Every finding on record at Metcalfe Nursing and Rehabilitation Center

Based on interview and review of the facility's Mail Distribution policy, it was determined the facility failed to ensure residents had the right to send and receive mail. In addition, the facility failed to ensure residents were able to receive letters, packages and other materials delivered to the facility for residents on Saturdays and Sundays. The total census was sixty-two (62). The findings include: Review of the facility's policy titled, Mail Distribution, undated, revealed it was the intent of the policy that the facility developed a system of resident mail transport, which involved the Activities Department and the person who received the mail, i.e., the Receptionist. Continued review revealed it also included provisions whereby the Activities Department was informed of the arrival of, or was given, the mail. Further review of the policy revealed the Activities Director or Designated Volunteer was to deliver the mail to the residents within twenty-four (24) hours. Interview with Resident Council members, on 10/18/2022 at 3:14 PM, revealed the facility was not delivering residents' mail on Saturdays and Sundays. Interview, with the Activities Director, on 10/20/2022 at 2:00 PM, revealed she and the Activities Assistant were responsible for delivering the mail to the residents during the week. She stated the Business Office employees were responsible for picking the mail up from the post office during the week. However, they were off on weekends, and therefore, no one delivered the mail to the facility or to the residents. The Activities Director stated she was aware of the facility's policy which noted the residents' right to have mail delivered, including on the weekends. Interview, with the Social Service Director, on 10/20/2022 at 2:00 PM, revealed no one was checking for residents' mail on Saturdays because the Business Office was closed. Interview, with the Accounts Receivable Clerk, from the Business Office, on 10/20/2022 at 2:35 PM, revealed she picked up the mail from the post office during the week. However, during the weekends the mail was not picked up because she was off. Interview, with the Director of Nursing (DON), on 10/20/2022 at 4:00 PM, revealed she was aware residents did not receive their mail on the weekends because no one was there to pick it up from the post office and deliver it to the facility. She further stated she would ensure the Activities Department delivered the residents' mail to them on weekends. The Administrator was out of town and not available for interview.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment; to help prevent and control the development and transmission of communicable diseases; and, to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) state guidelines for COVID-19. Multiple observations, from 10/18/2022 to 10/20/2022, revealed staff members were not providing assistance with COVID screening; not wearing required personal protective equipment (PPE) or wearing it incorrectly, in a Contact Precautions room; not performing correct hand hygiene; not disinfecting reusable medical equipment or not disinfecting it with the correct contact time; and inappropriate handling of trash in a Contact Precautions room. In addition, the facility failed to post instructional signage about COVID-19 for visitors to see at the facility's entrance and throughout the facility. The findings include: Review of the facility's policy titled, Standard Precautions, not dated, revealed Standard Precautions would be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard Precautions protocol included: handwashing; use of gloves when indicated, discarded in the proper receptacle, and hand hygiene when gloves were removed; use of gowns, when indicated, that fit at the neck, were tied at the neck into a shoelace bow, and overlapped at the back, completely covered clothing, and tied at the waist string into a shoelace bow; reusable resident care equipment that was not used for the care of another resident until it had been appropriately cleaned; and, environment surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces that were properly cleaned. Review of the Micro-Kill Germicidal Bleach Wipes canister label revealed directions that stated thirty (30) second contact time was required to kill bacteria and viruses and to reapply as necessary to ensure the surface remained wet for the entire contact time. Review of the facility's policy titled, Contact Precautions, not dated, revealed Contact Precautions were to be used, in addition to Standard Precautions, for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the residents' environment. Contact Precautions protocol included: to wear gloves when entering the room if any contact was to be made with the resident or items in the room, remove gloves before leaving the room, and wash hands or use waterless antiseptic agent (alcohol based hand rub (ABHR)) after removal of gloves. Additional protocol included to wear a gown when entering the room, if you anticipate your clothing will have substantial contact with the resident, the environment, or resident items. The policy also stated to wear a gown if the resident was incontinent, had diarrhea, an ileostomy, a colostomy, or wound drainage not contained by the dressing. It also stated to remove the gown before leaving the room. Further protocol for resident care equipment revealed, if the use of common equipment or items was unavoidable, then adequately clean and disinfect them before use on another resident. Review of the facility's policy titled, Facility Visitation, Communal Activities, Dining, and Resident Outings Guidelines, effective September 23, 2022, revealed the facility shall follow current guidelines and recommendations related to resident visitation as recommended by the Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS) through Memo QSO-20-39-NH, revised 09/23/2022. Review of the Centers for Medicare and Medicaid Services (CMS) document Ref: QSO-20-39-NH, revised 09/23/2022, Core Principles of COVID-19 Infection Prevention revealed: facilities should provide guidance (e.g., posted signs at entrances) about recommended actions for visitors who had a positive viral test for COVID-19, symptoms of COVID-19, or have had close contact with someone with COVID-19. Further review revealed instructional signage should be placed throughout the facility on visitor education for COVID- 19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, and hand hygiene). Review of the facility's document Nursing Home COVID-19 Visitor Screening Log revealed a slot for a staff member's initials indicating screening was performed by facility staff. 1. Observation, on 10/18/2022 at 10:20 AM, revealed, upon entry to the facility by the State Survey Agency (SSA) Surveyor Team the screening for COVID-19 was self-performed without assistance or instructions of front desk staff. Continued observation revealed the front lobby area, the front door, and throughout the facility had no signage for COVID/Visitation Precautions. Additional observation, on 10/19/2022 at 8:00 AM, revealed the front desk personnel were sitting at the desk. The front desk personnel provided no instruction in screening or assistance, so the survey team members self-screened again by utilizing the sign-in sheet, temperature check, and hand hygiene. Further observation revealed no signage on the front door or lobby area offering guidance to visitors for COVID symptoms or exposure. One (1) sign was noted to the left of the front door facing toward the inside of the facility above the hand hygiene station attached to the wall to the left of the entrance. Observation revealed this signage was out of eye sight range upon entry to the facility. Interview with the Accounts Receivable Clerk, on 10/21/2022 at 11:30 AM, revealed she opened the door for visitors and if possible would screen them using equipment and the sign in sheet. When asked if visitors were informed of signs and symptoms of COVID-19 to prevent them from entering the building, she stated there was a sign for them to read at the front door. During the interview, the SSA Surveyor observed a visitor enter the building without the front desk staff utilizing the in-person screening process. The front desk staff then looked at the screening document after the visitor had entered the building and left the lobby. Interview with the Accounts Payable/Payroll Clerk, on 10/21/2022 at 11:30 AM, revealed visitors were observed by staff to screen themselves without assistance. 2. Observation, on 10/18/2022 at 11:15 AM, of room [ROOM NUMBER]A, for Resident #62, revealed an isolation cart with personal protective equipment (PPE) with Contact Precautions signage on the door. Continued observation revealed, on 10/18/2022 at 11:45 AM, there was a visitor in the room with Resident #62. The visitor was not wearing any PPE. 3. Observation, on 10/19/2022 at 8:30 AM, of room [ROOM NUMBER], for Resident #28, revealed an isolation cart containing gowns and masks, but no gloves. In addition, the room door did not have signage indicating what type of isolation. Certified Nursing Assistant (CNA) #12 entered room [ROOM NUMBER] without a gown. The CNA came out of the room, and donned (put on) a gown. However, the gown did not cover the back. Further observation revealed CNA #12 did not don gloves before entering the room. upon exiting the room, CNA #12 did not perform hand hygiene. 4. Observation, on 10/19/2022 at 10:30 AM, revealed CNA #8 entered room [ROOM NUMBER] A, a contact isolation room. CNA #8 provided assistance to Resident #62, who was on contact precautions, without wearing a gown, gloves, or mask. 5. Observation, on 10/19/2022 at 6:45 PM, revealed an unknown staff member delivered a tray to Resident #62, in room [ROOM NUMBER]A, who was in contact precautions. Further observation revealed the staff member handled and adjusted the overbed table. However, no PPE was used, only hand sanitizer was used upon exiting the room. The staff member then obtained another tray and took it to another room. 6. Observation, on 10/20/2022 at 8:33 AM, revealed CNA #8 went into a contact isolation room to pick up the breakfast tray. She got the tray and placed it on the tray rack in the hallway. No PPE was used, and no hand hygiene was done when exiting the room. She continued to the next room, picked up the lunch tray, and placed it on the cart in the hallway. 7. Observation, on 10/20/2022 at 11:00 AM, revealed CNA #3 wheeled a Hoyer lift (a mechanical device used to assist staff in lifting and transferring residents) up the hallway into the storage room without disinfecting it. Per the observation, no disinfecting wipes were available for immediate use in the lift's bag/storage space. Interview with CNA #3, on 10/20/2022 at 11:05 AM, revealed she had not disinfected the Hoyer lift after use and prior to storage. She stated other staff would have no way of knowing the Hoyer lift had not been disinfected prior to its use on other residents. CNA #3 stated she knew disinfecting was important to stop the spread of germs, and she should have disinfected the lift prior to storage. 8. Observation, on 10/20/2022 at 11:07 AM, revealed a housekeeper, unidentified, came out of a contact precautions rom, 216A. The housekeeper got supplies from the cleaning cart outside the room. However, she did not change gloves and perform hand hygiene before retrieving items from the cart to take back into the room. Per the observation, the housekeeper only performed hand hygiene when she came out of the room for the third time. 9. Observation, on 10/20/2022 at 11:14 AM, revealed Certified Medication Technician (CMT) #2 went into room [ROOM NUMBER] (contact precautions for bed 216A) carrying a medication cup for the resident in bed 216B. Further observation revealed no gown or gloves were donned before entering the room. 10. Observation, on 10/20/2022 at 11:35 AM, revealed CMT #2 in room [ROOM NUMBER]B (Resident #23, who was on contact precautions). The CMT was in the room to administer medications to Resident #23. She put material from Resident #23's medication pass into Bed A's trash can (not on contact precautions). She then dumped towels from a trash bag in room [ROOM NUMBER] onto the floor and cleaned the floor under Resident #23's wheelchair. Additional observation, on 10/20/2022 at 7:15 PM, revealed Licensed Practical Nurse (LPN) #1 in room [ROOM NUMBER]B performing wound care. At completion of the wound care, the SSA Surveyor removed the PPE, but there was no trash can at the door. The resident, who resided in bed 210A (non-isolation) stated, Put that in my trash can, everyone else does. Observation of the trash can, which sat between the resident in bed 210A's bed and the oxygen concentrator revealed gowns were in the trash can. Interview with LPN #1, on 10/20/2022 at 7:30 PM, revealed placing trash from a contact isolation resident into another resident's trash could cause cross-contamination and possibly make the roommate ill. 11. Observation, on 10/20/2022 at 11:40 AM, revealed CNA #8 in Isolation room [ROOM NUMBER] with a gown on, but it was not tied at the neck or waist. After exiting room [ROOM NUMBER], CNA #8 entered room [ROOM NUMBER] without performing hand hygiene. CNA #8 then entered room [ROOM NUMBER], with no hand hygiene observed. CNA #8 then entered room [ROOM NUMBER], but exited the room abruptly without hand hygiene. 12. Observation, on 10/20/2022 at 6:20 PM, revealed CNA #8 went into residents' rooms with a rolling cart, which had a pulse oximeter and a thermometer. CNA #8 entered, with the cart, into room [ROOM NUMBER]B, and took the resident's temperature, which required touching the forehead. The thermometer did not have a cover, but touched the forehead directly. She did not disinfect the thermometer and only wiped the pulse oximeter after use for eight (8) seconds with Micro-Kill Germicidal Bleach Wipes (the label stated contact time was thirty (30) seconds). Per the observation, no hand hygiene was performed. The rolling cart was then taken into other residents' rooms. Interview with CNA #6, on 10/20/2022 at 12:00 PM, revealed education from the facility consisted of hand hygiene (HH) with a visual audit and isolation precautions. She stated other training was done by computer, and she knew all equipment should be disinfected between residents, and supplies to disinfect equipment were available. Interview with CNA #7, on 10/20/2022 at 4:20 PM, revealed training consisted of HH checkoffs, and staff did have in-services for isolation requirements and to disinfect equipment before and after use for each resident. Interview with CNA #13, on 10/20/2022 at 7:05 PM, revealed training consisted of videos for HH and use of PPE. CNA #13 stated she did not recall any audits or being instructed to disinfect equipment between resident use. Interview with CNA #14, on 10/20/2022 at 7:20 PM, revealed training consisted of HH, correct use of PPE, and being fit tested for N-95 respirators. He stated he self-screened for COVID every time he came to work. When asked about disinfecting resident shared equipment, he stated the only piece of equipment disinfected was the pulse oximetry unit, not the vital sign equipment. Interview with the Infection Preventionist (IP) Nurse, on 10/21/2022 at 9:20 AM, revealed she had worked at the facility for two (2) years and also was the Assistant Director of Nursing (ADON). She stated staff was educated to perform HH between residents and disinfect the equipment. She stated her expectation for staff members was to follow trainings and self-report if they had issues with performing a task or understanding the process. She stated staff should wash with soap and water after three (3) HH's with ABHR. Additionally, she stated, if during the screening process a visitor was symptomatic, he/she would be encouraged to test for COVID-19. Continued interview with the IP Nurse, on 10/21/2022 at 9:20 AM, revealed the only isolation residents was on Contact Precautions. The IP Nurse stated staff should follow the signage on the door. She stated HH audits were performed, but they were not recorded. She stated the front desk staff should screen visitors in for better source control of COVID. She stated staff from the East Hall should do the screening when the front desk personnel were not available. The IP nurse stated there were no COVID positive residents in the facility at present. Interview, with the Director of Nursing (DON), on 10/22/2022 at 11:00 AM, revealed she had held the position since December 2021, and her responsibility was to provide oversight of the Nursing Department. Continued interview revealed she provided assistance with IP. but she was not certified. Additional interview revealed her expectation for the staff was to follow the training protocol which was provided per the program annually. Further interview revealed staff was to abide by the signage for contact precautions, proper HH/PPE, and the supply cart should not be taken into an isolation room. The Administrator was out of town and was not available for interview.

