a message was sent out to staff, also have medical record communication board that all staff can see in the Electronic Medical Record (EMR). In an interview on 06/05/2023 at 2:45 PM with the Interim Administrator, she stated it was her expectation for increased supervision and to monitor the resident closer, as per the resident's care plan.

Based on interview, record review, review of the facility's policy, review of 906 [NAME] (Kentucky Administrative Regulations) 1:190, Section 1(4), a disqualifying offense, and review of the Kentucky Revised Statues (KRS) 209.032, it was determined the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation related to screening of new employees for one (1) of seven personnel files reviewed. Additionally, the facility failed to ensure it did not employ individuals who had been found guilty by a court of law for abuse, neglect, misappropriate of property, exploitation, or mistreatment in accordance with the facility's policy and the list of Kentucky Disqualifying Offenses. The findings include: Review of the facility's policy titled, Background Investigations, revised on 03/30/2023, revealed the facility would not employ individuals who: had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property; c.had a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation or resident property. Review of the Kentucky National Background Check Disqualifying Offenses effective 11/27/2018, Pursuant to 906 [NAME] 1:190, Section 1(4), a disqualifying offense was, a conviction of, or a plea of guilty, an [NAME] plea, or a plea of nolo contendere to: A misdemeanor offense related to: Theft occurring less than seven (7) years from the date of the criminal background check. Review of KRS 209.032, revealed Long Term Care facilities shall query the Cabinet' for substantiated findings of abuse, neglect or exploitation against an individual who was a perspective employee. Review of Licensed Practical Nurse (LPN) #3's Personnel Record revealed LPN #3 was hired on 06/01/2020. Further review revealed the LPN had a misdemeanor case filed on 05/16/2019 with a disposed date of 01/06/2020 as guilty. The LPN's sentence date was on 01/06/2020 for theft by unlawful taking, shoplifting under five hundred (500) dollars, with unsupervised probation of two (2) years. In an interview, on 06/05/2023 at 2:45 PM with the Administrator, she stated she has been the Interim Administrator since 04/12/2023. She stated the prior Administrator hired LPN #3 and the current Administrator was not aware of this charge on LPN #3's record. Further, she stated LPN #3 was hired on 06/01/2020 as an SRNA and the facility hired the LPN based on her charges being under five hundred ($500) dollars. The Administrator revealed LPN #3 completed the nursing program and was allowed to obtain her nursing license in 2021 and was then moved into the position as an LPN on 06/20/2021. However, review of the facility's policy revealed the facility would not employ individuals who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Additionally, review of the Kentucky National Background Check revealed a disqualifying offense was a conviction of a misdemeanor related to theft occurring less than seven (7) years from the date of the criminal background check.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to protect residents from misappropriation of property for one (1) of nineteen (19) sampled residents (Resident #12). On 04/27/2023 Licensed Practical Nurse (LPN) #4 stated Resident #12's medication (oxycodone) was missing, as well as, the narcotic sign-out sheet. Further, the LPN stated the last time he saw the resident's medication was on 04/24/2023. The findings include: Review of the facility's policy titled Controlled Substance Administration and Accountability, revision date 10/06/2022, revealed it was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. Further review revealed the facility had safeguards in place to prevent loss, diversion, or accidental exposure. Further review revealed that all controlled substances were accounted for in one of the following ways: All controlled substances obtained from a non-automated medication cart or cabinet were recorded on the designated usage form. Continued review revealed written documentation must be clearly legible with all applicable information provided. All specially compounded or non-stock Schedule II controlled substances from the pharmacy for a specific (resident) patient would be recorded on the Controlled Drug Record supplied with the medication. In all cases, the dose noted on the usage form must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or the other facility specified form and placed in the (resident's) patient's medical record. Review of facility's policy titled Narcotic Sign In and Sign Out Protocol/Missing Medication review date 10/07/2022, revealed the purpose was to provide a practice that ensures an accurate count of narcotics is maintained. The Kentucky Medication Aide (KMA), or nurse assigned to pass medications from a specific medication cart, shall ensure a correct narcotic count prior to accepting responsibility for those narcotics. Further review of the policy revealed that once the count was established, staff would accept responsibility for those narcotics and obtain the keys to the medication cart. Further, staff members would visually check the number of pills against the quantity noted to remain on the narcotic flow sheet and ensure all controlled substances were counted. If a medication count was wrong, staff would repeat the count for accuracy. Further, if the count continued to appear incorrect, staff were to contact the Director of Nursing ( DON). Review of the facility's investigation initiated on 04/28/2023 and completed on 05/04/2023 by the Director of Nursing (DON) revealed the DON received a call on 04/27/2023 from LPN #4. The LPN reported that Resident #12's Oxycodone were missing out of the medication cart. Continued review revealed LPN #4 reported to the DON he last remembered seeing the Oxycodone tabs on 04/24/2023, when he worked last. The DON contacted the Pharmacist who came to the facility and conducted a full medication stock check and found no discrepancies other than the missing Oxycodone. Review of Admission Record for Resident #12 revealed Resident was admitted to the facility on [DATE] with diagnoses of Chronic Venous Hypertension with ulcer, Dementia with other behaviorals and Hereditary Spastic Paraplegia. Review of the annual Minimum Data Set (MDS)dated 02/17/2023 revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15) which indicates cognitively intact. Further review of Section C of MDS revealed Resident #12 also had behaviors of Inattention, and Disorganized thinking. Review of Resident #12's Physician Orders revealed an order on 12/09/2022 for Oxycodone HCI five (5) milligram (mg) tab one (1) tab by mouth every twelve (12) hours as needed for pain. Observation on 05/31/2023 at 10:29 AM revealed Resident #12 was sleeping in his/her bed. In an interview on 05/31/2023 at 1:40 PM, Resident #12 stated he/she had been a resident for approximately two (2) years. Resident #12 stated he/she normally received his/her pain medications when he/she needed it. Resident #12 stated his/her pain was mainly in his/her right foot. He/she further stated that a few days ago when he/she asked for pain medications staff informed him/her he/she did not have any pain medication and would have to wait on pharmacy to deliver. Resident #12 was not sure of how long she/he waited for the medication. Later, Resident #12 stated he/she was informed by a staff member that his/her medications had been stolen. Resident #12 further stated that the cops came and searched everything in her/his room. In an interview on 06/01/2023 at 9:41 AM, LPN #4 stated that during the beginning of his shift, on 04/27/2023 around 6:30 PM, he and State Registered Nurse (SRNA)/Kentucky Medication Aide (KMA) #16 were conducting the Narcotics count and he noted that Resident #12 only had two (2) medications cards in the Narcotics drawer of the medication cart. LPN #4 stated he was familiar with this resident's medications and the resident normally had three (3) Narcotics cards on the cart, and upon further inspection noted Resident #12's Oxycodone (medication prescribed to help manage moderate to severe pain) was missing. Licensed Practical Nurse (LPN) #4 further stated, on 06/01/2023 at 9:41 AM, he checked Resident #12's orders to see if the Oxycodone had been discontinued by the Physician and found there was still an active order for the medication. LPN #4 stated he immediately contacted the Director of Nursing (DON) to report the missing Oxycodone. LPN #4 stated he was instructed to search all four (4) medication carts and the medication rooms for the missing medications. LPN #4 revealed he and SRNA #16 searched for the medications and could not find the missing Oxycodone. LPN #4 revealed that no other Narcotics were noted missing. Continued interview with LPN #4 revealed he had recent training on signing out Narcotics both on Narcotic sign out sheet and on the Medication Administration Record (MAR). LPN #4 stated he had failed to document the medication administration on the MAR due to the computer being slow and because he would get busy and forget to document on the MAR. LPN#4 further stated he was not aware of any other incidents of missing Narcotics. LPN #4 revealed he was aware of the policy requiring him to document on the Narcotics sign out log as well as the MAR. Interview on 06/01/2023 at 11:10 AM with the SRNA/KMA #16 revealed the SRNA was counting Narcotics with LPN #4 at change of shift when LPN #4 noted that a card of Oxycodone was missing for Resident #12. SRNA #16 stated she had counted that morning with LPN #3 and had noted that no Oxycodone or sign out log was there for Resident #12 but thought that maybe Resident #12 had ran out of Oxycodone. SRNA #16 stated that normally if medications were needed or low, night shift was responsible for ordering the resident's medications. The SRNA stated that Resident #12 very seldom requested pain medication during the day, therefore, SRNA was not familiar with the possible number that could have been in the missing Oxycodone card. She further stated that sometimes she forgot to document the Narcotics on the MAR due to becoming busy and often forgetting to sign. The SRNA stated she was aware of the policy for documenting on the Narcotics sign out log, as well as, the MAR. SRNA further stated that after LPN #4 contacted the DON, she assisted LPN #4 with searching all four (4) medication carts prior to leaving her shift that evening. In an interview on 06/01/2023 at 1:22 PM the Pharmacist stated he was contacted by the DON on 04/28/2023. The Pharmacist further stated he went to the facility that day and reconciled all medications on the carts, compared orders, medication profiles to the sheet counts with no discrepancies noted. The Pharmacist further stated he does monthly spot checks on narcotic counts and observes a medication pass monthly and provides staff reduction. Further, the Pharmacist stated his expectation was for documentation be on the Medication Administration Review (MAR) and on the Narcotics sheet. The Pharmacist further stated he contacted the Drug Enforcement Agency (DEA) regarding the missing narcotics. Interview on 05/31/2023 at 5:18 PM with the Director of Nursing (DON), she stated that she received a phone call from LPN #4 on 04/27/2023 at approximately 7:00 PM regarding Resident #12's missing Oxycodone. The DON further stated she instructed LPN #4 to search all medication carts and medication rooms to attempt to find the missing Oxycodone. The DON stated that Pharmacy, Administrator, and State Police were notified. Interview on 6/05/2023 at 2:45 PM with the Interim Administrator, she stated she was made aware of the Narcotic's diversion on 04/28/2023 by the DON. The Interning Administrator stated that the DON along with the Abuse Coordinator/Social Services Director (SSD) had started an investigation as well as a further search of the building for the Narcotics. She further stated she contacted the State Police, the Board of Directors, and Medical Director (MD) and requested the State Police report. The Interim Administrator stated her expectation was that the staff followed the policy and documented both on the Narcotic sign out log and the MAR.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure residents with a dementia diagnosis were provided individualized care needs to ensure care and services were maintained at their highest practicable mental, physical, and psychosocial well-being, for seven (7) of twenty-one (21) sampled residents (Resident #16, Resident #18, Resident #20, Resident #4, Resident #13, Resident #17, and Resident #14) 1. On 06/23/2022, staff observed Resident #16 kissing Resident #20 while groping Resident #18's breast. Record review revealed the resident had a Dementia diagnosis and was care planned for staff to assess/monitor and document the resident's behaviors. Review of the resident's care plan; however, was not updated to include the resident's sexual behaviors to prevent further behaviors. Additionally, on 12/18/2022, staff observed the resident humping and kissing Resident #18 in his/her room. The facility failed to ensure the resident's care plan was implemented to ensure the resident's stop sign was at his/her doorway to prevent others from entering his/her room uninvited. 2. On 06/23/2022, Resident #18 was observed by staff in the hallway, across from the nurse's station, with Resident #16, as he/she kissed Resident #20, and groped Resident #18's breast. The resident was care planned for wandering behaviors which required staff to access and monitor for these behaviors. The facility failed to ensure the care plan was implemented to determine its effectiveness and failed to revise the resident's care plan to address the resident's sexual behaviors, to ensure the safety of the resident. Subsequently, on 12/18/2022, the resident was observed in Resident #16's room, seated in his/her recliner as Resident #16 humped and kissed Resident #18. 3. On 06/23/2022, Resident #20 was observed in the hallway, with Resident #16 kissing him/her. However, there was no evidence to support the facility implemented the resident's care plan to assess/monitor the resident's behavior, related to wandering, to determine the effectiveness of the interventions. Additionally, the facility failed to revise the resident's care plan when the resident exhibited inappropriate sexual behaviors. 4. Resident #4 exhibited behaviors to include wandering, threatening residents and staff, being combative, and increased agitation. The resident was care planned for wandering; however, the facility failed to implement the resident's care plan to assess/monitor and document the effectiveness of its interventions. Additionally, the Medical Director (MD) recommended for the resident to have a sitter to prevent his/her behaviors. The facility; however, failed to ensure the resident's care plan was revised to provide increased supervision. 5. Resident #13 was observed on 01/30/2022 to wander on his/her floor the entire shift, with Resident #4. Record review revealed staff attempted to separate the residents, however, was unsuccessful. The facility failed to implement the resident's care plan to determine the root cause of the unsuccessful attempt to separate the residents. Additionally, the facility failed to provide 1:1 supervision as needed, as per the resident's care plan. 6. On 09/02/2022, Resident #17 was observed by staff kissing his/her roommate. The resident was care planned for staff to assess/monitor and document the resident's behaviors and to refer to his/her physician. However, the facility failed to ensure the resident's care plan was implemented to refer to behavior services and the facility failed to revise the resident's care plan to address the resident's inappropriate sexual behavior. 7. Record review revealed on 09/02/2022, Resident #14 was observed kissing his/her roommate, Resident #17. The facility failed to implement the resident's plan of care to assess and monitor the resident to prevent the resident from getting into bed with other residents, prevent his/her wandering, and/or revise the plan of care to include sexually inappropriate behaviors with interventions to determine its effectiveness. The facility's failure to ensure residents with Dementia and individualized care needs received the necessary services and care to maintain their highest practicable mental, physical, and psychosocial well-being, has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, ADL Care of Dementia Residents, revised 02/15/2022, revealed the care plan interventions for residents with dementia, were to be monitored on an ongoing basis for its effectiveness. The care plans were to be reviewed/revised as necessary. Additional policy review revealed that appropriate referrals were to be made if the current interventions were ineffective. 1. Review of the Admission Record for Resident #16 revealed the facility admitted the resident on 02/05/2015, with diagnoses which included Generalized Anxiety Disorder and Unspecified Dementia. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), indicating moderate cognitive impairment. Continued review revealed the facility had assessed the resident as having Zero (0) physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the facility had assessed the resident as having Zero (0) other behavioral symptoms not directed toward others such as physical symptoms of hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. Review of Resident #16's Care Plan initiated on 12/14/2021, revealed the resident had been care planned for 24-hour supervised/assisted care related to diagnosis of Depression and Anxiety, with an intervention to administer medications as ordered, monitor for effectiveness and adverse reactions, and notify the physician as needed. Continued review revealed a new intervention had been initiated on 12/14/2021 to include a stop sign in his/her doorway to deter other residents from entering his/her room uninvited. Further review revealed the resident had been care planned for being at risk for Altered Mood related to Depression and Anxiety, with interventions to include, administer medications as ordered, monitor for effectiveness and adverse reactions, and notify the physician as needed; assess, monitor, and document mood/behaviors such as sad affect, tearfulness, restlessness; and notify the physician of abnormal reactions; provide reassurance as needed; psych evaluation as needed. There, however, was no evidence to support the facility implemented Resident #16's care plan to monitor the effectiveness of the resident's care. Additionally, the facility failed to revise the resident's care plan when he/she exhibited sexually inappropriate behaviors, for the safety of the resident and other vulnerable residents. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, entered by LPN #2, revealed he came out of the South medication room and saw Resident #16 standing in the center of South Hall with his/her tongue down a male/female's (Resident #20) throat while at the same time groping another male/female resident's (Resident #18) breast. When Resident #16 saw LPN#2, he/she stopped and acted nonchalant like nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed he was informed by State Registered Nurse Aide (SRNA), [SRNA #10], in report of an interaction on dayshift between Resident #16 and another resident (Resident #18) in his/her room. Continued review revealed LPN #4 notified the SSD of the incident and was told to place Resident #16 on every fifteen (15) minute checks. However, the Care Plan was not revised to reflect Resident #16 had been placed on fifteen (15) minute checks after the incident occurred on 12/18/2022. 2. Record Review of Resident #18 revealed the facility admitted the resident on 09/10/2021, with diagnoses which included Unspecified Dementia with Unspecified Severity, Insomnia, Major Depressive Disorder, and Anxiety disorder. Review of Resident #18's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. a. Review of Resident #18's Comprehensive Care Plan dated 10/28/2021, revealed the facility care planned the resident for twenty four (24) hour supervision/assisted care related to Dementia with Behavioral Disturbance, anxiety, depression and wandering in hallways with exit-seeking behaviors, and wandering in and out of other residents' rooms, with interventions to include monitor placement of Wander Guard every shift; monitor front door alarm every day with monitoring device to ensure functioning correctly; no butter knives on meal tray to aid in the prevention of removal of Wander Guard; Wander Guard Bracelet on at all times related to exit seeking/wandering behaviors. Continued review revealed Resident #18 had been care planned for Altered Mood/Behaviors related to diagnosis of Dementia with behavioral disturbance, anxiety, and depression, with episodes of wandering in the facility with exit seeking behavior, and frequent wandering in and out of other resident's rooms, with new interventions to include, monitor the resident related to his/her habit of wandering in and out of other resident's rooms and to redirect him/her out of rooms, explain inappropriate behavior to him/her and remind him/her to refrain from going into other residents' rooms without invitation. The facility, however, failed to implement the resident's care plan to prevent the resident from wandering and going into other residents' rooms, to ensure the safety of the resident. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Interview on 02/16/2023 at 12:34 PM, with Resident #18's, Family Member #3, revealed he had not been made aware of the sexual interactions involving Resident #16 and Resident #18. Family Member #3 stated had Resident #18 been in his/her right mind, no one would have touched him/her in a sexual way. Interview on 02/14/2023 at approximately 12:30 PM, with SRNA #15, revealed Resident #18 was not capable of making the decision to participate in a sexual act with Resident #16. She stated she had reported the incident to the nurse on 12/18/2022 when she observed Resident #16 on top of Resident #18 in the recliner fondling and kissing Resident #18. 3. Review of Resident #20's medical record revealed the facility admitted the resident on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, and Anxiety Disorder. Review of Resident #20's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9), indicating moderate cognitive impairment. Review of Resident #20's Comprehensive Care Plan, dated 06/18/2021, revealed the facility care planned the resident for Altered Mood/Behavior related to anxiety and dementia with episodes of wandering with exit seeking behaviors, with interventions to include, administering medications as ordered by the physician, monitor for effectiveness of medications, as well as adverse reactions, notify physician as needed; assess, monitor and document mood/behaviors such as sad affect, restlessness, agitation, and wandering, and provide reassurance/redirection as needed, notify the physician of abnormal reactions. There was no evidence to support the facility implemented the resident's care plan to assess/monitor the resident's behavior related to wandering, to determine the effectiveness of the interventions. Additionally, the facility failed to revise the resident's care plan when the resident exhibited inappropriate sexual behaviors. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing Resident #20 while at the same time groping another male/female resident's (Resident #18's) breast. 4. Closed record review revealed the facility admitted , Resident #4 on 01/11/2022, with diagnoses which included Unspecified Alzheimer's disease, Unspecified Dementia with behavioral disturbance, Major Depressive Disorder, age-related cognitive decline, and Unspecified Psychosis,. Review of the Admission Minimum Data Set (MDS) Assessment for Resident #4, dated 01/17/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment. Continued review of the MDS, under Section E for Behaviors, revealed the resident exhibited behaviors to include physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually, daily. Further review revealed the resident had verbal behavioral systems that was directed toward others. These behaviors included threatening others, screaming at others, and cursing at others. Additional review revealed the resident had a diagnosis of non-Alzheimer's Dementia. Review of Resident #4's Comprehensive Care Plan, initiated on 01/12/2022, revealed Resident #4 was at risk for Altered Mood/Behaviors related to Dementia with Behavioral Disturbance, history of wandering, episodes of being verbally and physically abusive towards staff, rejection of care and Depression. Review of the care plan revealed the interventions for Resident #4 included: administering medications as ordered by Physician and monitoring for adverse reactions to the medications; monitoring and documenting any displayed mood/behaviors (such as sad affect, tearfulness, wandering); and report/notify abnormal reactions to the Physician. Per review of the care plan, additional interventions included: providing reassurance and redirection as possible; attempting to redirect the resident when displaying altered behaviors (such as wandering, cursing) by offering snack, reminiscing about family and his/her former career of factory supervisor, and toileting. Further review revealed the resident had Sundowners Syndrome with episodes of being physically abusive towards staff and rejecting care. Review of Resident #4's Progress Note, dated 01/14/2022, at 3:22 AM, documented by Licensed Practical Nurse (LPN) #4, revealed the resident had been up wandering, had increased agitation, and was combative and had hit staff with a water pitcher. Continued review revealed Resident #4 had hidden forks and butter knives in his/her drawer and stated to staff he/she would stab them if they kept bothering him/her. Per review, staff had been called to the room by Resident #4's roommate multiple times related to the resident throwing the roommate's objects at him/her. Additional review revealed Resident #4 had been observed going in and out of six (6) other residents' rooms and flipping the other residents' televisions onto the floor. Further review of the Progress Note revealed staff would continue to observe Resident #4's behavior. Review of the Progress Note for Resident #4, dated 01/14/2022 at 9:00 PM, documented by LPN #4, revealed the resident rummaged through other residents' rooms and became increasingly agitated and combative with staff and other residents around the nurse's station. Continued review revealed Resident #4 had taken a fork from another resident's meal tray and attempted to stab another resident and staff with the fork. Record review revealed the facility contacted the Medical Director and received a new order for a one (1) time dose of intramuscular (IM) Ativan (a medication used to treat anxiety) one (1) milligram (mg). Further review revealed the Medical Director told staff Resident #4 could not continue those behaviors and the resident might need a sitter, or a psychiatric (psych) evaluation. Review of the Progress Note for Resident #4, dated 01/18/2022 at 2:19 AM, revealed the resident had been wandering in the hallways and in and out of other residents' rooms, and became very agitated and combative. Continued review revealed Resident #4 had threatened multiple other residents and was aggressive towards other residents and staff. Per review of the Note, Resident #4 flipped chairs at the desk and a wheelchair in the lounge and attempted to hit staff with a wet floor sign. Further review revealed Resident #4 threw other residents' items into the hallway and screamed at the other residents. Review of the Note revealed per instructions from the Administrator and Medical Director, Resident #4 was placed on every fifteen (15) minute checks. However, additional review revealed no documented evidence the resident's care plan was revised with the increased need for supervision, to include a sitter. Review of the Progress Note for Resident #4, dated 01/27/2022 at 11:57 PM, revealed the resident had wandered into other residents' rooms, and became agitated at staff when they attempted to remove him/her from the other residents' rooms. Continued review revealed Resident #4 took other residents' personal items and threw them in the floor and hallway and threatened another resident who asked Resident #4 to leave his/her room. Review of the Behavioral Note for Resident #4, dated 01/30/2022 at 1:30 AM, revealed the resident wandered the hallways and into other residents' rooms and was short tempered with the staff. Continued review revealed Resident #4 was combative with staff and followed another resident around for most of the shift. Per review, when staff attempted to separate Resident #4 from the other resident, Resident #4 would go into other residents' rooms looking for the other resident he/she had been following. Record review revealed when the other resident attempted to get away from Resident #4, Resident #4 grabbed the other resident's shirt and punched him/her in the back. Further review revealed the staff separated Resident #4 from the other resident. However, Resident #4 continued to try to follow the other resident. Review of the Note further revealed Resident #4 was placed on every fifteen (15) minute checks per the Social Services Director (SSD) and the Administrator. Additional review revealed the facility failed to revise the resident's care plan to address the resident's behaviors. Interview on 02/15/2023 at 7:20 PM with LPN #4, revealed staff were unable to continuously monitor Resident #4 for the entire shift because of the staffing. LPN #4 stated staffing consisted of only two (2) nurses and two (2) State Registered Nursing Assistants (SRNA's) for the entire facility during the 7:00 PM to 7:00 AM shift for all four (4) halls. Interview on 02/08/2023 at 5:59 AM, with LPN #2 revealed the facility did not have the staff to provide one-on-one (1:1) supervision/care when residents needed increased supervision. He stated he had called Resident #4's family to sit with the resident; however, they were unable to come. Interview, on 02/15/2023 at 7:20 PM, with LPN #4 revealed staff did not report Resident #4's behaviors when they occurred because the resident's behaviors were normal. Continued interview revealed Resident #4 was admitted to the facility with dementia and behaviors that included wandering and going in and out of other residents' rooms. 5. Review of the Admission Record for Resident #13 revealed the facility admitted the resident on 01/11/2022, with diagnoses that included Unspecified Dementia without behavioral disturbance. Review of Resident #13's Admission MDS Assessment, dated 01/17/2022, revealed the facility assessed the resident to have a BIMS score of zero (0) indicating severe cognitive impairment. Review of Resident #13's Care Plan, initiated on 01/12/2022, revealed the facility care planned the resident as at risk for Altered Mood/Behaviors related to Dementia. Continued review revealed the interventions included administer medications as ordered by the Physician; assess, monitor and document any displayed mood/behaviors (such as sad affect, tearfulness, wandering, restlessness); provide reassurance/redirection as needed, and notify doctor of abnormal findings. Further review revealed the interventions additionally included: a psychiatric evaluation as needed initiated on 01/27/2022; and Social Services intervention for 1:1 supervision as needed, initiated on 03/31/2022. Additional review revealed no documented evidence to support the facility had implemented the resident's care plan to include 1:1 supervision as needed and no evidence to support the facility documented and monitored the effectiveness of the resident's care plan. Review of Resident #13's Progress Note, dated 01/30/2022 at 1:30 AM, revealed the resident had wandered the entire shift accompanied by another resident (later identified as Resident #4). Continued review revealed Resident #13 attempted to get away from the other resident and staff attempted to separate the two (2) residents without success. Per review of the Note, Resident #13 attempted to walk away from the other resident (Resident #4), the other resident grabbed the back of Resident #13's shirt and punched him/her in the back. Further review revealed staff separated the residents, Resident #13 wanted to sit down, and the other resident continued to attempt to follow Resident #13. Resident #13 was placed on every fifteen (15) minute checks per instructions from the SSD and the Administrator. However, the facility failed to document the unsuccessful attempt to separate the residents and provide 1:1 as needed, as per the resident's care plan. 6. Review of the Admission Record for Resident #17 revealed the facility admitted the resident on 05/31/2022, with diagnoses which included Unspecified Dementia with other Behavioral Disturbance and Altered Mental Status. Review of Resident #17's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. Review of Resident #17's Care Plan initiated on 06/06/2022, revealed the facility had care planned the resident to be at risk for Altered Mood/Behavior related to Dementia with Behavioral Disturbance, and a history of wandering. Continued review of the Care Plan revealed the interventions included: administering medication as ordered by the doctor; monitor for the effectiveness of the medication, as well as adverse reactions to medication, and report adverse reactions to the doctor. Review of the Care Plan revealed the interventions also included: assessing, monitoring and documenting the resident's mood/behaviors (examples include wandering episodes, tearfulness, restlessness, sad affect) and report abnormal findings to the doctor; provide reassurance/redirection as needed; pharmacy to review psychotropic medication use quarterly and as needed; psychiatric evaluation as needed; and Wander Guard bracelet on as ordered by the doctor. However, further review revealed no documented evidence to support the facility had implemented the resident's care plan, to assess/monitor and document the resident's behaviors to refer concerns to his/her psychiatrist/physician and failed to revise the resident's care plan to address the inappropriate sexual contact. Review of Resident #14's Progress Note, dated 09/02/2022 at 6:29 AM, documented by Licensed Practical Nurse (LPN) #1, revealed Resident #14 had been found kissing Resident #17, who was his/her roommate. Further record review revealed no evidence to support the facility documented the incident in Resident #17's medical record. Review of Resident #17's Therapy Note, dated 09/08/2022 at 2:36 PM, revealed the Psychiatrist #1 saw the resident for a follow-up psychiatric therapy via telehealth. Continued review revealed the resident was anxious and was not sure where he/she was during the visit. Interview on 02/14/2023 at 1:03 PM, with SRNA #1, revealed Resident #14 and Resident #17 were found disrobing each other on an unknown date. SRNA #1 stated she had reported this information to two (2) different charge nurses, the DON, and the Resident Care Coordinator (RCC) and suggested the residents should no longer be roommates. 7. Review of the Admission Record for Resident #14 revealed the facility admitted the resident on 08/15/2022, with diagnoses that included Agitation, Restlessness, Unspecified Dementia, Unspecified Severity, with other behavioral disturbance, Unspecified Depression, and Unspecified Anxiety disorder. Review of the Admission MDS Assessment for Resident #14, dated 08/22/2022, revealed the facility assessed the resident to have a BIMS score of five (5), indicating severe cognitive impairment. Review of the Care Plan for Resident #14 initiated on 08/16/2022, revealed the facility care planned the resident as at risk for Altered Mood/Behaviors related to Dementia with behavioral disturbance and Anxiety. Continued review revealed the interventions included: administering medications as ordered by the Physician and monitoring for the effectiveness of the medications as well as adverse reactions; notify the Physician as needed if abnormalities were observed. The care plan stated: assess, monitor and document mood/behaviors (such as sad affect, tearfulness, restlessness); notify the Physician of abnormal reactions; provide reassurance and redirection as needed; pharmacy to review the resident's psychotropic medication use quarterly and, as needed. Additional review revealed the interventions also included: provide redirection; assist the resident to his/her own room/bed when getting into other residents' beds in their rooms; and psychiatric evaluation as needed. However, there was no documented evidence to support the facility implemented the resident's care plan to assess and monitor the resident to prevent the resident from getting into bed with other residents, prevent his/her wandering, or revised to include sexually inappropriate behaviors with interventions to determine its effectiveness. Review of Resident #14's Progress Note, dated 09/02/2022 at 6:29 AM, documented by LPN #1, revealed Resident #14 had been found kissing Resident #17, who was his/her roommate. Observation on 02/14/2023 at 6:10 AM, revealed Resident #14 was lying on the couch in the common room, then pacing up and down the hallways, and in and out of other residents' rooms, without staff's oversight. Interview with LPN #4, on 02/14/2023 at 6:10 AM, revealed he was not aware Resident #14 was out of his/her bed and in the common room. Interview on 02/14/2023 at 1:03 PM, with State Registered Nursing Assistant (SRNA) #1 revealed Resident #14 and Resident #17 were found disrobing each other on an unknown date. SRNA #1 stated she had reported this information to two (2) different charge nurses, the DON, and the Resident Care Coordinator (RCC) and suggested the residents should no longer be roommates. However, review of multiple progress and psychiatric notes for Resident #14, dated 02/14/2023, revealed no documented evidence Resident #14 had any behaviors. Interview on 02/15/2023 at 7:20 PM with LPN #4, revealed the facility had multiple residents who wandered, and staff could not maintain visualization of all the residents throughout the 7:00 PM to 7:00 AM shift. LPN #4 stated he believed if appropriate interventions had been implemented for Resident #4 that his/her future behaviors might have been prevented. Interview on 02/07/2023 at 11:55 AM, with Registered Nurse (RN) #2, revealed if she witnessed a resident abuse another resident, she would separate the residents, notify her supervisor (the DON), and notify the families and doctors of the residents. She further stated there were many wandering residents in the facility and not all of their behaviors were documented. She stated that she receives annual dementia training. Interview on 02/08/2023 at 5:50 AM, with LPN #3 revealed the facility had two (2) nurses and two (2) or three (3) SRNA's on a typical 7:00 PM to 7:00 AM shift to cover all four (4) halls. LPN #3 stated there was no time to document all the residents' behaviors. Interview on 02/08/2023 at 5:59 AM, with Licensed Practical Nurse (LPN) #2 revealed the facility did not have the staff to provide one-on-one (1:1) supervision/care when residents needed increased supervision. He further stated the residents' behaviors were normal and there were multiple residents who wandered in the facility. Interview on 02/10/2023 at 11:41 AM, with the Minimum Data Set (MDS) Coordinator, revealed she was responsible for all care plan updates to the comprehensive care plan. She stated she followed the Resident Assessment Instrument (RAI) and care planned the problems triggered by the MDS. She stated behaviors, falls, and condition changes were discussed in the daily morning meeting. She further stated that she should have put additional interventions on the resident's care plan. Interview with the Director of Nursing (DON), on 02/16/2023 at 3:16 PM, revealed the MDS Coordinator completed the Comprehensive Care Plan based on the items triggered by the MDS. She further stated the MDS Coordinator was responsible for updating the care plan. Continued review revealed she it was her expectation care plans would have been revised to reflect the care needs of the residents. Interview on 02/21/2023 at 4:44 PM, with the Administrator, revealed it was her expectation that the care plan would be updated by the MDS Coordinator. She stated the MDS Coordinator attends the Morning Meetings held Monday through Friday where behaviors, falls, and significant change [TRUNCATED]

Based on observation, interview, and record review, it was determined the facility failed to conduct and document a facility-wide assessment to evaluate what resources were required to provide the necessary care and services for residents who required the use of a mechanical lift. On [DATE], staff transferred Resident #1 from a Geri chair to his/her bed utilizing the mechanical lift when the lift sling strap broke, and the resident fell to the concrete floor. Resident #1 fell approximately four (4) feet and sustained serious injuries which included fractures identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Resident #1 died related to his/her injuries from the fall. Review of the Facility Assessment revealed the facility failed to ensure there was a system in place to inspect the mechanical lift slings for safety. The Assessment also failed to specify an inspection schedule and failed to designate staff responsible for inspection of the mechanical lift slings to prevent accidents and serious injury. The facility's failure to ensure residents with Dementia, had their individualized care needs and the necessary services and care to maintain their highest practicable mental, physical, and psychosocial well-being were provided, has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is ongoing. The findings include: Review of Resident #1 electronic health record (EHR), dated [DATE], revealed the facility admitted him/her with diagnoses that included, Diabetes Mellitus, Chronic Diastolic Heart Failure, Thoracic Aortic Aneurysm, Morbid (severe) Obesity, and acquired Absence of Right Leg Above Knee. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) examination score of fourteen (14) of fifteen (15). This score indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revealed the facility-initiated mobility interventions, revised on [DATE]. The interventions included assistance to the Geri chair via a mechanical lift and two (2) staff assist for all transfers. Interview, on [DATE] at 11:41 AM, with Family Member #1, revealed Registered Nurse (RN) #1 reported to her, that on [DATE], while raised in the mechanical lift, the sling that held him/her broke, and Resident #1 fell to the floor and hit his/her head. Family Member #1 stated, Resident #1 told her there was only one staff member that operated the lift when the resident fell . Interview, on [DATE] at 2:50 PM with State Registered Nurse Aide (SRNA) #1 revealed on [DATE], she was alone while operating the mechanical lift with Resident #1. She stated she was positioned near the handles of the lift when the strap of the sling on the right side broke and the resident hit the floor head - first. Continued interview revealed SRNA #1 attempted to grab the resident. However, he/she slipped through her hands and his/her head hit the floor with a loud thud. Review of the facility's, Facility Assessment Tool, reviewed on [DATE], and updated on [DATE], revealed the facility assessed seventeen (17) residents to be dependent on staff for transfers. Per the Facility Assessment Tool, care and services were offered based on the resident's needs which included providing person centered/directed care with specific care or practices that included identifying hazards and risks for residents. Continued review of the Facility Assessment Tool revealed the facility developed policies to outline the purpose and procedures for staff to follow for care areas and practices. Further review revealed the facility would complete time - specified inspections of physical resources which included lift slings. However, the facility provided no documented evidence of specified inspection of lift slings. Interview, on [DATE] at 11:32 AM, with the Maintenance Director, revealed it was his responsibility to check machinery and equipment once per month. However, that did not include the mechanical lift slings. Further interview revealed all department heads had worked together on the Facility Assessment and provided input, but he definitely did not include the lift slings in time specified equipment inspections. Interview, on [DATE] at 9:00 AM with the Director of Nursing (DON), revealed the facility did not utilize slings from the mechanical lift's manufacturer. Per interview, it was her responsibility to remove slings from service that were damaged or worn. However, she stated surveillance had not occurred prior to the accident on [DATE], when Resident #1 fell to the floor from the lift sling. During interview, on [DATE] at 12:40 PM, the DON stated she participated in the facility's assessment; however, there were no policies in place to address the mechanical lift and safe patient (resident) handling at the time the accident occurred on [DATE]. Interview, with the Administrator, on [DATE] at 2:43 PM, revealed she was ultimately responsible for the Facility Assessment. She stated maintenance and surveillance of the mechanical lift slings had not been included in the facility's Assessment Tool, but it should have been. Further interview revealed there should have been a designated person(s) to assess the slings and a time specified schedule and process to ensure the slings remained in safe condition. Further interview revealed the facility did not have a policy in place for safe resident handling with mechanical lifts. Continued interview revealed that the slings were not adequately addressed in the Facility Assessment, but they should have been. Interview, on [DATE] at 2:20 PM, the Administrator stated there was no Facility Assessment Policy in place at the time of the accident on [DATE]. Interview, on [DATE] at 3:39 PM, with the Medical Director revealed it was her expectation the facility would have a policy or procedure in place to inspect the facility's equipment and slings.

Based on observation, interview, and record review, the lift's Manufacturer's Owner's Manual Safety Instructions and the Slings Manufacturer's Owner's Manual it was determined the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition regarding the mechanical lift equipment, specifically, the required lift slings for one (1) of twenty-one (21) sampled residents (Resident #1). The facility failed to follow the manufacturer's recommendations and utilized slings that were not recommended by the manufacturer. In addition, the facility failed to follow the manufacturer's maintenance recommendations for laundering and inspecting the lift slings. The facility assessed twelve (12) residents that required the use of a mechanical lift. On [DATE], during transfer from a Geri chair to his/her bed, Resident #1 was dropped from the mechanical lift when the lift sling strap broke. The resident fell approximately four (4) feet to the floor. Resident #1 hit his/her head on the concrete floor, causing substantial injuries. Emergency Medical Services (EMS) were called to the scene. Resident #1 was transferred to the local hospital for evaluation. Resident #1 was discharged from the local hospital with diagnoses from the fall that included: displaced comminuted supracondylar fracture of the right humerus; fracture of the seventh cervical vertebra; fracture of the first thoracic vertebra; and contusion of the scalp. Resident #1 was transferred to another hospital emergency department equipped to manage his/her injuries. On [DATE], Resident #1 was pronounced dead from injuries sustained in the accident on [DATE]. The facility's failure to maintain all mechanical, electrical, and resident care equipment in safe operating condition has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is ongoing. The findings include: Review of the Manufacturer's Owner's Manual Safety Instructions, for the battery-operated mechanical lift, not dated, revealed special care must be taken with residents unable to aid while being lifted and included severely handicapped residents. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use with their lifts and use of non-manufacturer's brand lift slings were unsafe and may result in injury to the resident or caregiver. Further review of the Manual's Maintenance Schedule included instructions to check the entire sling inventory for fraying, tearing, or excessive wear of any kind and replace worn or damaged slings with new Manufacturer's recommended slings. Per the warnings in the Owner's Manual, lifts should not be in operation unless all maintenance points passed inspection, which included a warning not to use slings unless recommended for use with the lift and never use frayed or damaged slings. Review of the Slings Manufacturer's Owner's Manual, not dated, revealed warnings to carefully inspect the sling before each use for wear and damage to the seams, fabric, straps, and strap loops. Per the manual's warnings, torn, cut, frayed, or broken slings could fail, resulting in serious personal injury. Continued review revealed only slings in good condition should be used and old, unusable slings should be destroyed and discarded. Further review of the manual specified washing instructions which included that bleached slings were unsafe and may result in serious injury. Review of the facility's Maintenance Records, dated [DATE] to [DATE], for the Mechanical Lifts that were in use when the accident occurred, on [DATE], revealed no documentation that the lift slings were inspected for damage or wear. Review of Resident #1's electronic health record (EHR) revealed the facility admitted him/her, on [DATE]. The resident's diagnoses include; Diabetes Mellitus, Chronic Diastolic Heart Failure, Thoracic Aortic Aneurysm, Morbid (Severe) Obesity, and acquired Absence of Right Leg Above Knee. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated, [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revealed the facility-initiated mobility interventions, revised on [DATE], which included assistance to Geri chair via mechanical lift and two (2) staff assist for all transfers. Review of Resident #1's Nurse's Progress Notes, dated [DATE], signed by Registered Nurse (RN) #1, revealed RN #1 was called to Resident #1's room, by a State Registered Nursing Assistant (SRNA) and found Resident #1 lying on his/her back on the floor. Continued review of the Progress Note revealed the lift sling was frayed and broke during Resident #1's transfer with the mechanical lift. Resident #1 fell to floor and sustained serious injuries. Observation, on [DATE] at 4:45 PM, revealed a non-manufacturer recommended sling had been used for Resident #1 at the time of the accident. Continued observation revealed the sling had brittle straps and multiple broken loops. Per observation, a total of eight (8) non-manufacturer recommended slings, were in operation on [DATE]. The sling loops were brittle, and the labels were faded so that washing instructions and sling size were not legible. Interview, on [DATE] at 11:41 AM, with Family Member #1, revealed RN #1 reported to her, on [DATE], that while Resident #1 was raised in the mechanical lift, the sling that held him/her broke and the resident fell to the ground and hit his/her head. Further interview revealed the lift sling fabric was frayed and contributed to the accident. Continued interview revealed Resident #1 was transferred by ambulance to a local hospital. Fractures were identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Per interview Resident #1 was transferred from the ED at the first hospital to a larger hospital to address the injuries sustained during the fall from the mechanical lift sling. Resident #1 expired from his/her injuries. Interview, on [DATE] at 2:50 PM with SRNA #1 revealed, on [DATE], she was alone while operating the mechanical lift with Resident #1. Per interview, she was positioned near the handles of the lift when the sling's strap's loop broke and the resident hit the floor, 'head - first. Continued interview revealed SRNA #1 attempted to grab the resident. However, the resident slipped through SRNA #1's hands and his/her head hit the floor with a loud thud. Interview, on [DATE] at 12:50 PM with Laundry Staff #1 revealed she washed the mechanical lift slings in the big washer most often. However, there were no posted laundry instructions prior to the accident that occurred on [DATE]. Per interview, she did not receive training or instruction regarding assessment of slings for dry, brittle, or damaged slings prior to the accident. Continued interview revealed she had not been given sling laundering instruction. She stated that the laundering instructions on the label were faded and not legible. Interview with Laundry Staff #1 revealed other staff often 'fill in' in the laundry department and they would not know how to wash the slings if the label was faded and no laundering instructions were posted. Interview, on [DATE] at 11:32 AM, with the Maintenance Director, revealed it was his responsibility to check the machinery and equipment once per month. However, that did not include the mechanical lift slings. Per interview, he was never asked to assess the slings and checking for frays and tears would be a nursing responsibility. Continued interview revealed the Maintenance Department included the Laundry Department and the staff knew how to wash the slings according to manufacturer's instructions by reading the labels on the slings. Per interview, he was not aware of special laundering instructions for the slings other than not to use fabric softener because it damaged the sling fabric. Further interview revealed the staff did not receive training regarding removing slings from service for damage, fray, or laundering. Interview, on [DATE] at 4:09 PM, with the DON revealed the facility did not follow the manufacturer's instructions for laundering the mechanical lift slings prior to the accident that occurred on [DATE], when the mechanical lift sling holding Resident #1 snapped, and the resident fell to the floor. Per interview there were a total of eight (8) slings removed from the nursing floors because the tags were faded and not legible. Continued interview revealed she examined the sling in use when Resident #1 was seriously injured and later discovered several of the sling loops broke easily and indicated the worn slings resulted from not following the manufacturer's instructions for laundering the slings. Interview, on [DATE] at 2:43 PM with the Administrator revealed the facility did not follow the mechanical lift manufacturer's instructions regarding the type of sling to use with the lifts, nor did the facility follow the sling manufacturer's instructions for laundering the slings. In addition, there was no process in place to routinely inspect the condition of the slings used with the mechanical lifts to prevent serious accident and injury. Per interview, there were no policies in place to address the mechanical lift and there should have been The Administrator stated resident safety was her responsibility. Interview, on [DATE] at 3:39 PM, with the Medical Director revealed it was her expectation the facility would have a policy or procedure in place to inspect the facility's equipment and slings.

Based on interview, record review, and review of the facility's Administrator's Job Description and policies, it was determined the facility failed to ensure it was administered in a manner that used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (3) of twenty-one (21) sampled residents (Resident #16, Resident #18, and Resident #20) with Dementia. On 06/23/2022, staff observed Resident #16 in the hallway across from the nurse's station, kissing and groping Resident #18's breasts. However, there was no documented evidence the facility reported the incident to the State Survey Agency (SSA) or Law Enforcement as sexual abuse, or thoroughly investigated the sexual abuse as per the facility's policy. On 12/08/2022, staff found Resident #16 on top of Resident #18 in a recliner chair in Resident #16's room, kissing and humping Resident #18. However, there was no documented evidence the Administrator ensured the allegation of sexual abuse was reported to the SSA or Law Enforcement, or thoroughly investigated the sexual abuse as per the facility's policy. The facility's administration failed to follow its policy related to discharge planning, transfers and discharges, and failed to ensure Social Services was provided in order to maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. The facility's failure to ensure it was administered in a manner that used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is ongoing. The findings include: Review of the facility's Administrator Position Description, undated, revealed the major duties included: operating the facility in accordance with established policies and procedures of the Governing Body; prepare and forward on time to the proper authorities all reports required by management; and write definite policies regarding the activities and duties of facility staff and explain the policies to staff to ensure the health care and safety of residents. Further review of the Description revealed additional major duties of the Administrator included: writing personnel policies and individual duties of staff to ensure they were known by all employees; and to supervise all Department Heads by performing regular rounds and conferences. Review of the facility's Abuse Prevention Policy, revised 01/25/2018 and last reviewed 09/09/2022, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Per policy review, all alleged violations involving abuse were to be reported immediately in accordance with State law through established procedures, to include the State Survey Agency (SSA/ licensure and certification agency) and other officials. Continued review of the Policy revealed an in-house investigation was to be performed by the Administrator and/or his/her designee and all appropriate agencies, such as the SSA and Ombudsman, were to be notified immediately after the suspected abuse was reported. Further review of the policy revealed the investigative results of the in-house investigation was to be reported to the outside entities within five (5) working days. Review of Resident #16's medical record revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated he/she was moderately cognitively impaired. Continued review revealed the facility assessed Resident #16 as having no behaviors directed towards others to include sexually abusing others. However, on 06/23/2022, Resident #16 was observed by Licensed Practical Nurse (LPN) #2 in the hallway across from the nurse's station, kissing Resident #20, and groping Resident #18's breasts. Further review revealed there was no documented evidence the facility reported the incident to the State Survey Agency (SSA) or Law Enforcement as sexual abuse as required, or thoroughly investigated the sexual abuse as per the facility's policy. Interview, on 02/14/2023 at 6:35 AM, with Licensed Practical Nurse (LPN) #2 revealed he had been in the medication room on 06/23/2022, and observed Resident #16, through the window, kissing Resident #18 and groping his/her breasts. Per LPN #2, when he exited the medication room Resident #16 and Resident #18 had returned to their rooms. LPN #2 stated he had not immediately reported the incident even though he believed the incident was sexual abuse. He stated for three (3) years he had observed Resident #16 displaying behaviors towards residents with Dementia, such as he observed during the incident involving Resident #18. Per LPN #2, Resident #18 really needed to be on one on one (1:1) supervision. Continued interview revealed he later reported the sexual abuse incident involving Resident #18 to the Director of Nursing (DON). LPN #2 stated he discussed the sexual incident involving Resident #18 kissing Resident #16 with the DON, who told him the incident was not reportable to the State since the incident did not appear to be unwanted. Interview with LPN #4 on 02/13/2023 at 8:00 AM, revealed he had received information from another staff member (State Registered Nursing Assistant [SRNA] #15) on 12/18/2022, about seeing Resident #16 on top of Resident #18, kissing and humping Resident #18. LPN #4 stated he reported the incident to the Social Services Director (SSD) on 12/18/2022. Interview, with SRNA #15 on 02/14/2023 at approximately 12:30 PM, revealed she had observed Resident #16 on top of Resident #18 fondling and kissing Resident #18. SRNA #15 stated Resident #18 was not capable of making the decision to participate in a sexual act with Resident #16. Further interview revealed she reported the incident to the nurse (LPN #4) immediately, and additionally stated Resident #18's spouse, who was also the resident's Power of Attorney (POA) was not notified or aware of the incident. Interview with Registered Nurse (RN) on 02/15/2023 at 4:36 PM, revealed Resident #16's sexually inappropriate behaviors were common knowledge at the facility. Further interview revealed the facility's Abuse Coordinator was well aware of Resident #16's inappropriate sexual behavior. However, the facility's Administration again failed to address the sexual abuse of Resident #18 by Resident #16 on 12/18/2022, when Resident #16 was observed by staff on top of Resident #18 in a recliner chair in Resident #16's room, kissing and humping Resident #18. The facility's Administration also failed to thoroughly investigate the sexual abuse of Resident #18 by Resident #16, as per facility policy. In addition, the facility's Administration failed to provide documented evidence allegations of sexual abuse were reported to the SSA or Law Enforcement. Interview on 02/14/2023 at 6:00 AM, with LPN #4 revealed he believed Resident #16 was abusing residents sexually, and the Resident Care Coordinator (RCC) told him it was for the good of the facility not to report. Continued interview revealed the LPN was very upset, about Resident #16's sexual incidents not having been reported after he told the Administrator and Medical Director about the incidents. LPN #4 stated I think it is a cover up. Further interview revealed about three (3) months ago there was an incident where Resident #16 molested and touched SRNA #10, and molested a resident. LPN #4 further stated that information should have been reported. Interview, with LPN #2 on 02/14/2023 at approximately 6:35 AM, revealed he witnessed Resident #16 kissing a resident who had dementia and groping another resident, with his/her hands on the other resident's breasts. Per interview, LPN #2 stated he put a note in about the incident. Continued interview revealed he did not report the incident at that time; however, he talked to the DON about it later. He stated the DON told him in order for it to be abuse there had to be unwanted contact by the victim. He stated the DON told him she put a note in stating there was no distress in the residents. According to LPN #2, that incident had not been the first time, he stated he had witnessed Resident #16, who had displayed that behavior ever since he first started working at the facility. Further interview revealed he had seen Resident #16 kissing other residents and some of those residents had dementia. The LPN further stated Resident #16's sexual behaviors had been happening for three (3) years, the resident should have had increased supervision, really needed one on one (1:1) supervision. He further stated they (administrative staff) gave staff the reason for not reporting Resident #16's sexual incidents was because the other residents had not been in distress; however, the incidents were abuse. Interview, with the DON on 02/16/2023 at 9:20 AM, and on 02/21/2023 at 3:05 PM, revealed the facility did not have oversight of its reporting and investigating processes, and had no one designated to ensure the reporting and investigations of sexual abuse allegations occurred. Continued interview revealed the facility had an in person training in November on abuse related to the new regulations which had gone into effect. Per the DON, the training consisted of printouts which were gone over with staff and the updated changes reviewed. She stated the printouts referred to a resident's capacity to consent in sexual interactions. She stated it could not be relied on whether the resident understood or what their Brief Interview for Mental Score (BIMS) scores were. Interview revealed residents were to be interviewed and a psychiatric (psych) consult performed for the resident. The DON stated however, the facility had no one who could come perform the psych evaluations of residents. She stated she had been notified by staff of residents being sexually inappropriate before and the facility usually tried to get to the bottom of it. According to the DON, the sexual allegations had been discussed in the facility's morning meetings; however, the facility did not report the allegations because there had not been any harm and we did not think it was abuse. Further interview revealed there needed to be more training and investigations performed. She further stated other residents deserved to be protected from sexual abuse; and if they did not have the ability to consent that was sexual abuse. Interview with the Administrator, on 02/16/2023 at 3:10 PM, and on 02/21/2023 at 3:30 PM, revealed in the facility's morning meetings changes in residents' condition were discussed, and the sexual allegations by Resident #18 would have been or should have been discussed. Per the Administrator, it was her expectation for the sexual allegations to have been discussed, and the residents' care plans updated with interventions to protect the resident and/or other residents. However, the Administrator stated she did not recall if the sexual allegations were discussed. The Administrator revealed the facility's Abuse Coordinator should direct staff on whether to report an incident or not, and if there was an injury the Abuse Coordinator would tell staff to start an investigation. According to the Administrator, the facility was reevaluating the entire (incident) process, and the would be more likely to extend the evaluation period of an incident, and report it if we were unable to determine if what occurred was abuse. The Administrator stated she thought if there had been an investigation it would have shown abuse. Continued interview revealed the Administrator stated the sexual incidents should have been reported. The Administrator stated the Medical Director was updated during the facility's Quarterly Quality Assurance Performance Improvement (QAPI) meetings. ` 38372

Based on interview, record review, and review of the facility's policy, investigations, and documentation, it was determined the facility failed to implement its Quality Assurance Performance Improvement (QAPI) program to identify opportunities for improvement in the care and services provided to residents. The facility's QAPI process failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards of quality of care regarding performance improvement measures were sustained. As a result, the facility's QAPI program failed to develop, implement, and monitor to ensure its effectiveness in addressing sexual abuse in the facility. (Refer to F600, F609, F610, and F835) Interview and record review revealed facility staff were aware of sexual abuse allegations; however, they failed to report the allegations to the State Survey Agency (SSA) and other State agencies and failed to conduct thorough investigations of the allegations. Therefore, the facility's QAPI program failed to develop and implement plans to prevent sexual abuse in the facility. The facility's failure to ensure it developed, implemented, and maintained an effective, comprehensive, data-driven QAPI program that focused on indicators regarding outcomes of care and quality of life for its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/ Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/ Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is ongoing. The findings include: Review of the facility's Administrator Position Description, undated, revealed the Administrator's major duties included: ensuring operation of the facility in accordance with the Governing Body's established policies and procedures; writing definitive policies in relation to the duties and activities of staff and explaining the policies to staff to ensure the safety and healthcare of facility residents. Review of the Description further revealed the Administrator's major duties also included the writing of individual duties of staff and personnel policies to ensure staff knew the policies and duties. In addition, the Administrator was to supervise all Department Heads by performing regular rounds and conferences. Review of the facility's Abuse Prevention Policy, revised 01/25/2018 and last reviewed 09/09/2022, revealed the definition of sexual abuse was the non-consensual sexual contact of any type with a resident. Continued policy review revealed all alleged violations involving abuse were to be reported immediately in accordance with State law through the facility's established procedures. Per review of the policy, reporting was to include alleged violations being sent to the State Survey Agency (SSA) and other officials, and all appropriate agencies, such as the SSA and Ombudsman, were to be notified immediately after the suspected abuse was reported. Further review of the policy revealed the Administrator and/or his/her designee was to perform an in-house investigation, and the results of the investigation were to be reported to the outside entities within five (5) working days. Interview, on 02/15/2023 at approximately 12:30 PM, and on 02/21/2023 at 2:23 PM, with the Minimum Data Set (MDS) Coordinator revealed she was part of the facility's QAPI team. She stated behaviors and allegations of abuse should be discussed in the QAPI meetings, to include sexual abuse allegations. Continued interview revealed she did not recall Resident #16's sexual incidents on 06/23/2022 and 12/18/2022 having been discussed in any Interdisciplinary Team (IDT) meeting she had attended, which included QAPI meetings. She stated she attended the facility's morning meetings and QAPI meetings. Per interview, the morning meetings were held Monday through Friday, and residents' behaviors, to include sexual incidents, were part of what was discussed in the meetings. The MDS Coordinator further stated she did not recall sexual behaviors of Resident #16 being discussed in the facility's QAPI meetings. Interview, with the Director of Nursing (DON) on 02/16/2023 at 9:20 AM, revealed the facility had no one designated to ensure the reporting and investigations of sexual abuse allegations. The DON stated the facility did not have oversight of its reporting and investigating process. Per interview, the DON stated in November the facility performed an in person training on abuse. Continued interview revealed the printouts talked about a resident's capacity to consent in sexual interactions, a resident's Brief Interview for Mental Score (BIMS) and whether the resident understood could not be relied on. The DON stated residents needed to be interviewed and there would need to be a psychiatric (psych) consult for the resident; however, the facility did not have anyone who could come perform psych evaluations. She revealed staff had notified her of residents being sexually inappropriate before they usually tried to get to the bottom of it. The DON stated other residents deserved to be protected from sexual abuse; and if they did not have capacity to consent that was sexual abuse. Interview revealed the facility had not reported Resident #16's sexual incidents because there is not any harm - we didn't think it was abuse. Per the DON, there needed to be more training and investigations performed. She stated in the morning meetings falls, allegations, including sexual allegations were discussed and what was to go to the monthly Performance Improvement Plan (PIP) meetings (monthly) was decided. Further interview revealed everything that went to PIP went to the facility's QAPI. The DON further stated the Medical Director attended the QAPI meetings, by phone or in-person. Interview, on 02/16/2023 at 3:10 PM, and on 02/21/2023 at 3:30 PM, with the Administrator revealed the facility needed to reevaluate its entire process for reporting and investigating allegations of abuse to improve its processes. Continued interview revealed the facility's current process had failed and she had not been aware of the extent of sexual abuse allegations which had occurred in the facility on 06/23/2022 and 12/18/2022. The Administrator stated the facility had morning meeting with all supervisors, and the report sheet, which noted residents' condition changes, was gone over. Further interview revealed the sexual allegations involving Resident #16 would have or should have been discussed; however, the Administrator did not recall if the allegations had been discussed. She further stated it was her expectation for allegations, including sexual allegations, to be discussed in the meetings, and for the MDS Coordinator to update the resident's care plan with interventions to protect the resident and other residents. In addition, the Administrator stated in the morning meetings it might be decided something should go to the PIP, then to the facility's quarterly QAPI meeting to be reviewed and the Medical Director updated. The Administrator further stated the facility did not have a system in place to audit or monitor for its effectiveness of its processes. Interview, on 02/21/2023 at 5:35 PM, with the Medical Director revealed QAPI meetings were held quarterly, and the facility had been religious with having those meetings. The Medical Director stated in the QAPI meetings they looked at falls, infections, etc. and decided what was to be done. Per the Medical Director, she was the facility's oversight person and would think they should notify me regardless. Continued interview revealed there had been a lot of research with elderly people having relations in nursing homes and there were sometimes when people had sexual relations in facilities. According to the Medical Director, residents were adults and it was difficult to say if they were consenting, and they should have had a psychiatric (psych) evaluation. Further interview revealed she attended the facility's QAPI meetings and allegations were discussed; however, she did not recall if the sexual abuse was discussed in the QAPI meetings. 38372

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 protect two (2) of twenty-one (21) residents (Resident #18 and Resident #20) from sexual abuse. On 06/23/2022, Resident #16 was observed by staff in the hallway, across from the nurse's station, kissing Resident #20 and groping Resident #18's breast. The facility, however, failed to assess and revise the resident's care plan to identify the potential risks to other residents related to Resident #16's behaviors. Additionally, interviews with staff revealed sexual abuse was not considered as the residents' Brief Interview for Mental Status (BIMS) score was low, or below eight (8), which indicated severe cognitive impairment. Further, the allegation of abuse was reported to the Director of Nursing (DON), however, staff were informed by the DON that the incident was not reportable or investigated as abuse because the residents did not appear to show that the sexual activity was unwanted. Subsequently, on 12/18/2022, Resident #16 was found by staff in his/her room on top of Resident #18, kissing and humping the resident on Resident #16's recliner chair. Further staff interviews revealed the sexual behavior in Resident #16's room did not appear to be unwanted by both residents. It was because this type of inappropriate unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the residents position would have experienced severe psychosocial harm, as a result of sexual abuse. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018 and reviewed on 09/09/2022, revealed each resident had the right to be free from verbal, sexual, physical, and mental abuse. Per the policy, sexual abuse was defined as, non-consensual sexual contact of any type with a resident. Further review revealed the residents' care plan would be revised to reflect new interventions to minimize reoccurrence and to treat any injury or harm identified through the assessment of the resident; other residents who may have potentially been affected, or were at risk, would be identified, and a plan of care would be developed or revised as appropriate to ensure safety. Review of the facility's policy titled Process to Report and Investigate Allegations of Abuse dated 02/02/2018, revealed that as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, Director of Nursing (DON), Social Service Director (SSD) immediately; make sure the residents responsible party and physician were notified of the allegation; and if another resident was involved and alleged to have caused the incident, an employee would be assigned to monitor one-on-one (1:1) until initial evaluation could be completed; once the evaluation was completed, the facility would contact the physician with the results for possible new orders to discharge or continue care; if the resident remained at the facility, the resident would be placed on fifteen (15) minute checks for the next seventy-two (72) hours; and the care team would update the care plan as appropriate. 1. Review of Resident #16's Progress Note dated 06/23/2022 at 11:13 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Medication Room and saw Resident #16 standing in the center of the South Hall with his/her tongue down a resident's [Resident #20] throat while at the same time groping another resident's [Resident #18] breast. Further review revealed that when Resident #16 saw LPN#2, he/she stopped and acted nonchalant as though nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed the LPN was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was informed during report, from a previous shift, about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Record review revealed the facility admitted Resident #16 on 02/05/2015 with diagnoses to include Unspecified Dementia and Generalized Anxiety Disorder. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of ten (10), indicating the resident was moderate cognitive impairment. Continued review, under Section E of the MDS, revealed the resident did not exhibit behaviors, to include hitting, kicking, pushing, scratching, grabbing, abusing others sexually. or wandering. Review of Resident #16's Annual MDS, dated [DATE], revealed the resident was assessed to have a BIMS score of ten (10), which indicated moderately cognitive impairment. Continued review, under Section E of the MDS, revealed the resident did not exhibit behaviors, to include hitting, kicking, pushing, scratching, grabbing, abusing others sexually, or wandering. Review of Resident #16's Comprehensive Care Plan, initiated on 02/05/2015 revealed the resident was care planned for altered mood, depression, and anxiety with psychoactive medication use. Further review revealed the resident had episodes of crying, with increased his/her depression. The goal of the care plan was for the resident to display a stable mood over the next ninety (90) days, with interventions to include assessing, monitoring and documenting mood/behaviors. There was no evidence; however, to support the facility revised the resident's care plan to include the resident's sexually inappropriate behaviors with increased supervision, to ensure the safety of the resident. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed Resident #16 was sexually inappropriate. She stated on one occasion, the resident asked her for a washcloth. RN #1 revealed she went to the linen closet to grab the resident his/her washcloth and the resident walked into the linen closet, kissing her directly in the mouth. The RN revealed she told the resident never to do that again, adding, I was off guard. She stated she told a couple of girls but did not report the incident. 2. Review of Resident #18's Progress Notes, late entry dated 06/23/2022 at 11:13 PM, revealed Licensed Practical Nurse (LPN) #2 came out of the south hall medication room and witnessed a resident (Resident #16), kissing another resident (Resident #20), while groping this resident's (Resident #18) breast. Continued review of the progress note revealed the resident just stood there, letting [Resident #16] touch him/her. Further review revealed the resident did not appear to resist nor did he/she show any signs of physical, emotional, or psychological distress. Continued review of the progress note revealed that when the resident [Resident #16] saw the nurse, he/she stopped and went to his/her room and this resident [Resident #18] started walking the hallway, which was normal for him/her. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Review of Resident #18's medical record revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Unspecified Dementia, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated 06/09/2022, revealed Resident #18 was assessed to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident had severe cognitive impairment. Continued review of the MDS, under Section E for Behaviors, revealed the facility had assessed the resident to have no behaviors or not behaviors directed towards others. These behaviors included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the facility had assessed the resident to wander daily. Review of Resident #18's Quarterly MDS Assessment, dated 12/01/2022, revealed the facility assessed the resident to have a BIMS score of 00 (zero), which indicated severe cognitive impairment. Further review, under Section E for Behaviors, revealed the resident was assessed to have behaviors which included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually, one (1) to three (3) days, within the review period. Continued review revealed the resident was assessed to wander four (4) to six (6) days, but less than daily. Review of Resident #18's Comprehensive Care Plan, revised on 06/16/2022, revealed the resident was care planned for altered mood/behavior related to Dementia with Behavioral Disturbance, Anxiety, and Depression. Further review of the care plan revealed the resident wandered in/out of other residents' rooms, took their snacks, and tended to take and eat off other's trays. The goal of the care plan was for the resident to display a stable mood over the next ninety (90) days with interventions to include assessing, monitoring and documenting the resident's mood/behaviors, monitoring the resident's habit of wandering in/out of other residents' rooms, taking their snacks, and eating food off other residents' meal trays, explain the inappropriate behavior to the resident and remind him/her to refrain from going into other's rooms without invitation. There was no evidence; however, to support the resident's care plan was revised to include his/her inappropriate sexual behavior, to include increased supervision, to ensure the safety of the resident. Interview with Family Member #3, on 02/16/2023 at 12:34 PM, revealed Resident #18 did not know who he was. He further stated that if the resident was in his/her right mind, no one would have touched him/her in a sexual way. Per the interview, the Family Member revealed he was distraught after discovering the facility did not do anything to prevent or protect the resident from abuse. Interview with State Registered Nursing Assistant (SRNA) #15, on 02/14/2023 at approximately 12:30 PM, revealed on 12/18/2022, she was walking down Resident #16's hall and looked into Resident #16's room and noticed Resident #18 sitting in Resident #16's recliner. She further stated Resident #16 was observed with his/her hands under Resident #18's shirt fondling and kissing him/her. SRNA #15 revealed she reported the incident to Registered Nurse (RN) #1 as Resident #18 was not capable of making the decision to participate in the sexual contact. SRNA #15 stated she believed the circumstance to be sexual abuse and should have been reported. She further stated that abuse was not generally reported when the residents' BIMS were low. Interview with State Registered Nursing Assistant (SRNA) #10, on 02/17/2023 at 8:52 PM, revealed she normally worked the night shift, on weekends. Per the interview, she stated she did not witness the incident between Resident #16 and Resident #18, on 12/18/2022. SRNA #10 revealed someone told her about the incident. Per the interview, Resident #18 often wandered into other residents' rooms, searching for food. Interview with LPN #4, on 02/14/2023 at approximately 8:00 AM, revealed on 12/18/2022, he was informed by State Registered Nursing Assistant (SRNA) #10, that during report/change in shifts, she was informed Resident #16 was observed on top of Resident #18 in a chair. Further, he stated he thought this would have been abuse and reported it to the Social Service Director (SSD). He stated he and SRNA #10 filled out an incident report; however, was told the allegation, did not meet. According to LPN #4, this had been an issue for years, not reporting abuse. He stated there had been a handful of residents with inappropriate touching and had made sexual comments. Further, he stated most of the residents had some form of dementia and he could not understand how a low BIMS score could have allowed residents to be abused. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed staff reported the incident between Resident #16 and Resident #18 on 12/18/2022; however, she did not mention it because she had already reported the resident multiple times. She further stated, this has gone on for some time. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed she was the abuse coordinator. Per the interview, she revealed the facility based its decision to report and investigate abuse based upon the residents' diagnosis of dementia. The SSD revealed the facility determined to investigate abuse based on the resident's reaction to the behavior and whether the resident was bothered by the behavior or not. Further, she stated Resident #16 had sexual behaviors. She stated LPN #4 called her at home, sometime in December, and reported Resident #16 was observed kissing Resident #18. She stated Resident #18 was not oriented. Per the interview, the SSD stated she advised the staff to put the residents on fifteen (15) minute checks. The SSD revealed she did not notify the resident's responsible party, but should have. Continued interview revealed the incident should have been reported to State Agency and investigated, thoroughly, to ensure the safety of the residents. 3. Review of Resident #20's progress note, dated 06/24/2022, revealed the resident was up wandering the halls. Per the note, the resident was noted to be anxious, confused, and agitated. Further review revealed the resident tried all exits looking for his/her children and husband. Continued review of the note revealed the resident was unable to redirect. Review of the resident's Progress Note, dated 06/25/2022 at 1:43 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the south hall medication room and witnessed a resident [Resident #16] kissing this resident [Resident #20] while groping another resident's [Resident #18's] breast. Continued review of the note revealed the resident [Resident #20] stood there letting the resident [Resident #16] kiss him/her. Per the progress note, the resident [Resident #20] did not appear to resist nor did he/she show any signs of physical, emotional, or psychological distress. LPN #2 documented that when the resident [Resident #16] saw LPN #2 coming, he/she stopped and went to his/her room, and this resident [Resident #20] went to his/her room. Review of Resident #20's medical records revealed the facility admitted Resident #20 on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, Anxiety Disorder, and Dysphagia. Review of the resident's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9), which indicated the resident had moderately impaired cognition. Further review, under Section E for Behaviors, revealed the resident did not exhibit any behaviors that included hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Further review revealed the resident exhibited wandering behaviors that occurred four (4) to six (6) days, but less than daily. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of six (6), which indicated severe cognitive impairment. Continued review, under Section E for Behaviors, revealed the resident exhibited physical behavioral symptoms (hitting kicking, pushing, scratching, grabbing, and/or abusing others) directed towards others. Further review revealed the resident exhibited verbal behavioral symptoms (threatening others, screaming at others, and cursing at others) directed toward others. These behaviors were exhibited one (1) to three (3) days within the review period. Further MDS review revealed the resident exhibited behaviors to include wandering four (4) to six (6) days, but less than daily. Review of Resident #20's Comprehensive Care Plan, revised 08/16/2022, revealed the resident was care planned for altered mood/behavior related to a diagnosis of Anxiety. Further review revealed the resident had episodes of wandering with exit seeking behaviors noted. The goal of the care plan was to stable the resident's mood over the next ninety (90) days. Interventions included assessing, monitoring, and documenting the resident's mood and behavior, and Social Service Director (SSD) would provide 1:1 as needed. The facility; however, failed to revise the resident's care plan to include his/her sexually inappropriate behavior and failed to ensure the care plan was implemented when 1:1 supervision was needed, to ensure the safety of the resident. Interview with Licensed Practical Nurse (LPN) #2, on 02/14/2023 at 6:35 AM, revealed on 06/23/2022, he was in the medication room and observed through the window, Resident #16 kissing Resident #20 and 'groping' Resident #18's breasts. LPN #2 stated when he exited the medication room, Resident #16 and Resident #20 returned to their rooms and he did not immediately report the incident. LPN #2 stated he later notified the Director of Nursing (DON) and she informed him that in order for the resident's sexual activity to be abusive, the behavior had to be unwanted by the residents. LPN #2 further revealed the DON told him to add a note in the resident's medical record stating there was no distress. Further interview with the LPN revealed this was not Resident #16's first time, adding it happened again with another resident. Further, he stated the resident should have been placed on one-to-one (1:1) supervision to ensure the safety of the residents and the residents who wandered into the resident's room. LPN #2 revealed the incident that had occurred between the residents was abuse. Interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed that when she was notified of suspected abuse, she would also notify the Administrator and Social Service Director (SSD) to discuss the concerns. Further, she stated the facility would conduct an investigation related to the allegations/incident and would place the residents on fifteen (15) minute checks or one-to-one (1:1) supervision, while the investigation was being completed. Continued interview revealed employees were trained on abuse on initial hire and annually. Per the interview, the DON revealed she had training on abuse, which was provided in November, with the update of the new regulations. The DON revealed that in her training, she was informed on the resident's capacity to consent in sexual interactions and that the facility could not rely upon the resident's BIMS score. The DON revealed the decision not to investigate or report the allegations were not based on the residents' BIMS score. She stated it was based on whether the residents were harmed by the incident. Continued interview with the DON revealed she was aware Resident #16 had behaved in a sexual way with staff. She stated she did not recall the incident that occurred on 12/18/2022 but remembers Resident #16 and Resident #18 were in a room, and they were kissing. Per the interview, she did not recall if the residents were placed on fifteen (15) minute checks. Additionally, she stated she did not think the resident's actions were abusive because it was determined none of the residents had experienced harm. Continued interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed she was made aware of Resident #16 kissing Resident #20 while groping Resident #18's breast, and should have reported both incidents to the State Agencies. The DON stated she spoke with Resident #16 and informed the resident he/she could not kiss or touch another resident unless that resident asks. Continued interview with the DON revealed that if the residents were unable to consent, then it would have been abuse and the residents deserved to be protected from abuse. The DON revealed it was her expectation that facility staff would follow the facility's policies and to notify her of any allegations of abuse. Further, she stated there should have been an investigation with witness statements to determine abuse. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed the Social Service Director (SSD) was the Abuse Coordinator and she would have expected staff to reach out to her regarding any allegations of abuse. The Administrator revealed it would have been her expectation that residents who were in verbal altercations would be placed on fifteen (15) minute checks and if there was an injury involved, then the facility would have conducted an investigation. Per the interview, the Administrator stated the facility considered the immediate reaction of the resident. She stated they determined if the residents were experiencing emotional distress, crying, or any overt reactions of distress, then it was considered abuse. The Administrator stated she was taking the resident's wishes under consideration. The Administrator revealed it would have; however, been her expectation staff would have followed the facility's policies to protect the residents from abuse. 36195