Based on interview and review of the facility's policy, it was determined the facility failed to provide residents with activities on Saturday and Sunday. The facility census was sixty-two (62). The findings include: Review of the facility's policy titled, Activity Procedures, undated, revealed the facility was to offer residents the opportunity for improving or maintaining physical functioning abilities in a recreational setting. Per the policy review, participation in exercise could also help maintain or increase cognitive abilities and feelings of self-worth and positive self-esteem. Interview with Resident Council members on 10/18/2022 at 3:14 PM, revealed the facility was not providing any scheduled activities for residents on Saturdays and Sundays. Interview with the Activities Director on 10/20/2022 at 2:00 PM, revealed the facility had provided supervised activities for the residents on weekends prior to the COVID pandemic. She stated, after COVID, the facility considered bringing activities back on weekends. Continued interview revealed she waited for the Administrator's direction regarding a starting date for provision of weekend activities. The Activities Director further stated she and the Activities Assistant on Fridays, provided residents with packets that contained coloring books and puzzles before the weekend. In an additional interview with the Activities Director on 10/21/2022 at 8:20 AM, revealed the President of the Resident Council brought the concerns of no scheduled activities on weekends to the Administrator's attention. She stated the concerns were not discussed during the Resident Council meetings; however, it had been a private conversation between the Administrator and the President of the Resident Council. Further interview revealed the Activities Director and her assistant were planning to leave early during the week so they could come back and provide activities on the weekends. Interview with the Director of Nursing (DON) on 10/20/2022 at 2:51 PM, revealed she had not heard that residents were complaining about activities not being provided on weekends, that issue had not been discussed with her. She stated she would talk to the Administrator, and they would get something in place for weekend activities. Further interview revealed facility staff could put the packets with coloring books and puzzles on the nurse's stations while the situation was being resolved. The Administrator was out of town and not available for interview.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to date and change weekly oxygen tubing as required for four (4) of thirty (30) sampled residents, Residents #28, #29, #37, and #54. The findings include: Review of the facility's policy titled, Respiratory Care Services Policy & Procedure, Oxygen Equipment: Supply Change, undated, revealed nasal cannulas and oxygen supply tubing were to be replaced every seven (7) days and as needed (PRN) per facility protocol. 1. Review of Resident #54's medical record revealed the facility admitted the resident, on 01/22/2019, with diagnoses to include Heart Failure, Coronary Artery Disease (CAD), Asthma, and Respiratory Failure. Review of Resident #54's Quarterly Minimum Data Set (MDS) Assessment, dated 09/03/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #54's Care Plan, dated 08/22/2022, revealed the resident received oxygen at two (2) liters per minute (LPM) per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/18/2022 at 11:45 AM, revealed the oxygen tubing in use for Resident #54 was dated 10/05/2022. The staff replaced it with new tubing and placed oxygen per nasal cannula (N/C) on the resident. 2. Review of Resident #29's medical record revealed the facility admitted the resident, on 03/03/2021, with diagnoses to include Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Diabetes, and Pulmonary Fibrosis. Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 07/23/2022, revealed a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognition. Review of Resident #29's Care Plan, dated 03/03/2021, revealed the resident received oxygen at three (3) LPM per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/18/2022 at 12:10 PM, revealed Resident #29's oxygen tubing was dated 10/05/2022, with no date on the humidifier bottle. 3. Review of Resident #37's medical record revealed the facility admitted the resident, on 03/22/2022 with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and Chronic Respiratory Failure with Hypoxia. Review of Resident #37's Quarterly MDS Assessment, dated 08/17/2022, revealed the resident had a BIMS score of twelve (12) of fifteen (15), which indicated the resident had moderate cognitive impairment. Review of Resident #37's Care Plan, dated 03/22/2022, revealed the resident received oxygen at three (3) LPM per nasal cannula or mask. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation, on 10/19/2022 at 9:15 AM, revealed Resident #37's oxygen tubing was dated 10/05/2022. 4. Review of Resident #28's medical record revealed the facility admitted the resident, on 08/12/2022, with diagnoses to include Atrial Fibrillation (AF), Peripheral Vascular Disease (PVD), and Shortness of Breath. Review of Resident #28's Admission Minimum Data Set (MDS) Assessment, dated 08/12/2022, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognition. Review of Resident #28's Care Plan, dated 09/23/2022, revealed the resident received oxygen at three (3) LPM per nasal cannula. However, the care plan did not have an intervention to include oxygen tubing change every seven (7) days and PRN. Observation of Resident #28, on 10/20/2022 at 2:00 PM, revealed oxygen therapy at 3 LPM per nasal cannula, but the oxygen tubing was not dated. The resident stated, at that time, that he/she had been on oxygen since admission, and this therapy was not new. Interview with the facility's contracted Respiratory Service Technician, on 10/19/2022 at 9:30 AM, revealed his company was a contracted service and oxygen tubing with nasal cannulas and humidifier water bottles were changed every two (2) weeks. He revealed he added a date sticker on the tubing line. He also reported he left extra tubing and bottles in the supply closet at the facility for as needed (PRN) use. Interview with the Director of Nursing (DON), on 10/22/2022 at 12:03 PM, revealed she was not aware of the facility's policy stating that oxygen tubing was to be changed weekly. She stated since she was made aware of this, the facility was in the process of adding oxygen tubing change to the Treatment Administration Record (TAR). She stated it was important to change oxygen tubing timely due to the risk of contamination from bacteria, which could cause infection and/or decreased airflow. The Administrator was out of town and not available for interview. 44974

Based on observation, interview, record review, review of medication package inserts, review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, and review of the facility's policy, it was determined the facility failed to store all drugs and biologicals under proper temperature control. Observation of the two (2) medication refrigerators revealed one (1) had temperatures outside the recommended range for drug storage. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed proper vaccine storage and handling played critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy, creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. Per CDC recommendations, vaccine temperatures should be monitored and documented at least twice daily if the refrigerator did not have a temperature monitoring device, which read minimum and maximum temperatures. Further review revealed best practices for storage of vaccines was to ensure that vaccines were not stored on the top shelf, floor, or door of the refrigerator as the temperature in these areas might differ significantly from the temperature in the body of the unit. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revised 07/21/2022, revealed the facility should ensure that medications were stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines. Further review revealed the listed range for refrigeration was thirty-six (36) to forty-six (46) degrees Fahrenheit. Review of the facility's Refrigerator Temperature logs, dated 10/15/2022 through 10/21/2022, revealed the Medication room [ROOM NUMBER] refrigerator was checked once per day. Additional review revealed, on two (2) of the seven (7) day period, the temperature was documented as thirty-four (34) degrees Fahrenheit. Observation, on 10/21/2022 at 11:56 AM, revealed the Medication room [ROOM NUMBER] refrigerator had a temperature of thirty-two (32) degrees Fahrenheit and contained the following medications labeled as requiring temperatures between thirty-six (36) and forty-six (46) degrees Fahrenheit: 1) one (1) Latanoprost 0.005% eye drops (used to treat increased pressure in the eye) 2) two (2) Novolog FlexPens (a fast acting insulin used to treat high blood sugar; 3) one (1) Magnesium Citrate bottle (laxative); 4) one (1) container of prefilled Prevnar syringes (pneumonia vaccine); 5) one (1) vial of tuberculosis testing solution; 6) one (1) container of prefilled Pneumovax syringes (vaccine to prevent pneumonia); 7) one (1) container of Engerix B prefilled syringes (vaccine to prevent Hepatitis B); 8) eight (8) Bisacodyl suppositories (laxative); 9) one (1) Acetaminophen 650 milligram (mg) suppository (pain reliever, fever reducer); 10) Promethazine 25 mg suppositories (treated nausea); 11) Lispro insulin; 12) Lantus insulin; 14) Novolin N insulin; 15) Novolin R insulin; 16) Novolin 70/30 insulin 10 mg; 17) Tresiba FlexTouch (a long acting insulin); and 18) Basaglar KwikPen (a long acting insulin). Observation, on 10/21/2022 at 11:56 AM, revealed the Medication room [ROOM NUMBER] refrigerator had a temperature of thirty-two (32) degrees Fahrenheit (freezing point)and contained Glargine insulin (the Basaglar KwikPen and Lantus) and Humulin insulin (the Lispro and Novolin insulins). Review of the package inserts for Glargine insulin at https://pi.lilly.com/us/basaglar-kwikpen-us-ifu.pdf and https://products.sanofi.us/lantus/lantus.html#Section-15.2, revealed the insulin should not be frozen. In addition, the inserts stated if the insulin had been frozen not to use it. Review of the package inserts for the Lispro insulin at https://www.drugs.com/pro/insulin-lispro.html#s-34069-5; for the Novolin-N insulin at https://www.drugs.com/pro/novolin-n.html#s-34069-5; for the Novolin-R insulin at https://www.drugs.com/pro/novolin-r.html#s-34069-5; for the Novolin 70/30 insulin at https://www.drugs.com/pro/novolin-70-30.html#s-34069-5; and for the Tresiba insulin at https://www.drugs.com/pro/tresiba.html#s-34069-5, revealed they should not be frozen. In addition, the inserts stated if the insulin had been frozen not to use it. Interview with Certified Medical Technician (CMT) #2, on 10/21/2022 at 11:30 AM, revealed she believed night shift staff performed temperature checks on the medication refrigerators. She stated she was not able to locate the temperature logs. Interview with CMT #1, on 10/21/2022 at 11:55 AM, revealed the Maintenance Department performed temperature checks on the medication refrigerators. She stated she was not able to locate the temperature logs. Interview with a Maintenance worker, on 10/21/2022 at 12:34 PM, revealed he checked the temperatures on the medication refrigerators every morning when he arrived at the facility. He stated he adjusted the temperature if he found it to be outside of a range of thirty-two (32) to forty (40) degrees Fahrenheit. Interview with the Director of Nursing (DON), on 10/26/2022 at 11:06 AM, revealed her expectation was for the Maintenance staff to check the temperatures on the medication refrigerators to make sure the temperatures were in the correct range. The DON stated she was unable to state what that range should be without looking it up online. After looking it up, she stated the temperature should be thirty-six (36) to forty-six (46) degrees Fahrenheit. Also, the DON stated temperature regulation of the medication refrigerators was important to ensure the medications were still effective and had not been damaged by improper storage. The Administrator was out of town and was not available for interview.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the comprehensive care plan (CCP) after each assessment following falls with interventions to prevent falls, for one (1) of thirty (30) sampled residents (Resident #42). Resident #42's CCP was not revised/updated for twelve (12) of the twenty-one (21) falls he/she experienced from 04/29/2022 through 10/14/2022. Refer to F-0689 The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed it was the facility's policy to review and update a resident's care plan when the desired outcome had not been met. Review of Resident #42's medical record revealed the facility admitted him/her on 04/23/2020, with diagnoses including Chronic Obstructive Pulmonary Disease, Polyneuropathy, Chronic Pain, Dizziness, History of Falls, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating mild cognitive impairment. Review of the facility's Event Log from 04/01/2022 to 10/14/2022, revealed Resident #42 experienced twenty-one (21) falls between 04/29/2022 through 10/14/2022. While conducting the review of Resident #42's falls from 04/29/2022 through 10/14/2022, the State Survey Agency (SSA) Surveyor noted a pattern of several falls occurring around toileting. However, review of the facility's documentation revealed no documentation noting any patterns determined for Resident #42's falls. Review of Resident #42's CCP, initially dated 04/24/2020, and most recently revised 08/27/2022, revealed Resident #42 would have no avoidable falls and/or no falls with injury before the next review of the CCP. Review of Resident #42's CCP for fall prevention interventions, dated 04/24/2020 to 04/28/2020, revealed the interventions included: answering the call light as promptly as possible each shift; offering toileting before and after meals and at bedtime; assisting the resident with clothing management; monitoring the condition of the resident's shoes; encouraging the use of nonslip socks/shoes; instructing the resident to ask for assistance before transfers; keeping the bedside table and call light within reach; placing a wheelchair pad alarm to alert staff; and using Meclizine (an antihistamine used to treat dizziness) to treat dizziness as ordered. Review of Resident #42's CCP for fall prevention, dated 01/19/2022 to 03/25/2022, revealed the interventions included: installing padded flooring to the resident's room; keeping the bed in the lowest position; and providing a hand bell for the resident to use in addition to the call bell. 1. Review of Resident #42's medical record revealed he/she experienced a fall on 04/29/2022 at 7:32 AM, when the resident stood up and tried to turn the wheelchair alarm off, fell into the wheelchair, and tipped the wheelchair over which resulted in the resident sustaining an abrasion to the right middle finger. Continued review revealed no new care plan interventions were noted following this fall. 2. Review of Resident #42's medical record revealed the resident experienced a fall on 05/02/2022 at 4:15 AM, when the resident attempted to go to the bathroom while the room was dark. Continued review revealed no new care plan interventions were noted following this fall. 3. Review of Resident #42's medical record revealed the resident experienced a fall on 05/02/2022 at 10:55 AM, when the resident slid on the mat in the bathroom and scraped his/her back. Continued review revealed no new care plan interventions were noted following this fall. 4. Review of Resident #42's medical record revealed the resident sustained a fall on 05/15/2022 at 6:00 PM, when the resident stood in front of the commode in the bathroom and fell . Continued review revealed no new care plan interventions were noted following this fall. 5. Review of Resident #42's medical record revealed the resident sustained a fall on 05/22/2022 at 8:08 AM, when he/she slid off the bed while trying to get up. Continued review revealed no new care plan interventions were noted following this fall. Per continued review of Resident #42's CCP revealed on 05/24/2022, the care plan had been modified to add the intervention of placing Dycem (a non-slip material used for stabilization and to prevent sliding) in the wheelchair seat to prevent falls. Additional review of Resident #42's CCP revealed on 05/25/2022, the care plan was modified to add the intervention of installing grab bars on top of the bathroom counter to assist the resident with balance. Per review of Resident #42's CCP, on 05/25/2022, the CCP was modified to add the intervention of consulting the pain pump management team about a medication review due to the resident's dizziness. Further review of Resident #42's CCP revealed on 06/02/2022, the CCP was modified to add the intervention of placing a stop sign at the bathroom door to remind the resident to ask for assistance with toileting. 6. Continued review of Resident #42's medical record revealed the resident experienced a fall on 06/03/2022 at 10:15 PM, while ambulating from the bathroom to the wheelchair. Continued review revealed no new care plan interventions were noted following this fall. 7. Review of Resident #42's medical record revealed the resident sustained a fall on 06/09/2022 at 7:30 PM, when he/she was making the bed and got his/her feet tangled in the blankets and fell . Continued review revealed no new care plan interventions were noted following this fall. 8. Review of Resident #42's medical record revealed the resident experienced a fall on 06/22/2022 at 5:29 AM, when trying to get back into bed. Continued review revealed no new care plan interventions were noted following this fall. 9. Review of Resident #42's medical record revealed the resident sustained a fall on 06/25/2022 at 7:50 AM, while attempting to transfer independently onto the toilet seat. Continued review revealed no new care plan interventions were noted following this fall. Additional review of Resident #42's CCP revealed on 07/10/2022, the care plan was modified to add an intervention of using a perimeter defined mattress to the resident's bed for positioning. 10. Review of Resident #42's medical record revealed the resident experienced a fall on 08/14/2022 at 5:04 AM, when he/she independently changed his/her briefs. Continued review revealed no new care plan interventions were noted following this fall. 11. Review of Resident #42's medical record revealed the resident experienced a fall on 08/21/2022 at 6:35 PM, when he/she reached for clothing in a drawer. Continued review revealed no new care plan interventions were noted following this fall. 12. Review of Resident #42's medical record revealed the resident experienced a fall from his/her wheelchair on 10/14/2022 at 1:20 PM, while looking for a light on the floor. Continued revealed no new care plan interventions were noted following this fall. Observation on 10/19/2022 at 11:53 AM, revealed Resident #42 in his/her room, sitting in his/her wheelchair, slumped forward and leaning to the right side. Interview with Resident #42 on 10/18/2022 at 3:36 PM, revealed he/she fell frequently due to dizziness, resulting in the facility placing a foam mat in the resident's room to prevent injuries. Continued interview revealed Resident #42 believed the dizziness was due to his/her pain medication. Resident #42 stated however, he/she needed the pain medication or his/her pain was unbearable and limited his/her ability to perform activities of daily living (ADL) and participate in activities. Further interview revealed there were some staff who did not answer his/her call light in a timely manner; however, the resident was unable to recall any names. Interview with Licensed Practical Nurse (LPN) #7 on 10/20/2022 at 5:45 PM, revealed she was aware Resident #42 had experienced multiple falls. She stated Resident #42's care plan interventions for fall prevention included having him/her wear nonskid socks, having a padded floor in the resident's room, and placing alarms in the resident's wheelchair, until the resident refused these alarms. Interview with the Assistant Director of Nursing (ADON), who also acted as the facility's Falls Coordinator, on 10/22/2022 at 11:15 AM, revealed the only other thing the facility could suggest for Resident #42 was a bubble due to his/her noncompliance with previously attempted interventions. The ADON stated she looked at the falls incident reports and worked with the facility's interdisciplinary team (IDT) to develop resident-specific interventions to prevent falls. She stated her expectation was for staff to provide increased supervision of Resident #42 by performing every two (2) hours checks of the resident to see if he/she needed assistance going to the bathroom. She stated however, she was unsure if this expectation was communicated in the resident's care plan, and made no attempt to look it up to determine if the checks were noted on the resident's care plan. Per the ADON, she provided education for staff regarding ensuring residents' care plans were being followed. Interview with the Director of Nursing (DON), on 10/22/2022 at 11:15 AM, revealed she was aware of Resident #42's history of falls and was able to access the CCP and read the interventions in place. She stated the care plan was an important communication tool for staff to know what each resident needed. Per the DON, tracking residents' falls was the responsibility of the ADON, Further interview revealed the facility had a committee that analyzed residents' falls, and the ADON would be able to give more details on the findings of that group, since that committee was her responsibility. The Administrator was out of town and was not available for interview.

Based on interview, record review, review of the facility's investigation information, and review of the facility's policy, it was determined the facility failed to timely report an allegation of staff to resident abuse for two (2) of thirty (30) sampled residents, Resident #48 and #13. Resident #48 told a staff member, on 09/14/2022, that two (2) Certified Nursing Assistants (CNA) had verbally abused him/her and were forceful when providing care on 09/13/2022; however, the alleged abuse was not reported to the State Survey Agency (SSA) within two (2) hours. In addition, the Five (5) Day Investigation Report was not reported to the SSA until 09/20/2022, six (6) days after the facility learned of the incident. Resident #13 told a staff member, on 09/15/2022, that two (2) CNA's had verbally abused the resident and provided rough treatment, date unknown; however, the alleged abuse was not reported to the SSA within two (2) hours. The findings include: Review of the facility's policy titled Resident Abuse, not dated, revealed residents had the right to be free from abuse, both verbal and physical. The policy stated any incidents of suspected abuse should be immediately reported to the employee's immediate supervisor and the Administrator. According to the policy, the Administrator would follow the facility's protocols for reportable incidents. Review of Resident #48's medical record revealed the facility admitted the resident on 02/23/2022, with diagnoses which included Diabetes, Chronic Diastolic Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/01/2022, revealed the facility assessed Resident #48 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #13's medical record revealed the facility admitted the resident on 04/05/2021, with diagnoses which included Diabetes, Dementia, COVID, and Hypertension. Review of the Quarterly MDS Assessment, dated 07/01/2022, revealed the facility assessed Resident #13 to have a BIMS score of twelve (12), which indicated the resident had moderately impaired cognition. Review of the facility's investigation information revealed the investigation was initiated on 09/14/2022, after Resident #48 reported to CNA #15 that CNA's #13 and #14 had been verbally abusive and forceful in the resident's care. However, the facility did not notify the SSA within two (2) hours, and the Five (5) Day Investigation Report was not completed until 09/20/2022, six (6) days after initiation. Further review revealed, during the investigation and interviews with residents who had a BIMS score of eight (8) or greater, Resident #13 reported the same two (2) CNA's had been rough with him/her. This allegation of abuse was reported to the Social Services Director (SSD), on 09/15/2022; however, the facility did not notify the SSA with two (2) hours. Interview with CNA #15, on 10/22/2022 at 12:33 PM, revealed she had been bathing Resident #48 when the resident told her that the night shift CNA's had been mean to him/her when providing his/her care. According to CNA #15, Resident #48 told her the CNA's were hateful and forceful when turning him/her in the bed. CNA #15 stated she informed the SSD of what Resident #48 had told her, immediately after completing the resident's bath. Interview with the SSD, on 10/20/2022 at 5:00 PM, revealed CNA #15 had informed her of the incident involving Resident #48 being abusive to the resident. The SSD stated Resident #48 had told CNA #15 during his/her bath that CNA #13 and CNA #14 had been very rough with his/her care and used rough language while providing care. Per interview, both CNA's were already out of the facility when the SSD was notified of the incident. Continued interview revealed she reported the incident to the Administrator/Abuse Coordinator, and he took control of the investigation after that. According to the SSD, she had assisted with performing the resident interviews after the incident with Resident #48, and during the interview with Resident #13, the resident informed the SSD that the same two (2) CNA's had been rough with the resident. Further interview revealed the SSD immediately stopped the interview with Resident #13 and had the Administrator and Director of Nursing (DON) return to Resident #13's room with her to handle the allegation. Interview with the DON, on 10/22/2022 at 12:03 PM, revealed the Administrator had the responsibility for reporting incidents of abuse to the proper authorities and within the required time frames. She stated she had not been involved with this reporting. The Administrator was out of town and was not available for interview.