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report suspected abuse violations within the required timeframe and failed to implement its abuse policies and procedures for two (2) of twenty-one (21) sampled residents (Resident #18 and Resident #20). Additionally, the facility failed to identify and report to the State Agencies, resulting in failure to protect the residents from further potential abuse by the alleged perpetrator. 1. On 06/23/2022, Resident #16 was observed by staff in the hallway across from the nurse's station kissing Resident #20 and groping Resident #18's breasts. Resident #16's sexual behavior was reported to the Director of Nursing (DON); however, the incident was not reported to State Agencies as an allegation of abuse. 2. An additional incident occurred on 12/18/2022, when Resident #16 was found by staff on top of Resident #18, in a recliner chair, in Resident #16's room, kissing and humping Resident #18. Staff interviews revealed the Social Service Director (SSD) discussed the concerns with the Administrator and Director of Nursing (DON); however, they did not report the incident because it was not reportable and the residents were in no distress. The facility failed to provide protection for the residents allowing ongoing access to the residents by the alleged perpetrator. Subsequently, the facility staff assumed that the incidents did not need to be reported because the residents had severe cognitive impairment; therefore, the facility failed to ensure reporting. The facility's failure to ensure it reported alleged abuse violations within the required timeframe to ensure the safety of its residents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018, and reviewed on 09/09/2022, revealed every resident had the right to be free from verbal, sexual, physical, and mental abuse. Continued review revealed the facility was committed to providing quality resident care in a safe, abuse free environment, and all reported suspicions of resident abuse would be followed up on by the facility's administrator or his/her designee. Further review revealed employees should report alleged abuse immediately to the charge nurse on duty, for the resident's area, and the charge nurse on duty must immediately contact the Administrator, and or the Director of Nursing (DON), and or the Social Services Director (SSD) about any allegations of abuse. Further review revealed allegations of abuse were to be reported immediately in accordance with state law through established procedures, including the state survey and certification agency, and other officials. Further review of the policy revealed the facility would report all alleged violations and all substantiated incidents to the State Agency and to all other required entities as required, and take all necessary corrective actions depending on the results of the investigation, and the facility would analyze the occurrences to determine what changes were needed, if any, to policies and procedures to prevent future occurrences. Review of the facility's policy titled, Process to Report and Investigate Allegations of Abuse, dated 02/02/2018, revealed for actual harm the facility would notify the Office of Inspector General (OIG), the Ombudsman, and the Police within two (2) hours, and for incidents of no actual harm, the facility would report to the same entities within twenty-four (24) hours, but should not wait that long to report. Continued review revealed, as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, DON, SSD immediately; make sure the residents responsible party and physician were notified of the allegation; and if another resident was involved and alleged to have caused the incident, an employee would be assigned to monitor one on one (1:1) until initial evaluation could be completed; once the evaluation was completed, the facility would contact the physician with the results for possible new orders to discharge or continue care; if the resident remained at the facility, the resident would be placed on fifteen (15) minute checks for the next seventy-two (72) hours; and the care team would update the care plan as appropriate. Review of the facility's policy titled, Reporting Suspected Crimes under the Federal Elder Justice Act, revised 03/10/2017 and reviewed on 10/19/2022, revealed it was the policy of the facility to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under section 1150 B of the Social Security Act (SSA) as established by the Patient Protection and Affordable Care Act (ACA). Continued review revealed staff must report a suspicious crime to the state survey agency and at least one law enforcement entity within a designated time frame by email, fax, or telephone. Further review revealed if the reportable event resulted in serious bodily injury, the staff member shall report the suspicion immediately, but no later than two (2) hours after forming the suspicion; if the reportable event did not result in serious bodily injury, the staff member shall report the suspicion not later than twenty -four (24) hours after forming the suspicion; failure to report in the required time frame would result in disciplinary action, including up to termination; and staff must report suspicion of an incident to the Charge Nurse, Administrator, DON, or SSD. Review of the Social Services Director's (SSD) Job Description, signed and dated by the SSD on 10/26/2020, revealed that when an allegation of suspected abuse, neglect, or exploitation was reported, the SSD would report to the Director of Nursing (DON) and/or Administrator and assist with reporting to the appropriate state agency, as well as the completion of a thorough investigation as assigned. Review of KRS Chapter 209.030, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. 1. Review of Resident #16's medical record revealed the facility admitted the resident on 02/05/2015, with diagnoses to include Unspecified Dementia and Generalized Anxiety Disorder. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Medication Room and saw Resident #16 standing in the center of South Hall with his/her tongue down another resident's [Resident #20's] throat while at the same time groping another resident's [Resident #18's] breast. When Resident #16 saw LPN#2, he/she stopped and acted nonchalant like nothing had happened. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, electronically signed by LPN #4, revealed he was informed by the State Registered Nursing Assistant (SRNA), in report of an interaction on dayshift between Resident #16 and another resident [Resident #18] in his/her room. Continued review revealed LPN #4 notified the Social Service Director (SSD) of the incident and was told to place Resident #16 on every fifteen (15) minute checks. Review of Resident #16's Progress Note, dated 12/19/2022 at 8:09 PM, electronically signed by the Social Service Director (SSD), revealed that after reviewing F609 and staff statements with the DON and the Administrator, it was determined the incident was not reportable at this time. Interview with Registered Nurse (RN) #1, on 02/15/2023 at 4:36 PM, revealed staff reported the incident between Resident #16 and Resident #18 on 12/18/2022; however, she did not mention it because she had already reported the resident multiple times. 2. Review of Resident #18's medical record revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Unspecified Dementia Major Depressive Disorder, and Anxiety Disorder. Review of Resident #18's Progress Note, dated 06/23/2022, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and witnessed Resident #16 kissing another male/female resident (Resident #20) while groping another male/female's (Resident #18's) breast. Per the note, Resident #18 just stood there letting Resident #16 touch him/her. Continued review revealed the resident, Resident #18, did not appear to resist, nor did he/she show any signs of physical, emotional, or psychological distress. The LPN documented that when the resident saw Resident #16, he/she stopped and went to his/her room and the resident, Resident #18, started walking the hallway which was his/her normal behavior. Interview with the Family Member #3, on 02/16/2023 at 12:34 PM, revealed Resident #18 often did not know who he/she was but if he/she had been in his/her 'right mind', no one would have touched him/her in a sexual way. Per the interview, Family Member #3 and his/her family were distraught at discovering the facility did not prevent the sexual abuse. Interview with State Registered Nursing Assistant (SRNA) #15, on 02/14/2023 at approximately 12:30 PM, revealed on 12/18/2022, she was walking down Resident #16's hall and looked into Resident #16's room and noticed Resident #18 sitting in Resident #16's recliner. She further stated Resident #16 was observed with his/her hands under Resident #18's shirt fondling and kissing him/her. SRNA #15 revealed she reported the incident to Registered Nurse (RN) #1 as Resident #18 was not capable of making the decision to participate in the sexual contact. Per the interview, SRNA #15 revealed the incident was sexual abuse and should have been reported. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed she was the abuse coordinator. Per the interview, the SSD revealed the facility determined to investigate abuse based on the resident's reaction to the behavior and whether the resident was bothered by the behavior or not. Further, she stated Resident #16 had sexual behaviors. She stated LPN #4 called her at home, sometime in December, and reported Resident #16 was observed kissing Resident #18. She stated Resident #18 was not oriented. Continued interview revealed the incident should have been reported to State Agencies. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed she had been made aware Resident #16 had been observed kissing a resident, Resident #20, while touching another resident's, Resident #18's, breast. The DON stated, looking back on the situation, it would have been considered sexual abuse and the facility should have reported the incident, and interventions should have been put in place for Resident #16 to prevent this from happening to other residents. Per the interview, she expected staff to provide her with all the details of an abuse allegation and document what was seen, who was around, and any other information that would assist her with the full picture of the situation so she could conduct a full investigation and report it. She also stated she expected all staff to follow the facility's policies related to abuse. 3. Review of the Admission Record for Resident #20 revealed the facility had admitted Resident #20 on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, Anxiety Disorder, and Dysphagia. 3. Review of Resident #20's medical records revealed the facility admitted Resident #20 on 06/11/2021, with diagnoses to include Unspecified Dementia, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing this resident while at the same time groping another male/female resident's (Resident #18's) breast. Per the note, (Resident #18) just stood there letting him/her (Resident #16) touch him/her. He/She did not appear to resist, nor did he/she show any signs of physical, emotional, or psychological distress. When the male/female resident (Resident #16) saw me, he/she stopped and went to his/her room and this resident went to his/her room. Interview on 02/14/2023 at 6:35 AM, with Licensed Practical Nurse (LPN) #2, revealed on 06/23/2022, he was in the medication room and observed through the window, Resident #16 kissing Resident #20 and 'groping' Resident #18's breasts. LPN #2 stated when he exited the medication room, Resident #16 and Resident #20 returned to their rooms and he did not immediately report the incident; however, later notified the DON about the incident. Continued interview with LPN #2, revealed the DON informed him the behavior was not abuse, thus could not be reported. Interview on 02/15/2023 at 4:36 PM with Registered Nurse (RN) #1 revealed Resident #16's sexually inappropriate behaviors were common knowledge at the facility and the Abuse Coordinator/SSD had been made aware. Interview with the Director of Nursing (DON), on 02/16/2023 9:20 AM, revealed if she were notified of any type of abuse, she would tell staff to remove the individual that was accused of the abuse and notify the SSD, and the Administrator, so that the incident would be discussed. Further interview revealed she reviewed the regulation for F609. Continued interview with the DON revealed the facility did not take the resident's BIMS into consideration when determining to report. She stated the facility did not report because there was no harm to the residents and thus was not abuse. The DON revealed that looking back, she would have considered the incidents sexual abuse and she should have reported both incidents to the State. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed the SSD was the Abuse Coordinator and she would have expected staff to reach out to her regarding any allegations of abuse and would have expected the SSD to notify her and the DON. She further stated staff should be directed by the SSD on whether or not to report an incident. Per the interview, she stated she looked at the immediate reaction of the resident, after the behavior, and if they were in the same manner, then it was determined no emotional distress occurred. Further, she stated that if the resident was crying or had overt reactions of distress, then it would have been considered abuse. The Administrator revealed it would have been her expectation that the facility's policies would have been followed to protect residents from abuse and to report alleged abuse allegations to the abuse coordinator. 36195

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure allegations of sexual abuse were thoroughly investigated for three (3) of twenty-one (21) sampled residents (Resident #16, Resident #18, and Resident #20). 1. On 06/23/2022, staff observed Resident #1 across from the nurse's station, kissing Resident #20 while 'groping' Resident #18's breasts. Record review revealed there was no evidence the facility investigated the incident to protect the residents from further abuse. 2. On 12/18/2022, staff found Resident #16 on top of Resident #18, in a recliner chair, in Resident #16's room, kissing and 'humping' Resident #18. Record review and interviews revealed there was no evidence to support the facility conducted a thorough investigation to prevent further abuse. The facility's failure to ensure all allegations of alleged abuse, including sexual abuse were thoroughly investigated has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 01/27/2023 at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on 01/22/2023. The facility was notified of the Immediate Jeopardy on 01/27/2023. Additionally, Immediate Jeopardy was identified on 02/22/2023 and was determined to exist on 01/16/2022 in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on 02/22/2023 and is Ongoing. The findings include: Review of the facility's policy titled, Abuse Prevention, revised on 01/25/2018, and reviewed on 09/09/2022, revealed designated staff would immediately review and investigate all reported incidents and/or allegations of abuse; the facility would investigate and report incidents or occurrences in accordance with federal and state regulations and guidelines; outside investigative bodies, such as local police, would be contacted by the Administrator and in accordance with state and local laws; and the Quality Assurance Committee would review for trends and/or patterns related to incidents. Per the policy, abuse was defined as, causing physical pain or injury to an individual, sexual abuse was defined as, non-consensual sexual. Review of the facility's policy titled Process to Report and Investigate Allegations of Abuse dated 02/02/2018, revealed that as soon as the facility was aware of an allegation of abuse or other reportable incident, staff should ensure the residents were safe, gather as much information as possible from the person reporting the allegation; notify the Administrator, Director of Nursing (DON), Social Service Director (SSD) immediately. Review of the Social Services Director's (SSD) Job Description, signed and dated by the SSD on 10/26/2020, revealed that when an allegation of suspected abuse, neglect, or exploitation was reported, the SSD would report to the Director of Nursing (DON) and/or Administrator and assist with reporting to the appropriate state agency, as well as the completion of a thorough investigation as assigned. 1. Review of Resident #16's medical record revealed the facility admitted the resident on, 02/05/2015, with diagnoses to include Generalized Anxiety and Unspecified Dementia. Review of Resident #16's Progress Note, dated 06/23/2022 at 11:13 PM, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South med room and saw Resident #16 standing in the center of South Hall with his/her tongue down a male/females (Resident #20) throat while at the same time groping another male/female's (Resident #18) breast. Review of Resident #16's Progress Note, dated 12/18/2022 at 9:07 PM, documented by LPN #4, revealed he was informed by State Registered Nurse Aide (SRNA), in report of an interaction on dayshift between Resident #16 and another resident (Resident #18) in his/her room. Continued review revealed LPN #4 notified the Social Service Director (SSD) of the incident and was told to place Resident #16 on every fifteen (15) minute checks. There was no evidence to support the facility completed a thorough investigation related to Resident #16's incidents of sexual abuse, to ensure the safety of the residents, as per the facility's policy. Interview with the Social Service Director (SSD), on 02/14/2023 at 1:52 PM, revealed. she had been made aware Resident #16 had very sexual behaviors such as kissing, groping, and humping other residents. Continued interview revealed LPN #4 had called her at home and reported an incident involving Resident #16 and she instructed LPN #4 to put the resident on 15-minute checks. Per the interview, she stated she should have conducted an investigation, reported the incident to the State, and should have notified the family of what had occurred. Further interview with the SSD revealed a complete and thorough investigation with witness statements would have ensured residents were kept safe from further abuse. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed she had been made aware Resident #16 had been observed kissing Resident #20 while touching Resident #18's breast. The DON stated, looking back on the situation, it would be considered sexual abuse and the facility should have investigated the incident, and interventions should have been put in place for Resident #16 to prevent this from happening to other residents. Per the interview, she discussed Resident #16 with the Social Service Director (SSD) in the past about his/her behaviors of kissing and touching other residents. The DON revealed the resident was told his/her behaviors were not appropriate unless the resident had entered his/her room. The DON stated that to her knowledge she was not aware the resident had been having sexual encounters with residents that were not consensual. She further stated every resident deserved to be protected from abuse rather it was consensual or not and if a resident was not able to consent then it was sexual abuse. 2. Review of Resident #18's medical record, on 09/10/2021, revealed the facility admitted the resident on 09/10/2021, with diagnoses to include Anxiety Disorder, Unspecified Dementia, and Major Depressive Disorder. Review of Resident #18's Progress Note, dated 06/23/2022, electronically signed by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and witnessed Resident #16 kissing another male/female resident (Resident #20) while groping another male/female's (Resident #18) breast. Review of Resident #18's Progress Note, dated 12/18/2022 at 9:14 PM, revealed the Licensed Practical Nurse (LPN) #4 was informed by State Registered Nursing Assistant (SRNA), [SRNA #10], that she was told in report from a previous shift about an incident between Resident #18 and Resident #16. Continued review of the progress note revealed LPN #4 notified the SSD of the incident and the resident was placed on fifteen (15) minute checks. Record review revealed no evidence to support the facility conducted a thorough investigation related to the incidents of abuse, to ensure the safety of the residents. Interview on 02/16/2023 at 12:34 PM, with Family Member #3 revealed Resident #18 often did not know who he/she was but if he/she had been in his/her 'right mind', no one would have touched him/her in a sexual way. Per the interview, Family Member #3 and his/her family were distraught at discovering the facility did not prevent the sexual abuse from occurring. Interview with the Director of Nursing (DON), on 02/16/2023 at 11:14 AM, revealed Resident #18 was a wanderer and loved to sing and dance. Per the interview, Resident #18's spouse was his/her responsible party (RP) because Resident #18 was not cognitively aware and was unable to make his/her own decisions. Continued interview revealed she was not aware of the incident that occurred with Resident #18 being in a recliner with Resident #16 on top of him/her. The DON stated she had been made aware of Resident #18 being in Resident #16's room, and Resident #16 had been observed kissing Resident #18. Per her recollection, Resident #18 had been taken out of Resident #16's room, and staff put the stop sign up on Resident #16's door. The DON further stated, she had been informed both residents were engaged in the behavior, and no one appeared to be in distress. Further interview revealed she did not remember if both residents were placed on 15-minute checks. The DON stated the incident was reported in day shift, however, she did not recall an investigation into the incident. The DON stated, looking at the situation now, the incident was sexual abuse, and it should have been investigated. 3. Review of Resident #20's medical record revealed the facility admitted the resident on 06/11/2021, with diagnoses to include Major Depressive Disorder, Unspecified Dementia, and Anxiety Disorder. Review of Resident #20's Progress Note, dated 06/25/2022 as a late entry, documented by Licensed Practical Nurse (LPN) #2, revealed he came out of the South Hall medication room and saw a male/female resident (Resident #16) kissing this resident (Resident #20) while at the same time groping another male/female resident's (Resident #18) breast. Record review revealed no evidence to support the facility had completed a thorough investigation to ensure the safety of the resident, as per the facility's policy. Interview with the Director of Nursing (DON), on 02/16/2023 at 9:20 AM, revealed if she were notified of any type of abuse, she would tell staff to remove the individual that was accused of abuse and notify the SSD and the Administrator. Per the interview, the DON revealed she discussed the incidents of abuse with the SSD and Administrator and would conduct an investigation and place the resident on fifteen (15) minute checks or one on one (1:1). Continued interview revealed employees were trained on abuse on initial hire and annually. Per the DON, training had been provided in November on abuse per the new regulations that went into effect. The training went over the resident's capacity to consent in sexual interactions. Further interview revealed she had been made aware of Resident #16 kissing Resident #20 while groping Resident #18's breast at the same time. However, could not recall the incident that occurred between Resident #16 and Resident #18, on 12/18/2022. The DON stated that all she knew from that incident was that the residents were kissing. Further interview with the DON revealed, that looking back, the incidents would have been considered sexual abuse and she should have conducted an investigation. Interview with the Administrator, on 02/16/2023 at 3:10 PM, revealed it was her expectation that the facility's policies would have been followed. 36195

Based on record review and interview, it was determined the facility failed to ensure the resident's comprehensive care plan was implemented for two (2) of twenty-one (21) sampled residents (Resident #1 and Resident #4). 1. On [DATE], the facility-initiated interventions to include the assistance of two (2) staff members for bed mobility and for all transfers. On [DATE], State Registered Nursing Assistant (SRNA) #1 attempted to transfer Resident #1 from his/her Geri-chair to his/her bed, without the assistance of staff, utilizing the mechanical lift. During the transfer, the sling from the mechanical lift broke and Resident #1 fell from the lift and sustained injuries to include fractures identified at the Cervical seven (C7) and Thoracic one (T1) vertebrae and a complete break of his/her right humerus bone. The resident expired on [DATE] as a result of his/her injuries. 2. The facility admitted Resident #4 on [DATE]. The facility care planned the resident for falls and for his/her safety needs to address his/her history of wandering. Further review of the resident's care plan revealed interventions were in place for staff to monitor the resident, complete hourly rounds, and document the resident's wandering behaviors. However, record review revealed there was no evidence to support the facility implemented the resident's care plan to prevent further behaviors, to include threatening other residents, throwing other resident's items, and wandering throughout the facility. The facility's failure to ensure residents' comprehensive care plan was implemented has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is Ongoing. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised [DATE], revealed it was the facility's policy to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the resident's comprehensive assessment. Further review of the policy revealed the explanation and guidelines included, qualified staff were responsible for carrying out interventions specified in the care plan, and were notified of their roles, and responsibilities. Review of the facility's State Registered Nursing Assistant (SRNA) job description, undated, revealed SRNA's were responsible for performing tasks in accordance with the facility's policy and procedures and the individual resident's plan of care, which included resident transfer assistance. Continued review of the job description revealed it was the SRNA's responsibility to ensure safe work practices and to follow the facility rules and procedures. Closed record review for Resident #1 revealed the facility admitted the resident on [DATE] with diagnoses that included Thoracic Aortic Aneurysm, Morbid (Severe) Obesity, and Acquired Absence of Right Leg above the Knee. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, initiated on [DATE] and revised on [DATE], revealed the resident was care planned for twenty-four (24) hour supervised/assisted care. The goal of the care plan was to have the resident maintain his/her highest level of functional ability within a safe environment over the next ninety (90) days. Further review revealed interventions included to approach the resident in a calm manner; introduce self and explain all procedures when providing care; assist of two (2) staff with the resident's bed mobility, assist with getting the resident into his/her Geri-chair utilizing the Mechanical Lift; and two (2) staff assist for all transfers. The resident's care plan; however, was not followed to have two (2) staff assist with all transfers. Record review of Resident #1's progress note, dated [DATE], signed by Registered Nurse (RN) #1, revealed RN #1 was called to Resident #1's room by a State Registered Nursing Assistant (SRNA) {SRNA #2} and found Resident #1 lying on his/her back on the floor. Continued review of the progress note revealed the lift sling was frayed and broke while in use, with the resident in the lift. Per the progress note, the resident complained of head, back, and shoulder pain. According to the progress note, the nurse notified Emergency Medical Services (EMS) and the resident was transferred to the hospital for evaluation. Review of the facility's Fall Review Assessment, dated [DATE], signed by the Director of Nursing (DON), revealed Resident #1 sustained injuries to his/her vertebral fractures at the levels of Cervical seven (C7) and Thoracic one (T1), hematoma to posterior head, and right humerus fracture. Continued review of the record revealed the cause of the fall was two-fold, the lift sling strap broke, and failure to have two (2) SRNA's in the room. Review of the Coroner's Report, dated [DATE], revealed Resident #1's cause of death was due to, blunt trauma, injuries of the spine and extremity, due to being moved by a Hoyer lift, when a strap broke, dropping the resident approximately four (4) feet to the floor, landing on his/her head. Interview with Family Member #1, on [DATE] at 11:41 AM, revealed Registered Nurse (RN) #1 reported to her, on [DATE], that while the resident was raised in the mechanical lift, the sling that held him/her broke and the resident fell to the ground, hitting his/her head. The family member further stated Resident #1 informed her that only one (1) staff member operated the lift and she thought there had to be two (2) staff to operate the mechanical lift. Interview with State Registered Nursing Assistant (SRNA) #1, on [DATE] at 2:50 PM, revealed on [DATE], she attempted to transfer the resident from his/her Geri-chair into his/her bed independently. Per the interview, the SRNA stated that when the resident was lifted in the air, the right sling strap broke. SRNA #1 revealed the resident fell to the floor, headfirst and she heard a loud thud. She further stated it was important to follow the care plan to avoid injury to the residents. SRNA #1 revealed she should have followed the care plan and had another person to assist her with operating the mechanical lift. Interview on [DATE] at 4:41 PM, with Kentucky Medication Aide (KMA) #2, , revealed she was unaware two (2) staff members were required for the mechanical lift. She added, I have been transferring the residents alone for years. Per the interview, it was the culture of the facility to perform resident care tasks alone. Further, she stated she did not usually review the resident's care plan prior to transfers to determine the assistance required for transfers utilizing the mechanical lift. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:14 PM, revealed Resident #1 was care planned for two (2) staff to assist with all transfers. Per the interview, the care plan was important to follow because it guides the staff on how to care for the residents and how to keep the residents safe. Continued interview with LPN #1 revealed not following the care plan could cause residents to sustain fractures and/or death. Interview on [DATE] at 12:11 PM, with Registered Nurse (RN) #1, revealed that on the day of the incident, [DATE], she was at the nurse's station when State Registered Nursing Assistant (SRNA) #2 informed her Resident #1 had fallen out of the sling from the mechanical lift. Further interview revealed she went to Resident #1's room immediately and believed Resident #1 had fractured his/her shoulder based upon the position of his/her arm. Per the interview, Resident #1 sustained a hematoma towards the back of his/her head and was surprisingly calm. RN #1 revealed she was concerned the resident had a head injury and immediately called Emergency Medical Services (EMS). Continued interview revealed Resident #1 was care planned for two (2) staff members to assist with transfers with the mechanical lift and the care plan should have been followed to prevent serious injury and death. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 12:25 PM, revealed she would have expected the nurses and aides to be aware of each resident's care plan and follow it. Per the interview, Resident #1 was care planned for two (2) persons assist and mechanical lift for transfers. She further stated a printed copy of the resident's care plan was in the binder for the SRNA's to follow for each resident. The MDS Coordinator revealed it was important to follow the resident's care plan to prevent the residents from experiencing falls, having broken bones, and/or death. Interview with the Medical Director, on [DATE] at 3:39 PM, revealed it was her expectation that staff would have followed each resident's care plan. Interview with the Director of Nursing (DON), on [DATE] at approximately 12:40 PM, revealed SRNA #1 should have followed Resident #1's care plan to have two (2) SRNA's operate the mechanical lift. Per the interview, it was her expectation that staff would review the residents' care plans prior to providing care. She further revealed this was important to prevent resident injury. Interview with the Administrator, on [DATE] at 2:43 PM, revealed it was her expectation the mechanical lift would have been operated by two (2) trained staff members. Further, she stated the residents' safety was her responsibility. 2. Review of Resident #4's Admission record revealed the facility admitted the resident on [DATE] with diagnoses to include Insomnia, Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Unspecified Psychosis. Review of Resident #4's Admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Further review of the MDS, under Section E for behaviors, revealed the resident was assessed to have behaviors daily. These behaviors included hitting, kicking, pushing, scratching, grabbing, threatening, and screaming at others. Additionally, the resident was assessed to have behavior symptoms not directed toward others, four (4) to five (5) days a week. These behaviors included physical symptoms such as hitting or scratching self, pacing and rummaging. Further, the resident was assessed for wandering, including intruding on the privacy or activities of others. The resident exhibited these behaviors four (4) to six (6) days, but less than daily. Review of Resident #4's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned to be at risk for falls/injury related to a history of wandering. Further review revealed interventions included monitoring the resident for safety needs and the resident was placed on hourly rounds. Continued review of the care plan revealed the resident was care planned for mood/behaviors related to Depression, new diagnoses of Disturbance, Sundowners, and being verbally and physically abusive towards staff. The goal of the care plan was to stabilize the resident's mood for the next ninety (90) days. Interventions included assessing, monitoring, and documenting any displayed mood/behaviors (sad affect, tearfulness, and wandering) and to attempt to redirect the resident when displaying altered behaviors. The facility failed to ensure the resident's care plan was implemented to ensure the effectiveness of the interventions related to wandering. Review of Resident #4's Progress Note, dated [DATE] at 3:22 AM, entered by Licensed Practical Nurse (LPN) #4, revealed Resident #4 was wandering, had increased agitation, and was combative and hit staff with a water pitcher. Continued review revealed the resident had hidden forks and butter knives in his/her drawer and stated to staff he/she would stab them if they kept bothering him/her. Further review revealed staff had been called to the room by Resident #4's roommate multiple times related to the resident throwing the roommate's objects at him/her. Additional review revealed, Resident #4 was observed going in and out of six (6) other residents' rooms and flipped other residents' televisions onto the floor. Per the Progress Note, staff would continue to observe Resident #4's behavior. There was no evidence to support the resident's care plan was implemented to ensure the effectiveness of the resident's interventions related to wandering. Review of the Progress Note, associated with Resident #15, dated [DATE] at 7:30 PM, documented by LPN #4, revealed Resident #15 was discovered on the floor on his/her back on top of the chuck and draw sheet next to the bed facing the doorway with no injures noted. Per the progress note, a wandering resident [Resident #4] had been seen going in and out of Resident #15's room and surrounding rooms minutes prior to finding Resident #15 on the floor. Review of the resident's care plan revealed the facility failed to implement the resident's care plan to ensure the resident's interventions related to wandering were effective. Review of Resident #4's Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #4 revealed the resident was wandering the halls and became agitated and combative, the entire shift. The LPN documented the resident was wandering in and out of rooms and threatened multiple other residents. Further review revealed the resident was aggressive towards staff, asking for his/her purse and grandbaby. LPN #4 noted the resident was throwing items from rooms into the hallway and screaming out. Per the note, the resident was placed on fifteen (15)-minute checks after speaking with the Administrator and Medical Director. However, there was no evidence to support the facility implemented the resident's plan of care to ensure the effectiveness of his/her interventions related to wandering. Interview with the Social Service Director, on [DATE] at 2:36 PM, revealed the nurses were responsible for adding the resident's behaviors to the daily report sheet and the report sheet was to go to the morning meeting for discussion. The SSD stated the facility did not have a process in place to determine if a resident with behaviors needed an assessment or to determine the effectiveness of the resident's care plan. Continued interview with the Social Service Director revealed it was important to ensure the resident's care plan was followed to ensure psychosocial harm had not occurred and to ensure appropriate interventions could be put in place. Interview with the Administrator, on [DATE] at 3:10 PM, revealed it was her expectation to ensure the facility's policies would have been followed. 47852

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accident hazards and that residents received adequate supervision and assistance to prevent accidents. The facility failed to identify and evaluate hazards and risks associated with the mechanical lift equipment and slings and further failed to reduce the associated hazards for three(3) of twenty-one (21) sampled residents (Resident #1, Resident #15, and Resident #22). 1. On [DATE], Resident #1 was dropped from the mechanical lift when the lift sling strap broke and the resident fell approximately four (4) feet to the floor during transfer from a Geri chair to his/her bed. Emergency Medical Services (EMS) were called to the scene and Resident #1 was transferred to the local hospital for evaluation. Resident #1 was discharged from the local hospital and was diagnosed to have a Displaced Comminuted Supracondylar Fracture (an injury to the upper arm bone at the narrowest point, above the elbow) of the right humerus, Fracture of the Seventh Cervical (C7) Vertebra (broken neck), Fracture of the First Thoracic (T1) Vertebra (the bone located in the upper part of the back) , and Contusion of the Scalp. The resident was transferred to another hospital and was admitted to an emergency department that was equipped to manage his/her injuries. The resident expired on [DATE], due to complications of his/her injuries. 2. On [DATE], Resident #20 called Registered Nurse (RN) #1 to Resident #15's room. Upon her arrival, she stated Resident #4 was standing over the resident's body, on the floor. RN #1 revealed she shook Resident #15, as the resident had stopped breathing. Interview revealed Resident #4 pulled the nurse's hair and stated, I want to take my baby home. Resident #15 was transported to the hospital with diagnosis to include a head hematoma from a fall from the resident's bed. The facility; however, failed to investigate the resident's fall thoroughly, to determine the root cause of the resident's fall and failed to provide increased supervision for Resident #4, for the safety of the resident, as well as other. Subsequently, on [DATE], Resident #15 was again found on the floor, of his/her room. Resident #4 was observed walking away from Resident #15's room. The facility failed to determine the root cause of the resident's fall, to include identifying Resident #4 as a potential risk. 3. On [DATE] Resident #22 was observed to be transferred from a Geri-chair to his/her bed using a mechanical lift. However, after the transfer had been completed, it was identified that staff had not utilized the sling that was designed for the use with their lifts, which was unsafe and would result in jury to the resident and caregiver. The facility's failure to ensure the residents' environment remained free of accident hazards and that residents received adequate supervision and assistance to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR S483.21, Comprehensive Care Plans (F656), at the highest scope and severity (S/S) of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.70, Facility assessment (838), at the highest S/S of a K; and 42 CFR S483.90, Maintain all mechanical, electrical, and resident care equipment in safe operating condition (F908), at the highest scope and severity S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689). The Immediate Jeopardy was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Additionally, Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, F610) at the highest S/S of a J; 42 CFR S483.21, Comprehensive Care Plans (F656) at the highest S/S of a J; 42 CFR S483.25, Free of Accident Hazards/Supervision/Devices (F689), at the highest S/S of a J; 42 CFR S483.40, Behavioral Health Services (F744) at the highest S/S of a K; 42 CFR S483.70 Administration (F835 and F838) at the highest scope and severity (S/S) of a J; and 42 CFR S483.75, Quality Assurance and Performance Improvement (F865), at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610); 42 CFR S483.25, Free of Accident/Hazards/Supervision/ Devices (F689); and 42 CFR S483.40 Behavioral Health Services (F744). The facility was notified of the Immediate Jeopardy on [DATE] and is Ongoing. Findings include: Review of the Facility's policy, titled Accidents and Supervision, Revised [DATE], revealed the residents' environment should remain as free of accident hazards as possible and each resident should receive adequate supervision and assistive devices to prevent accidents including, identification, evaluation, and implementation of interventions, and monitor to minimize hazards and risks. Interview with the Administrator on [DATE] at 2:43 PM revealed the facility did not have a policy to address the mechanical lift; however, revealed there should have been. Review of the Facility's State Registered Nursing Assistant (SRNA) job description, undated, revealed SRNA's were responsible for performing tasks in accordance with the Facility's policy and procedures and the individual residents' Plan of Care, which included resident transfer assistance. Per the job description, it was the responsibility of the SRNA to ensure safe work practices and to ensure the facility's rules and procedures were followed. Review of the facility's Mental and Physical Profile for SRNA's, undated, revealed the SRNA's had the ability to follow the facility's safety policy to prevent injury to self or others and had the ability to work as a team with other staff members. Review of the Battery-Operated Mechanical Lift's Manufacturer's Owner's Manual, Safety Instructions, undated, revealed special care would be taken with residents unable to aid while being lifted. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use for the manufacturer's mechanical lift only. Further review of the Manufacturer's recommendation revealed that utilizing the non-manufacturer's brand lift slings were unsafe and would result in injury to the resident or caregiver. Further review of the Manual's Maintenance Schedule included instructions to check the entire sling inventory for fraying, tearing, or excessive wear of any kind and replace any worn or damaged slings with new Manufacturer's slings. Continued review revealed that per the warnings in the owner's manual, the lift should not be utilized unless all maintenance points passed inspection. 1. Closed Record Review revealed the facility admitted Resident #1 on [DATE] with diagnoses that included, Diabetes Mellitus, Chronic Diastolic Heart Failure, Morbid (Severe) Obesity, and acquired Absence of Right Leg above the knee. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed, the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #1's Comprehensive Care Plan, revised [DATE], revealed the resident was care planned for mobility with interventions to include assistance with his/her Geri chair utilizing the mechanical lift. Additionally, the resident was care planned for two (2) staff assistants for all transfers. Review of Resident #1's Progress Note, dated [DATE], documented by the Director of Nursing (DON), revealed Resident #1 was transferred utilizing the mechanical lift by one (1) staff when the lift sling broke, and the resident fell . Per the progress note, the resident complained of pain in his/her head, shoulder, and back and was sent to the Emergency Department (ED) due to his/her injuries. Review of Resident #1's Progress Note, dated [DATE] at 2:23 PM, documented by Registered Nurse (RN) #1, revealed the RN was called to Resident #1's room, by a State Registered Nursing Assistant (SRNA unknown). Further review revealed Resident #1 was found lying on his/her back on the floor. Continued review of the progress note revealed the lift sling was frayed and broke while in use with the resident in the lift. Per the progress note, the resident complained of head, back, and shoulder pain. According to the progress note, the nurse notified Emergency Medical Services (EMS) and the resident was transferred to the hospital for evaluation. Review of the facility's Fall Review Assessment, dated [DATE], documented by the Director of Nursing (DON), revealed Resident #1 sustained injuries related to Vertebral Fractures at the levels of Cervical Seven (C7) and Thoracic One (T1), hematoma to his/her posterior head, and a right Humerus Fracture. Continued review of the record revealed the cause of the fall was two- fold, the lift sling strap broke and there was a failure to have two (2) SRNA's in the resident's room to assist with the lift. Review of the Hospital Medical Record, dated [DATE], revealed Resident #1 presented to the Emergency Department (ED) for evaluation of a traumatic injury sustained in a fall from a lift . Per the ED report, the resident was in a lift at his/her long term care facility, when he/she fell approximately four (4) feet onto a concrete floor. Continued review revealed the resident was on Eliquis (a blood thinner) for Atrial Fibrillation. Further review revealed a left scalp hematoma, and Computed Axial Tomography (CAT) scan imaging revealed an acute spinous process at Cervical seven (C7) a compression fracture of Thoracic one (T1), and a right fractured humerus. Resident #1 had been admitted to the hospital on [DATE] and expired on [DATE] as a result of his/her injuries. Review of the Coroner's Report, dated [DATE], revealed Resident #1's cause of death was a blunt trauma injuries of the spine and extremity. Further review revealed the manner of death was due to being moved by a Hoyer lift, when a strap broke, dropping the resident approximately four (4) feet to the floor, landing on his/her head. Review of Resident #1's Death Certificate, dated [DATE], revealed the identified cause or Resident #1's death was related to blunt trauma injuries of the spine and extremity. Observation on [DATE] at 4:45 PM revealed eight (8) slings were removed from service after Resident #1's incident, on [DATE]. Continued observation revealed the labels were faded so that the laundry instructions and sling size was not legible. Additionally, the sling loops were observed to be brittle and easily broken. Observation on [DATE] at 4:45 PM, of the Multi-Brand Compatible Slings, revealed the sling utilized on [DATE], the day of Resident #1's incident, revealed the sling originated from a different manufacturer, which was unsafe, per the manufacturer's recommendation. Interview on [DATE] at 11:41 AM, with Family Member #1, revealed Registered Nurse (RN) #1 reported to her, on [DATE], that while raised in the mechanical lift, the sling that held Resident #1 broke and the resident fell to the ground, hitting his/her head. Further interview revealed the lift sling fabric was frayed and contributed to the accident. Family Member #1 stated Resident #1 informed her there was only one (1) staff member that operated the lift when he/she fell . Family Member #1 revealed Resident #1 was transferred by ambulance to a local hospital and fractures were identified at C7 and T1 vertebrae and a complete break of the resident's right humerus bone. Per the interview, she stated Resident #1 was transferred from the Emergency Department (ED) at the first hospital to a larger hospital to better address the resident's care needs. Further interview revealed it was difficult to watch her parent in pain and the resident required medication to maintain blood pressure and a unit of blood following the accident. Family Member #1 revealed she thought it was the facility's policy to have two (2) staff when operating the mechanical lift. Interview on [DATE] at 2:50 PM with State Registered Nursing Assistant (SRNA) #1 revealed, on [DATE], she transferred Resident #1 to bed from the Geri chair, utilizing the mechanical lift. Continued interview revealed that while the resident was suspended in the air, the right side of the sling, near the resident's head, broke and the resident fell to the floor. Further interview revealed the resident hit the ground, headfirst. SRNA #1 revealed she attempted to grab the resident but heard a loud thud. She stated part of the resident's body landed on the metal legs of the mechanical lift. SRNA #1 revealed she grabbed one (1) of the resident's arms and legs and pulled the resident off the lift. Further, the SRNA revealed she then went to the resident's door to yell for help. Per the interview, she revealed she should not have transferred the resident alone. Interview on [DATE] at 3:35 PM, with SRNA #2 revealed, on [DATE], she was documenting at the nurse's station when she heard a thud and a shriek. Per the interview, Resident #1 could not move his/her right arm. SRNA #2 revealed she was aware SRNA #1 transferred the resident independently and knew the resident required an assist of two (2) staff for all transfers. SRNA #2 revealed she offered to assist with the transfer; however, SRNA #1 refused her help. SRNA #2 revealed she should have reported SRNA #1's refusal to accept assistance with the resident's transfer to management, to prevent injury. Interview with Registered Nurse (RN #1), on [DATE] at 12:11 PM, revealed it was the standard to utilize two (2) staff members when operating a mechanical lift and common sense to check the lift sling before using it on a resident. Continued interview revealed, on [DATE], she was at the nurse's station when SRNA #2 informed her Resident #1 fell out of the sling. Further interview revealed she went to the room and immediately thought Resident #1's shoulder was fractured because of the position of his/her arm. RN #1 stated that after assessing the resident, she knew the facility was in deep trouble and should have been. Continued interview revealed no part of Resident #1's body was on the lift sling. She stated she observed pillows placed under the residents' arms and legs. Further interview revealed that no part of the resident's body should have been moved until the resident was fully assessed after his/her fall with injury. RN #1 revealed the resident sustained a hematoma towards the back of her head and was surprisingly calm. RN #1 revealed this caused concern and she wondered if the resident had a head injury. She revealed she called the Emergency Medical Service (EMS) immediately. Review of the facility's policy titled, Fall Prevention and Management Policy, revised [DATE], revealed the purpose of the policy was to provide a process for fall reviews and fall prevention practices. Further review revealed it was the policy to minimize the risk of serious injury, recognize risks/causes of falls, and implement all prevention management interventions. Continued review of the policy revealed a fall was defined as the unintentional change in position, coming to rest on the ground, floor or on to the next lower surface. Continued review revealed that when a fall occurred, staff would note any statements made regarding the fall, assess the environment for factors that may have contributed to the fall, and document any non-compliance with prevention measures. Further review revealed staff would add necessary interventions to prevent the reoccurrence of the fall. Review of the facility's policy titled, Fall Prevention and Management, revised [DATE], revealed the nursing staff would complete an incident report under risk management, after any occurrence of a fall. Further review revealed the [resident's] care plan would be updated as needed. Interviews with staff revealed Resident #15 fell out of bed on [DATE] and [DATE]; however, there was no evidence to support that the resident's falls were investigated. Further interviews with staff revealed Resident #15 was pulled out of bed by Resident #4; however, the facility failed to implement Resident #4's care plan to prevent accidents and incidents. 2. Closed record review of Resident #4 revealed no evidence to support the facility documented the incidents identified on [DATE] and [DATE]. Review of Resident #4's Progress Note, dated [DATE], documented by Licensed Practical Nurse (LPN) #4 revealed the resident was wandering the halls and became agitated and combative, the entire shift. The LPN documented the resident was wandering in and out of rooms and threatened multiple other residents. Further review revealed the resident was aggressive towards staff, asking for his/her purse and grandbaby. LPN #4 Noted the resident was throwing items from rooms into the hallway and screaming out. Per the note, the resident was placed on fifteen (15)-minute checks after speaking with the Administrator and Medical Director. Review of Resident #4's Admission record revealed the facility admitted the resident on [DATE] with diagnoses to include Insomnia, Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Unspecified Psychosis. Review of Resident #4's Admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Further review of the MDS, under Section E for behaviors, revealed the resident was assessed to have behaviors daily. These behaviors included hitting, kicking, pushing, scratching, grabbing, threatening, and screaming at others. Additionally, the resident was assessed to have behavior symptoms not directed toward others, four (4) to five (5) days a week. These behaviors included physical symptoms such as hitting or scratching self, pacing and rummaging. Further, the resident was assessed for wandering, including intruding on the privacy or activities of others. He/She exhibited these behaviors four (4) to six (6) days, but less than daily. Review of Resident #4's Comprehensive Care Plan, initiated on [DATE], revealed the resident was care planned to be at risk for falls/injury related to a history of wandering. Further review revealed interventions included monitoring the resident for safety needs and the resident was placed on hourly rounds. Continued review of the care plan revealed the resident was care planned for mood/behaviors related to Depression, new diagnoses of Disturbance, Sundowners, and being verbally and physically abusive towards staff and rejecting care. The goal of the care plan was to stabilize the resident's mood for the next ninety (90) days. Interventions included assessing, monitoring, and documenting any displayed mood/behaviors (sad affect, tearfulness, and wandering). Interview with the Licensed Practical Nurse (LPN) #4, on [DATE] at 6:00 AM, revealed he was familiar with the incidents that occurred on [DATE] and [DATE]. Per the interview, LPN #4 revealed he thought Resident #15's fall should have been investigated. Further, he stated that after each incident, Resident #4 reported he/she dropped his/her baby both times. 3. Review of Resident #15's Progress Note, dated [DATE] at 9:25 AM, documented by Registered Nurse (RN) #1, revealed she was called to Resident #15's room, by a resident [Resident #20]. Per the progress note, Resident #15 was found face down on the floor and had a hematoma to the forehead, a reddened area to his/her back, knees, and elbows. Further review of the progress note revealed the resident was sent to the Emergency Department (ED) for further examination. Review of the Emergency Department (ED) Discharge Summary, dated [DATE], revealed Resident #15 presented to the ED for a possible fall with an unspecified head injury. Continued review revealed the nursing facility reported the resident was non-ambulatory, nonverbal, legally blind, had a history of congenital birth trauma and had a feeding tube. Further review revealed the nursing home reported the resident had a bruise on his/her forehead and scratches on his/her back. A physical exam revealed bruising to the left knee and right frontal forehead. Due to the resident's injuries and physical exam findings, a Cat Scan (CT) of the head, chest. abdomen and left knee were performed, and no acute injuries were found. Continued review revealed the resident was discharged back to the facility on [DATE]. Review of the facility's Fall Review Assessment, dated [DATE] at 9:15 AM, revealed Resident #15 was found lying face down on the floor beside the bed with a hematoma and bruise on the forehead, redness to the midback, bilateral elbow scratches and bruising to the chin. Continued review revealed the resident had been sent to the ED for evaluation. Review of the Progress Note, dated [DATE] at 1:35 PM, documented by Licensed Practical Nurse (LPN #7), revealed Resident #15 returned to the facility at 1:06 PM. Continued review revealed a skin observation revealed a knot and bruise were noted to the resident's forehead, bilateral elbows were scratched and bruised, scratches and bruises to the gastric tube site, and bruising to his/her chin. Review of the Progress Note, dated [DATE] at 7:30 PM, documented by LPN #4, revealed Resident #15 was discovered on the floor on his/her back on top of the chuck and draw sheet next to the bed facing the doorway with no injures noted. Per the progress note, a wandering resident [Resident #4] had been seen going in and out of Resident #15's room and surrounding rooms minutes prior to finding Resident #15 on the floor. Review of the facility's Fall Review Assessment, dated [DATE] at 7:30 PM, revealed Resident #15 had an unwitnessed fall and was found on the floor, on his/her back, on top of a chuck, with the drawsheet facing the doorway with no injuries noted. Review of Resident #15's Skin assessment dated [DATE] at 1:52 PM, revealed the resident had a knot and bruise noted to the forehead, bilateral elbows were scratched and bruised, scratches and redness to gastric tube site, and bruising to the chin. Review of Resident #15's Admission Record revealed the facility had admitted Resident #15 on [DATE], with diagnoses to include Blindness, Congenital malformation of the nervous system, Severe intellectual disabilities, Hearing loss, and Cerebral hemorrhage due to birth injury. Review of Resident #15's Quarterly MDS dated [DATE], revealed the facility had assessed the resident as being highly hearing impaired, indicating absence of useful hearing, and severely vision impaired, indicating no vision or sees only sees light, color, or shapes, and eyes did not appear to follow objects. Continued review revealed the facility had assessed the resident as having a Cognitive Skills for Daily Decision Making score of three (3), indicating severely impaired, never/rarely made decisions. Further review revealed the resident had been assessed as total dependence for care, meaning full staff performance every time, with two plus (2+) person physical assistance for Bed Mobility and Transfers. Review of Resident #15's Care Plan initiated on [DATE] and revised on [DATE], revealed the resident required twenty-four (24)-hour care related to Congenital Neurological Condition, nonverbal, legally blind and deaf, and was dependent on staff for all Activities of Daily Living care, with a Goal to include the resident would maintain status within a safe environment. Interventions initiated on [DATE] included approach in a calm manner, and a new intervention initiated on [DATE] to place a stop sign across the doorway to deter other residents from entering the room without invitation. Interview with Registered Nurse (RN) #1, on [DATE] at 4:36 PM, revealed that on [DATE], she was walking down the hall when Resident #20 came to her and stated very calmly, this child has come out of the bed and [his/her parent] needed to take him/her home. RN #1 stated she went to Resident #15's room and observed the resident face down on the floor. She stated the resident was unconscious. Per the interview, she shook the resident's head and the resident took a deep breath. The RN stated Resident #4 was standing over the resident's lifeless body. RN #1 revealed she called for help as she could not pick the resident up or move him/her. Continued interview revealed she did not document Resident #4 standing over Resident #15's body. Further, she stated she thought Resident #4 pulled Resident #15 out of his/her bed. Interview with Licensed Practical Nurse (LPN) #4, [DATE] at 6:00 AM, revealed Resident #15 was contracted and had a gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). Per the interview, LPN #4 revealed he was aware the resident has had two (2) falls. The first fall, RN #1 was involved, and the resident was sent to the ED. LPN #4 revealed the resident had a big knot on his/her head. LPN #4 revealed he worked the next night, on [DATE], when Resident #15 was found on the floor. The LPN revealed that while passing medications, Resident #15 was discovered on the floor with his/her chux off the bed with Resident #15 on it. LPN #4 revealed Resident #4 was observed leaving the resident's room. LPN #4 stated he contacted the Administrator. He stated Resident #15 was moved to a different room and a laser alarm was added to alert staff when Resident #4 wandered into the resident's room. LPN #4 revealed Resident #4 was on increased supervision; however, that was not enough. LPN #4 stated the resident needed one-on-one (1:1) supervision and the facility did not have enough staff to provide the increased supervision. Interview with the Resident Care Coordinator (RCC) #18, on [DATE] at 1:11 PM, revealed she did not know much about the incidents that occurred on [DATE] and [DATE], between Resident #4 and Resident #15, but knew Resident #15 was found on the floor, twice. She stated Resident #15 was vulnerable and while she did not see the incident, the position Resident #15 was positioned in did not seem as though Resident #15 could have placed himself/herself in that position. Interview with the Medical Director (MD), on [DATE] at 9:19 AM, revealed the resident was functionally a quadriplegic and questioned at the time of both accidents, how the incidents could possibly have occurred. Per the interview, the MD stated the facility advised her they suspected Resident #4 had pulled Resident #15 from his/her bed on both occasions. Interview with the Director of Nursing (DON), on [DATE] at 9:20 PM, revealed she could not remember the incidents between Resident #4 and Resident #15; however, recalled the charge nurse informing her Resident #15 was found on the floor, for the incident that occurred on [DATE], and was sent out to the Emergency Department (ED) for an evaluation. She further revealed LPN #4 notified her of Resident #15's fall, on [DATE]. Per the interview, LPN #4 was noticeably upset and reported Resident #15 was found on the floor and Resident #4 was observed coming out of Resident #15's room. The DON stated LPN #4 reported he thought Resident #4 pulled Resident #15 out of his/her bed. Continued interview revealed the facility should have completed a falls investigation and should have placed Resident #4 on one-to-one (1:1) observations, to ensure the safety of the resident. Interview with the Administrator, on [DATE] at 3:10 PM, revealed Resident #15 had a lot of developmental issues. Further, she stated the resident could not perform functions with his/her limbs. Per the interview, the Administrator stated staff informed her the resident fell out of bed. She stated that had she known about the additional information related to Resident #4 wandering in and out of residents' rooms, she would have expected Resident #15's fall to be investigated. Further, she stated there were no witnesses to the fall, as the facility did not have proof, and could not make assumptions. Review of the Manufacturer's Owner's Manual Safety Instructions, for the battery-operated mechanical lift, not dated, revealed special care must be taken with residents unable to aid while being lifted and included severely handicapped residents. Continued review revealed the Manufacturer's six (6) point slings were specifically designed for use with their lifts and use of non-manufacturer's brand lift slings were unsafe and may result in injury to the resident or caregiver. 3. Review of Resident #22's Medical Record revealed the facility admitted the resident on [DATE] with diagnoses to include Non-Alzheimer's Dementia, Anxiety, and Depression. Review of Resident #22's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely impaired. Review of Resident #22's State Registered Nursing Assistant (SRNA) Kardex (a tool used to give a brief overview of each residents care needs) revealed the resident required the use of a mechanical lift with two (2) staff assist for transfers. Observation on [DATE] at 1:50 PM, revealed State Registered Nursing Assistant (SRNA) #3 and SRNA #7 used the mechanical lift to transfer Resident #22 from the Geri chair to the bed; however, observation revealed the SRNA's utilized a lift sling that was not recommended by the manufacturer's recommendations. Interview on [DATE] at 1:20 PM, with SRNA #3 revealed she had worked at the facility for a year. Continued interview revealed that the utilization of the mechanical lift required the use of two (2) staff if the resident was not good with standing. Per interview, she had received training when hshe was hired. Interview with the Maintenance Director, on [DATE] at 11:32 AM, revealed it was his responsibility to check machinery and equipment once per month; however, he did not include the mechanical lift slings. Interview with the Director of Nursing (DON), on [DATE] at 4:09 PM, revealed the facility did not follow the manufacturer's instructions prior to the incident that occurred on [DATE]. Interview, on [DATE] at 2:43 PM with the Administrator revealed the facility did not follow the mechanical lift manufacturer's instructions regarding the type of sling to use with the lifts. Per the interview, she stated there was no process in place to routinely inspect the condition of the slings used with the mechanical lifts to prevent serious accident and injury. Per interview, there were no policies in place to address the mechanical lift and there should have been The Administrator stated resident safety was her responsibility. 36195

Based on observation, interview, and record review it was determined that the facility failed to ensure accuracy of the medical record related to documentation on hourly rounds for one (1) of five (5) sampled residents (Resident #1). Staff interviews revealed all residents were monitored (visually checked) by staff every hour for safety. In addition, Resident #1's care plan included an intervention for staff to monitor the resident on an hourly basis. Staff documented that the hourly check was completed at 5:00 PM on 01/20/19; however, the staff member who documented seeing the resident did not see the resident at 5:00 PM. On 01/20/19 at approximately 5:00 PM, Resident #1 (whom the facility assessed to be at risk for elopement) exited through the front door as a visitor entered the facility. The front door of the facility remains locked and a code was required to exit or a button pushed from outside the door to enter. The door did not alarm when the resident exited the building unsupervised. The outside temperature was 19 degrees Fahrenheit at 5:00 PM in the area. Resident #1 was outside the facility unsupervised approximately 11 minutes. Another resident alerted staff, who then assisted Resident #1 back inside at 5:11 PM. The facility assessed the resident to have sustained no injuries. The facility's failure to maintain an accurate medical record related to resident monitoring, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 02/05/19, was determined to exist on 01/20/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on 02/05/19. An acceptable Allegation of Compliance was received on 02/18/19, which alleged removal of Immediate Jeopardy on 02/15/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/15/19, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A policy was requested from the Administrator related to maintaining accurate records. The Administrator responded via facsimile on 02/07/19 that the facility did not have a policy on maintaining accurate records. Review of Resident #1's medical record revealed the facility admitted the resident on 11/12/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. The MDS further revealed that the resident was assessed to wander one (1) to three (3) days of the assessment period. Review of Resident #1's Comprehensive Plan of Care dated 11/21/18 revealed an intervention for staff to complete hourly monitoring on the resident for safety. Observation on 01/29/19 at 2:10 PM, revealed Resident #1 was observed walking in the hallway near the nurses' station and later that evening near his/her room. Review of the hourly monitoring for 01/20/19 revealed SRNA #1 had documented completing the hourly monitoring on Resident #1 at 5:00 PM on 01/20/19. However, review of the facility's video revealed Resident #1 exited the facility without staff knowledge via the front door when a visitor entered the facility at 5:00 PM on 01/20/19. The resident was outside the facility for approximately five (5) minutes and was between the double doors of the facility for another six (6) minutes, unsupervised by staff. Another resident saw the resident and alerted staff who assisted the resident inside and assessed the resident to have sustained no injuries. The temperature for 01/20/19 at 5:15 PM for the area was observed to be nineteen (19) degrees Fahrenheit on undergroundweather.com. Observation of the video showed snow scattered on the grass. Interview with State Registered Nurse Aide (SRNA) #1 on 01/29/19 at 4:40 PM and 6:00 PM revealed that Resident #1 had always wandered but had never tried to get out of the facility. The SRNA stated Resident #1 had been on hourly checks since admission. Further interview revealed that SRNA #1 had done an hourly check on Resident #1 at 4:00 PM. The SRNA stated she did not see the resident at 5:00 PM. However, review of the hourly monitoring sheet revealed SRNA #1 had initialed that she had seen Resident #1 at 5:00 PM. SRNA #1 stated that she was passing supper trays at that time and would have not completed the hourly check and she had not seen the resident at that time. Per SRNA #1, SRNA #2 should have completed the 5:00 PM hourly check on Resident #1. Further interview with SRNA #1 revealed that she just initialed it but did not actually see the resident. Interview with SRNA #2 on 01/29/19 at 3:56 PM and 6:15 PM revealed that she was working on the hallway where Resident #1 resides on the day the resident went outside of the facility. The SRNA stated Resident #1 was more confused that day than normal. Further interview revealed that SRNA #2 could not remember if she was doing the hourly monitoring. SRNA #2 stated no one specifically was assigned to complete the hourly rounds/monitoring and that the monitoring was a team effort. Interview with the Assistant Director of Nursing (ADON) on 01/29/19 at 2:35 PM revealed that hourly checks were standard for all new admissions. The ADON stated that she, the charge nurses, and the Director of Nursing monitored to ensure these hourly checks were completed. Further interview with the ADON on 01/31/19 at 5:32 PM revealed the hourly rounds were not specifically assigned and that the completion of the hourly rounds was completed by any nursing staff member on duty. The ADON stated she was not aware of any issues with the hourly rounds not being completed. **The facility alleged the following was implemented to remove Immediate Jeopardy on 02/15/19: 1. On 01/20/19, the Charge Nurse completed a new wandering risk assessment for Resident #1. 2. Resident #1's care plan was revised on 01/21/19 by the MDS Coordinator to address wandering/elopement risk and exit-seeking behaviors. A care plan meeting was held with Resident #1's daughter on 01/22/19. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Services Director, and Activity Director were present to discuss the resident's elopement, care plan interventions, and to review processes. 3. A sign was placed on the front door on 01/21/19 reminding visitors not to allow any resident to exit and to seek assistance from staff, if uncertain. 4. On 01/21/19, the Wandering Risk Assessment was reviewed and revised by clinical staff, administration, and management staff. The new form, the Wandering/Elopement Risk Assessment, included additional items that staff could mark to provide an accurate assessment of the resident. After the revisions, a new Wandering/Elopement Risk Assessment was completed on 01/21/19 by the DON on each of the eight (8) residents identified the previous night to be at risk for exit seeking (making statements of going home, aimless wandering, packing belongings, etc.). Care plans were also reviewed and updated by the MDS Coordinator on 01/21/19 for the eight (8) residents identified to be at risk. 5. On 01/21/19, the Administrator, Management, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation (Rehab) Director, and Environmental Services Director reviewed the elopement incident during the department supervisor morning meeting, and it was concluded that reinstituting the use of the WanderGuard system would be the most effective intervention. The DON obtained physician orders [REDACTED]. The Medical Records Clerk updated the Identification Record Book for Wandering Resident books and the poster for staff use to identify residents who were at risk. On 02/06/19, the Elopement/Missing policy was revised to include reimplementation of the facility WanderGuard system. 6. A WanderGuard bracelet was placed on Resident #1 on 01/21/19. 7. On 01/21/19, the Administrator and management reviewed and revised the Wandering Risk Assessment, Incident Report, and Elopement/Missing Resident policy. 8. On 02/01/19, the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation Director, and Environmental Services Director met to discuss the incident. Additional interventions implemented at that time included changing the hours that the front door was unlocked to 7:00 AM until 7:00 PM, and stationing a staff member to monitor the door. An office staff member was scheduled to monitor the door from 7:00 AM until 4:30 PM Monday through Friday. Then a staff member would be assigned the sole purpose of monitoring the door from 4:30 PM until 7:00 PM, when the front door is locked, and on the weekends from 7:00 AM until 7:00 PM. Staff assigned to monitor the door were educated regarding WanderGuard devices and provided a copy of the Identification Record Book for Wandering Residents for reference while on duty. In addition, staff assigned to monitor the front door were introduced to all residents with wandering behaviors so staff could visually identify the residents. 9. On 02/05/19, Wandering/Elopement risk assessments were completed by the DON, MDS Coordinator, and Social Services Director for all facility residents that had not been assessed prior to 01/21/19. Also, on 02/05/19, care plans were reviewed/revised by the DON, MDS Coordinator, and Social Services Director for all residents who were at moderate and high risk for elopement. If the residents were assessed at low risk for elopement, but were displaying behaviors of exit seeking, packing belongings, aimlessly wandering, or making statements of going home, they will be reassessed and their care plans updated at that time. 10. On 02/06/19, the DON, ADON, MDS Coordinator, Social Services Director, Environmental Services Director, Administrator, and Management staff reviewed the Comprehensive Care Plan Policy and no changes were made. 11. On 02/06/19, hourly rounds sheets were updated to include more detail regarding the whereabouts of the resident when monitored. 12. On 02/06/19, after review by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehab Director, and Environmental Services Director and agreement with Management and the President of the Board of Directors, additional changes were implemented to the front door. The button on the outside of the front door that allowed entry into the facility was removed. Entry into and exit from the facility will now require the assistance of a staff member at all times. Families were notified of this change by letter. The Door Alarm Policy was revised to reflect the removal of the button and the addition of staff monitoring the front door. 13. On 02/13/19, Management staff and the Administrator reviewed the Administrator's job description to ensure that appropriate responsibilities were outlined. 14. The ADON completed re-education regarding the elopement policy with all staff on duty the evening of the incident, 01/20/19, as well as with the oncoming staff upon return to work. 15. On 02/05/19, the Administrator, DON, and ADON educated nursing staff on duty regarding the importance of accurate and complete documentation. Nursing staff not present at that time were in-serviced by the ADON as they returned for their next shift. 16. On 02/06/19, the DON/ADON educated staff regarding the Comprehensive Care Plan Policy. Any staff not working that day was in-serviced prior to working their next shift. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 17. On 02/06/19, in-service training was provided by the DON/ADON with staff in all departments on duty to educate on the elopement/missing resident, WanderGuard transmitter use, maintenance and testing, and door alarm policy and procedure changes being implemented. 18. On 02/14/19, a post-test was given to staff in all departments to determine competency and understanding of the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and changes to the hourly round check sheets. A score of at least 80% will be required. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 19. On 02/13/19, the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Activity Director, Dietary Director, Environmental Services Director, and Business Services Director viewed a video titled, What is a care plan. The staff also completed a post-test to determine competency. 20. On 02/14/19, the Administrator completed a Centers for Medicare and Medicaid Services (CMS) Administrator Competency Assessment with a passing score of 89% achieved. Results were reviewed with Management on 02/15/19. 21. Daily during the department supervisor morning meeting (Monday through Friday) resident records will be reviewed for any change in condition by the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Dietary Manager, Activity Director, Environmental Services Director, Business Services Director, and Rehab Director. For any resident noted to have a change in status (clinical, behavior, etc.), the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and Infection Control Nurse will review the resident's care plan to ensure appropriateness. 22. Beginning 02/14/19, at least two (2) care plans will be audited daily during the morning meeting. The review will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and the Infection Control Nurse. 23. Members of the QA Committee will review hourly rounds completed for two (2) residents daily (Monday-Friday). At least four (4) of the residents who are audited will be residents who were identified to be at risk for elopement. 24. WanderGuard functioning is monitored daily by the nurse or Kentucky Medication Aide (KMA) and is documented in the North Nurses' Station Identification Record Book for Wandering Residents. WanderGuard placement will be monitored by assigned nursing staff every shift and documented as part of their daily documentation. 25. The Administrator, DON, ADON, MDS Coordinator, Social Services Director, or Infection Control Nurse will audit daily documentation completed by Nurses, KMAs, and SRNAs related to WanderGuard checks and hourly rounds following the morning meeting Monday through Friday to ensure completion. Any errors or omissions will be addressed by the DON/ADON and corrections made. The audits will be reviewed daily (Monday through Friday) during the morning department supervisor meetings, on the monthly QA reports, and during weekly and/or quarterly QA meetings with the Medical Director. 26. The Administrator will observe door monitor staff daily to verify that appropriate care is taken to supervise entry and exit of the facility by visitors and to be certain that no resident exits unescorted. This will be completed daily Monday through Friday and on weekends by visually monitoring staff at the front door. Results will be documented, any corrections made immediately as necessary, and reviewed during weekly QA meetings for four (4) weeks, then monthly. 27. The Administrator will continue to participate in daily morning department supervisor meetings and will review any resident issues, incidents/accidents, care plans, and QA audits each day. Administrator communicates with management daily by phone, email (electronic mail), text, or in person to discuss concerns, changes, issues, etc. Management meets with the Administrator weekly on site or more frequently, as needed. 28. The Board of Directors meets monthly with the Administrator and Management on site to review overall operations of the facility and address any issues or concerns. More frequent communication may be made if a situation arises requiring more timely notification. 29. On 01/31/19, a Quality Assurance quarterly meeting was held with the Medical Director present. During the meeting, staff discussed Resident #1's elopement on 01/20/19 and interventions that were put in place up until that date. 30. On 02/18/19, a QA meeting held by phone with the Medical Director, Administrator, ADON, MDS Coordinator, Social Services Director, Infection Control Nurse, Dietary Director, Activity Director, Environmental Services Director, Business Services Director, and Medical Records Clerk present to discuss any updates and revisions that had been made to the comprehensive care plan, door alarm, WanderGuard, and Elopement/Missing Resident Policies. In addition, staff discussed the update to the hourly round check sheets, QA audits, and in-services regarding accurate records were also discussed. Further, the need for weekly QA meetings, removal of the button at the facility entrance, staff monitoring of the front door, and audits were also discussed. ***The State Survey Agency verified that the following were implemented by the facility and Immediate Jeopardy was removed on 02/15/19, as alleged by the facility: 1. Review of a Wandering Risk assessment dated [DATE], revealed the new assessment was completed for Resident #1 and the resident was assessed to be at moderate risk. Interview with RN #1 on 01/31/19 at 6:40 PM, revealed she had completed the new Wandering Risk Assessment for Resident #1. 2. Record review and interview with the MDS Coordinator on 02/20/19 at 10:22 AM revealed she reviewed and updated Resident #1's care plan on 01/21/19 to address the resident's wandering and elopement risk. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, 10:42 AM with the MDS Coordinator, and 10:22 AM with the Social Service Director revealed all were in a care plan meeting with Resident #1's family member on 01/22/19. 3. Interview with the Administrator on 02/20/19 at 11:15 AM revealed signage was posted cautioning visitors about watching when they entered/exited to ensure a resident did not leave via the opened door. Observation on 01/30/19 at 1:00 PM, of the front door, revealed signage cautioning visitors who entered/exited to ensure that residents did not exit as they entered/exited the building. 4. Review of the revised Wandering Risk Assessments revealed a new assessment had been completed on 01/21/19 for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11. Interview with the Director of Nursing (DON) on 02/20/19 at 9:43 AM confirmed she had completed the Wandering Risk assessment on the previous eight (8) residents. Interview with the Minimum Data Set (MDS) Coordinator on 02/20/19 at 10:42 AM revealed she had reviewed and updated (as needed) all eight (8) residents' plans of care related to wandering/elopement risk. 5. Interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM, and on 02/19/19 at 4:36 PM with the Management Supervisor (the Administrator's Supervisor) confirmed administrative staff had met and decided to implement the WanderGuard System. The DON stated the physicians of the residents identified at risk for elopement were contacted. Review of policies and interview with the Administrator on 02/20/19 at 11:15 AM revealed the WanderGuard and Elopement policies were revised. Review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11's medical records confirmed orders for WanderGuard bracelets. Observation on 02/19/19 at 1:46 PM revealed the Identification Record Book for Wandering Residents had been updated and contained pictures of the eight (8) residents whom the facility had been assessed to be at risk for elopement. 6. Review of Resident #1's medical record and interview with the DON on 02/20/19 at 9:43 AM confirmed the facility implemented a WanderGuard bracelet for Resident #1 on 01/21/19. 7. Review of the Elopement/Missing policy and the Wandering Risk Assessment policy, and review of QA Meeting Minutes and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed the facility had reviewed and revised the policies on 02/06/19. 8. Interview with the Administrator on 02/20/19 at 11:15 AM confirmed the facility had extended the office hours so that staff was present in the front office from 7:00 AM to 7:00 PM. Review of training documentation and interview on 02/19/19 with the Business Manager at 3:40 PM, the Activity Aide at 4:05 PM, and the Receptionist/Billing Clerk at 3:27 PM revealed they had been educated regarding ensuring residents who wandered/were at risk for elopement did not leave the facility as visitors entered/exited. The staff were knowledgeable of the Identification Record Book and procedures for opening the front door. Observation of the entrance to the facility on [DATE] at 8:30 AM revealed the front door was locked and there was a button/doorbell that alerted office staff, who could then release the door. Interview with the Receptionist/Billing Clerk revealed she could visualize who was inside/outside the front door prior to releasing/opening the door. The Receptionist stated staff were always stationed at the door during the day. An observation of the Receptionist work area revealed monitors with a full view of the front door and an Identification Book that contained ten (10) residents' pictures with additional identifying information. An interview with the Business Manager on 02/19/19 at 3:40 PM revealed she had worked the past weekend and had monitored who entered and left the facility. The Business Manager stated staff had access to the Identification Book for Wandering Residents and were trained to observe the front door. She stated staff were instructed to observe the area around the front door prior to releasing the door for someone to enter or exit. 9. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, at 10:42 AM with the MDS Coordinator, and at 10:22 AM with the Social Services Director revealed all residents not previously assessed on 01/21/19 were reassessed using the Wandering/Elopement Assessment. In addition, the interviews revealed care plans of these residents were reviewed and revised as necessary. 10. Review of documentation and interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM revealed staff had reviewed the Care Plan policy on 02/06/19. 11. Review of the Hourly Round Form and interview on 02/19/19 at 5:17 PM with SRNA #3, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and on 02/20/19 with the Administrator at 11:15 AM revealed the Hourly Round Monitoring Form had been revised and staff were trained on the revised form. Review of the QA Audit form and interview with the Administrator on 02/20/19 at 11:15 AM revealed the audit form was revised to include the staff who completed the form and if their documentation was complete and accurate as to the location of the resident and the activity of the resident. 12. Review of the Door Alarm Policy and interview with the Administrator on 02/20/19 at 11:15 AM, revealed the Door Alarm Policy was revised on 02/06/19. According to the Administrator, the outside entry button was removed and the facility added staff to monitor the front entry from 7:00 AM to 7:00 PM daily. Additional interviews with the Receptionist/Billing Clerk on 02/20/19 at 3:27 PM and an Activity Aide on 02/19/19 at 4:05 PM revealed they had been assigned to monitor the front door. Both stated the front entrance was locked and access was only permitted with staff assistance. 13. Interview on 02/19/19 at 4:36 PM with the Management Supervisor and the Administrator on 02/20/19 at 11:15 AM revealed the Management Supervisor had reviewed with the Administrator the Administrator's job description and responsibilities. 14. Review of training documentation and interview with SRNA #3 on 02/19/19 at 5:17 PM, SRNA #4 on 02/19/19 at 5:35 PM, the ADON on 02/20/19 at 11:00 AM, and the Social Services Director on 02/20/19 at 10:22 AM confirmed the ADON provided training to staff on 01/21/19 regarding the Elopement Policy. 15. Review of training documentation and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM, revealed they had received training related to ensuring documentation is complete and accurate. 16. Review of training documentation and interview on 02/19/19 at 5:20 PM with LPN #3, LPN #2 at 5:57 PM, KMA #1 at 6:40 PM, and LPN #4 at 6:50 PM, and on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM confirmed the ADON and DON presented a training on 02/06/19 which covered review of the Comprehensive Care Plan policy. All stated that a post-test was also completed. 17. Review of in-service records revealed on 02/14/19 staff in all departments were educated regarding the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and the changes to hourly round check sheets. Further review revealed the staff completed a post-test with a passing score of at least 80%. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. Review of tests and interviews on 02/19/19 with SRNA #3 at 5:17 PM, SRNA #4 at 5:35 PM, Housekeeping staff at 6:58 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the MDS Coordinator at 10:42 PM, and the Social Services Director at 10:22 AM revealed all had taken a post-test after the recent trainings on elopement and the WanderGuard system. 18. Review of post-tests and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM revealed all completed post-testing after the recent in-service training. 19. Review of training documentation and interview on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, the Social Services Director at 10:22 AM, and the DON at 9:43 AM revealed they had received video training regarding completing care plans. The staff stated they also completed a post-test. Further review of training and testing documentation and interview on 02/20/19 at 11:15 AM, with the Administrator revealed the Administrator also completed the care plan video training and passed the post-test. 20. Review of testing information and interview on 02/19/19 at 4:36 PM with the Management Supervisor and on 02/20/19 at 11:15 AM with the Administrator revealed the Administrator completed the CMS Administrator Competency Assessment on 02/14/19 with a score of 89%. The staff stated the test results were also reviewed with the Management Supervisor on 02/15/19. 21. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed during morning meetings Monday through Friday, the staff reviewed resident records to identify whether a resident had had a change in condition. The care plans of these residents were also reviewed during the morning meeting and revised, if needed. 22. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed at least two (2) residents' care plans were reviewed during the morning meetings held Monday through Friday to ensure the care plans were accurate. 23. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting, the DON and ADON reviewed documentation (completed the day before) on hourly rounds to ensure the monitoring was completed and any problems were immediately corrected. 24. Review of Resident #1's and Resident #6's medical records revealed the residents utilized WanderGuard Bracelets. Further review revealed documentation that staff had monitored the function of the WanderGuard System and the function of the WanderGuard Bracelets daily. Interview with KMA #1 on 02/19/19 at 6:33 PM revealed she checked the functioning of the WanderGuard System daily by checking the front door (The front door is the only door equipped with the WanderGuard System. Other doors automatically alarm when opened.) and by checking the bracelet on each resident with a transmitter box. 25. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting the DON and ADON reviewed documentation (completed the day before) to ensure WanderGuard checks had been completed and any problems were immediately corrected. 26. Review of door audit documentation and interview with the Administrator on 02/20/19 at 11:15 AM revealed since 02/06/19, the Administrator was checking daily to ensure staff were monitoring the front door. No concerns had been identified. Per the Administrator, results of all audits go to the QA Meeting. 27. Review of documentation and interview with the Administrator on 02/20/19 at 11:15 AM, the DON at 9:43 AM, the ADON at 11:00 AM, and the Social Services Director at 10:22 AM revealed Morning Meetings were held daily Monday through Friday. The interviews revealed the Administrator attended the meetings and audits were reviewed during the meetings. Interview on 02/19/19 at 4:36 PM, with the Management Supervisor, and the Administrator on 02/20/19 at 11:15 AM revealed the Management Supervisor and the Administrator talked at least daily and the Management Supervisor met with the Administrator at the facility at least weekly. The Management Supervisor stated she also reviewed the Morning Meeting Notes. 28. Interview on 02/19/19 at 4:36 PM with the Management Supervisor, and with the Administrator on 02/20/19 at 11:15 AM confirmed the Board of Directors met with them monthly. The last meeting was held at the facility on 02/19/19. 29. Review of QA documentation and interview with the Administrator on 02/20/19 at 11:15 AM, and with the Medical Director at 10:01 AM, revealed during a quarterly QA meeting (01/31/19) staff discussed Resident #1's elopement and the interventions that had been put into place up until that date. 30. Review of QA Meeting Minutes and interview on 02/20/19 with the Administrator at 11:15 AM, the Social Services Director at 10:22 AM, and the Medical Director at 10:01 AM revealed the facility had conducted a QA Meeting on 02/18/19 to discuss upda