Based on interview, record review, review of the facility's policy, and review of Federal Regulations regarding Advance Directives, it was determined the facility failed to have a policy on Advance Directives which allowed two (2) of thirty (30) sampled residents, Residents #25 and #42 to have insufficient documentation concerning their directives for medical care. The findings include: Interview with the Social Service Director (SSD) on [DATE] at 10:30 AM, revealed the facility did not have a policy detailing how Advance Directives were to be obtained or what they should contain. Review of the facility's policy titled, Resident Rights, not dated, revealed the facility was to comply with the requirements specified in 42 CFR Part 489, Subpart 1, to provide information to all adult residents concerning the right to formulate an advance directive. Review of 42 CFR 489.100, Subpart 1, Advance Directives, revealed advance directives was defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Further review revealed skilled nursing facilities (SNF) must maintain written policies and procedures concerning Advance Directives with respect to all adult individuals receiving medical care, by or through the provider and were required to document in a prominent part of the individual's current medical record whether or not the individual had executed an Advance Directive. 1. Review of Resident #25's medical record revealed the facility admitted the resident on [DATE], with a primary diagnosis of Heart Failure. Review of the 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 fifteen (15), indicating the resident was cognitively intact. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed the resident to continue to have a BIMS score of fifteen (15). Additional review of Resident #25's medical record revealed a one (1) sheet Medical Directive Acknowledgement form dated [DATE], which contained a check mark noted beside the sentence stating, I have chosen to formulate the following directives for care. Continued review of the medical record and the Medical Directive Acknowledgement form revealed a separate box located at the bottom of the form that was checked as Yes by the area noting Use of CPR (Cardiopulmonary Resuscitation) in the event of cardiac or respiratory arrest, with the word verbal noted by Resident #25's name. Review of the form also revealed it did not list in detail Resident #25's directives beyond his/her CPR status (Such as use of Intravenous Fluids [IVF] or feeding tubes, or intubation). Further review of the Medical Directive Acknowledgement form revealed it contained an additional check mark documented by the, Durable Health Care Power of Attorney, which noted the method by which the resident had expressed his/her wishes for future care. Per review, the Resident Signature line contained no documented resident signature; however, the Facility Representative Acknowledgement area contained the facility's Social Services Director (SSD) signature and a signature was noted on the Physician Acknowledgement line. Further review on the line noted as Responsible Party/Surrogate Acknowledement Resident #25's Power of Attorney (POA), as noted on his/her admisison record, was printed, with documentation noting verbal rather than a written signature of the POA. In addition, record review further revealed no documented evidence noted in Resident #25's medical record verifying the resident had a Durable Health Care POA in place; and no evidence of a copy of a Durable Health Care POA located in his/her medical record. 2. Review of Resident #42's medical record revealed the facility admitted the resident on [DATE], with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #42 to have a BIMS score of fifteen (15), indicating the resident was cognitively intact. However, review of the latest Annual MDS assessment dated [DATE], revealed the facility assessed Resident #42 to have a BIMS score of eleven (11), indicating the resident was now assessed to have moderately impaired cognition. Record review further revealed Resident #42 was listed as being his/her own responsible party after the [DATE] MDS Assessment. Additional review of Resident #42's medical record revealed a one (1) sheet Medical Directive Acknowledgement form dated [DATE], which contained a check mark noted beside the sentence stating, I have chosen to formulate the following directives for care. Review of the Facility Representative Acknowledgement area revealed it contained the facility's SSD's signature and a signature was noted on the Physician Acknowledgement line. Review on the line noted as Responsible Party/Surrogate Acknowledement there was a printed name on the line with the word verbal documented beside the name. However, review of Resident #42's medical record revealed the person's name printed beside the word verbal on the Medical Directive Acknowledgement form was not listed in the resident's record as one (1) of his/her emergency contacts. Further review of the Medical Directive Acknowledgement form revealed it contained check marks by the Directives for Care and by the Durable Health Care Power of Attorney which indicated the methods by which the resident expressed his/her wishes for future care. Review of the form revealed there was also a box which read, To be completed only by a resident who had decisional capacity and Use of CPR in the event of cardiac or respiratory arrest which had No checked beside them. Record review further revealed no documented evidence noted in Resident #42's medical record verifying the resident had a Durable Health Care POA in place; and no evidence of a copy of a Durable Health Care POA located in his/her medical record. Additionally, there was no documented evidence of specific directives for Resident #42's care if he/she suffered a catastrophic incident. Interview with the MDS Coordinator on [DATE] at 4:52 PM, revealed she defined Advance Directives as a resident's code or CPR status. She stated if a resident had more specific wishes regarding the aspects of his/her care, the Physician would have to write an order clarifying those wishes. Per the MDS Coordinator, if the Physician wrote such orders they would be found in the facility's electronic health record (EHR) for the resident. She further stated the SSD handled the facility's Advance Directives process for residents with them and their families. Interview with the SSD on [DATE] at 10:30 AM, revealed the facility's process for giving Advance Directives information to residents began with their admission to the facility. She stated if the resident came to the facility from the hospital, the facility used the hospital information and then discussed the resident's code status and living will information with the resident and his/her family. Continued review revealed she also gathered relevant documents at the time of that discussion to present to the resident and his/her family. The SSD further stated she defined Advance Directives as a resident's desired code or CPR status. Further interview revealed Advance Directive were to be considered separately from a living will which detailed resident's wishes regarding use of a feeding tube or a ventilator (Even though this differed from the definitions in the Code of Federal Regulations). The Administrator was out of town and unavailable for interview.

Based on interview, record review, and review of the facility's documents and policies, it was determined the facility failed to protect two (2) of thirty (30) sampled residents from abuse, Resident #48 and Resident #13. Review of the facility's Investigation Report dated 09/14/2022, revealed Resident #48 was verbally abused on 09/13/2022, by Certified Nursing Assistant (CNA) #13 and CNA #14. In addition, while investigating the incident involving the verbal abuse of Resident #48, by CNA #13 and #14, the facility also identified the two (2) CNA's provided rough care on date(s) unknown. The findings include: Review of the facility's policy titled, Prohibiting Abuse, Neglect, Misappropriation and Exploitation, dated 11/2017, revealed it was a residents' right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion (including any physical or chemical restraint not required to treat the resident's medical symptoms), as well as neglect and exploitation. Continued review revealed residents were not to be subjected to abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members/resident representatives or legal guardians, friends or other individuals. Further policy review revealed verbal abuse referred to any oral, written or gestured language that included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of the facility's Five (5) Day Investigation Report, dated 09/14/2022, revealed the alleged perpetrators were night shift CNA #13 and CNA #14. Per review, the CNAs called Resident #48 dumb and retarded, and both CNAs were immediately suspended pending the investigation. Continued review revealed both CNAs were interviewed by telephone by the Director of Nursing (DON) and both denied the allegations of verbal abuse. The Report review revealed skin assessments were completed for residents with a Brief Interview for Mental Status (BIMS) score of less than nine (9), which indicated the residents had moderate to severe cognitive impairment, with no issues noted. Per review of the Report, all residents with a BIMS score of greater than eight (8), which indicated moderate to intact cognition, were interviewed. Continued review of the facility's Five (5) Day Investigation Report revealed during the course of the investigation, while conducting interviews with other interviewable residents living on the same unit as Resident #48, another resident, Resident #13, alleged the two (2) night shift CNAs who had been verbally abusive to Resident #48, were rough with him/her during care. Per review of the Report, Resident #13 stated he/she felt like a sack of potatoes, during provision of care, and requested the two (2) CNAs not provide care for him/her anymore. Review revealed Resident #13 described the same two (2) CNAs as being rough with him/her, as were in the initial allegation. Further review of the Report revealed the facility believed that there was enough evidence to substantiate the allegation of verbal abuse and providing care in a manner that Resident #13 perceived as impatient or rough. Review of the Report further revealed CNA #13 and CNA #14 were terminated. 1. Review of Resident #48's medical record revealed the facility admitted the resident on 02/23/2022, with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and Chronic Diastolic Congestive Heart Failure (CHF). Review of Resident #48's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14), which indicated the resident was cognitively intact. Interview with Resident #48 on 10/20/2022 at 9:45 AM, revealed the resident had never had any issues with staff in the past, until the night of the incident, 09/13/2022, when the two (2) night shift CNAs (CNA #13 and CNA #14) came into his/her room and were hateful and mouthy to him/her. Resident #48 stated he/she could not remember exactly what the CNAs said to him/her, and stated he/she could not recall the CNAs names. According to Resident #48, she had reported the incident to CNA#15 the next day. Per Resident #48, those girls were going to have to learn some manners. Further interview revealed the two (2) CNAs had not been back into his/her room to provide care since he/she reported how they treated him/her. Interview with CNA#15 on 10/22/2022 at 12:33 PM, revealed she was the primary bath aide on 09/14/2022, when Resident #48 told her that the night shift CNAs had been mean to him/her when they came in to change him/her. CNA #15 reported Resident #48 told her the CNAs were hateful and forceful with turning him/her. Per CNA #15, she reported what Resident #48 had told her to the SSD immediately after completing the resident's bath, as she had been trained to do. Further interview revealed she was never asked to provide a written statement regarding the incident during the facility's investigation. Interview with Family Member #4 on 10/20/2022 at 9:55 AM, revealed Resident #48 had been upset and cried when she repeated what happened during the incident to the family member. Further interview revealed the SSD followed up with Resident #48 and assured the resident the CNAs would not be back. Interview with the SSD on 10/20/2022 at 5:00 PM, revealed she had been informed of the incident involving Resident #48 by CNA #15 on 09/14/2022. She stated Resident #48 had told CNA #15, during his/her bath, that CNA #13 and CNA #14 were very rough with him/her when providing care and used rough language, and it upset the resident and made him/her cry. Further interview revealed both CNAs were already out of the facility when she was informed of the incident by CNA #15. The SSD further stated she reported the alleged incident information to the Administrator/Abuse Coordinator, and he took control of the investigation. 2. Review of Resident #13's medical record revealed the facility admitted the resident on 04/05/2021, with diagnoses of Diabetes and Dementia. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), which indicated the resident had moderate cognitive impairment. Interview with Resident #13 on 10/20/2022 at 5:25 PM, revealed the resident stated, I don't like to talk about it, referencing the incident. Resident #13 stated one (1) evening (on a date unknown) when asking for assistance to go to the dining room for dinner, two (2) CNAs arrived to help. Continued interview revealed the CNAs threw him/her around like a sack of potatoes, and rolled him/her against the side rail of the bed. Resident #13 stated, One of them gritted her teeth at me. They were bullies. Further interview revealed those two (2) CNAs had not been back in his/her room again after that evening. Resident #13 further stated he/she did not report the incident to the office; however, had reported it to the SSD when questioned. In addition, Resident #13 stated she was not afraid or hurt, but was still angry because of how he/she was treated by the CNAs. Interview with the SSD on 10/20/2022 at 5:00 PM, revealed while she was assisting with resident interviews on 09/15/2022, during the facility's investigation of the incident involving Resident #48 another resident, Resident #13, reported CNA #13 and CNA #14 had provided care for him/her that was rough, and Resident #13 had felt like a sack of potatoes. The SSD stated she immediately stopped the interview with Resident #13 and went immediately to the Administrator and Director of Nursing (DON). Further interview revealed she had the Administrator and DON go to Resident #13's room with her to talk with the resident. The SSD further stated from that point the Administrator took over with the incidents. Interview with the DON on 10/22/2022 at 12:03 PM, revealed abuse trainings were provided online for facility staff. Per interview, the facility provided updated abuse trainings after each incident with all staff. She revealed oversight was provided by educating supervisors for staff in addressing abuse and each CNA was talked to regarding abuse reporting, types or abuse, and monitoring for abuse. Further interview revealed walking rounds were to be completed by staff on the floor each shift to observe for any issues. The DON further stated nurses especially were instructed to do spot checks of all residents. The Administrator was out of town and was not available for interview.