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive care plan to prevent elopement for two (2) of five (5) sampled residents (Resident #1 and Resident #4). The facility assessed Resident #1 to be at moderate risk for wandering and elopement on 11/19/18. However, the facility failed to address Resident #1's elopement risk on the plan of care. On 01/20/19 at approximately 5:00 PM, Resident #1 exited through the front door of the facility as a visitor entered the facility. The outside temperature was 19 degrees Fahrenheit (F) at 5:00 PM in the area. Resident #1 was outside the facility unsupervised approximately five (5) minutes and then reentered the first exterior door into the vestibule (this area is not heated) and stayed in this area until another resident saw Resident #1. The other resident alerted staff at 5:10 PM. Staff entered the code to the front door of the facility and assisted Resident #1 back inside at 5:11 PM. The resident was assessed to have sustained no injuries. In addition, the facility assessed Resident #4 to be at risk for wandering/elopement on 07/12/18. However, the facility failed to address Resident #4's wandering behavioral symptoms and elopement risk on the plan of care. The facility's failure to ensure a comprehensive care plan was developed and implemented to prevent elopement for residents, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 02/05/19, and was determined to exist on 01/20/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on 02/05/19. An acceptable Allegation of Compliance was received on 02/18/19, which alleged removal of Immediate Jeopardy on 02/15/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/15/19, prior to exit on 02/20/19, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Comprehensive Plan of Care, last revised 08/27/18, revealed services were to be furnished to residents to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed each care plan should include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Review of the Elopement/Missing Resident Policy with a revision date of 08/27/18, revealed that all residents identified to be at risk for wandering or elopement shall, especially those with a history of prior wandering, be designated as such on their individual care plan. 1. Record review revealed the facility admitted Resident #1 on 11/12/18 with [DIAGNOSES REDACTED]. Review of an Initial Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), indicating Resident #1 was not interviewable. Further review of the MDS assessment revealed the facility assessed Resident #1 to have wandering behavior. Review of the Wandering/Risk Assessment for Resident #1 completed on 11/19/18, revealed the resident was at moderate risk for elopement. Review of a Comprehensive Care Plan dated 11/21/18, revealed Resident #1's wandering behavioral symptoms and elopement risk were not addressed on the plan of care. Review of a facility Elopement Report dated 01/20/19, revealed Resident #1 was discovered outside of the facility. The facility determined Resident #1 exited the front door when a visitor entered and was outside for approximately two (2) minutes. Continued review of the Elopement Report revealed Resident #1 was assessed by facility staff and was placed on fifteen (15) minute checks. However, after review of the video camera footage, it revealed that Resident #1 was outside of the facility from 5:00 PM until 5:11 PM. Observation on 01/29/19 at 10:30 AM, revealed Resident #1 was in the dining room involved in a group activity. Continued observation revealed Resident #1 had a wanderguard alarm bracelet noted to his/her right ankle. On 01/31/19 at 7:25 PM, Resident #1 was observed wandering in the hallway. Attempted interview with Resident #1 on 01/29/19 at 2:10 PM was unsuccessful due to the resident's cognition. Interview with State Registered Nursing Assistant (SRNA) #4 on 01/30/19 at 2:00 PM, revealed Resident #1 often displayed wandering behaviors and would voice wanting to go home. The SRNA stated the resident's behavioral symptoms would increase in the evenings. Interview with the Assistant Director of Nursing (ADON) on 01/31/19 at 5:35 PM and 6:50 PM revealed that Resident #1 at times stated that he/she wanted to go home and also sometimes packed his/her clothing. Further interview with the ADON revealed that anyone who was at moderate to high risk for wandering should have a care plan for wandering/elopement developed and implemented. Interview on 01/30/19 at 8:35 AM with the Director of Nursing (DON) revealed the Minimum Data Set Coordinator was responsible for creating the Care Plan after the admission assessment was completed. Per the DON, there was not a wandering care plan completed/developed for Resident #1 because the staff did not consider his/her behavior as wandering because he/she was just talking and visiting others. Interview with the MDS Coordinator on 01/31/19 at 4:18 PM and 02/04/19 at 10:00 AM, revealed Resident #1 liked to visit other residents in the facility. Further interview with the MDS Coordinator revealed she believed that hourly monitoring was enough supervision for the resident, even after his/her Wander Risk Assessment on 11/19/18 revealed that he/she was a moderate risk for Elopement/Wandering. 2. Record review revealed the facility admitted Resident #4 on 04/12/18 with [DIAGNOSES REDACTED]. Review of an Elopement Risk assessment dated [DATE] revealed the facility assessed Resident #4 to be at moderate risk for wandering. Review of Resident #4's Plan of Care revealed no Elopement/Wandering care plan. Review of Resident #4's Progress Notes dated 12/02/18, 12/16/18, and 01/06/19 revealed the resident had wandering behaviors at night. Further review revealed on 01/01/19, progress notes stated chronic wandering (does not specify at what time). On 01/29/19 at 10:40 AM Resident #4 was observed walking in the hall near the entry hall of the facility, wearing a wanderguard bracelet on his/her right ankle. Observation of Resident #4 on 01/31/19 at 4:10 PM revealed the resident was walking in the hallway with the assistance of a rolling walker and continued walking in the hall for fifteen (15) minutes. Interview at that time revealed Resident #4 lived a long way from there and did not know when he/she would get rested up. Interview with the MDS Coordinator on 01/31/19 at 4:40 PM, revealed Resident #4's wandering behavior should have been addressed in his/her comprehensive care plan. Continued interview with the MDS Coordinator revealed she did not know why wandering was not addressed on Resident #4's plan of care. Interview with the Administrator on 02/05/19 at 11:00 AM, revealed she expected that residents who exhibited wandering behavior should have wandering/elopement care plans. **The facility alleged the following was implemented to remove Immediate Jeopardy on 02/15/19: 1. On 01/20/19, the Charge Nurse completed a new wandering risk assessment for Resident #1. 2. Resident #1's care plan was revised on 01/21/19 by the MDS Coordinator to address wandering/elopement risk and exit-seeking behaviors. A care plan meeting was held with Resident #1's daughter on 01/22/19. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Services Director, and Activity Director were present to discuss the resident's elopement, care plan interventions, and to review processes. 3. A sign was placed on the front door on 01/21/19 reminding visitors not to allow any resident to exit and to seek assistance from staff, if uncertain. 4. On 01/21/19, the Wandering Risk Assessment was reviewed and revised by clinical staff, administration, and management staff. The new form, the Wandering/Elopement Risk Assessment, included additional items that staff could mark to provide an accurate assessment of the resident. After the revisions, a new Wandering/Elopement Risk Assessment was completed on 01/21/19 by the DON on each of the eight (8) residents identified the previous night to be at risk for exit seeking (making statements of going home, aimless wandering, packing belongings, etc.). Care plans were also reviewed and updated by the MDS Coordinator on 01/21/19 for the eight (8) residents identified to be at risk. 5. On 01/21/19, the Administrator, Management, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation (Rehab) Director, and Environmental Services Director reviewed the elopement incident during the department supervisor morning meeting, and it was concluded that reinstituting the use of the WanderGuard system would be the most effective intervention. The DON obtained physician orders [REDACTED]. The Medical Records Clerk updated the Identification Record Book for Wandering Resident books and the poster for staff use to identify residents who were at risk. On 02/06/19, the Elopement/Missing policy was revised to include reimplementation of the facility WanderGuard system. 6. A WanderGuard bracelet was placed on Resident #1 on 01/21/19. 7. On 01/21/19, the Administrator and management reviewed and revised the Wandering Risk Assessment, Incident Report, and Elopement/Missing Resident policy. 8. On 02/01/19, the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation Director, and Environmental Services Director met to discuss the incident. Additional interventions implemented at that time included changing the hours that the front door was unlocked to 7:00 AM until 7:00 PM, and stationing a staff member to monitor the door. An office staff member was scheduled to monitor the door from 7:00 AM until 4:30 PM Monday through Friday. Then a staff member would be assigned the sole purpose of monitoring the door from 4:30 PM until 7:00 PM, when the front door is locked, and on the weekends from 7:00 AM until 7:00 PM. Staff assigned to monitor the door were educated regarding WanderGuard devices and provided a copy of the Identification Record Book for Wandering Residents for reference while on duty. In addition, staff assigned to monitor the front door were introduced to all residents with wandering behaviors so staff could visually identify the residents. 9. On 02/05/19, Wandering/Elopement risk assessments were completed by the DON, MDS Coordinator, and Social Services Director for all facility residents that had not been assessed prior to 01/21/19. Also, on 02/05/19, care plans were reviewed/revised by the DON, MDS Coordinator, and Social Services Director for all residents who were at moderate and high risk for elopement. If the residents were assessed at low risk for elopement, but were displaying behaviors of exit seeking, packing belongings, aimlessly wandering, or making statements of going home, they will be reassessed and their care plans updated at that time. 10. On 02/06/19, the DON, ADON, MDS Coordinator, Social Services Director, Environmental Services Director, Administrator, and Management staff reviewed the Comprehensive Care Plan Policy and no changes were made. 11. On 02/06/19, hourly rounds sheets were updated to include more detail regarding the whereabouts of the resident when monitored. 12. On 02/06/19, after review by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehab Director, and Environmental Services Director and agreement with Management and the President of the Board of Directors, additional changes were implemented to the front door. The button on the outside of the front door that allowed entry into the facility was removed. Entry into and exit from the facility will now require the assistance of a staff member at all times. Families were notified of this change by letter. The Door Alarm Policy was revised to reflect the removal of the button and the addition of staff monitoring the front door. 13. On 02/13/19, Management staff and the Administrator reviewed the Administrator's job description to ensure that appropriate responsibilities were outlined. 14. The ADON completed re-education regarding the elopement policy with all staff on duty the evening of the incident, 01/20/19, as well as with the oncoming staff upon return to work. 15. On 02/05/19, the Administrator, DON, and ADON educated nursing staff on duty regarding the importance of accurate and complete documentation. Nursing staff not present at that time were in-serviced by the ADON as they returned for their next shift. 16. On 02/06/19, the DON/ADON educated staff regarding the Comprehensive Care Plan Policy. Any staff not working that day was in-serviced prior to working their next shift. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 17. On 02/06/19, in-service training was provided by the DON/ADON with staff in all departments on duty to educate on the elopement/missing resident, WanderGuard transmitter use, maintenance and testing, and door alarm policy and procedure changes being implemented. 18. On 02/14/19, a post-test was given to staff in all departments to determine competency and understanding of the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and changes to the hourly round check sheets. A score of at least 80% will be required. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 19. On 02/13/19, the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Activity Director, Dietary Director, Environmental Services Director, and Business Services Director viewed a video titled, What is a care plan. The staff also completed a post-test to determine competency. 20. On 02/14/19, the Administrator completed a Centers for Medicare and Medicaid Services (CMS) Administrator Competency Assessment with a passing score of 89% achieved. Results were reviewed with Management on 02/15/19. 21. Daily during the department supervisor morning meeting (Monday through Friday) resident records will be reviewed for any change in condition by the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Dietary Manager, Activity Director, Environmental Services Director, Business Services Director, and Rehab Director. For any resident noted to have a change in status (clinical, behavior, etc.), the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and Infection Control Nurse will review the resident's care plan to ensure appropriateness. 22. Beginning 02/14/19, at least two (2) care plans will be audited daily during the morning meeting. The review will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and the Infection Control Nurse. 23. Members of the QA Committee will review hourly rounds completed for two (2) residents daily (Monday-Friday). At least four (4) of the residents who are audited will be residents who were identified to be at risk for elopement. 24. WanderGuard functioning is monitored daily by the nurse or Kentucky Medication Aide (KMA) and is documented in the North Nurses' Station Identification Record Book for Wandering Residents. WanderGuard placement will be monitored by assigned nursing staff every shift and documented as part of their daily documentation. 25. The Administrator, DON, ADON, MDS Coordinator, Social Services Director, or Infection Control Nurse will audit daily documentation completed by Nurses, KMAs, and SRNAs related to WanderGuard checks and hourly rounds following the morning meeting Monday through Friday to ensure completion. Any errors or omissions will be addressed by the DON/ADON and corrections made. The audits will be reviewed daily (Monday through Friday) during the morning department supervisor meetings, on the monthly QA reports, and during weekly and/or quarterly QA meetings with the Medical Director. 26. The Administrator will observe door monitor staff daily to verify that appropriate care is taken to supervise entry and exit of the facility by visitors and to be certain that no resident exits unescorted. This will be completed daily Monday through Friday and on weekends by visually monitoring staff at the front door. Results will be documented, any corrections made immediately as necessary, and reviewed during weekly QA meetings for four (4) weeks, then monthly. 27. The Administrator will continue to participate in daily morning department supervisor meetings and will review any resident issues, incidents/accidents, care plans, and QA audits each day. Administrator communicates with management daily by phone, email (electronic mail), text, or in person to discuss concerns, changes, issues, etc. Management meets with the Administrator weekly on site or more frequently, as needed. 28. The Board of Directors meets monthly with the Administrator and Management on site to review overall operations of the facility and address any issues or concerns. More frequent communication may be made if a situation arises requiring more timely notification. 29. On 01/31/19, a Quality Assurance quarterly meeting was held with the Medical Director present. During the meeting, staff discussed Resident #1's elopement on 01/20/19 and interventions that were put in place up until that date. 30. On 02/18/19, a QA meeting held by phone with the Medical Director, Administrator, ADON, MDS Coordinator, Social Services Director, Infection Control Nurse, Dietary Director, Activity Director, Environmental Services Director, Business Services Director, and Medical Records Clerk present to discuss any updates and revisions that had been made to the comprehensive care plan, door alarm, WanderGuard, and Elopement/Missing Resident Policies. In addition, staff discussed the update to the hourly round check sheets, QA audits, and in-services regarding accurate records were also discussed. Further, the need for weekly QA meetings, removal of the button at the facility entrance, staff monitoring of the front door, and audits were also discussed. ***The State Survey Agency verified that the following were implemented by the facility and Immediate Jeopardy was removed on 02/15/19, as alleged by the facility: 1. Review of a Wandering Risk assessment dated [DATE], revealed the new assessment was completed for Resident #1 and the resident was assessed to be at moderate risk. Interview with RN #1 on 01/31/19 at 6:40 PM, revealed she had completed the new Wandering Risk Assessment for Resident #1. 2. Record review and interview with the MDS Coordinator on 02/20/19 at 10:22 AM revealed she reviewed and updated Resident #1's care plan on 01/21/19 to address the resident's wandering and elopement risk. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, 10:42 AM with the MDS Coordinator, and 10:22 AM with the Social Service Director revealed all were in a care plan meeting with Resident #1's family member on 01/22/19. 3. Interview with the Administrator on 02/20/19 at 11:15 AM revealed signage was posted cautioning visitors about watching when they entered/exited to ensure a resident did not leave via the opened door. Observation on 01/30/19 at 1:00 PM, of the front door, revealed signage cautioning visitors who entered/exited to ensure that residents did not exit as they entered/exited the building. 4. Review of the revised Wandering Risk Assessments revealed a new assessment had been completed on 01/21/19 for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11. Interview with the Director of Nursing (DON) on 02/20/19 at 9:43 AM confirmed she had completed the Wandering Risk assessment on the previous eight (8) residents. Interview with the Minimum Data Set (MDS) Coordinator on 02/20/19 at 10:42 AM revealed she had reviewed and updated (as needed) all eight (8) residents' plans of care related to wandering/elopement risk. 5. Interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM, and on 02/19/19 at 4:36 PM with the Management Supervisor (the Administrator's Supervisor) confirmed administrative staff had met and decided to implement the WanderGuard System. The DON stated the physicians of the residents identified at risk for elopement were contacted. Review of policies and interview with the Administrator on 02/20/19 at 11:15 AM revealed the WanderGuard and Elopement policies were revised. Review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11's medical records confirmed orders for WanderGuard bracelets. Observation on 02/19/19 at 1:46 PM revealed the Identification Record Book for Wandering Residents had been updated and contained pictures of the eight (8) residents whom the facility had been assessed to be at risk for elopement. 6. Review of Resident #1's medical record and interview with the DON on 02/20/19 at 9:43 AM confirmed the facility implemented a WanderGuard bracelet for Resident #1 on 01/21/19. 7. Review of the Elopement/Missing policy and the Wandering Risk Assessment policy, and review of QA Meeting Minutes and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed the facility had reviewed and revised the policies on 02/06/19. 8. Interview with the Administrator on 02/20/19 at 11:15 AM confirmed the facility had extended the office hours so that staff was present in the front office from 7:00 AM to 7:00 PM. Review of training documentation and interview on 02/19/19 with the Business Manager at 3:40 PM, the Activity Aide at 4:05 PM, and the Receptionist/Billing Clerk at 3:27 PM revealed they had been educated regarding ensuring residents who wandered/were at risk for elopement did not leave the facility as visitors entered/exited. The staff were knowledgeable of the Identification Record Book and procedures for opening the front door. Observation of the entrance to the facility on [DATE] at 8:30 AM revealed the front door was locked and there was a button/doorbell that alerted office staff, who could then release the door. Interview with the Receptionist/Billing Clerk revealed she could visualize who was inside/outside the front door prior to releasing/opening the door. The Receptionist stated staff were always stationed at the door during the day. An observation of the Receptionist work area revealed monitors with a full view of the front door and an Identification Book that contained ten (10) residents' pictures with additional identifying information. An interview with the Business Manager on 02/19/19 at 3:40 PM revealed she had worked the past weekend and had monitored who entered and left the facility. The Business Manager stated staff had access to the Identification Book for Wandering Residents and were trained to observe the front door. She stated staff were instructed to observe the area around the front door prior to releasing the door for someone to enter or exit. 9. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, at 10:42 AM with the MDS Coordinator, and at 10:22 AM with the Social Services Director revealed all residents not previously assessed on 01/21/19 were reassessed using the Wandering/Elopement Assessment. In addition, the interviews revealed care plans of these residents were reviewed and revised as necessary. 10. Review of documentation and interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM revealed staff had reviewed the Care Plan policy on 02/06/19. 11. Review of the Hourly Round Form and interview on 02/19/19 at 5:17 PM with SRNA #3, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and on 02/20/19 with the Administrator at 11:15 AM revealed the Hourly Round Monitoring Form had been revised and staff were trained on the revised form. Review of the QA Audit form and interview with the Administrator on 02/20/19 at 11:15 AM revealed the audit form was revised to include the staff who completed the form and if their documentation was complete and accurate as to the location of the resident and the activity of the resident. 12. Review of the Door Alarm Policy and interview with the Administrator on 02/20/19 at 11:15 AM, revealed the Door Alarm Policy was revised on 02/06/19. According to the Administrator, the outside entry button was removed and the facility added staff to monitor the front entry from 7:00 AM to 7:00 PM daily. Additional interviews with the Receptionist/Billing Clerk on 02/20/19 at 3:27 PM and an Activity Aide on 02/19/19 at 4:05 PM revealed they had been assigned to monitor the front door. Both stated the front entrance was locked and access was only permitted with staff assistance. 13. Interview on 02/19/19 at 4:36 PM with the Management Supervisor and the Administrator on 02/20/19 at 11:15 AM revealed the Management Supervisor had reviewed with the Administrator the Administrator's job description and responsibilities. 14. Review of training documentation and interview with SRNA #3 on 02/19/19 at 5:17 PM, SRNA #4 on 02/19/19 at 5:35 PM, the ADON on 02/20/19 at 11:00 AM, and the Social Services Director on 02/20/19 at 10:22 AM confirmed the ADON provided training to staff on 01/21/19 regarding the Elopement Policy. 15. Review of training documentation and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM, revealed they had received training related to ensuring documentation is complete and accurate. 16. Review of training documentation and interview on 02/19/19 at 5:20 PM with LPN #3, LPN #2 at 5:57 PM, KMA #1 at 6:40 PM, and LPN #4 at 6:50 PM, and on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM confirmed the ADON and DON presented a training on 02/06/19 which covered review of the Comprehensive Care Plan policy. All stated that a post-test was also completed. 17. Review of in-service records revealed on 02/14/19 staff in all departments were educated regarding the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and the changes to hourly round check sheets. Further review revealed the staff completed a post-test with a passing score of at least 80%. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. Review of tests and interviews on 02/19/19 with SRNA #3 at 5:17 PM, SRNA #4 at 5:35 PM, Housekeeping staff at 6:58 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the MDS Coordinator at 10:42 PM, and the Social Services Director at 10:22 AM revealed all had taken a post-test after the recent trainings on elopement and the WanderGuard system. 18. Review of post-tests and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM revealed all completed post-testing after the recent in-service training. 19. Review of training documentation and interview on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, the Social Services Director at 10:22 AM, and the DON at 9:43 AM revealed they had received video training regarding completing care plans. The staff stated they also completed a post-test. Further review of training and testing documentation and interview on 02/20/19 at 11:15 AM, with the Administrator revealed the Administrator also completed the care plan video training and passed the post-test. 20. Review of testing information and interview on 02/19/19 at 4:36 PM with the Management Supervisor and on 02/20/19 at 11:15 AM with the Administrator revealed the Administrator completed the CMS Administrator Competency Assessment on 02/14/19 with a score of 89%. The staff stated the test results were also reviewed with the Management Supervisor on 02/15/19. 21. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed during morning meetings Monday through Friday, the staff reviewed resident records to identify whether a resident had had a change in condition. The care plans of these residents were also reviewed during the morning meeting and revised, if needed. 22. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed at least two (2) residents' care plans were reviewed during the morning meetings held Monday through Friday to ensure the care plans were accurate. 23. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting, the DON and ADON reviewed documentation (completed the day before) on hourly rounds to ensure the monitoring was completed and any problems were immediately corrected. 24. Review of Resident #1's and Resident #6's medical records revealed the residents utilized WanderGuard Bracelets. Further review revealed documentation that staff had monitored the function of the WanderGuard System and the function of the WanderGuard Bracelets daily. Interview with KMA #1 on 02/19/19 at 6:33 PM revealed she checked the functioning of the WanderGuard System daily by checking the front door (The front door is the only door equipped with the WanderGuard System. Other doors automatically alarm when opened.) and by checking the bracelet on each resident with a transmitter box. 25. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting the DON an

Based on interview, observations, record review, and review of the facility's policy and procedures, it was determined the facility failed to provide supervision to prevent accidents/elopements for one (1) of five (5) sampled residents (Resident #1). On 01/20/19 at approximately 5:00 PM, Resident #1 (whom the facility assessed to be at risk for elopement) exited through the front door without staff knowledge as a visitor entered the facility. The front door of the facility remains locked and a code was required to exit or a button pushed from the outside to enter. The door did not alarm when the resident exited the building unsupervised. The outside temperature in the area was 19 degrees Fahrenheit (F) at 5:00 PM. The resident was wearing a jogging suit and shoes. Resident #1 was outside unsupervised for approximately five (5) minutes and then reentered the first exterior door into the vestibule, which is not heated. The resident stayed in this area until another resident saw Resident #1 outside the facility in the vestibule. The other resident alerted staff at 5:10 PM. Staff entered the code to the front door of the facility and assisted Resident #1 back inside at 5:11 PM. The facility assessed the resident to have sustained no injuries. In addition, staff interviews revealed all residents were checked (staff were to visually check on the resident) every hour for safety; however, facility staff failed to visually check on Resident #1 at 5:00 PM as scheduled. Further, the facility's policy on Elopement/Missing Residents directed that all identified wanderers shall be included in an Identification Record Book for Wandering Residents (book was to include a picture of each resident identified at risk for wandering/elopement). However, when the incident occurred, the facility was not utilizing the Identification Record Book for Wandering Residents and this book was not available for staff use. The facility's failure to ensure residents' supervision to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/05/19, and was determined to exist on 01/20/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on 02/05/19. An acceptable Allegation of Compliance was received on 02/18/19, which alleged removal of Immediate Jeopardy on 02/15/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/15/19, prior to exit on 02/20/19, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Elopement/Missing Resident policy dated 08/27/18 and revised 01/21/19, revealed that residents remain safely within the facility, or with designated staff/family members when out of the facility. Further review revealed that all residents that are identified at risk for wandering or elopement shall be designated as such on their individual care plan and shall be included in an Identification Record Book for wandering residents. Interview with the Administrator on 01/29/19 at 6:25 PM, revealed there was no policy regarding hourly monitoring of residents who wandered. Review of Resident #1's medical record revealed the facility admitted the resident on 11/12/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident to wander one (1) to three (3) days of the assessment period. The facility also assessed the resident to walk without mobility devices. Review of the Wandering Risk Assessment completed on 11/19/18 by the Social Worker, revealed the facility assessed Resident #1 as a moderate risk for wandering. Interview with the Administrator on 01/30/19 at 4:20 PM, revealed that wandering and elopement risk assessments were used interchangeably. Further interview revealed that if a resident was a wanderer they were also considered to be an elopement risk. Review of Resident #1's Comprehensive Plan of Care dated 11/19/18, revealed the facility had addressed Resident #1 to be at risk for Falls/Injury/Pain related to [DIAGNOSES REDACTED]. Further review of the care plan revealed the plan of care did not address the resident's wandering behavioral symptoms or that the resident was at risk for elopement. Observation of Resident #1 on 01/29/19 at 10:30 AM, revealed the resident was in the dining room involved in an activity. A Wanderguard alarm bracelet was noted to Resident #1's right ankle. Further observations of Resident #1 on 01/29/19, 01/30/19, and 01/31/19 revealed him/her wandering in the hallway near the nurses' station and near his/her bedroom door. Review of an Incident Report involving Resident #1 dated 01/20/19 at 5:15 PM, with a revision date of 01/21/19 at 12:37 PM, revealed the following: Predisposing situation, factors; Active Exit Seeker, Wanderer, and Wandering with no rational purpose. Head to toe assessment completed with vital signs stable and supervision of resident to be increased from hourly to every fifteen (15) minutes. Resident oriented to person only. No injuries observed post incident. Resident was let outside by a visitor and was noted to be outside about two (2) minutes. Family, Medical Director, MD, and the police department notified. Resident unable to give a description related to Dementia. Other info on incident report reveals that Resident #1 had been on [MEDICATION NAME] (treats moderate to severe Dementia of the Alzheimer's type) 5 mg twice a day and it was discontinued on 01/10/19 per pharmacy recommendation. Review of the facility's video surveillance footage from 01/20/19 revealed that Resident #1 was dressed in jogging pants, a sweatshirt, and a pair of shoes. The resident was carrying books in his/her arms. Further review revealed at 5:00 PM, Resident #1 was standing at the front door. As a visitor was opening the door to come in, Resident #1 proceeded to exit the door. No staff or residents were visible in the area at the time. At 5:01 PM, Resident #1 was observed walking down the sidewalk in front of the facility. At 5:03 PM, the resident was walking by the side of the building and then into the parking lot. Then at 5:04 PM, he/she was observed walking back toward the front of the facility. At 5:05 PM, Resident #1 was at the front door. Further review of the video revealed at 5:06 PM, Resident #1 could be seen going through the first double door into the vestibule where there is a second entry door, which was locked. Resident #1 was observed looking through the entry door into the facility. From 5:07 PM to 5:10 PM, Resident #1 could be seen walking around between the doors peering in through the entry door at times. At 5:10 PM, another resident that was sitting in the waiting area near the front exit door was seen leaving the area; Resident #1 was still between the doors. At 5:11 PM, State Registered Nurse Aide (SRNA) #9 approached the front door, opened the door, and assisted Resident #1 back inside. SRNA #9 assisted Resident #1 to a nearby chair and immediately put his/her coat over the resident's shoulders and began to rub Resident #1's hands and arms. This continued for approximately two (2) minutes. At 5:13 PM, SRNA #9 was observed leaving the area. Resident #1 sat in the same chair and waited. There was no staff observed inside or outside during the video surveillance until SRNA #9 arrived at 5:11 PM. There was no one except the visitor observed during these times. Review of weatherunderground.com revealed the temperature on 01/20/19 for the area at 5:15 PM was nineteen (19) degrees Fahrenheit. Interview on 01/29/19 at 1:45 PM with SRNA #9 revealed she was not working at the time of the incident, but had stayed at the facility due to the weather. The SRNA stated a resident came to the nurses' station saying that a (lady/man) was stuck in between the front doors and needed help to get inside. SRNA #9 stated she hurried down the hall to the front door and observed Resident #1 standing there between the doors at the entrance. The SRNA stated I got (him/her) inside as quick as I could and put my coat on (him/her) and began to rub (his/her) hands to warm (him/her) up. SRNA #9 stated the resident was so cold. Per SRNA #9, Resident #1 sat in the chair with another resident staying with him/her until she could go notify the nurse. The SRNA stated after she told the nurse, she went back to Resident #1 and continued warming him/her until Registered Nurse (RN) #1 got there. SRNA #9 stated that Resident #1 was confused and was saying that there was a bus coming to pick him/her up. Further interview with the SRNA revealed that Resident #1 was only oriented to name at the time. Interview on 01/31/19 with RN #1 at 6:18 PM, revealed that SRNA #9 came and informed her of Resident #1's incident. RN #1 stated she went to the front lobby and brought the resident down to his/her room and began the skin assessment. She stated that the resident's vital signs were stable at the time. Further interview revealed that the resident's temperature was normal, although he/she was cold; there was no frostbite noted. The RN stated she notified the Medical Director and received orders to begin monitoring the resident every fifteen (15) minutes. RN #1 said at that time she did not know that Resident #1 had been outside of the facility. Per RN #1, she notified the resident's family and the Assistant Director of Nursing (ADON). She stated the Administrator came in later, reviewed the camera footage, and determined Resident #1 had been outside of the facility. Review of the Accident/Incident Report, titled Elopement, dated 01/20/19, revealed Resident #1 left the facility as a visitor entered the door. The Report further revealed that Resident #1 was assisted back inside by a staff member. The facility's final investigation concluded that on 01/20/19 as a visitor entered the building, Resident #1 was near the door and exited. Interview on 01/29/19 at 11:05 AM and 01/30/19 at 2:00 PM with SRNA # 4 revealed that Resident #1 wandered a lot and would even say, I want to go home all the time. SRNA #4 stated Resident #1 would sometimes go into other residents' rooms, but could easily be redirected. Further interview revealed Resident #1's behaviors would get worse in the evenings, like he/she was sundowning. SRNA #4 stated calling Resident #1's daughter normally helped and sometimes she would come in to visit or she would inform the nurse. Phone interview with Resident #1's family member on 01/30/19 at 6:30 PM revealed that the resident talks about leaving during her visits with him/her at the facility; and as well as when she speaks with the resident on the phone. The family member stated the resident had never tried to get out before. Interview with the Assistant Director of Nursing (ADON) on 01/31/19 at 5:35 PM and 6:50 PM revealed that Resident #1 sometimes would state that he/she wanted to go home and would sometimes pack his/her clothing. The ADON stated if redirection did not help with the behavior, she would inform the nurse of the behavior. Further interview with the ADON on 01/29/19 at 2:35 PM revealed that hourly checks was a standard for all new admissions and that she (the ADON), the Charge Nurses, and the Director of Nursing (DON) monitored to ensure these hourly checks were completed. Interview with SRNA #1 on 01/29/19 at 4:40 PM and 6:00 PM revealed that Resident #1 had always wandered but had never tried to get out of the facility that she was aware of. Per the SRNA, Resident #1 had been on hourly checks since admission. Further interview revealed that SRNA #1 had last done an hourly check at 4:00 PM on 01/20/19 and that was the last time she actually laid eyes on Resident #1 before the incident. SRNA #1 stated that she was Resident #1's nurse aide for that day. Review of the hourly monitoring sheet revealed SRNA #1 had initialed that she had seen Resident #1 at 5:00 PM. However, SRNA #1 stated that she was passing supper trays at that time and did not do the 5:00 PM check on Resident #1. The SRNA stated SRNA #2 should have completed the 5:00 PM hourly check on Resident #1 because she was the SRNA left on the floor at the time. Interview with SRNA #2 on 01/29/19 at 3:56 PM and 6:15 PM, revealed that she was working on the hallway where Resident #1 resides on the day Resident #1 went outside of the facility unsupervised. The SRNA stated Resident #1 was confused that day. Further interview revealed that SRNA #2 could not remember if she was doing the hourly monitoring, but stated no one specifically was assigned to complete the hourly rounds/monitoring and that the monitoring was a team effort. Interview with the Director of Nursing (DON) on 02/05/19 at 11:30 AM, revealed that all residents were monitored hourly for general safety needs and there was no special monitoring of residents at risk of wandering at the time of the incident. Interview with the Administrator on 02/05/19 at 11:00 AM, revealed that staff should have been using the Wander Identification Book at the time of the incident. The Administrator stated that when the facility stopped using the wanderguard system, they continued the use of the Wanderer Identification Book. However, further interview with the Administrator revealed she did not ensure that the book was updated and staff were knowledgeable of the information the book contained. Further interview revealed that there was no special monitoring of the residents at risk for wandering/elopement after the discontinuation of the wanderguard system. **The facility alleged the following was implemented to remove Immediate Jeopardy on 02/15/19: 1. On 01/20/19, the Charge Nurse completed a new wandering risk assessment for Resident #1. 2. Resident #1's care plan was revised on 01/21/19 by the MDS Coordinator to address wandering/elopement risk and exit-seeking behaviors. A care plan meeting was held with Resident #1's daughter on 01/22/19. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Services Director, and Activity Director were present to discuss the resident's elopement, care plan interventions, and to review processes. 3. A sign was placed on the front door on 01/21/19 reminding visitors not to allow any resident to exit and to seek assistance from staff, if uncertain. 4. On 01/21/19, the Wandering Risk Assessment was reviewed and revised by clinical staff, administration, and management staff. The new form, the Wandering/Elopement Risk Assessment, included additional items that staff could mark to provide an accurate assessment of the resident. After the revisions, a new Wandering/Elopement Risk Assessment was completed on 01/21/19 by the DON on each of the eight (8) residents identified the previous night to be at risk for exit seeking (making statements of going home, aimless wandering, packing belongings, etc.). Care plans were also reviewed and updated by the MDS Coordinator on 01/21/19 for the eight (8) residents identified to be at risk. 5. On 01/21/19, the Administrator, Management, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation (Rehab) Director, and Environmental Services Director reviewed the elopement incident during the department supervisor morning meeting, and it was concluded that reinstituting the use of the WanderGuard system would be the most effective intervention. The DON obtained physician orders [REDACTED]. The Medical Records Clerk updated the Identification Record Book for Wandering Resident books and the poster for staff use to identify residents who were at risk. On 02/06/19, the Elopement/Missing policy was revised to include reimplementation of the facility WanderGuard system. 6. A WanderGuard bracelet was placed on Resident #1 on 01/21/19. 7. On 01/21/19, the Administrator and management reviewed and revised the Wandering Risk Assessment, Incident Report, and Elopement/Missing Resident policy. 8. On 02/01/19, the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation Director, and Environmental Services Director met to discuss the incident. Additional interventions implemented at that time included changing the hours that the front door was unlocked to 7:00 AM until 7:00 PM, and stationing a staff member to monitor the door. An office staff member was scheduled to monitor the door from 7:00 AM until 4:30 PM Monday through Friday. Then a staff member would be assigned the sole purpose of monitoring the door from 4:30 PM until 7:00 PM, when the front door is locked, and on the weekends from 7:00 AM until 7:00 PM. Staff assigned to monitor the door were educated regarding WanderGuard devices and provided a copy of the Identification Record Book for Wandering Residents for reference while on duty. In addition, staff assigned to monitor the front door were introduced to all residents with wandering behaviors so staff could visually identify the residents. 9. On 02/05/19, Wandering/Elopement risk assessments were completed by the DON, MDS Coordinator, and Social Services Director for all facility residents that had not been assessed prior to 01/21/19. Also, on 02/05/19, care plans were reviewed/revised by the DON, MDS Coordinator, and Social Services Director for all residents who were at moderate and high risk for elopement. If the residents were assessed at low risk for elopement, but were displaying behaviors of exit seeking, packing belongings, aimlessly wandering, or making statements of going home, they will be reassessed and their care plans updated at that time. 10. On 02/06/19, the DON, ADON, MDS Coordinator, Social Services Director, Environmental Services Director, Administrator, and Management staff reviewed the Comprehensive Care Plan Policy and no changes were made. 11. On 02/06/19, hourly rounds sheets were updated to include more detail regarding the whereabouts of the resident when monitored. 12. On 02/06/19, after review by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehab Director, and Environmental Services Director and agreement with Management and the President of the Board of Directors, additional changes were implemented to the front door. The button on the outside of the front door that allowed entry into the facility was removed. Entry into and exit from the facility will now require the assistance of a staff member at all times. Families were notified of this change by letter. The Door Alarm Policy was revised to reflect the removal of the button and the addition of staff monitoring the front door. 13. On 02/13/19, Management staff and the Administrator reviewed the Administrator's job description to ensure that appropriate responsibilities were outlined. 14. The ADON completed re-education regarding the elopement policy with all staff on duty the evening of the incident, 01/20/19, as well as with the oncoming staff upon return to work. 15. On 02/05/19, the Administrator, DON, and ADON educated nursing staff on duty regarding the importance of accurate and complete documentation. Nursing staff not present at that time were in-serviced by the ADON as they returned for their next shift. 16. On 02/06/19, the DON/ADON educated staff regarding the Comprehensive Care Plan Policy. Any staff not working that day was in-serviced prior to working their next shift. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 17. On 02/06/19, in-service training was provided by the DON/ADON with staff in all departments on duty to educate on the elopement/missing resident, WanderGuard transmitter use, maintenance and testing, and door alarm policy and procedure changes being implemented. 18. On 02/14/19, a post-test was given to staff in all departments to determine competency and understanding of the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and changes to the hourly round check sheets. A score of at least 80% will be required. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 19. On 02/13/19, the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Activity Director, Dietary Director, Environmental Services Director, and Business Services Director viewed a video titled, What is a care plan. The staff also completed a post-test to determine competency. 20. On 02/14/19, the Administrator completed a Centers for Medicare and Medicaid Services (CMS) Administrator Competency Assessment with a passing score of 89% achieved. Results were reviewed with Management on 02/15/19. 21. Daily during the department supervisor morning meeting (Monday through Friday) resident records will be reviewed for any change in condition by the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Dietary Manager, Activity Director, Environmental Services Director, Business Services Director, and Rehab Director. For any resident noted to have a change in status (clinical, behavior, etc.), the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and Infection Control Nurse will review the resident's care plan to ensure appropriateness. 22. Beginning 02/14/19, at least two (2) care plans will be audited daily during the morning meeting. The review will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and the Infection Control Nurse. 23. Members of the QA Committee will review hourly rounds completed for two (2) residents daily (Monday-Friday). At least four (4) of the residents who are audited will be residents who were identified to be at risk for elopement. 24. WanderGuard functioning is monitored daily by the nurse or Kentucky Medication Aide (KMA) and is documented in the North Nurses' Station Identification Record Book for Wandering Residents. WanderGuard placement will be monitored by assigned nursing staff every shift and documented as part of their daily documentation. 25. The Administrator, DON, ADON, MDS Coordinator, Social Services Director, or Infection Control Nurse will audit daily documentation completed by Nurses, KMAs, and SRNAs related to WanderGuard checks and hourly rounds following the morning meeting Monday through Friday to ensure completion. Any errors or omissions will be addressed by the DON/ADON and corrections made. The audits will be reviewed daily (Monday through Friday) during the morning department supervisor meetings, on the monthly QA reports, and during weekly and/or quarterly QA meetings with the Medical Director. 26. The Administrator will observe door monitor staff daily to verify that appropriate care is taken to supervise entry and exit of the facility by visitors and to be certain that no resident exits unescorted. This will be completed daily Monday through Friday and on weekends by visually monitoring staff at the front door. Results will be documented, any corrections made immediately as necessary, and reviewed during weekly QA meetings for four (4) weeks, then monthly. 27. The Administrator will continue to participate in daily morning department supervisor meetings and will review any resident issues, incidents/accidents, care plans, and QA audits each day. Administrator communicates with management daily by phone, email (electronic mail), text, or in person to discuss concerns, changes, issues, etc. Management meets with the Administrator weekly on site or more frequently, as needed. 28. The Board of Directors meets monthly with the Administrator and Management on site to review overall operations of the facility and address any issues or concerns. More frequent communication may be made if a situation arises requiring more timely notification. 29. On 01/31/19, a Quality Assurance quarterly meeting was held with the Medical Director present. During the meeting, staff discussed Resident #1's elopement on 01/20/19 and interventions that were put in place up until that date. 30. On 02/18/19, a QA meeting held by phone with the Medical Director, Administrator, ADON, MDS Coordinator, Social Services Director, Infection Control Nurse, Dietary Director, Activity Director, Environmental Services Director, Business Services Director, and Medical Records Clerk present to discuss any updates and revisions that had been made to the comprehensive care plan, door alarm, WanderGuard, and Elopement/Missing Resident Policies. In addition, staff discussed the update to the hourly round check sheets, QA audits, and in-services regarding accurate records were also discussed. Further, the need for weekly QA meetings, removal of the button at the facility entrance, staff monitoring of the front door, and audits were also discussed. ***The State Survey Agency verified that the following were implemented by the facility and Immediate Jeopardy was removed on 02/15/19, as alleged by the facility: 1. Review of a Wandering Risk assessment dated [DATE], revealed the new assessment was completed for Resident #1 and the resident was assessed to be at moderate risk. Interview with RN #1 on 01/31/19 at 6:40 PM, revealed she had completed the new Wandering Risk Assessment for Resident #1. 2. Record review and interview with the MDS Coordinator on 02/20/19 at 10:22 AM revealed she reviewed and updated Resident #1's care plan on 01/21/19 to address the resident's wandering and elopement risk. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, 10:42 AM with the MDS Coordinator, and 10:22 AM with the Social Service Director revealed all were in a care plan meeting with Resident #1's family member on 01/22/19. 3. Interview with the Administrator on 02/20/19 at 11:15 AM revealed signage was posted cautioning visitors about watching when they entered/exited to ensure a resident did not leave via the opened door. Observation on 01/30/19 at 1:00 PM, of the front door, revealed signage cautioning visitors who entered/exited to ensure that residents did not exit as they entered/exited the building. 4. Review of the revised Wandering Risk Assessments revealed a new assessment had been completed on 01/21/19 for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11. Interview with the Director of Nursing (DON) on 02/20/19 at 9:43 AM confirmed she had completed the Wandering Risk assessment on the previous eight (8) residents. Interview with the Minimum Data Set (MDS) Coordinator on 02/20/19 at 10:42 AM revealed she had reviewed and updated (as needed) all eight (8) residents' plans of care related to wandering/elopement risk. 5. Interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM, and on 02/19/19 at 4:36 PM with the Management Supervisor (the Administrator's Supervisor) confirmed administrative staff had met and decided to implement the WanderGuard System. The DON stated the physicians of the residents identified at risk for elopement were contacted. Review of policies and interview with the Administrator on 02/20/19 at 11:15 AM revealed the WanderGuard and Elopement policies were revised. Review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11's medical records confirmed orders for WanderGuard bracelets. Observation on 02/19/19 at 1:46 PM revealed the Identification Record Book for Wandering Residents had been updated and contained pictures of the eight (8) residents whom the facility had been assessed to be at risk for elopement. 6. Review of Resident #1's medical record and interview with the DON on 02/20/19 at 9:43 AM confirmed the facility implemented a WanderGuard bracelet for Resident #1 on 01/21/19. 7. Review of the Elopement/Missing policy and the Wandering Risk Assessment policy, and review of QA Meeting Minutes and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed the facility had reviewed and revised the policies on 02/06/19. 8. Interview with the Administrator on 02/20/19 at 11:15 AM confirmed the facility had extended the office hours so that staff was present in the front office from 7:00 AM to 7:00 PM. Review of training documentation and interview on 02/19/19 with the Business Manager at 3:40 PM, the Activity Aide at 4:05 PM, and the Receptionist/Billing Clerk at 3:27 PM revealed they had been educated regarding ensuring residents who wandered/were at risk for elopement did not leave the facility as visitors entered/exited. The staff were knowledgeable of the Identification Record Book and procedures for opening the front door. Observation of the entrance to the facility on [DATE] at 8:30 AM revealed the front door was locked and there was a button/doorbell that alerted office staff, who could then release the door. Interview with the Receptionist/Billing Clerk revealed she could visualize who was inside/outside the front door prior to releasing/opening the door. The Receptionist stated staff were always stationed at the door during the day. An observation of the Receptionist work area revealed monitors with a full view of the front door and an Identification Book that contained ten (10) residents' pictures with additional identifying information. An interview with the Business Manager on 02/19/19 at 3:40 PM revealed she had worked the past weekend and had monitored who entered and left the facility. The Business Manager stated staff had access to the Identification Book for Wandering Residents and were trained to observe the front door. She stated staff were instructed to observe the area around the front door prior to releasing the door for someone to enter or exit. 9. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, at 10:42 AM with the MDS Coordinator, and at 10:22 AM with the Social Services Director revealed all residents not previously assessed on 01/21/19 were reassessed using the Wandering/Elopement Assessment. In addition, the interviews revealed care plans of these residents were reviewed and revised as necessary. 10. Review of documentation and interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM revealed staff had reviewed the Care Plan policy on 02/06/19. 11. Review of the Hourly Round Form and interview on 02/19/19 at 5:17 PM with SRNA #3, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and on 02/20/19 with the Administrator at 11:15 AM revealed the Hourly Round Monitoring Form had been revised and staff were trained on the revised form. <

Based on observation, interview, record review, and review of the Administrator's Job Description, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility changed their system for monitoring residents at risk for elopement approximately one (1) year ago. Although the facility changed their system (discontinued use of Wanderguard), the facility failed to monitor this change and ensure their policy related to elopement/missing residents was implemented and that residents at risk for elopement had care plans addressing their behavioral symptoms of wandering and elopement risk. On 01/20/19 at approximately 5:00 PM, Resident #1 (assessed to be at risk for elopement) exited through the front door as a visitor entered the facility. The door did not alarm when the resident exited the building unsupervised. The outside temperature was 19 degrees Fahrenheit at 5:00 PM in the area. Resident #1 was outside the facility unsupervised approximately five (5) minutes and then reentered the first exterior door into the vestibule. The resident was between the double doors for another six (6) minutes before staff assisted the resident back inside the building. The facility's policy on Elopement/Missing Residents directed that all identified wanderers shall be included in an Identification Record Book for Wandering Residents (book was to include a picture of each resident identified at risk for wandering/elopement). However, when the incident occurred, the Administrator failed to ensure the facility was utilizing the Identification Record Book for Wandering Residents. This book was not available for staff use. The facility's failure to ensure the Administrator used its resources effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/05/19, and was determined to exist on 01/20/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on 02/05/19. An acceptable Allegation of Compliance was received on 02/18/19, which alleged removal of Immediate Jeopardy on 02/15/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/15/19, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description, not dated, revealed the administrator was responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be established and maintained in accordance with established policies. Review of Major Tasks, Duties and Responsibilities revealed: To Operate the facility in accordance to establish Policies and Procedures of Governing Body, Write definite policies regarding duties and activities of all staff, which will assure health care and safety of the residents and others and explain these policies so that the aim and purpose of the facility may be achieved by cooperative efforts. Review of the facility's Elopement/Missing Resident policy dated 08/27/18 and 01/21/19 revealed that residents were to remain safely within the facility, or with designated staff/family members when out of the facility. Further review revealed all residents that were identified at risk for wandering or elopement shall be designated as such on their individual care plan and shall be included in an Identification Record Book for wandering residents. Review of the facility's investigation and review of video footage revealed on 01/20/19 at approximately 5:00 PM, Resident #1 exited the facility without staff knowledge via the front door when a visitor entered the facility. The resident was outside the facility for approximately five (5) minutes and was in the vestibule between the double doors of the facility for another six (6) minutes unsupervised by staff. The outside temperature in the area was 19 degrees Fahrenheit. Another resident saw the resident and alerted staff who assisted the resident inside and assessed the resident to have no injuries. Review of the Wandering Risk Assessment completed on 11/19/18 by the Social Worker revealed the facility assessed Resident #1 as a moderate risk for wandering. However, the facility failed to address Resident #1's elopement risk on the plan of care. Interview with the MDS Coordinator on 01/31/19 at 4:18 PM and 02/04/19 at 10:00 AM, revealed Resident #1 liked to visit other residents in the facility. Further interview with the MDS Coordinator revealed she believed that hourly monitoring was enough supervision for the resident, even after his/her Wander Risk Assessment on 11/19/18 revealed that he/she was a moderate risk for Elopement/Wandering. Interview with the Assistant Director of Nursing (ADON) on 01/31/19 at 5:35 PM revealed that a resident who scored as moderate to high on the Wander Risk Assessment was to have this care need addressed on the resident's care plan. Interview with the Administrator on 01/30/19 at 4:20 PM and 02/05/19 at 11:00 AM revealed that wandering and elopement were used interchangeably and if a resident was assessed to be a moderate or high risk for wandering, depending on the resident's ability to move around, this also puts them at risk for elopement, and it should be care planned. However, Resident #1 visited other residents of the facility and therefore the facility did not care plan the wandering for the resident. The Administrator stated that when the facility stopped using the wanderguard system, they continued the use of the Wanderer Identification Book. However, further interview with the Administrator revealed she did not ensure that the book was updated and that staff were knowledgeable of the information the book contained. **The facility alleged the following was implemented to remove Immediate Jeopardy on 02/15/19: 1. On 01/20/19, the Charge Nurse completed a new wandering risk assessment for Resident #1. 2. Resident #1's care plan was revised on 01/21/19 by the MDS Coordinator to address wandering/elopement risk and exit-seeking behaviors. A care plan meeting was held with Resident #1's daughter on 01/22/19. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Services Director, and Activity Director were present to discuss the resident's elopement, care plan interventions, and to review processes. 3. A sign was placed on the front door on 01/21/19 reminding visitors not to allow any resident to exit and to seek assistance from staff, if uncertain. 4. On 01/21/19, the Wandering Risk Assessment was reviewed and revised by clinical staff, administration, and management staff. The new form, the Wandering/Elopement Risk Assessment, included additional items that staff could mark to provide an accurate assessment of the resident. After the revisions, a new Wandering/Elopement Risk Assessment was completed on 01/21/19 by the DON on each of the eight (8) residents identified the previous night to be at risk for exit seeking (making statements of going home, aimless wandering, packing belongings, etc.). Care plans were also reviewed and updated by the MDS Coordinator on 01/21/19 for the eight (8) residents identified to be at risk. 5. On 01/21/19, the Administrator, Management, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation (Rehab) Director, and Environmental Services Director reviewed the elopement incident during the department supervisor morning meeting, and it was concluded that reinstituting the use of the WanderGuard system would be the most effective intervention. The DON obtained physician orders [REDACTED]. The Medical Records Clerk updated the Identification Record Book for Wandering Resident books and the poster for staff use to identify residents who were at risk. On 02/06/19, the Elopement/Missing policy was revised to include reimplementation of the facility WanderGuard system. 6. A WanderGuard bracelet was placed on Resident #1 on 01/21/19. 7. On 01/21/19, the Administrator and management reviewed and revised the Wandering Risk Assessment, Incident Report, and Elopement/Missing Resident policy. 8. On 02/01/19, the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehabilitation Director, and Environmental Services Director met to discuss the incident. Additional interventions implemented at that time included changing the hours that the front door was unlocked to 7:00 AM until 7:00 PM, and stationing a staff member to monitor the door. An office staff member was scheduled to monitor the door from 7:00 AM until 4:30 PM Monday through Friday. Then a staff member would be assigned the sole purpose of monitoring the door from 4:30 PM until 7:00 PM, when the front door is locked, and on the weekends from 7:00 AM until 7:00 PM. Staff assigned to monitor the door were educated regarding WanderGuard devices and provided a copy of the Identification Record Book for Wandering Residents for reference while on duty. In addition, staff assigned to monitor the front door were introduced to all residents with wandering behaviors so staff could visually identify the residents. 9. On 02/05/19, Wandering/Elopement risk assessments were completed by the DON, MDS Coordinator, and Social Services Director for all facility residents that had not been assessed prior to 01/21/19. Also, on 02/05/19, care plans were reviewed/revised by the DON, MDS Coordinator, and Social Services Director for all residents who were at moderate and high risk for elopement. If the residents were assessed at low risk for elopement, but were displaying behaviors of exit seeking, packing belongings, aimlessly wandering, or making statements of going home, they will be reassessed and their care plans updated at that time. 10. On 02/06/19, the DON, ADON, MDS Coordinator, Social Services Director, Environmental Services Director, Administrator, and Management staff reviewed the Comprehensive Care Plan Policy and no changes were made. 11. On 02/06/19, hourly rounds sheets were updated to include more detail regarding the whereabouts of the resident when monitored. 12. On 02/06/19, after review by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Activity Director, Dietary Director, Rehab Director, and Environmental Services Director and agreement with Management and the President of the Board of Directors, additional changes were implemented to the front door. The button on the outside of the front door that allowed entry into the facility was removed. Entry into and exit from the facility will now require the assistance of a staff member at all times. Families were notified of this change by letter. The Door Alarm Policy was revised to reflect the removal of the button and the addition of staff monitoring the front door. 13. On 02/13/19, Management staff and the Administrator reviewed the Administrator's job description to ensure that appropriate responsibilities were outlined. 14. The ADON completed re-education regarding the elopement policy with all staff on duty the evening of the incident, 01/20/19, as well as with the oncoming staff upon return to work. 15. On 02/05/19, the Administrator, DON, and ADON educated nursing staff on duty regarding the importance of accurate and complete documentation. Nursing staff not present at that time were in-serviced by the ADON as they returned for their next shift. 16. On 02/06/19, the DON/ADON educated staff regarding the Comprehensive Care Plan Policy. Any staff not working that day was in-serviced prior to working their next shift. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 17. On 02/06/19, in-service training was provided by the DON/ADON with staff in all departments on duty to educate on the elopement/missing resident, WanderGuard transmitter use, maintenance and testing, and door alarm policy and procedure changes being implemented. 18. On 02/14/19, a post-test was given to staff in all departments to determine competency and understanding of the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and changes to the hourly round check sheets. A score of at least 80% will be required. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. 19. On 02/13/19, the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Activity Director, Dietary Director, Environmental Services Director, and Business Services Director viewed a video titled, What is a care plan. The staff also completed a post-test to determine competency. 20. On 02/14/19, the Administrator completed a Centers for Medicare and Medicaid Services (CMS) Administrator Competency Assessment with a passing score of 89% achieved. Results were reviewed with Management on 02/15/19. 21. Daily during the department supervisor morning meeting (Monday through Friday) resident records will be reviewed for any change in condition by the Administrator, DON, ADON, MDS Coordinator, Infection Control Nurse, Social Services Director, Dietary Manager, Activity Director, Environmental Services Director, Business Services Director, and Rehab Director. For any resident noted to have a change in status (clinical, behavior, etc.), the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and Infection Control Nurse will review the resident's care plan to ensure appropriateness. 22. Beginning 02/14/19, at least two (2) care plans will be audited daily during the morning meeting. The review will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, and the Infection Control Nurse. 23. Members of the QA Committee will review hourly rounds completed for two (2) residents daily (Monday-Friday). At least four (4) of the residents who are audited will be residents who were identified to be at risk for elopement. 24. WanderGuard functioning is monitored daily by the nurse or Kentucky Medication Aide (KMA) and is documented in the North Nurses' Station Identification Record Book for Wandering Residents. WanderGuard placement will be monitored by assigned nursing staff every shift and documented as part of their daily documentation. 25. The Administrator, DON, ADON, MDS Coordinator, Social Services Director, or Infection Control Nurse will audit daily documentation completed by Nurses, KMAs, and SRNAs related to WanderGuard checks and hourly rounds following the morning meeting Monday through Friday to ensure completion. Any errors or omissions will be addressed by the DON/ADON and corrections made. The audits will be reviewed daily (Monday through Friday) during the morning department supervisor meetings, on the monthly QA reports, and during weekly and/or quarterly QA meetings with the Medical Director. 26. The Administrator will observe door monitor staff daily to verify that appropriate care is taken to supervise entry and exit of the facility by visitors and to be certain that no resident exits unescorted. This will be completed daily Monday through Friday and on weekends by visually monitoring staff at the front door. Results will be documented, any corrections made immediately as necessary, and reviewed during weekly QA meetings for four (4) weeks, then monthly. 27. The Administrator will continue to participate in daily morning department supervisor meetings and will review any resident issues, incidents/accidents, care plans, and QA audits each day. Administrator communicates with management daily by phone, email (electronic mail), text, or in person to discuss concerns, changes, issues, etc. Management meets with the Administrator weekly on site or more frequently, as needed. 28. The Board of Directors meets monthly with the Administrator and Management on site to review overall operations of the facility and address any issues or concerns. More frequent communication may be made if a situation arises requiring more timely notification. 29. On 01/31/19, a Quality Assurance quarterly meeting was held with the Medical Director present. During the meeting, staff discussed Resident #1's elopement on 01/20/19 and interventions that were put in place up until that date. 30. On 02/18/19, a QA meeting held by phone with the Medical Director, Administrator, ADON, MDS Coordinator, Social Services Director, Infection Control Nurse, Dietary Director, Activity Director, Environmental Services Director, Business Services Director, and Medical Records Clerk present to discuss any updates and revisions that had been made to the comprehensive care plan, door alarm, WanderGuard, and Elopement/Missing Resident Policies. In addition, staff discussed the update to the hourly round check sheets, QA audits, and in-services regarding accurate records were also discussed. Further, the need for weekly QA meetings, removal of the button at the facility entrance, staff monitoring of the front door, and audits were also discussed. ***The State Survey Agency verified that the following were implemented by the facility and Immediate Jeopardy was removed on 02/15/19, as alleged by the facility: 1. Review of a Wandering Risk assessment dated [DATE], revealed the new assessment was completed for Resident #1 and the resident was assessed to be at moderate risk. Interview with RN #1 on 01/31/19 at 6:40 PM, revealed she had completed the new Wandering Risk Assessment for Resident #1. 2. Record review and interview with the MDS Coordinator on 02/20/19 at 10:22 AM revealed she reviewed and updated Resident #1's care plan on 01/21/19 to address the resident's wandering and elopement risk. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, 10:42 AM with the MDS Coordinator, and 10:22 AM with the Social Service Director revealed all were in a care plan meeting with Resident #1's family member on 01/22/19. 3. Interview with the Administrator on 02/20/19 at 11:15 AM revealed signage was posted cautioning visitors about watching when they entered/exited to ensure a resident did not leave via the opened door. Observation on 01/30/19 at 1:00 PM, of the front door, revealed signage cautioning visitors who entered/exited to ensure that residents did not exit as they entered/exited the building. 4. Review of the revised Wandering Risk Assessments revealed a new assessment had been completed on 01/21/19 for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11. Interview with the Director of Nursing (DON) on 02/20/19 at 9:43 AM confirmed she had completed the Wandering Risk assessment on the previous eight (8) residents. Interview with the Minimum Data Set (MDS) Coordinator on 02/20/19 at 10:42 AM revealed she had reviewed and updated (as needed) all eight (8) residents' plans of care related to wandering/elopement risk. 5. Interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM, and on 02/19/19 at 4:36 PM with the Management Supervisor (the Administrator's Supervisor) confirmed administrative staff had met and decided to implement the WanderGuard System. The DON stated the physicians of the residents identified at risk for elopement were contacted. Review of policies and interview with the Administrator on 02/20/19 at 11:15 AM revealed the WanderGuard and Elopement policies were revised. Review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #10, and Resident #11's medical records confirmed orders for WanderGuard bracelets. Observation on 02/19/19 at 1:46 PM revealed the Identification Record Book for Wandering Residents had been updated and contained pictures of the eight (8) residents whom the facility had been assessed to be at risk for elopement. 6. Review of Resident #1's medical record and interview with the DON on 02/20/19 at 9:43 AM confirmed the facility implemented a WanderGuard bracelet for Resident #1 on 01/21/19. 7. Review of the Elopement/Missing policy and the Wandering Risk Assessment policy, and review of QA Meeting Minutes and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed the facility had reviewed and revised the policies on 02/06/19. 8. Interview with the Administrator on 02/20/19 at 11:15 AM confirmed the facility had extended the office hours so that staff was present in the front office from 7:00 AM to 7:00 PM. Review of training documentation and interview on 02/19/19 with the Business Manager at 3:40 PM, the Activity Aide at 4:05 PM, and the Receptionist/Billing Clerk at 3:27 PM revealed they had been educated regarding ensuring residents who wandered/were at risk for elopement did not leave the facility as visitors entered/exited. The staff were knowledgeable of the Identification Record Book and procedures for opening the front door. Observation of the entrance to the facility on [DATE] at 8:30 AM revealed the front door was locked and there was a button/doorbell that alerted office staff, who could then release the door. Interview with the Receptionist/Billing Clerk revealed she could visualize who was inside/outside the front door prior to releasing/opening the door. The Receptionist stated staff were always stationed at the door during the day. An observation of the Receptionist work area revealed monitors with a full view of the front door and an Identification Book that contained ten (10) residents' pictures with additional identifying information. An interview with the Business Manager on 02/19/19 at 3:40 PM revealed she had worked the past weekend and had monitored who entered and left the facility. The Business Manager stated staff had access to the Identification Book for Wandering Residents and were trained to observe the front door. She stated staff were instructed to observe the area around the front door prior to releasing the door for someone to enter or exit. 9. Review of documentation and interview on 02/20/19 at 9:43 AM with the DON, at 10:42 AM with the MDS Coordinator, and at 10:22 AM with the Social Services Director revealed all residents not previously assessed on 01/21/19 were reassessed using the Wandering/Elopement Assessment. In addition, the interviews revealed care plans of these residents were reviewed and revised as necessary. 10. Review of documentation and interview on 02/20/19 with the Administrator at 11:15 AM and the DON at 9:43 AM revealed staff had reviewed the Care Plan policy on 02/06/19. 11. Review of the Hourly Round Form and interview on 02/19/19 at 5:17 PM with SRNA #3, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and on 02/20/19 with the Administrator at 11:15 AM revealed the Hourly Round Monitoring Form had been revised and staff were trained on the revised form. Review of the QA Audit form and interview with the Administrator on 02/20/19 at 11:15 AM revealed the audit form was revised to include the staff who completed the form and if their documentation was complete and accurate as to the location of the resident and the activity of the resident. 12. Review of the Door Alarm Policy and interview with the Administrator on 02/20/19 at 11:15 AM, revealed the Door Alarm Policy was revised on 02/06/19. According to the Administrator, the outside entry button was removed and the facility added staff to monitor the front entry from 7:00 AM to 7:00 PM daily. Additional interviews with the Receptionist/Billing Clerk on 02/20/19 at 3:27 PM and an Activity Aide on 02/19/19 at 4:05 PM revealed they had been assigned to monitor the front door. Both stated the front entrance was locked and access was only permitted with staff assistance. 13. Interview on 02/19/19 at 4:36 PM with the Management Supervisor and the Administrator on 02/20/19 at 11:15 AM revealed the Management Supervisor had reviewed with the Administrator the Administrator's job description and responsibilities. 14. Review of training documentation and interview with SRNA #3 on 02/19/19 at 5:17 PM, SRNA #4 on 02/19/19 at 5:35 PM, the ADON on 02/20/19 at 11:00 AM, and the Social Services Director on 02/20/19 at 10:22 AM confirmed the ADON provided training to staff on 01/21/19 regarding the Elopement Policy. 15. Review of training documentation and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM, revealed they had received training related to ensuring documentation is complete and accurate. 16. Review of training documentation and interview on 02/19/19 at 5:20 PM with LPN #3, LPN #2 at 5:57 PM, KMA #1 at 6:40 PM, and LPN #4 at 6:50 PM, and on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM confirmed the ADON and DON presented a training on 02/06/19 which covered review of the Comprehensive Care Plan policy. All stated that a post-test was also completed. 17. Review of in-service records revealed on 02/14/19 staff in all departments were educated regarding the WanderGuard Policy, Door Alarm Policy, Elopement/Missing Resident Policy, Comprehensive Care Plan Policy, and the changes to hourly round check sheets. Further review revealed the staff completed a post-test with a passing score of at least 80%. Any staff not present on 02/14/19 will be tested upon returning to work. Staff currently on leave will receive training and testing prior to returning to work for their next shift. Review of tests and interviews on 02/19/19 with SRNA #3 at 5:17 PM, SRNA #4 at 5:35 PM, Housekeeping staff at 6:58 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the MDS Coordinator at 10:42 PM, and the Social Services Director at 10:22 AM revealed all had taken a post-test after the recent trainings on elopement and the WanderGuard system. 18. Review of post-tests and interview on 02/19/19 with LPN #4 at 6:50 PM, SRNA #3 at 5:02 PM, LPN #3 at 5:20 PM, SRNA #7 at 6:43 PM, KMA #1 at 6:33 PM, LPN #2 at 5:55 PM, SRNA #10 at 6:05 PM, and SRNA #8 at 6:25 PM, and on 02/20/19 with the Social Services Director at 10:22 AM revealed all completed post-testing after the recent in-service training. 19. Review of training documentation and interview on 02/20/19 with the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, the Social Services Director at 10:22 AM, and the DON at 9:43 AM revealed they had received video training regarding completing care plans. The staff stated they also completed a post-test. Further review of training and testing documentation and interview on 02/20/19 at 11:15 AM, with the Administrator revealed the Administrator also completed the care plan video training and passed the post-test. 20. Review of testing information and interview on 02/19/19 at 4:36 PM with the Management Supervisor and on 02/20/19 at 11:15 AM with the Administrator revealed the Administrator completed the CMS Administrator Competency Assessment on 02/14/19 with a score of 89%. The staff stated the test results were also reviewed with the Management Supervisor on 02/15/19. 21. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed during morning meetings Monday through Friday, the staff reviewed resident records to identify whether a resident had had a change in condition. The care plans of these residents were also reviewed during the morning meeting and revised, if needed. 22. Review of documentation and interview on 02/20/19 at 11:15 AM with the Administrator, the ADON at 11:00 AM, the MDS Coordinator at 10:42 AM, and the DON at 9:43 AM revealed at least two (2) residents' care plans were reviewed during the morning meetings held Monday through Friday to ensure the care plans were accurate. 23. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting, the DON and ADON reviewed documentation (completed the day before) on hourly rounds to ensure the monitoring was completed and any problems were immediately corrected. 24. Review of Resident #1's and Resident #6's medical records revealed the residents utilized WanderGuard Bracelets. Further review revealed documentation that staff had monitored the function of the WanderGuard System and the function of the WanderGuard Bracelets daily. Interview with KMA #1 on 02/19/19 at 6:33 PM revealed she checked the functioning of the WanderGuard System daily by checking the front door (The front door is the only door equipped with the WanderGuard System. Other doors automatically alarm when opened.) and by checking the bracelet on each resident with a transmitter box. 25. Review of Morning Meeting Documentation Audits and interview on 02/20/19 with the Administrator at 11:15 AM, the DON at 9:43 AM, and the ADON at 11:00 AM revealed daily in the morning meeting the DON and ADON reviewed documentation (completed the day before) to ensure WanderGuard checks had been completed and any problems were immediately corrected. 26. Review of door audit documentation and interview with the Administrator on 02/20/19 at 11:15 AM revealed since 02/06/19, the Administrator was checking daily to ensure staff were monitoring the front door. No concerns had been identified. Per the Administrator, results of all audits go to the QA Meeting. 27. Review of documentation and interview with the Administrator on 02/20/19 at 11:15 AM, the DON at 9:43 AM, the ADON at 11:00 AM, and the Social Services Director at 10:22 AM revealed Morning Meetings were held daily Monday through Friday. The interviews revealed the Administrator attended the meetings and audits were reviewed during the meetings. Interview on 02/19/19 at 4:36 PM, with the Management Supervisor, and the Administrator on 02/20/19 at 11:15 AM revealed the Management Supervisor and the Administrator talked at least daily and the Management Supervisor met with the Administrator at the facility at least weekly. The Management Supervisor stated she also reviewed the Morning Meeting Notes. 28. Interview on 02/19/19 at 4:36 PM with the Management Supervisor, and with the Administrator on 02/20/19 at 11:15 AM confirmed the Board of Directors met with them monthly. The last meeting was held at the facility on 02/19/19. 29. Review of QA documentation and interview with the Administrator on 02/20/19 at 11:15 AM, and with the Medical Director at 10:01 AM, revealed during a quarterly QA meeting (01/31/19) staff discussed Resident #1's elopement and the interventions that had been put into place up until that date. 30. Review of QA Meeting