Based on interviews, record review, document review, review of the Certified Nursing Assistant (CNA) Job Description, and review of the facility's policy, it was determined the facility failed to accurately maintain medical records on food and fluid consumption for one (1) of thirty (30) sampled residents (Resident #7). The findings include: Review of the facility's policy titled, Documenting of Food Consumption, not dated, revealed nursing personnel shall record each resident's intake of meals immediately following mealtime. The policy further stated intake of meals shall be recorded by food categories, and documentation of consumption by food categories provided in-depth information on a resident's food intake patterns. Per the policy, the Food Service Manager and/or Consultant Dietitian, along with nursing personnel, would monitor intake routinely or according to the resident's individual care plan. Review of the facility's document titled, Certified Nursing Assistant Job Description, not dated, revealed CNA's were to report and document nutritional and fluid intake. Further review revealed CNA's performed and documented resident care activities according to written and verbal instructions from the charge nurse. Review of the facility's Competency Based Orientation packet for CNA's and the CNA Skills Checklist revealed CNA's were responsible for documentation of resident consumption per the facility's policy. Review of Resident #7's Point Click Care (a software to record certain resident information) records revealed CNA #9 charted the resident consumed 75 to 100% of his/her food and drank 360 milliliters (ml) of fluids, on 10/20/2022 during his/her lunch time. It was also recorded that Resident #7 was given a Magic Cup (120 ml, a nutritional product) at 2:00 PM. It was recorded that CNA #8 signed the copy of the charting that this Magic Cup was given between breakfast and lunch. Observation, on 10/20/2022, during lunch time, revealed Resident #7 consumed about 35% of his/her food and drank a small Styrofoam cup of liquid filled with ice. After lunch, the CNA, who assisted the resident with his/her food agreed with the observation. According to the Staff Development Coordinator, the Styrofoam cup was eight (8) ounces or 240 ml. Interview with CNA #9, on 10/21/2022 at 8:20 AM, revealed she recorded Resident #7 ate 75 to 100 % of his/her food and drank 360 ml of fluids on 10/20/2022 during his/her lunch time. She stated she did not see the resident's tray after he/she finished eating, and she did not observe the resident eating his/her food. She said the amount of food and drink was reported to her. CNA #9 stated she did not remember who told her how much Resident #7 ate or drank for lunch on 10/20/2022. She also stated that two (2) years ago she was told that a small Styrofoam cup contained 360 ml. Further interview with CNA #9, on 10/22/2022 at 10:10 AM, revealed she received training on how to record information correctly when she was hired. Interview with Licensed Practical Nurse (LPN) #5, on 10/21/2022 at 9:12 AM, revealed CNA #9 should not have charted the food the resident consumed if she did not see it. She stated she expected CNA's to document correct information. She stated there was a potential of harm for the resident if inaccurate information was recorded because the resident could lose weight, could become malnourished, and skin integrity could be jeopardized. Interview with the Registered Dietitian (RD), on 10/21/2022 at 9:21 AM, revealed Resident #7 did not have significant changes during the last assessment. She said it was normal for this resident to intake forty-four percent (44%) of his/her food. She stated it was care planed for Resident #7 to intake nine hundred forty (940) ml of fluids with meals and additional intake between his/her meals. She said her expectations were that CNA's and nurses charted correct information about residents' intake because it was a base for her assessments of residents. The RD stated Resident #7 did not lose weight. Per the interview, there was a potential harm for a resident if the charting was incorrect. She stated the potential for harm included weight loss, skin integrity problems, dehydration, and anything nutrition related. Review of Resident # 7's clinical chart confirmed his/her weight did not fluctuate, and he/she did not lose weight. Interview with LPN #6, on 10/22/2022 at 10:15 AM, revealed the Staff Development Coordinator trained her on reporting accurate information. After the training, she stated, the staff had to check off on the training that was completed. Interview with the Staff Development Coordinator, on 10/22/2022 at 10:20 AM, revealed CNA's were trained by more experienced CNA's on how to chart food and liquids intakes. She said CNA's also were trained on how to document intake information in Point Click Care. She said her expectation was that CNA's would document each meal and fluid intake with one-hundred percent (100%) of accuracy. The Staff Development Coordinator said there was a potential for harm for a resident such as weight loss, impaired skin integrity, and dehydration if there was inaccurate intake information recorded. She said if the CNA was not sure of the milliliters in the size of the cup, he/she would be able to look it up on the kiosk. Interview with the Director of Nursing (DON), on 10/20/2022 at 4:15 PM, revealed CNAs were responsible to accurately document tasks performed. She stated, if a resident did not eat because he/she was sleeping, she expected CNAs to record this information; and, in this instance, it would be incorrect to record the resident refused food. The DON stated she expected the staff to record findings correctly. Further interview with the DON, on 10/21/2022 at 9:40 AM, revealed the nursing staff relied on the information CNAs charted. She said her expectation was that the charting information would be accurate. She said there was a potential for harm for a resident such as dehydration, malnutrition, and impaired skin integrity if charting was not recorded correctly. The Administrator was out of town and was not available for interview.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to keep staff food and drink items in the designated staff area and not in the residents' food nourishment room. The findings include: Review of the facility's policy titled, Food Brought in From Outside/Home, not dated, revealed the residents had the right to have foods brought in by family or visitors, and the facility had the responsibility to ensure the residents' safety. The State Survey Agency (SSA) Surveyor requested, from the Director of Nursing (DON), the facility's policies titled, Break Room Policy and Drink and Food but did not receive them. Observation of the nourishment room located on the 200 Hall, on 10/19/2022 at 6:19 PM, revealed six (6) used Styrofoam cups, with lids and straws, and two (2) bottles of soda that belonged to the staff. The cups were placed around the sink and next to the ice maker. Observation of the nourishment room located on the 100 Hall, on 10/20/2022 at 10:00 AM, revealed three (3) used Styrofoam cups, with lids and straws, that belonged to the staff. The cups were placed around the sink. Interview with Certified Medical Tech (CMT) #2, on 10/21/2022 at 10:54 AM, revealed staff had a break room that was located next to the residential dining room. She said that the nourishment room on the 100 Hall also had a refrigerator for the staff. According to CMT #2, some employees left their drinks and bottles in the nourishment room because they were not allowed to bring the drinks to the nurses' station while working, but they were allowed to leave them in the nourishment room. Interview with Certified Nursing Assistant (CNA) #4, on 10/21/2022 at 11:15 AM, revealed the staff had a break room where they could keep their drinks and food. She said staff members were also allowed to put their drinks and food in the room with the nourishment refrigerator. CNA #4 stated that there was a potential of cross contamination if one (1) of the employees was sick. Interview with the Activities Assistant, on 10/21/2022 at 11:35 AM, revealed the facility had a break room for their employees where they could put their drinks and food. She said she always had her cup with her or in the fridge. She stated there was a possibility of cross contamination if staff members placed their cups and food in the nourishment room. Interview with Licensed Practical Nurse (LPN) #5, on 10/21/2022 at 11:40 AM, revealed the staff was provided with a break room where they could take their drinks and food. She stated the facility had a policy addressing food and drinks. She said the nurses oversaw the nourishment rooms. According to LPN #5, staff members were allowed to keep their cups and food in the nourishment rooms. She stated there was a potential of harm for a resident because of cross contamination. Interview with the Director of Nursing (DON), on 10/21/2022 at 12:05 PM, revealed staff had a break room and had to adhere to the policy addressing food and drinks. The DON stated no one was allowed to use their food or drinks at the nurses' station. She stated the staff could not use the refrigerator that was assigned for the residents. The DON stated she saw staff members putting their drinks and food in the nourishments room. The DON admitted she did not tell staff Yes or No whether they could put their food and drinks in the nourishment room. Per the interview, she stated the potential of harm for residents could be cross contamination. The Administrator was out of town and was not available for interview.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of thirty (30) sampled residents, Resident #42. Resident #42 experienced twenty-five (25) falls from 04/14/2022 through 10/21/2022. The findings include: The State Survey Agency (SSA) Surveyor requested the facility's policy on Falls; however, the facility did not provide the policy as requested. Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to a safe environment. Review of Resident #42's medical record revealed the facility admitted the resident on 04/23/2020, with diagnoses that included History of Falling, Polyneuropathy, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Dizziness, Ataxic Gait, and Unspecified Dementia. Review of Resident #42's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), indicating he/she was moderately cognitively impaired. Review of Resident #42's initial care plan dated 04/23/2020, revealed it included interventions for fall prevention. Continued review revealed the interventions were noted as answering call lights as promptly as possible each shift, offering toileting before and after meals and at bedtime, and assisting the resident with clothing management. Review additionally revealed other interventions which were monitoring condition of resident's shoes, applying Dycem (a non-slip material used for stabilization and to prevent sliding) to the wheelchair seat, encouraging use of nonskid socks, installing a grab bar on the bathroom counter, instructing resident to ask for assistance prior to transfers, keeping the bed in the lowest position. Further review revealed the interventions also included keeping the bedside table and call light within reach, use of perimeter defining mattress and padded flooring, following up with the pain pump provider for a medication dose reduction due to dizziness, and placing a wheelchair pad alarm to alert staff. Review of the facility's Event Log for the time period of 04/01/2022 through 10/17/2022, revealed Resident #42 experienced twenty-five (25) falls. Review revealed the falls occurred: on 04/14/2022 while attempting to transfer to the wheelchair; on 04/21/2022 at 9:15 AM when getting out of bed to go to the bathroom; on 04/26/2022 at 6:20 AM when he/she refused to lie down on the bed and slid onto the floor; on 04/29/2022 at 7:32 AM when he/she stood up and tried to turn the wheelchair alarm off, fell back into the wheelchair, and tipped the wheelchair over, which resulted in an abrasion to his/her right middle finger; on 05/01/2022 at 4:40 AM when he/she attempted to transfer from the wheelchair to the commode and did not use the call bell to obtain assistance; on 05/02/2022 at 4:15 AM when he/she attempted to go to the bathroom while the room was dark; on 05/02/2022 at 10:55 AM when he/she slid on the mat in the bathroom and scraped his/her back; on 05/03/2022 at 10:00 PM when he/she was discovered with his/her pants down around the ankles trying to get back into bed; on 05/04/2022 at 4:55 PM when he/she was making the bed without assistance; on 05/15/2022 at 6:00 PM when he/she was standing in front of the commode and fell ; on 05/22/2022 at 8:08 AM when he/she slid off the bed while trying to get up; on 05/24/2022 at 3:00 PM, cause unknown cause, and Dycem was applied to his/her wheelchair; on 06/01/2022 at 2:45 PM when he/she attempted to transfer to the toilet and fell backwards into the wheelchair, which flipped over; on 06/03/2022 at 10:15 PM while ambulating from the bathroom to get to the wheelchair; on 06/04/2022 at 1:06 PM when he/she used the call light three (3) times for assistance and no one came, so he/she went to the bathroom on his/her own and fell ; on 06/08/2022 at 5:20 PM, cause unknown when he/she was found in the floor and refused help to get up; and on 06/09/2022 at 7:30 PM when he/she was making the bed and got his/her feet tangled in the blankets and fell . Further review of the facility's Event Log, for the same timeframe of 04/01/2022 through 10/17/2022, revealed Resident #42 additionally experienced falls: on 06/22/2022 at 5:29 AM when he/she was trying to get back into bed; on 06/25/2022 at 7:50 AM when he/she fell while attempting to transfer independently onto the toilet seat; on 07/22/2022 at 12:50 PM when he/she was found with one (1) knee on the metal base of the bedside table, and was noted to have been drowsy; on 08/14/2022 at 5:04 AM when he/she fell while independently changing his/her brief; on 08/21/2022 at 6:35 PM when he/she fell while reaching for clothing in a drawer; on 09/30/2022 at 1:30 PM when he/she fell while the Pain Management Nurse was assisting him/her from the wheelchair to the bed; and finally on 10/14/2022 at 1:20 PM when he/she fell out of the wheelchair while looking for a light on the floor, a total of twenty-four (24) falls. Review of Resident #42's Progress Note dated 10/21/2022, revealed the resident sustained a fall on 10/21/2022 at 10:00 AM, while attempting to get clothes out of his/her closet. This fall was the twenty-fifth (25) fall Resident #42 experienced for the timeframe of 04/01/2022 through 10/17/2022. Observation on 10/19/2022 at 11:53 AM, revealed Resident #42 sitting in his/her wheelchair in his/her room, slumped forward and to the right side of the wheelchair. Interview with Resident #42 on 10/18/2022 at 3:36 PM, revealed the resident fell frequently due to dizziness, which resulted in the facility placing a foam mat in the resident's room to prevent injuries. Resident #42 stated he/she believed the dizziness he/she experienced was due to the pain medication he/she was prescribed. Further interview revealed Resident #42 needed the pain medication, or he/she experience unbearable pain which limited his/her ability to perform activities of daily living (ADL) and participate in activities. Interview with Licensed Practical Nurse (LPN) #7 on 10/20/2022 at 5:45 PM, revealed she was aware of the multiple falls Resident #42 had experienced. Per LPN #7, Resident #42 did not like to ask for staff assistance and had disabled the position change alarms on his/her wheelchair. Continued interview revealed Resident #42 also had removed the nonskid socks utilized. The LPN stated in her experience, when Resident #42's room door was kept open, Resident #42 was more likely to be compliant with interventions that prevented falls. She stated this was because staff performed more frequent incontinence checks and reminded the resident to ask for assistance. Interview with the Social Services Director (SSD) on 10/22/2022 at 10:30 AM, revealed Resident #42 had a history of being resistant to care and had experienced multiple falls. Continued interview revealed the facility had installed a padded floor and alarms in Resident #42's room, as well as other standard interventions such as nonskid socks and keeping the bed in the lowest position. The SSD revealed she though alarms irritate residents. Further interview revealed Resident #42 became groggy when his/her pain pump was refilled; however, the SSD did not recall that being discussed in the care plan meetings. Interview with the MDS Coordinator on 10/20/2022 at 4:33 PM, revealed Resident #42 attempted to do things independently when he/she was not strong enough to transfer without assistance, and that resulted in falls. Continued interview revealed the padded floor which had been implemented for Resident #42 had been the best intervention the facility had implemented as it helped prevent the resident from sustaining significant injury with any of the falls. She stated the facility had attempted other interventions, such as a dose reduction on some Resident #42's medications and giving the resident a handbell in addition to the call light to alert staff when he/she needed assistance. The MDS Coordinator further stated Resident #42 had refused some interventions, including the use of position change alarms. Interview with the Assistant Director of Nursing (ADON) on 10/22/2022 at 11:15 AM, revealed due to Resident #42's noncompliance with previously attempted interventions, the only other thing the facility could suggest for the resident was a bubble to prevent further falls. Continued interview revealed she had educated Resident #42 on the importance of using his/her call light for assistance and had educated staff on the importance of answering the resident's call light in a timely manner. Per the ADON, her expectation was for staff to perform every two (2) hour checks of Resident #42 to see if the resident needed assistance going to the bathroom. Further interview revealed however, she was unsure if that expectation was communicated in Resident #42's care plan. Interview with the Director of Nursing (DON) on 10/22/2022 at 11:21 AM, revealed Resident #42 had refused help from staff in the past. Per the DON, this included a previous incident on an unspecified date during which Resident #42 threw a trash can at staff members when they tried to assist him/her up off the commode. Continued interview revealed Resident #42 had also fallen while rummaging through drawers in his/her room. According to the DON, Resident #42's current care plan interventions for fall prevention included the resident having a padded floor in his/her room, maintaining his/her bed in the lowest position, installing wireless position change alarms, applying nonskid socks to the resident's feet, providing one (1) person assistance with toileting as allowed by the resident, and keeping the call light in his/her reach. Further interview revealed Resident #42 had a grab bar installed on the bathroom counter in his/her room, a nonskid pad on his/her wheelchair seat, nonskid material to the door handle in his/her bathroom, and a perimeter defining mattress. The Administrator was out of town and not available for interview.