Based on interview, record review, and review of the facility's policy and procedures it was determined the facility failed to develop/revise the person-centered comprehensive care plan for one (1) of six (6) sampled residents (Resident #1). Resident #1 sustained eight (8) falls from 11/16/17 through 03/26/18. After each fall, the facility documented on the resident's care plan that the resident had sustained a fall; however, the facility only revised the resident's care plan to prevent further falls on two (2) occasions, 12/29/17 and 03/15/18. On 03/15/18, the facility re-educated staff to monitor the resident more frequently; however, the facility failed to develop the care plan with detailed instructions for monitoring frequently. On 04/13/18 at approximately 9:00 PM, Resident #1 was attempting to get up unassisted from the wheelchair. Staff positioned the resident at the nurses' station to monitor the resident. However, staff left the resident unattended and failed to supervise the resident. Resident #1 attempted to get up unassisted and fell , resulting in a fractured left hip that required surgical repair. The findings include: Review of the facility's policy titled, Fall/Risk Committee Policy Statement, last revised 04/09/14, revealed the facility would maintain a safe living environment and would attempt to prevent accidents, especially falls. Further review revealed the facility would operationalize a fall/risk committee which would meet weekly to monitor and investigate falls. The facility's policy revealed the committee would ensure residents who had been identified as having a high fall risk would have individualized interventions documented in their care plan. Review of the facility's policy and procedure titled, Fall Prevention and Management, last revised 09/01/17, revealed the facility would implement fall prevention management interventions to prevent further falls for residents. Review of Resident #1's medical record revealed the facility admitted the resident on 09/25/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 09/25/17 revealed the facility identified the resident was at risk for falls and developed interventions that included keeping the environment free of obstruction, having the call light within reach and encouraging to ring for assistance as needed, encouraging rest periods, assisting with ambulation utilizing two (2) staff persons and a gait belt, and utilizing a wheelchair as the major mode of transportation. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE], and review of Fall Review Assessments for Resident #1 from 11/16/17 through 03/26/18 revealed Resident #1 sustained eight (8) falls (11/16/17, 11/24/17, 01/07/18, 02/23/18, 03/25/18, and 03/26/18) while attempting to transfer/ambulate unassisted, including three (3) falls from a wheelchair. Continued review of Resident #1's Comprehensive Care Plan dated 09/25/17 revealed the facility updated the care plan indicating Resident #1 had sustained a fall; however, they only implemented interventions to prevent further falls on 12/29/17 and 03/15/18. On 12/29/17, the facility implemented bedside mats to the floor on both sides of the resident's bed. On 03/15/18, the facility re-educated staff to attempt to toilet the resident every two (2) hours and monitor the resident more frequently. However, the care plan provided no detailed instruction for monitoring frequently. Interview with Licensed Practical Nurse (LPN) #4 on 04/27/18 at 2:47 PM and State Registered Nurse Aide (SRNA) #3 on 04/24/18 at 8:29 AM revealed on 04/13/18, Resident #1 had attempted to stand unassisted from his/her wheelchair several times prior to falling. The staff stated they positioned Resident #1 at the nurses' station in his/her wheelchair so staff could monitor the resident more frequently. However, SRNA #3 stated she and LPN #4 left the nurses' station to answer call lights, leaving Resident #1 without supervision. SRNA #3 stated when she returned to the nurses' station she found Resident #1 lying on the floor. Review of Resident #1's Fall Review Assessments revealed on 04/13/18 at approximately 9:00 PM, Resident #1 attempted to get up unassisted, fell from a wheelchair, and was found lying on the floor at the nurses' station. Resident #1 had pain to his/her left hip. The facility transferred the resident to the emergency room for an evaluation. Review of Resident #1's History and Physical dated 04/14/18, from the Acute Care Hospital, revealed the resident was admitted to the hospital on [DATE], after falling on 04/13/18. The resident was diagnosed with [REDACTED]. Interview with the MDS Coordinator on 04/25/18 at 5:27 PM, revealed she was a member of the Fall/Risk Committee. The MDS Coordinator stated it was important to determine the root cause of a resident's fall in order to implement interventions to prevent further falls. She stated, I guess we could do better at determining the root cause of the fall. Interview with the Social Services Director on 04/25/18 at 4:53 PM, revealed she was also a member of the Fall/Risk Committee. The SSD stated the Committee met weekly to review resident falls that had occurred the previous week. The SSD stated that at times if residents had several falls, We just run out of interventions. During continued interview with the SSD she stated, I guess we don't really look at the big picture and are not getting to the root cause of the fall like we should; therefore, we are not implementing effective interventions. Interview with the Assistant Director of Nursing (ADON) on 04/25/18 at 5:39 PM, revealed she was a member of the Fall/Risk Committee and was responsible for completing fall investigations. However, she stated she had not identified that Resident #1 had multiple falls while attempting to ambulate/transfer unassisted, and had implemented no interventions specific to these causes.

Based on record review, interview, and review of the facility's policy and procedures it was determined the facility failed to have an effective system in place to ensure residents received appropriate supervision and interventions to prevent falls for one (1) of six (6) sampled residents (Resident #1). On 04/13/18 at approximately 9:00 PM, Resident #1 was noted to be restless and attempting to get up unassisted from the wheelchair. Staff initiated an intervention of placing the resident at the nurses' station to increase the resident's supervision to prevent falls. However, the staff left the resident unattended at the nurses' station and the resident sustained [REDACTED]. The findings include: Review of a facility policy and procedure titled, Fall Prevention and Management, last revised 09/01/17, revealed the facility would minimize the risk of serious injury, recognize risk/causes of falls, and implement fall prevention management interventions to prevent further falls for residents. Review of Resident #1's medical record revealed the facility admitted the resident on 09/25/17 with [DIAGNOSES REDACTED]. Review of Resident #1's initial Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed the resident to have a history of falls prior to being admitted to the facility, and to utilize a motion sensor alarm daily. Review of Resident #1's Comprehensive Care Plan dated 09/25/17 revealed the facility identified the resident was at risk for falls and implemented interventions that included keeping the environment free of obstruction, having the call light within reach and encouraging to ring for assistance as needed, encouraging rest periods, assisting with ambulation utilizing two staff persons and a gait belt, and utilizing a wheelchair as the major mode of transportation. A review of Resident #1's Care Area Assessment (CAA) dated 10/02/17 revealed Resident #1 ambulated with a shuffled gait, was impulsive, lost balance at times, had poor safety awareness, attempted to get up unassisted, had to be reminded to ask for assistance with standing, and had periods of increased confusion. A review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status score of three (3), which indicated the resident was cognitively impaired. The resident required extensive assistance of two individuals for bed mobility and transfers, and required extensive assistance of one (1) individual for ambulation. The facility also assessed the resident's balance to be unsteady during transitions/walking, and the resident required a wheelchair for mobility. Further review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE] and Review of Fall Review Assessments for Resident #1 from 11/16/17 through 03/26/18 revealed Resident #1 had sustained eight falls (11/16/17, 11/24/17, 01/07/18, 02/23/18, 03/25/18, and 03/26/18) while attempting to transfer/ambulate unassisted, including three falls from the wheelchair. The MDS further revealed the resident no longer utilized a motion sensor alarm. Further review of Resident #1's comprehensive care plan dated 09/25/17 revealed that although the facility updated the care plan each time Resident #1 sustained a fall, the only interventions the facility implemented to prevent further falls was on 12/29/17, when the facility implemented bedside mats for the floor on both sides of the resident's bed, and on 03/15/18, when the facility re-educated staff to attempt to toilet the resident every two hours and monitor the resident more frequently; however, the care plan provided no detailed instruction for monitoring frequently. Further review of Resident #1's care plan revealed on 03/20/18, the resident's sensor pad alarm was discontinued as a result of recommendations made by the Interdisciplinary Team (IDT). Interview with the Assistant Director of Nursing (ADON) on 05/21/18 at 1:30 PM, revealed the facility IDT met on 03/20/18, and decided to discontinue all resident alarms because they believed they were restraining the residents and the facility wanted to institute a restraint-free environment. The facility discontinued all alarms without conducting individualized resident assessments to determine the risks versus benefits of having the alarm. Review of a nurse's progress note dated 03/26/18 at 2:57 PM revealed Resident #1's Power of Attorney (POA) voiced concerns regarding Resident #1's multiple falls in the facility and the removal of the resident's bed and wheelchair alarms. Further, on 04/13/18 during a resident care conference, Resident #1's daughter again voiced concerns regarding the removal of Resident #1's alarm. The documentation stated that the ADON and the Social Services Director educated the POA that removing the alarms was a regulation put forth by CMS (Centers for Medicare and Medicaid Services). The note further stated the facility was attempting to use the least restrictive devices and the resident had falls mats at the bedside, and educated the POA that the resident had the right to fall. Review of a facility Fall Review Assessment revealed on 04/13/18 at approximately 9:00 PM, Resident #1 was found lying on the floor at the nurses' station. The assessment stated the resident attempted to get up unassisted and fell from the wheelchair. Further review revealed Resident #1 complained of pain to his/her left hip and was sent to the emergency room to be evaluated. Interview with Licensed Practical Nurse (LPN) #4 on 04/27/18 at 2:47 PM and State Registered Nurse Aide (SRNA) #3 on 04/24/18 at 8:29 AM, revealed they provided care for Resident #1 during the night shift on 04/13/18. The staff stated that Resident #1 had attempted to stand unassisted from his/her wheelchair several times prior to falling on 04/13/18. They stated they decided to place Resident #1 at the nurses' station in his/her wheelchair so they could provide the resident with increased supervision. However, SRNA #3 stated she and LPN #4 left the nurses' station to answer call lights, leaving Resident #1 without supervision. SRNA #3 stated when she returned to the nurses' station she found Resident #1 lying on the floor. Review of Resident #1's Acute Care Hospital History and Physical dated 04/14/18 revealed Resident #1 was admitted to the hospital on [DATE], after falling on 04/13/18, and was diagnosed with [REDACTED]. Interview with the Social Services Director on 04/25/18 at 4:53 PM, revealed she was part of the Fall/Risk Committee. The SSD stated the Committee met weekly and reviewed falls that had occurred in the facility the previous week. The SSD stated that at times if residents have had several falls we just run out of interventions. Continued interview with the SSD stated, I guess we don't really look at the big picture and are not getting to the root cause of the fall like we should; therefore we are not implementing effective interventions. Interview with the Assistant Director of Nursing (ADON) on 04/25/18 at 5:39 PM, revealed she was responsible for completing fall investigations. However, she had failed to identify that Resident #1 had multiple falls while attempting to ambulate/transfer unassisted, but had implemented no interventions specific to these identified causes of Resident #1's falls. Additionally, the ADON stated that all resident alarms were removed in the building without consideration or individualized assessment of the risk/benefits for individual residents including Resident #1.

Based on observation, interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to ensure staff utilized assistive devices when assisting one (1) of fifteen (15) sampled residents (Resident #13) to transfer and ambulate. It was facility policy to use gait belts when assisting residents with transfers and ambulation. During a transfer on 04/21/15, two (2) State Registered Nurse Aides (SRNAs) were assisting Resident #13 in the bathroom when the resident began to fall. The SRNAs were lifting the resident from the floor when they heard a pop. An x-ray was obtained which determined the resident had a humeral fracture of the left arm. The findings include: Review of the facility's policy titled General Safety Rules, date unknown, revealed all resident lifting and transfer shall be done by two (2) employees with the use of a gait belt. Review of the facility's policy titled Preventing Slips and Falls, date unknown, revealed steps shall be taken by all employees to minimize the risks of slips and falls. Review of the facility's policy titled Fall Protocol, with a revision date of 05/01/14, revealed transfer assistive devices such as a gait belt should be used during resident transfers. Record review revealed the facility admitted Resident #13 on 08/02/13 and readmitted him/her on 03/31/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment completed on 04/07/15, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 11, determining the resident's cognition to be moderately impaired; however, the facility assessed the resident to be interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require extensive assistance with two (2) plus person physical assist with transfers. Review of the Profile Care Plan Approaches and the Comprehensive Care Plan, dated 12/28/13, revealed the facility determined the resident required one (1) to two (2) person assist with transfers. Review of the facility's investigation dated 04/21/15 at 11:30 AM, revealed during a transfer from the commode Resident #13 began to fall. The two (2) SRNAs assisting the resident raised the resident from the floor back to the commode. During the transfer, the SRNAs heard a popping sound. An assessment was completed by facility staff and an x-ray was obtained. Further review revealed the SRNAs failed to use a gait belt during the transfer resulting in a humeral fracture of the resident's left arm. Further review revealed the SRNAs received verbal counseling related to the incident and not using a gait belt with the transfer that resulted in a fracture. Observations of the resident made on 06/18/15 at 12:35 PM and 1:45 PM, revealed the resident to be sitting up in a Geri-chair and a sling noted to the left arm. Interview with Resident #13 on 06/18/15 at 7:45 PM stated, They broke my arm in the bathroom. Further interview revealed the resident stated he/she was starting to fall during the transfer and they (the SRNAs) caught me. Interview with the Administrator and Director of Nursing (DON) on 06/18/15 at 8:45 PM, revealed it was facility policy to use gait belts with all resident transfers and the staff was expected to use them. Interview with SRNA #4 on 06/18/15 at 8:49 PM, revealed although she had been trained to use a gait belt during transfers, a gait belt was not used during the transfer of Resident #13 on 04/21/15. Interview with SRNA #5 on 06/19/15 at 10:17 AM, revealed that she had also been trained to use gait belts during resident transfers. However, she failed to use one during the transfer of Resident #13. Interview with Unit Manager (UM) #1 on 06/19/15 at 12:28 PM revealed she was responsible for monitoring gait belt use and she had identified a problem prior to the incident. The UM stated she had increased the frequency that she conducted rounds and constantly reminded staff to use gait belts.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to protect one (1) of fifteen (15) sampled residents (Resident #13) from neglect. Facility policy required the use of a gait belt when assisting residents to transfer and ambulate. On 04/21/15, two (2) State Registered Nurse Aides (SRNAs) assisted Resident #13 to the bathroom where the resident started to fall and was lowered to the floor. When lifting the resident up from the floor, the SRNAs heard a pop. An x-ray of the resident's left arm revealed a fractured humerus. Although both SRNAs had been trained and knew the use of a gait belt was required, the SRNAs failed to use a gait belt when assisting Resident #13 to the bathroom. The findings include: Review of the facility's policy titled Resident Abuse and Neglect, revision date of 01/09/15, revealed neglect was defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's policy titled General Safety Rules, date unknown, revealed, All resident ambulation shall be accomplished with the use of a gait belt. No exceptions! Review of the facility's policy titled Fall Protocol, revision date of 05/01/14, revealed residents should be transferred using a gait belt. Record review revealed the facility originally admitted the resident on 08/02/13, and readmitted the resident on 03/31/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment completed on 04/07/15, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 11. The facility assessed the resident's cognition to be moderately impaired; however, the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require extensive assistance with two (2) plus person physical assist with transfers. Review of the Profile Care Plan Approaches and the Comprehensive Care Plan, dated 12/28/13, revealed the facility determined the resident required one (1) to two (2) person assist with transfers. Review of the facility's investigation dated 04/21/15, revealed on that date at 11:30 AM, Resident #13 was . being transferred from the commode when resident's leg gave out. State Registered Nurse Aides (SRNAs) then had to lower the resident to the floor. When lifting the resident back to the commode, they heard a popping noise. Observations of the resident on 06/18/15 at 12:35 PM and at 1:45 PM revealed the resident was sitting up in a Geri-chair and a sling was noted to the resident's left arm. During an interview with Resident #13 on 06/18/15 at 7:45 PM, he/she stated, They broke my arm in the bathroom. Further interview revealed the resident stated he/she was starting to fall during the transfer and they (the SRNAs) caught me. Interview with SRNA #5 on 06/18/15 at 7:33 PM, revealed she and SRNA #4 were assisting Resident #13 with a transfer from the commode to the wheelchair when the resident began to lose his/her balance and started to fall. The SRNA stated as they were assisting the resident back onto the commode, they heard a pop. Further interview with SRNA #5 on 06/19/15 at 10:17 AM, revealed the SRNAs were not using a gait belt during the transfer of Resident #13 on 04/21/15. She stated she had been trained to use gait belts with transfers and had received a verbal write-up for not using one during the transfer. According to the facility's Fall Protocol policy, residents should be transferred using a gait belt. Interview with SRNA #4 on 06/18/15 at 7:59 PM, revealed she was assisting the resident on his/her left side during the transfer. The SRNA stated that the resident was starting to fall and the two (2) SRNAs assisted him/her back to the commode. SRNA #4 stated, We heard it pop and I knew it was broke. Further interview with the SRNA on 06/18/15 at 8:49 PM, revealed a gait belt was not used during the transfer. The SRNA stated they had been trained to use gait belts with all transfers and had received a verbal write-up for not using a gait belt during the transfer. Review of the x-ray of Resident #13's left humerus and forearm, dated 04/21/15 at 2:04 PM, revealed an acute proximal humeral and humeral neck fracture. Component of impaction at the fracture site. Review of the Employee Counseling Form dated 04/22/15, addressed to SRNAs #4 and #5 revealed verbal counseling related to noncompliance with standard of care. Further review revealed the stated problem being the SRNAs . did not use gait belt when transferring resident, resulting in fracture. Interview with the Administrator and Director of Nursing (DON) on 06/18/15 at 8:45 PM revealed it was the facility's policy to use gait belts with all transfers. The DON stated, They should have been using a gait belt.

Based on interview, record review, and review of the facility's investigation it was determined the facility failed to maintain patient care equipment in safe operating condition according to manufacturer's guidelines for twelve (12) of sixty (60) facility beds. On 07/04/15, Resident #19's bed malfunctioned while the resident was lying in bed. The head and foot of the automatic bed rose spontaneously to the highest position and became locked in place. The resident was diagnosed with [REDACTED]. The facility failed to obtain or follow manufacturer's guidelines for the maintenance of Resident #19's bed along with eleven (11) other beds of the same model to ensure they were in safe operating condition. The findings include: Interview with the Administrator on 08/20/15 at 5:30 PM, revealed the facility did not have a policy related to the maintenance of resident care equipment. Review of the Transfer of Ownership document revealed the facility obtained the donated beds on 06/22/11. Review of the facility's investigation, dated 07/04/15, revealed Resident #19's water pitcher spilled down the foot of the resident's bed onto the electrical control box. The facility determined the spilled water entered the control box and caused the bed to malfunction. Resident #19 was found folded in the malfunctioned bed with the head and foot of the bed in the highest position and locked in place. Facility staff was unable to unlock the resident's bed from the upright position, but was able to utilize the bed linens to lift Resident #19 out of the bed and transfer the resident to a Geri-chair and later to a new bed. Further review revealed the resident did not complain of pain at the time of the incident; however, during the evening medication pass the resident complained of right knee pain. A Computerized Tomography (CT) scan, dated 07/06/15, revealed a distal femur fracture. Interview with Resident #19 on 08/19/15 at 2:30 PM, revealed the resident's water pitcher had been spilled on the bed and a short time later the bed malfunctioned. The resident stated the foot and head of the bed came up and I was a sandwich. Interview with Maintenance Staff Person #1 on 08/19/15 at 3:46 PM, revealed Resident #19's bed was one (1) of twelve (12) same model beds that had been donated to the facility. Maintenance Staff Person #1 stated the Manufacturer's Guidelines were not given to the facility at the time of the donation and the facility had not obtained guidelines since then. Further interview revealed the beds were repaired using spare parts that were also donated to the facility. Maintenance Staff Person #1 stated parts for the beds were no longer available for purchase. Further interview revealed after Resident #19's bed malfunctioned on 07/04/15, maintenance staff checked the remaining eleven (11) beds. The electrical control box covers were removed and inspected for moisture or corrosion. No concerns were identified with the eleven (11) beds and the facility continued to utilize the beds. Maintenance Staff Person #1 stated the bed manufacturer was not notified of the bed malfunction and the facility did not attempt to obtain preventive guidelines or instructions. Preventive measures were not implemented for the remaining eleven (11) beds and facility staff was not educated on malfunction precautions. Further interview with Maintenance Staff Person #1 on 08/20/15 at 1:52 PM revealed all resident beds were inspected monthly to ensure the bed controls, brakes, wheels, loose parts, plugs, and rails functioned properly. Maintenance Staff Person #1 stated the facility did not have a specific checklist or guideline to determine what needed to be inspected on the beds. Interview with the bed Manufacturer Representative on 08/20/15 at 10:20 AM, revealed manufacturer guidelines were no longer available related to that bed model being obsolete. The Manufacturer Representative stated Resident #19's bed model had been discontinued in 1993 and parts for the model had not been manufactured since 1998. Further interview revealed prior to any maintenance or repairs to the beds the facility should have referred to the Manufacturer Instructions or recommendations for maintenance. The Manufacturer Representative also stated the facility should have reported any bed malfunction that resulted in resident harm. Interview with the Maintenance Director on 08/20/15 at 2:12 PM, revealed twelve (12) beds were donated to the facility and the maintenance staff did not receive training or manufacturer's guidelines to ensure the donated beds were maintained properly. The Maintenance Director confirmed monthly bed inspections were completed on all facility beds; however, the facility did not have a policy pertaining to the maintenance of resident care equipment and no specific guidelines were utilized for the bed inspections. The Maintenance Director stated after Resident #19's bed malfunctioned the bed was removed from the facility and the eleven (11) remaining models were inspected for moisture or corrosion. The facility did not utilize manufacturer guidelines during the inspection of the eleven (11) beds and did not identify any concerns. Further interview revealed no preventive measures were put into place to ensure another bed malfunction did not occur. The facility continued to utilize the remaining eleven (11) beds for resident use. The Maintenance Director stated that type of malfunction shouldn't happen ever again. The Maintenance Director stated he had instructed staff to raise the beds to the highest level, using the control panel at the foot of the bed, in the event side rail controls failed to work properly. Further interview revealed maintenance staff had replaced the motor in one of the other eleven (11) beds due to resident overuse. The Maintenance Director stated spare parts were used during the repair. Interview with the Administrator on 08/20/15 at 5:30 PM revealed she was aware of Resident #19's bed malfunction. The Administrator stated the eleven (11) beds that were the same model as Resident #19's bed were inspected after the bed malfunction and no concerns were identified. Further interview confirmed no manufacturer guidelines were utilized. The Administrator stated no preventive measures were put into place to ensure the other eleven (11) beds did not malfunction and facility staff was not educated on precautions to take with the beds. The Administrator stated Resident #19's bed model was some of the facility's better beds and functions very well. Further interview revealed she did not feel the maintenance staff should have done anything more.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure comprehensive plans of care were developed that addressed the care needs for one (1) of fifteen (15) sampled residents (Residents #13) related to the utilization of gait belts for transfers. The facility assessed Resident #13 to require extensive assistance of two (2) staff persons with transfers and had a facility policy to use gait belts with all transfers. However, facility staff failed to utilize a gait belt during a transfer of Resident #13 on 04/21/15, resulting in a humeral [MEDICAL CONDITION]'s left arm. Although the comprehensive care plan identified that Resident #13 needed assistance with transfers, the plan of care failed to include the intervention for staff to utilize a gait belt when transferring or ambulating the resident. In addition, the care plan interventions were also unclear on the number of staff required to assist the resident with transfers. The plan of care directed that one to two staff persons assist the resident with transfers. The findings include: Review of the facility's policy titled Care Planning for the Resident, review date of 05/01/14, revealed the objection was to develop a plan of care to . ensure care and services are provided to help each resident improve as possible and maintain the highest practicable well-being. Further review of the policy revealed the Interdisciplinary Care Plan Team was responsible for the development of an individual comprehensive plan of care for each resident. The policy also stated that clinical approaches that require quick reference when providing care would be identified on the resident profile (nurse aide care plan). Review of the facility's policy titled General Safety Rules, date unknown, stated, All resident ambulation shall be accomplished with the use of a gait belt. No exceptions! Review of the facility's policy titled Fall Protocol, revision date of 05/01/14, revealed residents should be transferred using a gait belt. Record review revealed the facility admitted the resident on 08/02/13. The resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment completed on 04/07/15, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 11, determining the resident's cognition to be moderately impaired. The resident was assessed to be interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require the physical extensive assistance of two (2) plus persons with transfers. Review of the facility's investigation dated 04/21/15 at 11:30 AM revealed two (2) State Registered Nurse Aides (SRNAs) were assisting Resident #13 with a transfer from the commode. The resident began to fall and the SRNAs lifted the resident back to the commode. During this transfer, the SRNAs heard a pop. After an assessment was completed, a left forearm x-ray was ordered and completed. Review of the x-ray, dated 04/21/15 at 2:04 PM, revealed a humeral [MEDICAL CONDITION]'s left arm. Further review of the facility's investigation revealed the SRNAs received verbal counseling related to not using a gait belt during the transfer of Resident #13, which resulted in a fracture. Review of the Profile Care Plan Approaches, used by the facility as the Nurse Aide Care Guide and the Comprehensive Care Plan, both dated 12/28/13, revealed the facility assessed the resident to require one (1) to two (2) person assist with transfers. The plan of care did not specify whether one (1) person assist or two (2) person assist should be provided. Neither did the Profile Care Plan Approaches or the Comprehensive Care Plan instruct staff to use a gait belt during transfers of Resident #13. Interview with SRNA #4 on 06/18/15 at 8:49 PM revealed she was responsible for following the nurse aide care plan daily and using a gait belt was not a care area listed on the care plan. Further interview revealed the nurse aide care plan was the guide for care required by the residents. The SRNA stated she was aware of the gait belt use policy; however, a gait belt was not used during the transfer of Resident #13 on 04/21/15. The inappropriate transfer resulted in a humeral [MEDICAL CONDITION]'s left arm. Interview with SRNA #5 on 06/19/15 at 10:17 AM, revealed a gait belt was not used during the transfer of Resident #13 on 04/21/15. She stated the information was not listed on the nurse aide care plan. The SRNA stated she was responsible for reviewing and following the nurse aide care plan daily. Interview with Unit Manager (UM) #1 on 06/19/15 at 12:28 PM, revealed she was a part of the Interdisciplinary Care Planning Team that was involved with the development of residents' comprehensive care plans. The UM stated that staff was responsible for reviewing and following the care plan for each resident. According to the UM, staff was to utilize the gait belt when assisting residents with transfers and ambulation. The UM stated since it was facility policy to use the gait belt, the use of the gait belt was not included as an intervention on the resident's comprehensive plan of care or the nurse aide plan of care. She further stated she had identified a concern with the lack of gait belt usage during rounds and she had increased rounds. The UM said she constantly reminded staff to use gait belts. Interview with the Director of Nursing (DON) on 06/19/15 at 1:18 PM revealed using gait belts with transfers and ambulation was a facility policy; however, because this was a facilitywide policy it is not care planned. Further interview revealed nurse aides were expected to review and sign the care plan needs sheet daily. The nurses were expected to review the care needs daily as well. Interview with the Administrator on 06/19/15 at 1:39 PM revealed direct care staff should be reviewing and following the resident care needs daily. Further interview revealed using a gait belt should have been addressed on the care plan for Resident #13.