Based on interview, record review, review of facility investigations, and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated for two (2) of three (3) residents (Residents #1 and #2), and failed to prevent further potential abuse, while the investigation was in progress. On 07/13/2021, Adult Protective Services (APS) notified the facility that State Registered Nurse Aide (SRNA) #3 allegedly abused Resident #1. The facility initiated an investigation regarding SRNA #3 intentionally spraying water in Resident #1's face during a bath, giving the resident a cup of water and telling the resident it contained poison, pushing the resident in bed, and turning a fan toward the resident's face to make him/her cold. Interview with SRNA #8 revealed he witnessed SRNA #3 physically abuse Resident #1 and Resident #1 reported SRNA #3 sprayed the resident in the face and gave the resident poisoned water on the night of 07/11-12/2021. The facility initiated an investigation and suspended SRNA #3 on 07/13/2021. However, the facility failed to conduct a thorough investigation. There was documented evidence SRNA #8 gave Resident #1 a whirlpool bath on 07/11/2021 at 10:24 PM. However, there was no documented evidence the facility investigated/interviewed SRNA #3 regarding all of the alleged allegations, including whether the SRNA was in the shower/whirlpool bathroom the night of 07/11-07/12/2021; nor, anything about giving the resident poison, pushing the resident, or turning a fan toward the resident. In addition, there was no documented evidence the facility asked SRNA #8 about the resident's whirlpool bath on 07/11/2021. According to an interview with SRNA #8, SRNA #3 assisted her with getting the resident into the whirlpool tub, even though the resident only required one (1) staffs' assistance. There was no documented evidence the facility considered SRNA #6 or Licensed Practical Nurse (LPN) #2's concerns with SRNA #3's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, although the facility's investigation was not completed until 07/16/2021, review of SRNA #3's schedule revealed the SRNA returned to work on 07/15/2021, resulting in the facility's failure to follow their policy and ensure Resident #1 and other potential residents' safety and protection. In addition, on 07/22/2021, Resident #1 reported to the State Survey Agency (SSA) Surveyor that SRNA #3 was a bully. The resident stated, He torments me. He thumps me on the head Scared when he comes around He is mean! If I die, he did it. The SSA reported the resident's statements to the Administrator, who stated she was aware Resident #1 was afraid of SRNA #3; however, the Administrator failed to [MEDICATION(S)] to protect the residents as required by the facility's policy. The SRNA was moved to another unit and continued to provide resident care. In addition, review of the facility's investigation revealed the facility unsubstantiated Resident #1's allegations of 07/22/2021, stating the resident could not identify any specifics about when or how this had occurred and stated SRNA had not provided care for the resident since he returned to work on 07/15/2021. Further, the facility failed to investigate an allegation of abuse on 07/17/2021, when Resident #1 alleged someone hit the resident on the back with a shovel. Review of a facility investigation for Resident #2 revealed on 07/13/2021, SRNA #5 observed SRNA #11 place a pillow over Resident #2's face two (2) times because the resident was yelling while SRNA #11 was talking on her personal cell phone. SRNA #5 failed to ensure Resident #2's safety and left SRNA #11 in the room with Resident #2 unattended while she reported the incident to LPN #1 and the Director of Nursing (DON). The facility terminated SRNA #11 on 07/16/2021 due to using foul language. However, the facility failed to determine whether SRNA #11 abused Resident #2. The facility's failure to ensure abuse allegations were thoroughly investigated has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/29/2021 and was determined to exist on 06/25/2021, at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609 and F610). The facility was notified of the Immediate Jeopardy on 07/29/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 08/06/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 08/06/2021 as alleged, prior to exit on 08/12/2021, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Resident Abuse,not dated, revealed residents had the right to be free from abuse, both verbal and physical. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Mental abuse included but is not limited to, humiliation, harassment, threats of punishment, or deprivation. Further, the policy stated the resident's safety and protection would first be assured and if the incident involved an employee, the employee would be immediately placed on suspension until completion of the investigation. The policy did not address criteria for completion of an investigation, nor completing a thorough investigation. The policy stated, If the allegation is substantiated the employee will be terminated. If applicable, the Administrator will report the incident to the State Nurse Aide Abuse Registry and/or other state authorities. 1. Review of a facility investigation initiated on 07/13/2021, revealed on 07/13/2021 at approximately 1:20 PM Central Standard Time (CST), Adult Protective Services (APS) entered the facility to investigate, last night [SRNA #3] abused [Resident #1] . he gave [the resident] a whirlpool bath and sprayed [the resident] in the face on purpose. It was also alleged that the SRNA gave [the resident] a cup of water full of poison, pushed [the resident] around in the bed and put a fan in [the resident's] face to make [the resident] colder. According to the facility's investigation, Resident #1 was assessed and the resident had no signs/symptoms of any injuries of unknown origin and SRNA #3 was suspended. Review of Resident #1's medical record revealed SRNA #8 documented the resident received a whirlpool bath on 07/11/2021 at 10:24 PM. Further review of the facility's investigation revealed on 07/13/2021, the Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) interviewed Resident #1 and asked the resident if a staff member had intentionally mistreated or abused the resident. The resident answered no. The staff also asked Resident #1 if SRNA #3 had ever given the resident a whirlpool bath. The investigation revealed the resident answered no. According to the investigation, they asked the resident what he/she thought about SRNA #3 and the resident stated, He likes to play tricks. The resident added, He's a pain in the ass. There was no documented evidence the facility asked Resident #1 about being sprayed in the face with water, poison, being pushed in bed nor about a fan. Continued review of the facility's investigation revealed two (2) documented interviews with SRNA #3, one dated 07/12/2021 (the day before APS entered with the complaint) and one dated 07/13/2021. The documentation revealed the DON and ADON interviewed SRNA #3 by phone and asked questions including: Have you ever given [Resident #1] a whirlpool bath or shower? Have you ever made any remarks or comments to [Resident #1] that may have been taken to be derogatory in nature towards [the resident]? Has [the resident] ever stated [he/she] did not like you or like the care you were providing? According to the investigation, SRNA #3 answered no to all the questions. However, there was no documented evidence the facility investigated/interviewed the SRNA regarding all alleged allegations, including whether the SRNA was in the shower/whirlpool bathroom the night of 07/11-07/12/2021; nor, anything about a poison, pushing the resident, or a fan. Further review of the facility's investigation, revealed on 07/12/2021 (the day before APS reported the allegations to the facility) the facility typed a summary of staffs' responses to the question, Have you ever seen another employee be inappropriate with a resident, verbally or physically? If so, elaborate on what you witnessed. According to the typed report, two (2) staff stated they had witnessed concerns regarding SRNA #3. SRNA #6 reported that Resident #1 told him on 07/12/2021 that SRNA #3 had sprayed the resident in the face with the water during a bath, tried to dunk the resident's head in the tub, and gave the resident a glass of water and told the resident it was poisoned and the resident would be dead by morning. The facility's report stated Resident #1 denies any happenings. Further review revealed LPN #2 witnessed [SRNA #3] turning the fan on the desk to blow towards two residents [including Resident #1] and she had to tell him not to turn the fan on them and he never did it again. Interview with SRNA #6 on 07/22/2021 at 5:30 PM revealed on 07/12/2021 at approximately 1:00 AM, Resident #1 reported during the evening shift on 07/11/2021, that SRNA #3 and SRNA #8 put the resident in the whirlpool tub, and SRNA #3 sprayed the resident in the face anytime he/she attempted to speak. The resident also reported that SRNA #3 told him/her that he hoped the resident enjoyed the water because it contained poison and he/she would be dead by morning. SRNA #6 stated he reported the allegations to RN #1 at approximately 1:10 AM on 07/12/2021. Further interview revealed that on the morning of 07/14/2021, at the end of his shift, at approximately 7:00 AM, the DON questioned him regarding the allegations. During the conversation with the DON, SRNA #6 stated he also reported to the DON that he had observed SRNA #3 being abusive toward Resident #1 on 06/25/2021. He stated on 06/25/2021, SRNA #6's second day of employment, he and SRNA #3 were transferring Resident #1 to his/her bed. When Resident #1 attempted to sit down on the bed, SRNA #3 shoved the resident into the enabler bar, hitting his/her right hip on the enabler bar. Continued interview with SRNA #6 revealed that Resident #1 stated to SRNA #3, 'I wish you would go away'. SRNA #3 got in the resident's face nose to nose, and stated, 'I wish you would die'. SRNA #6 stated he told SRNA #3 that he could not talk to residents that way, and SRNA #3 just shook his head, smiled, and walked out of Resident #1's room. Continued interview with SRNA #6 revealed during his scheduled shift on 07/16/2021, Resident #1 asked him whether SRNA #3 would be back to work. SRNA #6 stated he told the resident he did not know, and the resident replied, I hope not, because if he comes back, he will do something bad to me. He stated he immediately reported the statement to Licensed Practical Nurse (LPN) #5 and all she did was shake her head. Further review of the facility's investigation revealed the facility interviewed SRNA #8 and asked the same question, Have you ever seen another employee be inappropriate with a resident, verbally or physically? If so, elaborate on what you witnessed. According to the investigation, the SRNA's response was nothing. However, there was no documented evidence the facility asked the SRNA about the resident's whirlpool bath on 07/11/2021. Interview with SRNA #8 on 07/26/2021 at 3:55 PM revealed on 07/11/2021 SRNA #3 assisted her with transferring Resident #1 into the whirlpool bath, even though the resident only required the assistance of one (1) staff for transfers, then he left the room. The SRNA denied SRNA #3 sprayed water in the resident's face. Interview with SRNA #3 on 07/21/2021 at 6:05 PM revealed he denied all the allegations. SRNA #3 also denied giving Resident #1 a whirlpool bath and denied assisting SRNA #8 with transferring the resident to the whirlpool bathtub on 07/11/2021. SRNA #3 stated he returned to work on 07/15/2021 on the same unit where Resident #1 resided and worked from 7:00 PM until 11:00 PM. He stated he had not worked with Resident #1 since 07/12/2021; however, he had not been instructed not to enter Resident #1's room or provide care to Resident #1. He stated he was instructed to take another SRNA with him if he went into Resident #1's room. Review of facility's investigation completed on 07/16/2021, revealed the facility unsubstantiated the allegations involving Resident #1 and SRNA #3 based on the following: Resident #1 denied concerns related to the care SRNA #3 provided; SRNA #3 had never provided a bath for Resident #1; Resident #1 did not have a fan in his/her room (even though the allegation was not specifically about the resident having a fan in his/her room). The investigation stated there was one incident where a staff member observed a fan blowing on the resident at the nurse's station; however, when alerted, SRNA #2 repositioned the fan. Further, the investigation stated SRNA #3 supported that he had never provided a bath to the resident and other than the accidental fan incident, had not been involved in any of the other interactions alleged. However, interview with LPN #2 on 07/22/2021 at 6:37 PM revealed approximately two (2) months prior, Resident #1 was sitting at the nurse's station and complained of being cold. She stated she asked SRNA #3 get the resident a blanket, but instead he turned the oscillating fan on high and pointed it directly at Resident #1. The LPN stated approximately two (2) weeks later, when she got to the nurse's station, SRNA #3 had the fan turned on facing Resident #1. She stated Resident #1 told SRNA #3 not to do that or he/she would hit him. LPN #2 stated she told SRNA #3 to turn the fan off or she would write him up. Record review revealed no documented evidence the facility identified through their investigation that SRNA #3 assisted the resident into the shower/whirlpool room on 07/11/2021, the night the resident reported the incident occurred. Further, there was no evidence the facility considered SRNA #6 or LPN #2's concerns with SRNA #3's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, although the facility investigation was not completed until 07/16/2021, review of SRNA #3's schedule revealed the SRNA returned to work on 07/15/2021, resulting in the facility's failure to follow their policy and ensure the resident's safety and protection as required by the facility policy. Interview with Resident #1 on 07/22/2021 at 7:46 PM, who had a Brief Interview for Mental Status (BIMS) score of twelve (12), revealed he/she did not like SRNA #3. On 07/22/2021, immediately after the interview with Resident #1, the State Survey Agency reported to the Administrator that the resident stated SRNA #3 was a bully. He torments me. He thumps me on the head. He sprayed water on my face. He pushes me in the bed, and I hit the rail. In addition, the State Survey Agency reported the resident was scared when he comes around. He put a fan in front of my face. He is mean! If I die, he did it. Review of a facility Self-Reported Incident Form dated 07/22/202, revealed the facility reported the allegations of abuse regarding SRNA #3 abusing Resident #1 to the State Survey agency. The facility listed the description of the incident as Allegation of staff turning a fan on [him/her], thumping [his/her] head, pushing down into bed causing a bruise. The facility did not list measures taken to protect the resident during the investigation as required by the form, including whether SRNA #3 was suspended. Review of SRNA #3's work time revealed he continued to work at the facility during the investigation and was not suspended as required by the facility's policy. SRNA #3 worked the North Unit, where Resident #1 resided on 07/22/2021 from 7:00 PM - 11:00 PM. Review of the facility's investigation revealed the facility also unsubstantiated the abuse allegations of 07/22/2021. The facility stated Resident #1 restated the allegations regarding SRNA #3 to the Administrator and the DON, but could not identify any specifics about when or how this had occurred. The investigation further stated that the interview with SRNA #3 supported that he had not provided any care to Resident #1 since his return to work on 07/15/2021 and all staff present on 07/22/2021 confirmed he had not provided care for the resident. The facility did not consider that these were the same allegations made prior to 07/15/2021 and did not investigate the allegations further. The facility cited the same information regarding why the allegation was unsubstantiated as the 07/16/2021 investigation: SRNA #3 had never provided a bath to Resident #1; the resident did not have a fan in his/her room; and the incident with the fan was at the nurse's station, but was moved away from the resident when asked. Further, there was no evidence the facility addressed Resident #1's allegation of being thumped on the head. Interviews with the Director of Nursing (DON) on 07/21/2021 at 6:30 PM and 07/26/2021 at 6:22 PM revealed the facility was made aware of allegations regarding SRNA #3 on 07/13/2021 when APS entered the facility. She stated she assisted with the investigations and the allegations were unsubstantiated. The DON stated SRNA #3 was interviewed in person and by phone on 07/13/2021, and he denied the allegations. The DON stated Resident #1 also denied all allegations against SRNA #3 during the initial investigation completed on 07/16/2021. According to the DON, during staff interviews for the investigations, she did not question whether SRNA #3 was in the shower room at any time because that was not part of the allegation. Further, according to the DON, she was aware that SRNA #6 reported concerns but the SRNA did not report that SRNA #3 told Resident #1, I wish you would die. Continued interview with the DON revealed RN #1 spoke to Resident #1 after the allegation was reported to her on 07/12/2021 and RN #1 stated the allegation did not occur. She stated at no time when Resident #1 was interviewed, did he/she state that he/she was fearful of SRNA #3, nor did the resident state he/she did not feel safe when SRNA #3 was working. The DON stated that SRNA #3 was suspended on 07/13/2021 and returned to work on 07/15/2021. Interview with the Administrator on 07/26/2021 at 7:56 PM revealed she completed the investigations for Resident #1. She also stated she was initially notified of the abuse allegations regarding Resident #1 and SRNA #3 when APS entered the facility on 07/13/2021. She stated when performing interviews regarding the allegation, she did not question related to SRNA #3 assisting with transferring Resident #1 into the whirlpool bath. She stated RN #1 spoke with Resident #1 on 07/12/2021 and the resident felt it was more like a dream and the RN did not consider it an allegation of abuse. She stated SRNA #3 was suspended on 07/13/2021 pending the investigation and returned to work on 07/15/2021. According to the Administrator, the facility had completed their investigation on 07/15/2021, even though the investigation was dated 07/16/2021 and was not reported to the State Survey Agency until 07/16/2021. She stated SRNA #3 did not perform care for Resident #1 when he returned to work on 07/15/2021. The Administrator stated she did not consider SRNA #6's interview/concerns when making the determination whether abuse occurred because she was not aware the SRNA had witnessed any abuse. Continued interview with the Administrator on 07/26/2021 at 7:56 PM, revealed she moved SRNA #3 to work on the East Unit of the facility on 07/22/2021 after the State Survey Agency reported Resident #1's allegations. Even though the facility's abuse policy required that staff be removed from direct care, SRNA #3 was not suspended and worked with residents. She stated she moved him to the other unit for the SRNA's safety and for the safety of Resident #1. The Administrator stated she was aware Resident #1 did not feel safe with SRNA #3, but the only action taken was to advise SRNA #3 not to go into Resident #1's room or provide care to Resident #1 on 07/22/2021. According to the Administrator, the facility did not determine abuse occurred as a result of the 07/22/2021 report, even though the resident stated the allegations occurred and SRNA #6 witnessed abuse. Review of a Behavior Note dated 07/17/2021 at 10:30 AM revealed Resident #1 stated that his/her back was hurting and that somebody had hit him/her in the back with a shovel. LPN #1 documented that no redness or bruising was noted to Resident #1's back and there were no shovels in the facility. Further review of the Behavior Note revealed staff were instructed to always provide care to Resident #1 with two (2) staff members. Continued interviews with the DON on 07/21/2021 at 6:30 PM and 07/26/2021 at 6:22 PM revealed on 07/17/2021, LPN #1 reported to her that Resident #1 stated that someone hit him/her on the back with a shovel. She stated no investigation was completed related to the allegation because no one had been in the resident's room and there were no markings on the resident and the resident stated he/she was full of[OBSCENITY]when asked about the incident. The DON further stated it was impossible because there were no shovels in the building. Continued interview revealed the DON stated, We would know if someone was packing a shovel in the building. The DON stated Resident #1 was vulnerable; however, if the facility reported and investigated everything that Resident #1 said, they would be reporting daily. Further interview with the Administrator on 07/26/2021 at 7:56 PM revealed staff reported the allegation that Resident #1 had made on 07/17/2021 about someone hitting him/her on the back with a shovel. She stated she did not consider the statement an allegation of abuse because, There is no possible way that someone hit the resident with a shovel. The Administrator stated, That statement in and of itself is impossible, so I don't see how it could be an allegation of abuse. She stated she never considered, nor investigated whether someone hit the resident on the back with any object. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 12/31/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation initiated on 07/13/2021 and completed on 07/16/2021, revealed during the lunch meal service on 07/13/2021, SRNA #5 observed SRNA #11 place a pillow over Resident #2's face. The investigation stated Resident #2 was not interviewable. Review of SRNA #5's handwritten witness statement dated 07/13/2021 revealed she entered Resident #2's room and SRNA #11 was feeding Resident #2 lunch when Resident #2 began yelling. The statement stated that SRNA #11 removed the pillow from under Resident #2's head, threw the pillow on the resident's face, held her hand on the pillow for five (5) seconds, then removed the pillow. SRNA #5 documented in her statement, I saw this happen twice. Interview with SRNA #5 on 07/22/2021 at 10:53 AM revealed on 07/13/2021, before lunch, she entered Resident #2's room and SRNA #11 was on her cell phone in the resident's room, on the left side of the resident's bed. Resident #2 was in bed, screaming. SRNA #11 made a growling sound as if she was frustrated, and took the resident's pillow from underneath his/her head. SRNA #11 threw the pillow over Resident #2's face and placed her hand on top of the pillow for approximately five (5) seconds. According to SRNA #5, the resident stopped screaming, but started screaming again after SRNA #11 removed the pillow. SRNA #11 then placed the pillow over the resident's face a second time, held the pillow for approximately five (5) seconds. The SRNA stated I stated to to [SRNA #11] you don't need to be doing that. SRNA #5 revealed she looked in the hallway and saw SRNA #4 leaving a resident's room. SRNA #5 stepped out of Resident #2's room, to the empty room next door and explained to SRNA #4 what had just happened, leaving SRNA #11 along with the resident. She stated she sent SRNA #4 into Resident #2's room, while she went to report the incident to a nurse. SRNA #5 revealed she reported the incident to LPN #1 and to the DON, who requested LPN #1 have SRNA #11 to leave Resident #2's room. SRNA #5 stated she should not have left Resident #2 alone in the room with SRNA #11 and should have called for help from the resident's room. Further interview with SRNA #5 on 07/26/2021 at 8:50 PM revealed she wrote out her statement as soon as the incident occurred, before administration staff interviewed her. She stated administration interviewed her three times, and each time, her statement remained the same. Interview with SRNA #4 on 07/22/2021 at 10:16 AM revealed on 07/13/2021, during lunch, SRNA #5 reported she had just witnessed SRNA #11 place a pillow over Resident #2's face. SRNA #4 stated she instructed SRNA #5 to go get LPN #1 and SRNA #4 went into Resident #2's room, where she observed SRNA #11 sitting in the resident's recliner, talking on the phone. LPN #1 came into Resident #2's room a little later and told SRNA #11 to leave the resident's room. SRNA #4 revealed she did not see anything on Resident #2's face, and the resident's pillow was behind the resident's head when she entered the room. Review of LPN #1's handwritten witness statement, not dated, revealed SRNA #5 reported to her that SRNA #11 had placed a pillow on Resident #2's face two (2) times. Review of SRNA #11's (the alleged perpetrator) written statement the pillow had fallen onto the resident's face and she never placed her hand over the pillow. Continued review of the facility's investigation revealed a resident (not identified) stated SRNA #11 had treated him/her inappropriately. According to the resident, SRNA #11 hateful. Further review of the facility's investigation revealed two staff had witnessed SRNA #11 cursing. One SRNA stated SRNA #11 told a resident to lay the [OBSCENITY] down. Another SRNA witnessed SRNA #11 tell a resident that he/she was going to keep their ass in bed. Interview with the APS investigator on 07/22/2021 at 5:15 PM revealed she was looking to substantiate the case. She stated SRNA #5's story was clear. The SRNA was 100% clear of what she observed. She was 100% clear that what she observed was intentional. The APS Investigator stated that SRNA #5 was one of the most credible witnesses she had ever interviewed. Further review of the facility's investigation revealed the facility could neither substantiate or unsubstantiated abuse due to lack of corroborating witnesses and stories presented for the event. The investigation summary stated that the interview with the reporting SRNA indicated some changes in her information, including the viewpoint of the event and the contact of the pillow with the resident two times, rather than just once. However, there was no information in the facility's investigation that indicated SRNA #5's statements regarding what happened had ever changed, including the interview with the State Survey Agency. According to the investigation, SRNA #11 had breached facility policy by utilizing inappropriate language in the vicinity of residents; therefore, the facility followed the disciplinary action policy and terminated the employment of the SRNA on 07/16/2021. Interview with the DON on 07/26/2021 at 6:22 PM revealed she was alerted to the abuse allegation regarding Resident #2 and SRNA #11 on 07/13/2021 prior to 1:00 PM. She stated she directed LPN #1 to question SRNA #11 about the allegation and then escort her off the premises. Further interview revealed the facility could not determine whether abuse occurred because SRNA #5's story was not consistent. During the first interview, SRNA #5 stated she observed SRNA #11 put a pillow over the resident's head once and during the next interview, she stated she observed the incident twice. However, there was no documented evidence SRNA #11's story changed or was inconsistent. Further, the DON could not explain what impact that had (whether it happened once or twice) on determining whether abuse occurred. Interview with the Administrator on 07/26/2021 at 7:56 PM revealed she was unavailable when the allegation of abuse was made against SRNA #11. She stated she did not substantiate the abuse allegation because they had two (2) staff with two (2) different stories and the resident was not interviewable. The Administrator stated, I am not the judge and [NAME], I could not 100 percent state it occurred. **The facility implemented the following actions to remove the Immediate Jeopardy on 08/06/2021: 1. (a) State Registered Nurse Aide (SRNA) #3 was terminated from employment on 08/02/2021 and SRNA #11 was terminated on 07/16/2021 by the Administrator. (b) The Social Services Director (SSD) completed a Patient Health Questionnaire (PHQ9) (module to screen the presence and severity of depression) interview with Resident #1 on 08/03/2021, with no noted change in the resident's mood/depression score. Resident #1 received psychiatric services and the facility notified the consulting practitioners of the allegations on 08/02/2021. (c) The SSD completed a PHQ9 interview with Resident #2 on 08/03/2021, no changes were identified with the resident's mood/depression score. 2. (a) As of 08/03/2021, all residents with a Brief Interview for Mental Status (BIMS) score of nine (9) and above were interviewed by the SSD. The interview was to determine if there were any care related concerns, including but not limited to: if the resident had experienced or witnessed abuse by a staff member; any staff member that the resident did not want providing their direct care; any staff the resident was afraid of, if so, residents were asked to elaborate. After completion of resident interviews, the facility identified no concerns regarding resident care and/or abuse. (b) All staff were interviewed by the Administrator, Director of Nursing (DON), and/or Assistant Director of Nursing (ADON) as of 08/05/2021. The interviews were to identify any concerns regarding resident care by their peers to include but not limited to if they had witnessed resident abuse by staff and if they were aware of any residents that were afraid of any staff member. The facility identified no concerns during the staff interviews. (c) On 08/04/2021, skin assessments were performed on all residents with a BIMS' score of less than nine (9) by the Wound Care Nurse and the Restorative Nurse to identify any injuries of unknown origin. The facility identified no concerns. Furthermore, beginning 08/09/2021, head to toe skin assessments would be performed weekly on the resident's scheduled day by the DON, ADON, and/or Wound Care Nurse to identify injuries of unknown origin as well as monitor non-interviewable residents for signs/symptoms of abuse. 3. (a) Education was provided to staff on 08/05/2021 by the Administrator, DON, ADON, and Dietary Manager (to dietary staff). The education included but was not limited to review of the facility's Abuse Policy - definitions of the different types of abuse; protection of the resident (i.e., immediate suspension of any staff member alleged of resident abuse), immediate reporting of suspected abuse, and providing a detailed statement of the abuse allegation to the investigator. The facility locked the time clock for any employee on medical leave and they were notified th [TRUNCATED]

Based on interview, record review, review of a facility investigation, and review of the facility's abuse policy, it was determined the facility failed to ensure four (4) allegations of abuse were reported timely for one (1) of three (3) sampled residents (Residents #1). On 06/25/2021, State Registered Nurse Aide (SRNA) #6 witnessed SRNA #3 abuse Resident #1. There was no documented evidence SRNA #6 immediately reported the allegation to the facility. SRNA #3 continued to provide resident care at the facility. The SRNA failed to report the abuse allegation until the facility interviewed him on 07/14/2021, (19 days later) regarding other allegations of abuse involving Resident #1. Interview with Licensed Practical Nurse (LPN) #2 on 07/22/2021 revealed on two occasions in the previous two (2) months, SRNA #3 positioned a fan to blow cold air toward Resident #1, even though he knew the resident was already cold. After the second incident, Resident #1 told SRNA #3 not to do that or he/she would hit him. The facility failed to ensure the allegation was reported to the Administrator and the State Survey Agency (SSA). On 07/11/2021 at approximately 1:00 AM, Resident #1 reported to SRNA #6 that SRNA #3 sprayed the resident in the face with water when the resident attempted to speak while in the whirlpool tub. The resident also reported that SRNA #3 told the resident there was poison in his/her water and he hoped he/she enjoyed it because he/she would be dead by morning. SRNA #6 stated he reported the allegations to RN #1 at approximately 1:10 AM on 07/12/2021. RN #1 spoke with the resident and believed the resident was dreaming; subsequently, she did not report the allegations to the Administrator and state agencies were not notified. The Administrator stated she was not aware of the allegations until Adult Protective Services (APS) entered the facility on 07/13/2021 to investigate abuse allegations regarding Resident #1. Review of a Behavior Note dated 07/17/2021 at 10:30 AM revealed Resident #1 stated that his/her back was hurting and that somebody had hit him/her in the back with a shovel. Interviews with the Director of Nursing and the Administrator revealed they were aware of the incident; however, there was no documented evidence the allegation was reported to the SSA as required. The facility's failure to ensure abuse allegations were reported has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/29/2021 and was determined to exist on 06/25/2021, at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 07/29/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 08/06/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 08/06/2021 as alleged, prior to exit on 08/12/2021, which lowered the scope and severity to D at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Resident Abuse, not dated, revealed residents had the right to be free from abuse, both verbal and physical. The policy stated any incidents of suspected abuse should be immediately reported to the employee's immediate supervisor and the Administrator. According to the policy, the Administrator would follow the facility's protocols for reportable incidents. Review of Resident #1's medical record revealed the facility admitted the resident on 05/17/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff for bed mobility and extensive assistance of one (1) staff member for transfers, toileting, hygiene, and bathing. Further review revealed the facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of twelve (12). Interview with State Registered Nurse Aide (SRNA) #6 on 07/22/2021 at 5:30 PM revealed on 06/25/2021, he was assisting SRNA #3 with transferring Resident #1 to bed. SRNA #6 stated when Resident #1 attempted to sit down on the bed, SRNA #3 shoved the resident into the enabler bar (small bed rail) and the resident hit his/her right hip on the enabler bar. Continued interview revealed Resident #1 stated to SRNA #3, I wish you would go away. According to SRNA #6, SRNA #3 responded by getting in the resident's face, nose to nose, and stated, I wish you would die. SRNA #6 stated he told SRNA #3 he could not talk to the residents that way, and SRNA #3 shook his head, smiled, and walked out of Resident #1's room. SRNA #6 stated he was aware that he should have reported the incident immediately; however, he stated it was his second day of work and there were rumors that it did not do any good to report abuse because the Director of Nursing (DON) and the Administrator would not do anything about it. Further interview with SRNA #6 revealed on 07/12/2021, at approximately 1:00 AM, Resident #1 reported to him that earlier that evening on 07/11/2021, SRNA #3 and SRNA #8 put the resident in the whirlpool tub and SRNA #3 sprayed the resident in the face anytime Resident #1 attempted to speak. The resident also reported that SRNA #3 told him/her that his/her water contained poison, and he hoped he/she enjoyed it because he/she would be dead by morning. SRNA #6 stated he reported the allegations to Registered Nurse (RN) #1 at approximately 1:10 AM on 07/12/2021. He stated RN #1 went to the resident's room and talked to Resident #1 after he reported the allegation. Interview with RN #1 on 07/21/2021 at 2:45 PM revealed between 1:00 AM and 2:00 AM on 07/12/2021, SRNA #6 reported Resident #1 told him that SRNA #3 sprayed him/her in the face with water when he gave him/her a whirlpool bath on 07/11/2021. She stated she went and spoke to Resident #1 and the resident acted like it was all a dream. The RN stated she may have passed the information along in report, but was not sure. However, she stated she did not report the allegation to Administration or complete an incident report because she thought the resident was dreaming. She stated she did not feel like the allegation was true because Resident #1 also told the RN that he/she thought the RN was going to give him/her poison instead of medication. RN #1 stated the way the resident was talking I knew it wasn't true. Continued interview with SRNA #6, 07/22/2021 at 5:30 PM on 07/22/2021 at 5:30 PM, revealed he noticed RN #1 did not send SRNA #3 home after he reported the resident's allegations on 07/12/2021, which made him worry whether the facility would address the resident abuse. SRNA #6 stated he called APS (Adult Protective Services) and notified them of the resident's allegations to ensure someone investigated SRNA #3's abuse of Resident #1. Review of a facility investigation revealed the next day, on 07/13/2021 at approximately 1:20 PM Central Standard Time (CST), Adult Protective Services (APS) entered the facility to investigate, last night [SRNA #3] abused [Resident #1] . he gave [the resident] a whirlpool bath and sprayed [the resident] in the face on purpose. It was also alleged that the SRNA gave [the resident] a cup of water full of poison, pushed [the resident] around in the bed and put a fan in [the resident's] face to make [the resident] colder. The facility also reported the allegations to the State Survey Agency on 07/13/2021. Continued interview with SRNA #6 on 07/22/2021 at 5:30 PM, revealed on the morning of 07/14/2021 at approximately 7:00 AM, at the end of his shift, the Director of Nursing (DON) questioned him regarding the allegations. He stated at that time, he told the DON about what he observed on 06/25/2021, SRNA #3 turning the fan to blow toward Resident #1 when the resident was cold, and the allegations Resident #1 made on 07/12/2021. Further interview with SRNA #6 on 07/22/2021 at 5:30 PM, revealed on his next scheduled shift on 07/16/2021, Resident #1 questioned him whether SRNA #3 would be back to work. He stated he told the resident he did not know the decision was not up to him. He stated Resident #1 replied, I hope not, because if he comes back, he will do something bad to me. He stated he immediately reported the resident's statement to LPN #5, who just shook her head. Interview with LPN #5 on 07/26/2021 at 8:21 PM revealed she denied SRNA #6 reported any allegations to her on 07/16/2021. She stated if SRNA #6 had reported that Resident #1 was afraid if SRNA #3 came back he would do something bad to him/her, she would have reported it immediately to the DON. Interview with LPN #2 on 07/22/2021 at 6:37 PM revealed approximately two (2) months prior, Resident #1 was sitting at the nurse's station and complained of being cold. She stated she asked SRNA #3 to get Resident #1 a blanket; however, instead he turned the oscillating fan on high and pointed it directly at Resident #1. LPN #2 stated she felt SRNA #3 was intentionally trying to make the resident colder and stated she should have reported it as an allegation of abuse. Continued interview with LPN #2 revealed approximately two (2) weeks later, she arrived at the nurse's station and saw SRNA #3 had the fan turned toward Resident #1. She stated Resident #1 told SRNA #3 not to do that or he/she would hit him. LPN #2 stated she then told SRNA #3 to turn the fan off or she would write him up. LPN #2 again stated she did not report the incident to anyone. Review of a Behavior Note dated 07/17/2021 at 10:30 AM revealed Resident #1 stated his/her back was hurting and that somebody had hit him/her in the back with a shovel. LPN #1 documented that no redness or bruising was noted to Resident #1's back and there were no shovels in the facility. Further review of the Behavior Note revealed staff were instructed to always provide care to Resident #1 with two (2) staff members. There was no documented evidence the allegation was reported to the Administrator or the State Survey Agency, as required. Interview with Resident #1 on 07/22/2021 at 7:46 PM, who had a Brief Interview for Mental Status (BIMS) score of twelve (12), revealed he/she did not like SRNA #3. The resident stated, He is a bully. He torments me. He thumps me on the head. He sprayed water on my face. He pushed me in the bed, and I hit the rail. Resident #1 further stated, I am scared when he comes around. He put a fan in front of my face. He is mean! If I die, he did it! Interviews with the DON on 07/21/2021 at 6:30 PM and 07/26/2021 at 6:22 PM and with the Administrator on 07/26/2021 at 7:56 PM revealed they were not aware of any allegations regarding SRNA #3 abusing Resident #1 until 07/13/2021 when APS entered the facility. They stated once they initiated an investigation, they determined RN #1 spoke with Resident #1 on the night of 07/12/2021 when SRNA #6 reported abuse allegations. RN #1 thought the resident was dreaming and did not believe there was an allegation of abuse to report to the Administrator. They stated they agreed with RN #1's determination that it did not need to be reported. According to the DON, SRNA #6 and LPN #2 reported things during investigative interviews; however, SRNA #6 never reported that SRNA #3 told Resident #1, I wish you would die. She stated if that had been reported, she would have reported the allegation to state agencies. Continued interview with the DON and Administrator revealed they were both aware that the resident stated someone hit him/her with a shovel. Both stated it was impossible that the resident was hit by a shovel and did not report the allegation. The DON stated if the facility reported everything that Resident #1 said, they would be reporting daily. The Administrator stated, That statement in and of itself is impossible, so I don't see how it could be an allegation of abuse. **The facility implemented the following actions to remove the Immediate Jeopardy on 08/06/2021: 1. (a) State Registered Nurse Aide (SRNA) #3 was terminated from employment on 08/02/2021 and SRNA #11 was terminated on 07/16/2021 by the Administrator. (b) The Social Services Director (SSD) completed a Patient Health Questionnaire (PHQ9) (module to screen the presence and severity of depression) interview with Resident #1 on 08/03/2021, with no noted change in the resident's mood/depression score. Resident #1 received psychiatric services and the facility notified the consulting practitioners of the allegations on 08/02/2021. (c) The SSD completed a PHQ9 interview with Resident #2 on 08/03/2021, no changes were identified with the resident's mood/depression score. 2. (a) As of 08/03/2021, all residents with a Brief Interview for Mental Status (BIMS) score of nine (9) and above were interviewed by the SSD. The interview was to determine if there were any care related concerns, including but not limited to: if the resident had experienced or witnessed abuse by a staff member; any staff member that the resident did not want providing their direct care; any staff the resident was afraid of, if so, residents were asked to elaborate. After completion of resident interviews, the facility identified no concerns regarding resident care and/or abuse. (b) All staff were interviewed by the Administrator, Director of Nursing (DON), and/or Assistant Director of Nursing (ADON) as of 08/05/2021. The interviews were to identify any concerns regarding resident care by their peers to include but not limited to if they had witnessed resident abuse by staff and if they were aware of any residents that were afraid of any staff member. The facility identified no concerns during the staff interviews. (c) On 08/04/2021, skin assessments were performed on all residents with a BIMS' score of less than nine (9) by the Wound Care Nurse and the Restorative Nurse to identify any injuries of unknown origin. The facility identified no concerns. Furthermore, beginning 08/09/2021, head to toe skin assessments would be performed weekly on the resident's scheduled day by the DON, ADON, and/or Wound Care Nurse to identify injuries of unknown origin as well as monitor non-interviewable residents for signs/symptoms of abuse. 3. (a) Education was provided to staff on 08/05/2021 by the Administrator, DON, ADON, and Dietary Manager (to dietary staff). The education included but was not limited to review of the facility's Abuse Policy - definitions of the different types of abuse; protection of the resident (i.e., immediate suspension of any staff member alleged of resident abuse), immediate reporting of suspected abuse, and providing a detailed statement of the abuse allegation to the investigator. The facility locked the time clock for any employee on medical leave and they were notified that they could not return to work until completion of the abuse education/in-service. Furthermore, the abuse education/in-service was included in the new hire orientation for all new employees. (b) On 08/04/2021, the Contracted Nurse Consultant provided in-service education to the Administrator, DON, ADON, and SSD on conducting a thorough abuse investigation. (c) Beginning on 08/09/2021, the Administrator and/or the SSD conducted five (5) resident interviews to determine any concerns regarding the care provided by staff; experienced and/or witnessed abuse by staff; fear of staff; and, if there were any staff, they did not want providing their care. The facility would address any concerns timely. This would continue weekly for four (4) weeks, monthly for two (2) months, and then quarterly. (d) Beginning on 08/09/2021, the Administrator and/or SSD would conduct five (5) staff interviews to identify any concerns related to staff performance of resident care. This would continue monthly for two (2) months and quarterly for three (3) quarters to determine any concerns related to resident care. (e) Beginning 08/05/2021 and continuing weekly, the DON, ADON, and/or Staff Development (SDC) completed compliance rounds to monitor for circumstances or care observations that could potentially indicate abuse. 