Based on interview, record review, policy review, and review of the facility's fall investigation, it was determined the facility failed to ensure one of eighteen sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. Resident #1 was assessed as a high risk for falls and to require an alarming seat belt restraint while up in the wheelchair due to attempting to get up unassisted. The facility failed to ensure resident safety by monitoring implementation of interventions determined necessary to prevent accidents/injuries to Resident #1. On 07/11/11, Resident #1 was placed in a wheelchair that did not contain an alarming seatbelt. The resident stood from a sitting position in the wheelchair and fell . The resident sustained [REDACTED]. The findings include: A review of the facility's Fall/Risk Committee Policy Statement (revised 06/01/11) revealed staff was required to assess all residents for fall risk upon admission, quarterly, and as needed. Residents identified as having a high fall risk would have individualized interventions documented on their care plan. The facility admitted Resident #1 on 04/10/10, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be totally dependent and to require the assistance of two staff persons for transfers. An Incident Report completed on 06/10/11, revealed Resident #1 was found lying on the floor and unable to explain what happened. The Falls Risk Evaluation dated 06/10/11, revealed the facility assessed Resident #1 to have a summary score of 20. According to the evaluation, a score of 10 or above represented a high risk for falls. A review of nurse's notes dated 06/10/11, at 8:30 AM, revealed Resident #1 sustained a fall, reason unknown. Further review of the nurse's notes revealed the Falls Committee met on 06/14/11, and determined due to Resident #1's cognitive loss/Dementia and attempts to get up without assistance, an alarming seat belt restraint would be implemented while up in a wheelchair. Record review revealed on 06/14/11, Resident #1 was care planned to need a bed/chair alarm at all times, and an alarming seat belt while up in a wheelchair, to be checked every 30 minutes and released every 2 hours. This intervention was added to the resident's Certified Nursing Assistant (CNA) care plan and the resident's Medication Administration Record (MAR) to be checked each shift. A review of the Incident Report and Fall Review assessment dated [DATE], at 10:55 AM, revealed Resident #1 was in the wheelchair when the resident attempted to stand/transfer without assistance and fell to the floor. The report noted the alarming seat belt was not in place/use at the time of the fall. Review of nurse's notes dated 07/11/11, at 10:50 AM, revealed Resident #1 was sitting in a wheelchair at the nurse's desk on the South Hall. Resident #1 stood up and then fell forward onto the floor. The bed/chair alarm was sounding and Licensed Practical Nurse (LPN) #2 witnessed the fall. Resident #1 complained of left elbow pain and was transferred to the hospital. The resident was diagnosed with [REDACTED]. Resident #1 was observed on 07/20/11, at 10:15 AM, sitting in a wheelchair in front of the South Hall nurses' station. A chair and seat belt alarm were in place. A sling was observed on the resident's left upper arm. An interview with Certified Medication Assistant (CMA) #1 on 07/21/11, at 9:50 AM, revealed staff was responsible to ensure seat belt restraints were in place. The CMA stated seat belt restraints and alarms were documented on the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) and the CNA care plans. The CMA stated it was the CMA's responsibility to check for the presence of the resident restraints/alarms and to document this on the MAR/TAR twice per day, at 9:00 AM and 9:00 PM. Further interview with CMA #1 revealed the CMA had verified the resident's chair alarm on 07/11/11, but had not checked the resident's seat belt. Review of Resident #1's MAR revealed staff had signed the MAR on 07/11/11, indicating the seat belt was in place at 7:00 AM, prior to the resident's fall. An interview conducted with CNA #1 on 07/21/11, at 11:15 AM, revealed she was assigned to provide Resident #1's care on 07/11/11. CNA #1 stated if a resident utilized a restraint it would be indicated on the CNA Care plan. The CNA stated she did not always look at care plans at the beginning of the shift and would sometimes get verbal report from the CNA on the prior shift. CNA #1 stated she transferred Resident #1 to the wheelchair from a personal recliner with the assistance of another CNA. CNA #1 stated she did not check to ensure the seat belt restraint was on the resident. The CNA stated she had not taken care of Resident #1 in July until two days prior to Resident #1's fall. Review of records revealed CNA #1 signed Resident #1's Restraint Flow Sheet indicating she had checked the restraint every 30 minutes and released the restraint every 2 hours. Further interview with CNA #1 revealed, "I didn't pay attention to the checklist I was signing; thought it was the chair alarm." The CNA said she could see Resident #1 had a chair alarm. The CNA stated she had been trained to sign the restraint checklist after observing the restraint on the resident. Furthermore the CNA reported she should have checked the CNA care plan to see if restraints were ordered. An interview conducted with CNA #2 on 07/21/11, at 1:40 PM, revealed she was familiar with Resident #1 but was not responsible for Resident #1's care on the day of the fall. The CNA reported she helped CNA #1 transfer Resident #1 to the wheelchair from the commode and did not notice if the seat belt restraint was in place. The CNA stated she had taken care of Resident #1 earlier in the month and remembered the resident had a seat belt restraint at that time. The CNA said she expected CNA #1 would manage Resident #1's restraint since she was assigned to provide Resident #1's care. Further interview revealed it was the CNA's responsibility to review the CNA care plan at the beginning of each shift to determine each resident's care needs. The CNAs were also responsible to check restraints every 30 minutes, release every 2 hours, and document in CNA restraint checklist check that the release was performed. An interview conducted with LPN #2 on 07/21/11, at 6:40 PM, revealed she was at the South Hall nurses' desk at the time of the incident. LPN #2 stated she observed Resident #1 stand up and also heard the chair alarm sounding. The LPN stated before she could get to the resident he/she fell . Further interview revealed seat belt restraints were monitored through the sign-off on the TAR/MAR. The LPNs were responsible to check after the CMAs to ensure restraint and alarm check-offs were being performed. Furthermore, the LPN stated visual checks were performed to ensure residents' alarms and seat belt restraints were in place. LPN #2 reported she was familiar with Resident #1 and aware Resident #1 had an order for [REDACTED].#1's fall on 07/11/11. An interview with the Director of Nursing (DON) on 07/21/11, at 2:10 PM, revealed nurses were trained in orientation to monitor the use of seat belt restraints by following behind the CMAs to see if they were documenting on the MAR/TAR that residents' restraints were in place. Nurses were also trained to go behind CMAs and do visual checks to ensure restraints were in place.

Based on interview, record review, incident reports, and fall investigation review, it was determined the facility failed to provide care in accordance with the resident's written care plan for one of eighteen sampled residents. Resident #1 was assessed and care planned to require an alarming seat belt restraint to the wheelchair at all times. However, on 07/11/11, the resident was placed in a wheelchair without an alarming seat belt, stood up unassisted, and sustained a fall resulting in a left elbow fracture. The findings include: The facility admitted Resident #1 on 04/10/11, with [DIAGNOSES REDACTED]. An Incident Report completed on 06/10/11, revealed Resident #1 was found lying on the floor and unable to explain what happened. A review of the Fall Risk Evaluation dated 06/10/11, revealed the facility assessed Resident #1 at high risk for falls with a score of 20. According to the evaluation, a score of 10 or above represented a high risk for falls. A review of the Physical Restraints Care Area Assessment (CAA) dated 06/14/11, revealed Resident #1 required an alarming seat belt restraint while up in the wheelchair due to attempts to get up without assistance. A review of the resident's comprehensive care plan revealed Resident #1 had a care need identified related to potential for falls which was updated on 06/14/11, to include an alarming seat belt. Review of the Certified Nursing Assistant (CNA) care plan (no date) revealed an alarming seat belt restraint was to be utilized when the resident was up in the wheelchair. Review of the nurse's note dated 07/11/11, at 10:50 AM, revealed Resident #1 was sitting in a wheelchair by the nurses' station on the South Hall. The resident stood up and fell to the floor. The resident was assessed with [REDACTED]. The resident was diagnosed with [REDACTED]. A review of the Incident Report and Fall Review assessment dated [DATE], revealed Resident #1 was in the wheelchair when the resident attempted to stand/transfer unassisted and fell to the floor. The report identified an alarming seat beat restraint was not implemented or in place as required on the resident's plan of care when the resident fell . Resident #1 was observed on 07/20/11, at 10:15 AM, sitting in the wheelchair in front of the South Hall nurses' station. A chair and seat belt alarm were in place. A sling was observed on the resident's left upper arm. An interview with CNA #1 on 07/21/11, at 11:15 AM, revealed she was assigned to provide Resident #1's care on the day the fall occurred (07/11/11). CNA #1 stated resident restraints would be included on the CNA care plan. The CNA reported she did not always look at the care plans at the start of her shift and would sometimes get verbal report from the CNA on the prior shift. CNA #1 reported she received in-service training about once a month on restraints and stated she was trained to apply alarming seat belt restraints per the resident's care plan. CNA #1 stated on the day Resident #1 fell she (CNA #1) failed to check the CNA care plan prior to caring for Resident #1 and failed to check the alarming seat belt restraint after transferring Resident #1 to the wheelchair. An interview with CNA #2 on 07/21/11, at 1:40 PM, revealed she assisted CNA #1 to transfer Resident #1 into the wheelchair on the day of the fall/incident. The CNA stated she had taken care of Resident #1 earlier in the month and remembered the resident had a seat belt restraint at that time. CNA #2 said she did not notice if Resident #1's alarming seat belt was in place as she was only assisting CNA #1 with a transfer. CNA #2 stated she would have expected CNA #1 to manage any application of restraints. CNA #2 reported all CNAs are trained to review the CNA care plans at the beginning of each shift to determine the resident care needs. An interview with Certified Medication Assistant (CMA) #1 on 07/21/11, at 9:50 AM, revealed seat belt restraints and alarms were documented on the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) and the CNA care plans. The CMA stated it was the CMA's responsibility to ensure the CNAs were applying alarms/restraints as required and to document this on the MAR/TAR twice per day, at 9:00 AM and 9:00 PM. According to the CMA, on the day of the resident's fall with injury, she only verified the chair alarm to be in place, and did not check for the alarming seat belt. However, record review of Resident #1's MAR indicated [REDACTED]. An interview with the Director of Nursing (DON) on 07/21/11, at 2:10 PM, revealed nurses were trained in orientation to monitor the use of restraints. The nurse was responsible to check behind the CMAs to see if they were documenting on the MAR/TAR that residents' restraints were in place. The DON stated nurses were also trained to go behind CMAs and do visual checks to ensure restraints were in place. An interview conducted with LPN #2 on 07/21/11, at 6:40 PM, revealed on the day of the incident she observed Resident #1 stand up and also heard the chair alarm sounding. The LPN stated before she could get to the resident he/she fell . Further interview revealed seat belt restraints were monitored through the sign-off on the TAR/MAR. The LPNs were responsible to check after the CMAs to ensure restraint and alarm check-offs were being performed. Furthermore, the LPN stated visual checks were performed to ensure residents' alarms and seat belt restraints were in place. LPN #2 reported she was familiar with Resident #1 and aware Resident #1 had an order for [REDACTED]. An interview with the Administrator 07/21/11, at 7:00 PM, revealed the facility had no policy related to Care Plans or Care Plan implementation.

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision and monitoring to prevent accidents for one (1) of eight (8)sampled residents (resident #1) who displayed wandering and elopement behavioral symptoms. Resident #1 was identified by the facility as a risk for elopement on September 26, 2010, and a wanderguard bracelet was placed on the resident at that time. However, no other care plan interventions were developed to address the risk of elopement from the facility. On Sunday October 10, 2010, at 10:45 a.m., resident #1 exited the facility without staff knowledge, utilizing a side exit door on the North Unit. Resident #1 was located at 11:20 a.m. on October 10, 2010, in the employee parking lot, at the side of the facility, by facility staff. The resident was absent from the facility and unsupervised by facility staff for 35 minutes. The failure to ensure adequate supervision and monitoring placed residents in the facility at risk for serious injury, harm, impairment, or death. The findings include: Observation on October 12, 2010, revealed only the facility's front door was equipped with the wanderguard alarm system. Three side exit doors which were accessible by mobile residents were equipped with alarms. However, the side exit doors were not equipped with the wanderguard alarm system. The observation of the three side exit doors revealed all of the door alarms sounded when opened; however, the alarms did not sound with the intensity of the wanderguard alarm system at the facility's front door. Review of the facility policy entitled "Door Alarms" dated January 24, 2004, revealed when an exterior door alarm sounded staff was required to complete a visual check of the exterior and interior areas to determine if a resident exited the door. Observation conducted on October 13, 2010, at 12:57 p.m., revealed resident #1 in a wheelchair propelling self in the hallway of the facility. Further observation on October 13, 2010, at 1:14 p.m., revealed resident #1 propelled down to the nurses' station and continued down the hallway past the nursing station. Interviews conducted on October 12, 2010, at 2:30 p.m., with SRNA #1, at 2:45 p.m., with RN #1, and at 2:58 p.m., with LPN #1, and on October 13, 2010, at 1:35 p.m., and with LPN #2 at 2:40 p.m., revealed resident #1 propelled the wheelchair up and down the hallways in the facility daily. Review of nurse's notes dated September 26, 2010, revealed resident #1 was attempting to open the front door of the facility, and the resident stated, "I'm want to look for my car." The nurse's notes stated a wanderguard bracelet was applied; however, no other interventions were implemented at that time. Review of the nurse's notes dated October 10, 2010, at 11:50 a.m., revealed resident #1 was found outside the facility by SRNA #1. Review of the facility's investigation dated October 10, 2010, into resident #1's elopement revealed the facility's exterior video surveillance showed resident #1 exited the North Unit side door on October 10, 2010, at 10:46 a.m. The investigation stated SRNA #1 found resident #1 in the employee parking lot at 11:30 a.m., when SRNA #1 went to lunch. The investigation revealed SRNA #2 heard the North Unit side door alarm, observed resident #3 with the resident's hand on the door handle, redirected the resident away from the door, reset the door alarm, and clocked out for lunch. The investigation concluded that SRNA #2 did not perform an exterior inspection as per door alarm protocol, and had assumed resident #3 pushed on the door handle sounding the side door alarm. Review of the facility investigation revealed the resident was absent from the facility, and unsupervised by facility staff, for at least 35 minutes. An interview conducted on October 12, 2010, at 2:30 p.m., with SRNA #1, revealed on October 10, 2010, the SRNA exited the facility through the front door and walked around the side of the building to the employee parking lot. The SRNA found resident #1 in a wheelchair just off the sidewalk from the North Unit side door. An interview conducted on October 12, 2010, at 2:45 p.m., with RN #1 revealed on October 10, 2010, the RN returned from lunch about the time SRNA #1 was bringing resident #1 back into the facility. RN #1 stated resident #1's wanderguard bracelet and all door alarms were checked and functioning properly. The RN indicated an investigation was initiated and staff told her that another staff member heard the North Unit door alarm but thought a different resident had pushed on the door, so the staff did not perform a visual inspection of the exterior. An interview conducted on October 13, 2010, at 1:30 p.m. and 2:25 p.m., with SRNA #3 and SRNA #4 revealed the SRNAs were working on the North Unit on October 10, 2010. Both SRNAs stated there were three staff members (one nurse and two SRNAs) on the North Unit on the weekends. The interview revealed the nurse and one of the SRNAs took lunch break from 10:30-11:00 a.m., and the other SRNA took lunch from 11:00-11:30 a.m. The SRNAs stated one staff member was on the North Unit when resident #1 exited the facility through the North Unit side door. The interview revealed SRNA #4 was the staff member on the North Unit when resident #1 exited the building. SRNA #4 denied hearing the North side door alarm, or seeing resident #1 on the North Unit during that time. The SRNA stated he/she was in and out of resident rooms and was not at the nurses' station (near the exit door). An interview conducted on October 19, 2010, at 1:05 p.m., with SRNA #2 revealed the SRNA was working on the South Unit on Sunday, October 10, 2010. SRNA #2 stated he/she was walking up the North Unit hallway toward the time clock at around 10:45 a.m., and heard the North Unit exit door alarm. The SRNA revealed when he/she reached the exit door resident #3 was standing at the door with the resident's hand on the door handle. The SRNA #2 redirected resident #3 away from the door, reset the alarm panel, and clocked out for lunch. SRNA #2 stated he/she did not perform a visual inspection of the exterior area because the SRNA thought resident #3 had activated the North Unit exit door. According to SRNA #2, he/she was unaware resident #3 had been pushing resident #1 in the wheelchair earlier that morning. An interview conducted on October 13, 2010, at 1:35 p.m., with LPN #2 revealed the LPN wrote a physician's order, and placed the wanderguard bracelet on resident #1, on Sunday, September 26, 2010, because the resident was wandering around the front door. Interviews conducted on October 12, 2010, at 3:10 p.m., and on October 13, 2010, at 3:40 p.m., with the DON revealed when a side exit door alarm sounded, staff was required to check the alarm reset panel to determine which door was opened, and observe the interior and exterior area surrounding the door to ensure there were no residents outside the facility prior to resetting the alarm. The DON stated the facility thought resident #3 let resident #1 out the North Unit side door because resident #3 was pushing resident #1 in a wheelchair throughout the facility earlier that day. The DON revealed staff reviewed the facility's exterior video surveillance for October 10, 2010, and verified resident #1 exited the facility out the North Unit side door. According to the DON, the facility video indicated that no staff opened the door to perform a visual inspection of the exterior after resident #1 exited the facility. The DON stated when a wanderguard bracelet was applied to a resident no other interventions were implemented to monitor the wandering resident. The interview revealed the facility did not perform additional monitoring of residents with wanderguard bracelets. An interview conducted on October 13, 2010, at 4:17 p.m., with the Administrator revealed the review of the exterior video surveillance indicated resident #1 exited the facility on Sunday October 10, 2010, at 10:45 a.m., and was found by SRNA #1 at 11:20 a.m. The interview revealed the facility's front door was the only door equipped with the wanderguard alarm system, which sounded when the door was opened and a resident with a wanderguard bracelet was in the area. The Administrator stated the three side exit doors were equipped with an alarm system that sounded when the doors were opened. According to the Administrator, the wanderguard alarm was louder and more intense than the side exit door alarms. Interviews conducted on October 13, 2010, at 2:00 p.m., with SRNA #5, at 2:10 p.m., with LPN #3, at 2:40 p.m., with SRNA #6, and at 3:00 p.m., with LPN #4, and on October 19, 2010, at 1:05 p.m., with SRNA #2 revealed when a side exit door alarm sounded, staff was required to check the alarm reset panel to determine which door was opened, and observe the interior and exterior area surrounding the door to ensure there were no residents outside the facility prior to resetting the alarm. ** An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on October 19, 2010, which alleged removal of Immediate Jeopardy effective October 16, 2010. A partial extended survey was conducted on October 18-19, 2010, which determined the Immediate Jeopardy was removed on October 16, 2010. Interviews with the Administrator and the Director of Nursing (DON), observations, and review of facility records on October 18-19, 2010, revealed on October 10, 2010, an immediate head count was performed for all facility residents following the discovery of the elopement of resident #1. Two additional head counts were performed on the same date to ensure all residents were accounted for. On October 11, 2010, the facility initiated head counts performed every four hours around the clock and documented on the 24-hour communication sheets and the resident census sheet. The head counts were performed by the nursing staff utilizing the resident census sheet to do a visual accountability. The head counts practice continued until October 12, 2010, at which time a monitor (Charge Nurse) was placed at each nurses' station at all times. If the Charge Nurse left the nurses' station to perform other duties the Charge Nurse was responsible to ensure a replacement staff member visually monitored the exit doors in his/her absence. The Charge Nurse was required to sign a monitoring form which indicated the Charge Nurse or designee was on duty monitoring the doors. In the event of an emergency situation, the South Unit Charge Nurse shall assign a person to remain in the front hallway where a visual and auditory monitoring can be performed of all three side exit doors. The nursing supervisor in-serviced staff on this new practice from October 12, 2010, through October 15, 2010. Observations were conducted on October 18-19, 2010, that verified each nurses' station had at least one staff member monitoring the side exit doors at all times. The monitoring forms were also reviewed and the forms indicated staff was monitoring the exit doors as planned. Interviews with the Administrator, observations, and review of facility records on October 12-19, 2010, revealed on October 11, 2010, deterrent strips (mesh strips that display a large, red Stop sign) which covered the width of the doorway were placed over each side exit doorway. The deterrent strips were observed over the exit doorways on October 19, 2010. Interviews with Charge Nurses and review of the facility records on October 18-19, 2010, revealed the Charge Nurses were to visually inspect the alarm panel four times during each shift (a total of eight times in 24 hours) and document the alarm panel status on the communication sheet. This practice continued until October 12, 2010. Interviews with the Administrator and the DON, observations, and review of the facility records on October 12-19, 2010, revealed the Department Head supervisors verbally reviewed the Door Alarm Protocol with their respective staff as each employee reported for their work duties. The Protocol was documented as a Memo and posted at each nurses' station and at the time clock. Observations on October 12, 2010, verified the Memos were posted at the nurses' stations and at the time clock. Interview with the Administrator, observations, and review of the facility records on October 18-19, 2010, revealed a new Protocol was initiated regarding an "Identification Record" to be compiled of each resident assessed to be at risk of elopement. The "Identification Record" contained a picture image of the resident with identifying information for use in the event of an elopement. A copy of the completed "Identification Record" binder will be kept in the Medical Records office, at each nurses' station, and in the Business office, and a poster of the residents will be placed in the employee break room for ongoing reference. Observations on October 19, 2010, verified the "Identification Record" binders and poster were in the designated areas. Interview with the Administrator and the Maintenance Supervisor, observation, and review of the facility records on October 18-19, 2010, revealed on October 13, 2010, a new "back-up" door alarm was placed on the side exit doors. The "back-up" door alarm sounded, in addition to the original door alarm, and must be manually disarmed by a key. The Charge Nurse was responsible for disarming the second alarm and carried the disarming key. Observations on October 18-19, 2010, verified the "back-up" alarms were in place on the side exit doors. The temporary alarms will be replaced with permanently mounted alarm units which were ordered on October 13, 2010. Interview with the Administrator and the DON and review of the facility records on October 18-19, 2010, revealed on October 13, 2010, the facility revised the Door Alarm protocol/policy to include the "back-up" door alarms applied to the side exit doors. The protocol/policy also included the staff instruction for response to a triggered door alarm. All employees were verbally in-serviced on the protocol/policy on October 13, 2010. Interviews with staff on October 18-19, 2010, confirmed staff attended the in-service training and was knowledgeable of the information regarding the revised door alarm protocols. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed the following additions have been added to the Orientation practice. Nursing staff shall orient all employees upon hire and at least annually on the Elopement Policy and the Door Alarm Policy and provide each a copy of the policies. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed the following additions have been added to the Quality Assurance practice. The DON or ADON shall review shift reports on a daily basis to ensure the signature of the assigned charge nurse was documented for the monitoring of the doors and the door alarm panel. Once the Immediate Jeopardy has been removed the DON will summarize the daily reviews on a monthly basis as part of the QI review. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed staff was in-serviced on October 11-15, 2010, that in the event of a triggered door alarm nursing staff was to inspect the exterior and interior area for any residents and initiate an immediate head count of all facility residents. Interviews with staff on October 19, 2010, confirmed staff attended the in-service training and was knowledgeable of the information regarding the door alarm protocols. Based on the above findings, it was determined on October 19, 2010, the Immediate Jeopardy was removed effective October 16, 2010. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systemic changes and quality of assurance activities.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive plan of care was revised for one (1) of eight (8) sampled residents (resident #1). On September 26, 2010, resident #1 attempted to open the front door of the facility and stated he/she wanted to find his/her car. Although the facility placed a wanderguard bracelet on the resident, there was no evidence the facility revised the resident Care Plan to include additional interventions for supervision to prevent elopement. In addition, even though the resident exhibited wandering behavior, there was no evidence the facility revised the Care Plan to include interventions for the behavior. On October 10, 2010, at 10:45 a.m., resident #1 exited the facility without staff knowledge. The resident was found outside the facility in a parking lot by a staff member 35 minutes later. This facility's failure to implement additional interventions placed the resident at risk for serious harm, injury, impairment, or death. The findings include: Observation conducted on October 13, 2010, at 12:57 p.m., revealed resident #1 in a wheelchair displaying wandering behavior, as defined by the MDS 2.0 User's Manual to include locomotion with no discernible, rational purpose, which can be manifested by walking or wheelchair. The resident was propelling self in the hallway of the facility. Further observation on October 13, 2010, at 1:14 p.m., revealed resident #1 propelled down to the nurses' station and past the station down the hallway of the facility. Review of resident #1's medical record revealed the resident propelled independently in the wheelchair throughout the facility. According to resident #1's nurse's notes dated September 26, 2010, resident #1 was attempting to open the front door of the facility; the resident stated, "I'm want to look for my car." The nurse's notes stated a wanderguard bracelet was applied at the time. Review of resident #1's comprehensive Care Plan dated November 15, 2008, revealed the resident's wandering behavioral symptoms were not addressed as a care need on resident #1's care plan. The plan of care included an update on September 26, 2010, which stated the resident had attempted to open the front door. The goal was listed as "free from elopement." The only interventions listed were to notify the physician and apply a wanderguard. No further supervision interventions were identified. There was no evidence the wandering behavior was identified as a care problem, and no interventions included in the Care Plan to address the behavior. Interview conducted on October 12, 2010, at 3:10 p.m., and on October 19, 2010, at 8:50 a.m. and 10:40 a.m., with the Director of Nursing (DON) revealed there were 12 residents assessed by the facility to be at risk for wandering/elopement with wanderguard bracelets in place. According to the DON, these 12 residents wore wanderguard bracelets due to displaying wandering behavioral symptoms. The DON stated a resident's wandering behavior was not identified as a care plan problem. The DON said the wanderguard bracelet was usually added as an intervention under another previously identified care plan problem. Observation on October 12, 2010, revealed only the facility's front door was equipped a wanderguard alarm system. However, three additional exit doors were observed, accessible to resident #1, which were not equipped with the wanderguard system. Observation of the three side exit doors revealed all of the door alarms sounded when opened; however, the alarms did not sound with the intensity of the wanderguard alarm system at the facility's front door. Review of the nurse's notes dated October 10, 2010, at 11:50 a.m., and the facility investigation report dated October 10, 2010, revealed resident #1 exited the facility, without staff knowledge, and was found by SRNA #1 in the employee parking lot at the side of the building 35 minutes later. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on October 19, 2010, which alleged removal of Immediate Jeopardy effective October 16, 2010. A partial extended survey was conducted on October 18-19, 2010, which determined the Immediate Jeopardy was removed on October 16, 2010. Interviews with the Administrator and the Director of Nursing (DON) and review of the facility records on October 18-19, 2010, revealed the facility reassessed all residents in the facility on October 12, 2010, utilizing an Elopement Risk Assessment. Other than the 12 residents previously assessed to be at risk for elopement, no other residents were identified as an elopement risk. The facility implemented new Elopement care plans for each of the 12 residents assessed to be at risk for elopement with multiple interventions to be implemented to include visual checks every two hours. Observations revealed the residents' care plans were followed and all interventions related to wandering/elopement for residents were implemented. Review of the facility's in-service records and interviews with the Administrator and DON on October 18-19, 2010, revealed staff was re-educated on October 15, 2010, by the DON on the facility's new Elopement Risk Assessment, the new 3.0 MDS assessment forms and the new Elopement care plan to include visual checks every two hours. Interviews with staff on October 19, 2010, confirmed staff attended the in-service trainings and was knowledgeable of the information regarding the new Elopement resident assessment and care plan information. Based on the above findings, it was determined on October 19, 2010, the Immediate Jeopardy was removed effective October 16, 2010. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the effectiveness of quality assurance activities related to assessment of residents' needs as they relate to wandering/elopement, and implementation of interventions to ensure elopements do not occur.

Based on observation, interview, and record review, it was determined the Administration of the facility failed to ensure the facility's resources were utilized effectively and efficiently to provide the required care and services to the residents. The facility Administration failed to ensure resident #1 had interventions in place to prevent elopement, and failed to ensure staff implemented the door alarm policy. (Refer to F280 and F323.) Resident #1, who was assessed by the facility to be at risk for wandering/elopement, exited the facility without staff knowledge on October 10, 2010. The resident was located in the employee parking lot, at the side of the facility 35 minutes later. The facility Administration's failure to ensure adequate supervision was provided placed residents in the facility at risk for serious injury, harm, impairment, or death. The findings include: Review of nurse's notes dated September 26, 2010, revealed resident #1 attempted to exit the facility, and had a wanderguard bracelet placed at that time. Observation on October 12, 2010, revealed only the facility's front door was equipped with the wanderguard system. Further observation revealed the three additional side doors were equipped with only an alarm that sounded when the door was opened. Review of the facility Door Alarm policy dated January 24, 2004, revealed when a door alarm sounded staff should observe both the interior of the facility and the exterior of the facility. Review of the facility's investigation into resident #1's elopement dated October 10, 2010, revealed the facility's exterior video surveillance showed resident #1 exited the North Unit side door on October 10, 2010, at 10:45 a.m. The investigation stated SRNA #1 found resident #1 in the employee parking lot at 11:30 a.m. The investigation revealed SRNA #2 heard the North Unit side door alarm, observed resident #3 with the resident's hand on the door handle, redirected the resident away from the door, reset the door alarm, and clocked out for lunch. According to the investigation the exterior video revealed no staff member observed the exterior of the facility prior to resetting the alarm. The investigation concluded that SRNA #2 did not perform an exterior inspection of the facility, as per door alarm protocol, assuming resident #3 pushed on the door handle, sounding the side door alarm. (Refer to F323.) An interview conducted on October 19, 2010, at 8:50 a.m. and 10:40 a.m., with the Director of Nursing (DON) revealed the wanderguard bracelets were an intervention added to a resident's care plan when the bracelet was applied to the resident. In addition, the DON stated a resident's wandering behavior was not identified as a care plan problem; therefore, no other interventions were implemented other than the wanderguard bracelet. (Refer to F280.) An interview conducted on October 13, 2010, at 4:17 p.m. and on October 19, 2010, at 1:25 p.m., with the Administrator revealed the facility's front door was the only door equipped with the wanderguard alarm system, which only sounded when the door was opened and a resident with a wanderguard bracelet was in the area. The Administrator stated the three side exit doors were equipped with an alarm system that sounded when the doors were opened. According to the Administrator, the wanderguard alarm was louder and more intense than the side exit door alarms. The interview revealed the Administrator was unaware there was only one intervention (wanderguard) implemented for residents identified to exhibit wandering behavioral symptoms, even though the wanderguard system was present only on the front door. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on October 19, 2010, which alleged removal of Immediate Jeopardy effective October 16, 2010. A partial extended survey was conducted on October 18-19, 2010, which determined the Immediate Jeopardy was removed on October 16, 2010. Interviews with the Administrator and the Director of Nursing (DON) and review of the facility records on October 18-19, 2010, revealed the facility reassessed all residents in the facility on October 12, 2010, utilizing a Elopement Risk Assessment. Other then the 12 residents previously assessed to be at risk for elopement who wore wanderguard bracelets, no other residents were identified as an elopement risk. The facility implemented new Elopement care plans for each of the 12 residents assessed to be at risk for elopement with multiple interventions to be implemented to include visual checks every two hours. Observations revealed the residents' care plans were followed and all interventions related to wandering/elopement for residents were implemented. Review of the facility's in-service records and interviews with the Administrator and DON on October 18-19, 2010, revealed staff was re-educated on the facility's new Elopement Risk Assessment, the new 3.0 MDS assessment forms, and the new Elopement care plan to include visual checks every two hours. Interviews with staff on October 19, 2010, confirmed staff attended the in-service training and was knowledgeable of the information regarding the new Elopement resident assessment and care plan information. Interviews with the Administrator and the Director of Nursing (DON), observations, and review of facility records on October 18-19, 2010, revealed on October 10, 2010, an immediate head count was performed for all facility residents following the discovery of the elopement of resident #1. Two additional head counts were performed on the same date to ensure all residents were accounted for. On October 11, 2010, the facility initiated head counts performed every four hours around the clock and documented on the 24-hour communication sheets and the resident census sheet. The head counts were performed by the nursing staff utilizing the resident census sheet to do a visual accountability. The head counts practice continued until October 12, 2010, at which time a monitor (Charge Nurse) was placed at each nurses' station at all times. If the Charge Nurse left the nurses' station to perform other duties, the Charge Nurse was responsible to ensure a replacement staff member visually monitored the exit doors in his/her absence. The Charge Nurse was required to sign a monitoring form which indicated the Charge Nurse or designee was on duty monitoring the doors. In the event of an emergency situation, the South Unit Charge Nurse shall assign a person to remain in the front hallway where a visual and auditory monitoring can be performed of all three side exit doors. The nursing supervisor in-serviced staff on this new practice from October 12, 2010, through October 15, 2010. Observations were conducted on October 18-19, 2010, that verified each nurses' station had at least one staff member monitoring the side exit doors at all times. The monitoring forms were also reviewed and the forms indicated staff was monitoring the exit doors as planned. Interviews with the Administrator, observations, and review of facility records on October 12-19, 2010, revealed on October 11, 2010, deterrent strips (mesh strips that display a large, red Stop sign) which covered the width of the doorway were placed over each side exit doorway. The deterrent strips were observed over the exit doorways on October 19, 2010. Interviews with Charge Nurses and review of the facility records on October 18-19, 2010, revealed the Charge Nurses were to visually inspect the alarm panel four times during each shift (a total of eight times in 24 hours) and document the alarm panel status on the communication sheet. This practice continued until October 12, 2010. Interviews with the Administrator and the DON, observations, and review of the facility records on October 12-19, 2010, revealed the Department Head supervisors verbally reviewed the Door Alarm Protocol to their respective staff as each employee reported for their work duties. The Protocol was documented as a Memo and posted at each nurses' station and at the time clock. Observations on October 12, 2010, verified the Memos were posted at the nurses' stations and at the time clock. Interview with the Administrator, observations, and review of the facility records on October 18-19, 2010, revealed a new Protocol was initiated regarding an "Identification Record" to be compiled of each resident assessed to be at risk of elopement. The "Identification Record" contained a picture image of the resident with identifying information for use in the event of an elopement. A copy of the completed "Identification Record" binder will be kept in the Medical Records office, at each nurses' station, and in the Business office, and a poster of the residents will be placed in the employee break room for ongoing reference. Observations on October 19, 2010, verified the "Identification Record" binders and poster were in the designated areas. Interview with the Administrator and the Maintenance Supervisor, observation, and review of the facility records on October 18-19, 2010, revealed on October 13, 2010, a new "back-up" door alarm was placed on the side exit doors. The "back-up" door alarm sounded in addition to the original door alarm, and must manually be disarmed by a key. The Charge Nurse was responsible for disarming the second alarm and carried the disarming key. Observations on October 18-19, 2010, verified the "back-up" alarms were in place on the side exit doors. The temporary alarms will be replaced with permanently mounted alarm units which were ordered on October 13, 2010. Interview with the Administrator and the DON and review of the facility records on October 18-19, 2010, revealed on October 13, 2010, the facility revised the Door Alarm protocol/policy to include the "back-up" door alarms applied to the side exit doors. The protocol/policy also included the staff instruction for response to a triggered door alarm. All employees were verbally in-serviced on the protocol/policy on October 13, 2010. Interviews with staff on October 18-19, 2010, confirmed staff attended the in-service training and was knowledgeable of the information regarding the revised door alarm protocols. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed the following additions have been added to the Orientation practice. Nursing staff shall orient all employees upon hire and at least annually on the Elopement Policy and the Door Alarm Policy and provide each a copy of the policies. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed the following additions have been added to the Quality Assurance practice. The DON or ADON shall review shift reports on a daily basis to ensure the signature of the assigned Charge Nurse was documented for the monitoring of the doors and the door alarm panel. Once the Immediate Jeopardy has been removed the DON will summarize the daily reviews on a monthly basis as part of the QI review. The Administrator oversees the QI meetings. Interview with the Administrator and review of the facility records on October 18-19, 2010, revealed staff was in-serviced on October 11-15, 2010, that in the event of a triggered door alarm nursing staff was to inspect the exterior and interior area for any residents and initiate an immediate head count of all facility residents. Interviews with staff on October 19, 2010, confirmed staff attended the in-service training and was knowledgeable of the information regarding the door alarm protocols. Based on the above findings, it was determined on October 19, 2010, the Immediate Jeopardy was removed effective on October 16, 2010. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality of assurance activities.