4. (a) The contracted Vice President (VP) of Operations and/or contracted Nurse Consultant would be notified of any abuse allegations by the Administrator to ensure the Abuse Allegation Checklist was utilized to ensure regulatory compliance. (b) The Quality Assurance and Performance Improvement (QAPI) Tool for monitoring of compliance with abuse included, resident protection; immediate reporting; and conduction of a thorough investigation; would be completed by the Administrator and/or SSD with any allegation of abuse for two (2) months, and would continue quarterly thereafter. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 08/06/2021 as alleged: 1. (a) Interview with the Administrator on 08/11/2021 at 6:29 PM revealed she terminated State Registered Nurse Aide #11's employment on 07/16/2021 due to using foul language in resident care areas. She stated she terminated SRNA #3's employment on 08/02/2021 following State Survey Agency's investigation findings. Review of SRNA #3's and SRNA #11's employee files confirmed termination of employment. (b and c) Interview with the SSD on 08/11/2021 at 2:15 PM revealed she completed the Patient Health Questionnaire (PHQ9) interview with Resident #1 and Resident #2 on 08/03/2021 and there were no changes in their mood/depression scores. She stated Resident #1 was under the care of the facility's Psychiatrist, who were notified of the allegations on 08/02/2021. Review of Resident #1's and Resident #2's PHQ9 interviews dated 08/03/2021, revealed no changes in the residents' mood/depression scores. 2. (a) Interview with the SSD on 08/11/2021 at 2:15 PM revealed she completed interviews with all residents with a Brief Interview for Mental Status of nine (9) and above on 08/03/2021. The SSD stated the interviews were to determine any concerns related to staff performance of care needs, experienced and/or witnessed abuse by staff, fear of staff, and any staff identified that the residents did not want to perform their care. She stated she did not identify any concerns during the residents' interviews. (b) Interviews with the Administrator on 08/11/2021 at 6:29 PM and the DON on 08/11/2021 at 5:58 PM revealed they completed staff interviews on 08/05/2021. Both stated the interviews were to identify any concerns regarding resident care by their peers to include but not limited to if they had witnessed resident abuse by staff and if they were aware of any residents that were afraid of any staff member. (c) Interviews with the Wound Care Nurse on 08/11/2021 at 1:40 PM and the Restorative Nurse on 08/11/2021 at 1:45 PM revealed they began skin assessments of all residents on 08/02/2021 and completed resident skin assessments on 08/04/2021. Further interview revealed the nurses did not did not identify any concerns related to injuries of unknown origin or anything that would make them suspicious of abuse. Review of skin assessments revealed the Wound Care Nurse and Restorative Nurse completed the assessments between 08/02/2021 and 08/04/2021, with no concerns identified. The Wound Care Nurse stated that she performed weekly skin assessments unless she was off and then another staff would perform them in her absence. The resident assessments included an evaluation for suspicious injuries and injuries of unknown origin. 3. (a) Interviews on 08/11/2021 with the Dietary Manager at 2:31 PM, the DON at 5:58 PM, and the Administrator at 6:29 PM revealed they provided education to all facility staff on the abuse policy by 08/05/2021. They stated the education consisted of definitions of the different types of abuse; protection of the resident (i.e., immediate suspension of any staff member alleged of resident abuse); immediate reporting of suspected abuse; and providing a detailed statement of the abuse allegation to the investigator. They stated staff on medical leave or who had not received the education would not work until the education was completed. The Administrator and DON stated the abuse education was a part of the new hire orientation that new staff completed upon hire. Interviews on 08/11/2021 with LPN #3 at 1:20 PM, LPN #6 at 1:30 PM, the Wound Care Nurse at 1:40 PM, the Restorative Nurse at 1:45 PM, the Staff Development Coordinator (SDC) at 1:55 PM, the DM at 2:31 PM, SRNA #12 at 3:25 PM, SRNA #5 at 3:38 PM, Certified Medication Aide (CMT) #4 at 3:53 PM, and SRNA #13 at 5:45 PM revealed they had all received abuse education from the Administration. The Education included the definitions of the different types of abuse; protection of the resident (i.e., immediate suspension of any staff member alleged of resident abuse); immediate reporting of suspected abuse; and providing a detailed statement of the abuse allegation to investigator. Review of the abuse education and in-service sign in sheets revealed all staff completed the required abuse education by 08/05/2021. (b) Interviews with the SSD on 08/11/2021 at 2:15 PM, the DON on 08/11/2021 at 5:58 PM, and the Administrator on 08/11/2021 at 6:29 PM and review of the in-service sign in sheet revealed they received an abuse in-service from the contract Nurse Consultant on 08/04/2021. They stated the education consisted of the abuse policy and conducting a thorough abuse investigation. Interview with the contracted Nurse Consultant on 08/11/2021 at 4:40 PM revealed she provided abuse education to the Administrator, DON, ADON, and SSD on 08/04/2021 utilizing the abuse policy and conducting a thorough abuse investigation as well as utilizing the QAPI tool. (c) Interview with the SSD on 08/11/2021 at 2:15 PM revealed she performed five (5) resident interviews on 08/09/2021 to determine any concerns regarding the care provided by staff regarding experienced and/or witnessed abuse by staff; fear of staff; and if there were any staff, they did not want providing their care. She stated she did not identify any concerns related to resident care or abuse. The SSD stated they would continue resident interviews weekly for four (4) weeks, then conduct them monthly for two (2) months, and then conduct them quarterly. Review of five (5) resident interviews completed on 08/09/2021 revealed no concerns regarding resident care or abuse. (d) Interview with the Administrator on 08/11/2021 at 6:29 PM revealed she began five (5) staff interviews on 08/09/2021 to determine if there were any concerns related to staff performance of resident care. She stated they would continue staff interviews monthly for two (2) months and quarterly for three (3) quarters. (e) Interview with the DON on 08/11/2021 at 5:58 PM revealed she had begun performing weekly rounds on 08/05/2021 to monitor for any circumstances or care observations that might indicate potential abuse. Review of the round reports initiated on 08/05/2021 revealed no concerns with resident care or abuse. 4. (a) Interview with the contracted Nurse Consultant on 08/11/2021 at 4:40 PM revealed she would be notified of any abuse allegations by the Administrator to ensure the Abuse Allegation Checklist was utilized to ensure regulatory compliance. She stated no allegations of abuse had been reported since 08/06/2021. (b) Interview with the Administrator on 08/11/2021 at 6:29 PM revealed the Quality Assurance and Performance Improvement (QAPI) Tool for monitoring compliance with abuse included: resident protection; immediate reporting; and conduction of a thorough investigation; would be completed by either herself and/or the SSD with any allegation of abuse for two (2) months and would continue quarterly thereafter. She stated thus far, she had not received any abuse allegations and had not utilized the QAPI tool.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined the facility failed to ensure two (2) of three (3) residents (Residents #1 and #2) were free from abuse. On 06/25/2021 State Registered Nurse Aide (SRNA) #6 observed SRNA #3 push Resident #1 onto the bed, causing the resident's right hip to strike the bed's enable bar. When Resident #1 told SRNA #3 that he/she wished he would leave, SRNA #3 told Resident #1, I wish you would die. On 07/12/2021, at approximately 1:10 AM Resident #1 reported to SRNA #6 that on the evening of 07/11/2021 SRNA #3 had sprayed water in his/her face, and told him/her that the water was poisoned and he/she would be dead by morning. However, although SRNA #6 reported the resident's allegations immediately to Registered Nurse #1, the RN determined the resident was dreaming and took no further action. In addition, both SRNA #6 and LPN #2, witnessed SRNA #3 intentionally direct a fan to blow on Resident #1, because the resident reported being cold and did not like a fan turned toward him/her. However, LPN #2 took no further action other than threatening to write up SRNA #3. Interview with Resident #1, on 07/22/2021 at 7:46 PM, revealed the resident confirmed that SRNA #3 had verbally and physically abused him/her and stated, I am scared when he comes around, he is mean, if I die, he did it. Although the facility investigated the allegations and suspended SRNA #3 after Adult Protective Services (APS) came to the facility on [DATE], the facility unsubstantiated the allegations and allowed SRNA #3 to return to work on 07/15/2021, without increased supervision or monitoring in place to prevent further abuse to residents. In addition, on 07/13/2021, SRNA #5 observed SRNA #11 place a pillow over Resident #2's face twice because the resident was yelling out while SRNA #11 was trying to talk on her personal cell phone. Although SRNA #5 repeatedly told facility administration the details of the event, the facility's investigation revealed they were unable to make a determination if the abuse allegation was substantiated or unsubstantiated. However, the facility terminated SRNA #11's employment on 07/16/2021, because another staff reported she heard the SRNA curse in the hallway of the facility. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/29/2021 and was determined to exist on 06/25/2021, at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 07/29/2021. An acceptable Allegation of Compliance was received on 08/11/2021, which alleged removal of the Immediate Jeopardy on 08/06/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 08/06/2021 as alleged, prior to exit on 08/12/2021, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Resident Abuse, undated, revealed residents had the right to be free from abuse. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Further, the facility's policy stated mental abuse included but was not limited to, humiliation, harassment, threats of punishment, or deprivation. The policy stated any employee who suspected abuse should immediately report it to their immediate supervisor and the Administrator. Furthermore, the policy stated the facility would first ensure the resident's safety and protection, and if an employee was involved, the employee would be immediately placed on suspension until completion of the investigation. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 05/17/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set Assessment (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The assessment also indicated the resident had adequate vision/hearing, understood/understands, and had no hallucinations or delusions. In addition, the facility assessed the resident to have no physical or verbal behaviors and did not reject care. Further, the assessment revealed it was very important for the resident to be able to choose personal preferences, and required the physical assistance of one staff for transfers, personal hygiene and bathing. Review of Resident #1's care plan, revealed the resident planned to remain in the facility for long-term placement and the goal for the resident was to adjust to the facility by having positive interaction with staff and accept placement in the facility. The care plan stated the resident was very demanding argumentative. Interventions for staff to follow included, approaching the resident in a calm/quiet manner, offer comfort/reassurance, and encourage the resident to express feelings. The care plan also indicated the resident required assistance with activities of daily living, including one-person assist with transfers. Review of a facility investigation report initiated on 07/13/2021, revealed on 07/13/2021 at approximately 1:20 PM, Adult Protective Services (APS) entered the facility to investigate reports of abuse by SRNA #3 to Resident #1. The allegations involved SRNA #3 intentionally spraying Resident #1 in the face with water during a bath, giving the resident a cup of water with poison in it, pushing the resident into bed and pointing a fan to blow on the resident to make the resident cold. Further review of the report revealed the facility suspended SRNA #3 on 07/13/2021. Continued review of the report revealed the facility immediately assessed the resident and found no signs/symptoms of injury. The investigation stated upon interview with Resident #1, the resident denied any concerns related to the care provided by SRNA #3. Although the report stated Resident #3 had reported some of the concerns listed in the APS allegations in the past, it was determined those reports were a dream the resident had. In addition, the investigation stated that another staff member had observed SRNA #3 turn on a fan at the nurse's station, which was blowing on Resident #1, but SRNA #3 described that incident as accidental. Continued review of the investigation revealed the facility unsubstantiated the abuse allegations and allowed SRNA #3 to return to work on 07/15/2021, on the unit where Resident #1 resided with no restrictions or increased oversight. Observation and interview with Resident #1, on 07/22/2021 at 7:46 PM, revealed the resident was lying in bed, alert and able to answer questions appropriately. When asked about SRNA #3 by name, the resident immediately stated, I don't like him, he's mean, he's a bully, he torments me. Resident #1 then stated, He thumped me on the head, sprayed water in my face, and he pushed me in the bed, and I hit the rail. I am scared when he comes around, if I die, he did it. Resident #1 denied having any problems or concerns with other staff in the facility providing care to him/her. Interview with SRNA #6, on 07/22/2021 at 5:30 PM, and on 07/27/2021 at 4:45 PM, revealed he had observed SRNA #3 being abusive to Resident #1. SRNA #6 stated he was assisting SRNA #3 to transfer Resident #1 to bed. The SRNA stated Resident #1 liked to adjust his/her clothes before getting into bed. The SRNA stated when the resident finished with his/her clothes and stated he/she was ready, SRNA #3 was on the resident's left side, and as the resident started to sit down on the side of the bed, SRNA #3 shoved the resident causing the resident's right hip to hit the enabler bar on the bed. SRNA #6 stated he witnessed SRNA #3 shove the resident's left hip, say to the resident How many times do I have to tell you to sit as close to the bar as you can, so I don't have to pull you up in bed. SRNA #6 stated Resident #1 told SRNA #3 I wish you would go away, and in response, SRNA #3 got right down in (his/her) face, nose to nose, and said I wish you would die. SRNA #6 stated he told SRNA #3 man you can't talk to residents like that, and SRNA #3 just shook his head, smiled, and walked out of the room. SRNA #6 stated he did not report the incident at that time, because it was his second day at work, and he had been told by some other staff, that it would not do any good to report anything, because the Administrator and Director of Nursing (DON) would not do anything about it. SRNA #6 stated he thought about what could happen to other residents by not reporting what he had witnessed, and stated It weighed heavy on me. Continued interview with SRNA #6, revealed he was coming into work on 07/11/2021, for the 11:00 PM to 7:00 AM shift, and encountered SRNA #3 and SRNA #8 outside the facility on break. SRNA #6 stated he heard the two (2) SRNA's complaining the nurse had made them give Resident #1 and another resident a bath, because day shift had not been able to get them done. SRNA #6 stated the SRNAs were aggravated and mad because they had to give the baths. SRNA #6 stated later on during his shift at approximately 1:00 AM on 07/12/2021, Resident #1 reported to him that yesterday on evening shift (07/11/2021), SRNA #3 and SRNA #8 gave him/her a bath and SRNA #3 sprayed water in his/her face with the shower head anytime he/she started to talk. The resident also stated that SRNA #3 had given him/her a cup of water and said it had poison in it and he hoped he/she would be dead by morning. Continued interview with SRNA #6, revealed he reported these allegations to RN #1 at approximately 1:10 AM on 07/12/2021. He stated RN #1 went into Resident #1's room after he reported the allegations, but he did not go into the room with RN #1 and did not know what the nurse and Resident #1 talked about. Review of Resident #1's bath record revealed staff had given Resident #1 a bath on 07/11/2021 during second shift. Interview with SRNA #8 on 07/26/2021 at 3:55 PM, revealed on 07/11/2021, SRNA #3 assisted her with transferring Resident #1 into the whirlpool bath, and was present in the shower room. However, she stated SRNA #3 left soon after the resident was in the tub and did not assist with the bath. SRNA #8 denied having any knowledge of SRNA #3 spraying water in the resident's face. Interview with RN #1 on 07/21/2021 at 2:45 PM, revealed between 1:00 AM and 2:00 AM on 07/12/2021, SRNA #6 reported to her that Resident #1 told him that SRNA #3 had sprayed water in his/her face while giving him/her a whirlpool bath on 07/11/2021. RN #1 stated she went to Resident #1's room and asked the resident about the allegation, but stated, (Resident #1) acted like it was all a dream. RN #1 stated she did not report the allegation to her supervisor or the Administrator and did not complete an incident report because she thought the resident was dreaming and it was not true. Review of a Nursing Note dated 07/12/2021, revealed at 12:20 AM, the nurse documented, Resident using call light frequently, has been up to the bathroom with assist x 7 times so far this shift. The entry also stated Resident #1 stated .I am going to die tonight. Someone is going to poison me . Continued interview with SRNA #6, on 07/22/2021 at 5:30 PM, and on 07/27/2021 at 4:45 PM, revealed he called APS on 07/12/2021, and reported everything he had witnessed SRNA #3 do to Resident #1. The SRNA stated he called APS, because he did not think the facility's administration would take action to prevent further abuse to Resident #1 or other residents in the facility. SRNA #6 stated he never heard anything else about the allegations, until the morning of 07/14/2021 at the end of the shift at approximately 7:00 AM, when the DON questioned the SRNA regarding the allegations. SRNA #6 stated he told the DON what Resident #1 had told him about the shower on 07/11/2021, and he also told her about witnessing SRNA #3 shove Resident #1 into the enabler bar on 06/25/2021. In addition, SRNA #6 also stated he told the DON about witnessing SRNA #3 turn a fan in the direction of Resident #1, because he knew the resident did not like the fan to blow on him/her. SRNA #3 stated he could not recall the specific dates this had occurred. Interview with Licensed Practical Nurse (LPN) #2, on 07/22/2021 at 6:37 PM, revealed approximately two (2) months ago, (exact date unknown), Resident #1 was sitting at the nurse's station and complained of being cold. LPN #2 stated she told SRNA #3 to get Resident #1 a blanket. However, LPN #2 stated instead of going to get the blanket, he deliberately turned the oscillating fan on high and pointed it directly at Resident #1. LPN #2 stated she instructed SRNA #3 to turn the fan off. However, instead of turning off the fan SRNA #3 stated, (Resident #1) is hot. LPN #2 stated she told SRNA #3 that he knew the resident was cold, and to turn the fan off and get the resident a blanket. LPN #2 stated she did not report the incident to her supervisor or Administrator as required because I thought me telling him as a charge nurse was good enough. However, LPN #2 stated obviously, it wasn't because he done it again. Continued interview with LPN #2 revealed approximately two (2) weeks later, (exact date unknown), she had been performing treatments and when she got back to the nurse's station, SRNA #3 had the fan turned on high blowing on Resident #1, who was sitting at the nurse's station. LPN #2 stated Resident #1 told SRNA #3 not to do that or he/she would hit him. The LPN stated, I told him to turn it off or I would write him up. However, LPN #2 stated she did not report the incident to her supervisor or Administrator until the DON called her (exact date unknown) asking questions about SRNA #3. Continued interview with SRNA #6, on 07/22/2021 at 5:30 PM, and on 07/27/2021 at 4:45 PM, revealed he was caring for Resident #1 on 07/16/2021. SRNA #6 stated, (Resident #3) asked me to lean down so the resident could tell me something. SRNA #6 stated the resident asked him if SRNA #3 would be back to work. SRNA #6 stated he told Resident #1 he did not know, and the resident stated, I hope not, because if he comes back, he will do something bad to me. SRNA #6 stated he immediately reported what the resident had said to Licensed Practical Nurse (LPN) #5. However, SRNA #6 stated LPN #5 only shook her head and took no further action. Interview with LPN #5 on 07/26/2021 at 8:21 PM, revealed she denied SRNA #6 reported any allegations to her on 07/16/2021. Interview with SRNA #3, on 07/21/2021 at 6:05 PM, revealed he routinely worked with Resident #1. SRNA #3 denied all the allegations of abuse or mistreatment to Resident #1, including spraying water in the resident's face, telling the resident the water was poisoned, shoving the resident in the bed or deliberately turning the fan on the resident. SRNA #3 stated on 07/13/2021, prior to the beginning of his shift, Adult Protective Services (APS), the Assistant Director of Nursing (ADON), the DON, and the Administrator interviewed him regarding the allegations of abuse to Resident #1. SRNA #1 stated he told the individuals interviewing him he had not done any of the alleged acts, but did state he had accidentally turned the fan on Resident #1 one time. SRNA #1 stated the Administrator suspended him and he did not work his scheduled 3:00 PM to 11:00 PM shift on 07/13/2021. SRNA #3 stated he returned to work on 07/15/2021, and worked from 7:00 PM until 11:00 PM, on the same unit where Resident #1 resided. However, SRNA #3 stated he had not cared for Resident #1 since 07/12/2021. SRNA #3 stated the facility did not instruct him to stay out of Resident #1's room, but did say they (administration) posted on our page (electronic communication from facility to staff), to take a witness when going into (Resident #3's) room. Interviews with the DON, on 07/21/2021 at 6:30 PM, and 07/26/2021 at 6:22 PM, revealed the facility was made aware of the allegations regarding Resident #1 and SRNA #3 on 07/13/2021 when APS entered the facility. The DON stated she interviewed Resident #1 with the Administrator on 07/13/2021, and the resident denied all of the allegations, but did say he/she didn't like (SRNA #3). The DON stated Resident #1 did not say he did anything to him/her, he/she just didn't like his tendencies. The DON stated she believed SRNA #6 had called APS and reported the allegations involving SRNA #3 and Resident #1, and believed that the resident had reported the allegations to him. However, the DON stated RN #1 checked on Resident #1 when SRNA #3 reported what the resident had told him on 07/12/2021, and the RN did not think it happened and thought Resident #1 was dreaming. The DON also stated RN #1 told Resident #1 on 07/12/2021, that any allegation should be reported to (the DON or Administrator). The DON stated no other staff or resident had ever made allegations against SRNA #3 to her, and stated, He is like a big teddy bear. Interview with the Administrator, on 07/22/2021 at 8:46 PM, and on 07/26/2021 at 7:56 PM, revealed she became aware of the abuse allegations involving Resident #1 and SRNA #3 when APS entered the building on 07/13/2021. She stated she was not aware of any allegations prior to 07/13/2021. However, she stated her investigation of the allegations revealed RN #1 talked with Resident #1 after SRNA #6 told her what Resident #1 had told him on 07/12/2021. The Administrator stated RN #1 told her she believed the resident was dreaming, so the Administrator stated she did not consider it an allegation of abuse. The Administrator stated therefore, the allegation was unsubstantiated and SRNA #3 returned to work at the facility on 07/15/2021. The Administrator stated SRNA #3 returned to work on the unit where Resident #1 resided, because that was his assigned area. However, the DON stated the facility had not increased monitoring or oversight for SRNA #3, and did not explain how the facility planned to protect other residents from potential abuse by SRNA #3. Continued interview with the Administrator during the 07/22/2021 interview at 8:46 PM, revealed she stated, I think knowing the history of this resident (Resident #3), he (SRNA #3) will not be assigned to the resident anymore. Review of SRNA #3's schedule revealed the SRNA worked the North Unit, where Resident #1 resided on 07/15/2021, 07/20/2021, and 07/22/2021 from 7:00 PM until 11:00 PM. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 12/31/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired and totally dependent on two (2) staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Further review of the MDS revealed Resident #2 displayed verbal behavioral symptoms such as screaming and cursing others. Review of Resident #2's care plan dated 05/19/2015, revealed the resident had impaired cognition, talks nonsensical and frequently yelled out. Interventions initiated included staff providing a calm structured routine. Review of a facility investigation initiated on 07/13/2021, revealed SRNA #5 reported an allegation of physical abuse involving what she described as SRNA #11 placing a pillow on the face of Resident #2 when providing feeding assistance to the resident. The report stated staff immediately assessed Resident #2 and found no signs/symptoms of respiratory distress or physical markings/discolorations on the resident's face. Continued review of the report revealed it stated there were no other witnesses to the event or other residents/staff in the vicinity. The report stated administration interviewed SRNA #11 who stated the pillow briefly fell on to Resident #1's face, when she pulled it out from under the resident's head for repositioning. SRNA #11 told administration it was only on the resident's face briefly and she did not place her hand on the pillow when it was on the resident's face. Further review of the report revealed documented interviews with the witness (SRNA #5), indicated some changes in her information, including her viewpoint of the event and the contact of the pillow with the resident 2 times rather than just once. Continued review of the facility's investigation revealed the report stated due to lack of corroborating witnesses and stories presented for the event, the facility cannot substantiate or unsubstantiated this allegation. However, the facility terminated SRNA #11's employment on 07/16/2021, for utilizing inappropriate language in the hearing vicinity of residents Interview with SRNA #5 on 07/22/2021 at 10:53 AM, and on 07/26/2021 at 8:50 PM, and review of SRNA #5's handwritten witness statement dated 07/13/2021, revealed she was going to Resident #2's room to see if SRNA #11 wanted to go to lunch. SRNA #5 stated the door of the resident's room was closed when she approached it, so she knocked on the door and opened it. SRNA #5 stated the window shades were drawn, there were no lights on, and the room was dark. SRNA #5 stated SRNA #11 was talking on her cell phone. SRNA #5 stated when SRNA #11 stopped talking for a minute, she asked her about lunch. However, SRNA #5 stated SRNA #11 just kept talking on the phone. SRNA #5 stated Resident #2 was in bed and was screaming out, which the resident normally does. SRNA #5 stated SRNA #11 kind of growled out of frustration then took the pillow out from under the resident's head. SRNA #5 stated SRNA #11 then threw the pillow over the resident's face and placed her hand on the pillow to hold it down. SRNA #5 stated when Resident #2 stopped yelling, SRNA #11 removed the pillow. SRNA #5 stated she said OK (SRNA #11) you want to go to lunch, but SRNA #11 did not answer. SRNA #5 stated she stayed in the room and Resident #2 screamed out again, and SRNA #11 again put the pillow over the resident's face and placed her hand on the pillow to hold it down. SRNA #5 stated, I told her you don't need to be doing things like that, but SRNA #5 stated SRNA #11 rolled her eyes, did not say anything, and kept talking on the phone. SRNA #5 stated SRNA #11 kept her hand on the pillow approximately five (5) seconds each time, until the resident quit screaming. SRNA #5 stated she looked out in the hallway and could see another SRNA leaving a resident's room and stepped out of Resident #2's room and went into the empty room next door, and called SRNA #4 in there and explained to SRNA #4 what had occurred in Resident #2's room. SRNA #5 stated she sent SRNA #4 back into Resident #2's room, while she went to report the incident to a nurse. SRNA #5 revealed she reported the incident to LPN #1 and to the DON. Further interview with SRNA #5 revealed she wrote out a witness statement on 07/13/2021. SRNA #5 stated facility administration had verbally interviewed her three (3) times, and stated, Each time I have told them the same thing exactly as it happened. Interview with SRNA #4 on 07/22/2021 at 10:16 AM, revealed on 07/13/2021 during lunch, SRNA #5 came to her and reported she had just witnessed SRNA #11 place a pillow over Resident #2's face. SRNA #4 stated she instructed SRNA #5 to go get LPN #1 and she went into Resident #2's room, where she stated she observed SRNA #11 sitting in the resident's recliner, talking on a cell phone. SRNA #4 stated LPN #1 came into Resident #2's room a little later, and told SRNA #11 to leave the room. SRNA #4 revealed she did not see anything on Resident #2's face, and the resident's pillow was behind the resident's head. SRNA #4 stated she was aware that SRNA #11 had been having problems at home, and stated, Her mood had changed. SRNA #4 further revealed she has worked with SRNA #5 quite a bit, and had never known the SRNA to make any accusations about any other staff, and stated, She is an honest person. Interview with LPN #1 on 07/22/2021 at 11:40 AM, and review of the LPN's written witness statement, not dated, revealed SRNA #5 reported an abuse allegation to her and the DON on 07/13/2021 at approximately 12:15 PM. She stated SRNA #5 reported that SRNA #11 had placed a pillow over Resident #2's face twice and each time placed her hand on the pillow to keep it on the resident's face. LPN #1 revealed she went to Resident #2's room and asked SRNA #11 to leave the room. LPN #1 stated the DON instructed her to question SRNA #11 about the incident. LPN #1 stated when she questioned SRNA #11, she had a lost look on her face and told me she was upset with her husband. The LPN stated when she told SRNA #11 what SRNA #5 had reported, SRNA 11 stated she was just trying to straighten the resident's pillow. LPN #1 stated she instructed SRNA #11 to leave the facility. LPN #1 stated due to the way SRNA #11 was acting, I believe she done it. LPN #1 stated SRNA #11 did not try to argue, did not deny the allegation, and was not upset about the accusation. LPN #1 stated SRNA #11 had exhibited a bad attitude for the last couple of months, and had a strange look on her face. LPN #1 stated she completed a skin assessment on Resident #2, and the resident's face was slightly red, however the resident's room temperature was warm and the resident was wearing a flannel gown. Review of SRNA #11's typed witness statement dated 07/14/2021, revealed she was feeding Resident #2 and her husband kept calling on her personal cell phone. She stated she answered her phone and was attempting to get her husband to leave her alone, when SRNA #5 entered Resident #2's room. SRNA #11's statement stated Resident #2 was not eating well, therefore, she was going to pull the resident up in the bed and reposition him/her. SRNA #11 stated that she pulled the pillow out from under Resident #2's head and laid the pillow above the resident's head. The SRNA's statement stated being on the cell phone distracted her, and the pillow fell over Resident #2's face. SRNA #11's statement stated she grabbed the pillow off the resident's face and put it back under the resident's head. She stated that SRNA #5 left Resident #2's room and she continued to feed Resident #2. The SRNA's statement stated after she finished feeding the resident she went to the bathroom, and when she came out, someone told her to go home, because someone reported that she was being mean to Resident #2. Interview with SRNA #1 on 07/21/2021 at 4:15 PM, revealed she had worked with SRNA #11 approximately two (2) weeks ago (exact date unknown) for the first time. She stated they were walking down the hall past the nurse's station and could hear Resident #2 yelling out from her room. SRNA #1 stated SRNA #11 said, I wish she would shut the [OBSCENITY] up. SRNA #1 stated she should have reported it because it was inappropriate for her to say that, but she did not report it because she had never worked with her before and stated, I really did not know how to take it. SRNA #1 stated she reported the incident when administration interviewed her on 07/13/2021, regarding Resident #2 and SRNA #11. Interview with the DON 07/26/2021 at 6:22 PM, revealed she was alerted to the abuse allegation regarding Resident #2 and SRNA #11 on 07/13/2021, prior to 1:00 PM. She stated she directed LPN #1 to question SNRA #11 about the allegation and then escorted SRNA #11 off the premises. She stated she was in the middle of working on the abuse allegation involving Resident #1 and SRNA #3 when SRNA #5 reported the allegation. The DON stated she could not determine that the allegation of abuse occurred because SRNA #5's story changed twice during the interview process. The DON gave the example of during the first interview, SRNA #5 stated she observed SRNA #11 hold the pillow on Resident #2's face, and during the next interview, SRNA #5 stated SRNA #11 placed the pillow on Resident #2's face twice. However, the facility could produce no other evidence to indicate that SRNA #5 had ever changed her statement or account of the incident. Interview with the Administrator on 07/26/2021 at 7:56 PM, revealed she was unavailable when SRNA #5 made the allegation of abuse against SRNA #11, and the DON dealt with the situation. The Administrator stated she did not substantiate the allegation of abuse because SRNA #5 stated she witnessed the abuse occur, but SRNA #11 denied doing it. Therefore, the Administrator stated, We had two (2) staff with two (2) different stories and the resident was not interviewable. The DON stated, I am not the judge and [NAME], I could not 100 percent state it occurred. In addition, the Administrator was unable to verbalize why the facility substantiated SRNA #1's allegation of SRNA #11 cursing in the hallway and terminated the employee, but was unable to substantiate the allegation made by SRNA #5. Interview with Resident #2's son on 07/22/2019, at 5:34 PM, revealed the Administrator called him on 07/13/2021, and reported there had been an allegation of abuse involving Resident #2. The son stated the Administrator would not share the details of the allegation with him, but stated his sister and Resident #2's spouse visited the resident at the facility on 07/13/2021. When the spouse and resident's daughter arrived back home, they told the son that Resident #2 looked like he/she had run a mile, because the resident's face was so red, and that Resident #2's left eye was bruised. The son stated his sister also said it appeared Resident #1's nose was swollen and crooked. Continued interview with the son revealed the Administrator called him back a few days later (exact day unknown) and told him the findings of the investigation were inconclusive. Observation of a skin assessment for Resident #2 on 07/22/2021 at 4:30 PM, revealed the resident's face was slightly red, and the right side of the resident's nose appeared slightly swollen. **The facility implemented the following actions to remove the Immediate Jeopardy on 08/06/2021: 1. (a) State Registered Nurse Aide (SRNA) #3 was terminated from employment on 08/02/2021 and SRNA #11 was terminated on 07/16/2021 by the Administrator. (b) The Social Services Director (SSD) completed a Patient Health Questionnaire (PHQ9) (module to screen the presence and severity of depression) interview with Resident #1 on 08/03/2021, with no noted change in the resident's mood/depression score. Resident #1 received psychiatric services and the facility notified the consulting practitioners of the allegations on 08/02/2021. (c) The SSD completed a PHQ9 interview with Resident #2 on 08/03/2021, no changes were identified with the resident's mood/depression score. 2. (a) As of 08/03/2021, all residents with a Brief Interview for Mental Status (BIMS) score of nine (9) and above were interviewed by the SSD. The interview was to determine if there were any care related concerns, including but not limited to: if the resident had experienced or witnessed abuse by a staff member; any staff member that the resident did not want providing their direct care; any staff the resident was afraid of, if so, residents were asked to elaborate. After completion of resident interviews, the facility identified no concerns regarding resident care and/or abuse. (b) All staff were interviewed by the Administrator, Director of Nursing (DON), and/or Assistant Director of Nursing (ADON) as of 08/05/2021. The interviews were to identify any concerns regarding resident care by their peers to include but not limited to if they had witnessed resident abuse by staff and if they were aware of any residents t [TRUNCATED]

Based on interview, record review, facility policy review, and review of job descriptions, it was determined the facility failed to provide pharmaceutical services to prevent diversion of controlled medication for one (1) of three (3) sampled residents (Resident #3). According to the facility's policy and the facility's Charge Nurse job description, a nurse was required to count controlled medications and other medications with a risk of abuse or diversion. However, the facility failed to follow the policy and allowed staff members other than licensed nurses to count and control the facility's narcotic medications. In April 2021, the facility's Pharmacy Consultant notified the facility of concerns that Certified Medication Technician (CMT) #3 was administering more controlled medications than other staff. However, there was no documented evidence the facility took any action to monitor/prevent drug diversion. On 06/21/2021, staff determined Resident #3 had a card of Oxycodone (controlled medication) missing and CMT #3 was the last person that had access to the medication. Police were notified and found that CMT #3 had medications that were not prescribed for her in her possession. CMT #3 tested positive for Opioid and Oxycodone. The findings include: Review of the facility's policy titled, Inventory Control of Controlled Substances revision date of 01/01/2013, revealed the facility directed the incoming and outgoing nurses to count all Schedule 2 controlled substances and other medications with a risk of abuse or diversion. The medications were to be counted at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet. The policy did not address how the facility would monitor for drug diversion. Review of the Job Description for Certified Medication Techinician (CMT), dated 12/07/2016, revealed the CMT would report changes in residents' conditions to the nurse supervisor. Review of the Job Description for Charge Nurse dated 12/07/2016, revealed the Charge Nurse would count controlled drugs. Review of Resident #3's medical record revealed the facility admitted the resident on 11/17/2017, and readmitted the resident on 11/13/2020, with diagnoses that included [CONDITION(S)] (COPD), [CONDITION(S)], [CONDITION(S)] Disease, Anxiety, Disorder of Bone, Type 2 Diabetes, and Leg Pain. Review of Resident #3'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 14, indicating the resident was cognitively intact. Continued review of the assessment revealed the resident had frequent pain and his/her pain was assessed at a two (2). The facility used the numeric rating scale of 0-10 with zero meaning no pain and 10 meaning severe, horrible pain. Review of Resident #3's Comprehensive Care Plan with a revision date of 07/16/2020, revealed the resident was at risk for pain and staff was directed to administer Oxycodone pain medication as ordered. Review of Resident #3's Physician's Orders dated 04/20/2021, revealed the physician ordered Oxycodone HCL 5 (five) milligram (mg) one (1) tablet every six (6) hours as needed (PRN), for pain. Review of Resident #3's Medication Administration Record (MAR) revealed in April 2021, Resident #3 received nine (9) doses of Oxycodone for pain, and six (6) doses were given by Certified Medication Technician (CMT) #3. Review of Resident #3's MAR for May 2021, revealed he/she received 27 doses of the pain medication, and 21 doses were given by CMT #3. Further review of Resident #3's MAR revealed in June 2021, the resident received 17 doses of Oxycodone for pain, and CMT #3 administered nine (9) doses of the pain medication. Review of July 2021's MAR revealed as of 07/21/2021, Resident #3 had received five (5) doses of the PRN pain medication. Review of an Misappropriation of Narcotics Investigation for Resident #3, dated 06/21/2021, revealed on 06/21/2021, a card of Oxycodone and the narcotic record for the Oxycodone were absent from the medication cart and the narcotic record. Continued review of the investigation revealed CMT #3 was the last staff member to sign out any narcotics for Resident #3. Further review revealed the CMT was also identified to have signed out more narcotics than other staff, and included residents who did not often request pain medication. Further review of the investigation revealed the facility notified law enforcement. It was noted that two (2) containers of narcotic medications were found on the CMT when law enforcement arrived. CMT #3 did not have any prescriptions for the narcotic medications found on her. The facility did an in-facility rapid drug screen on the CMT. CMT #3 tested positive for Opioids, and Oxycodone. Interview with Resident #3 on 07/26/2021 at 5:35 PM, revealed the resident did not ask for pain medication often, but when he/she did ask for pain medication he/she asked CMT #3 for [MEDICATION(S)], more times than Oxycodone. Interview with Licensed Practical Nurse (LPN) #1 on 07/22/2021 at 11:40 AM and, at 2:49 PM revealed CMT's completed the narcotic counts at the beginning and end of every shift, and that had always been the process. LPN #1 stated she was suspicious of CMT #3 taking residents' narcotics for approximately nine (9) months and had reported her concerns in October 2020 to the previous Director of Nursing (DON) #2. LPN #1 stated she had also reported to DON #1 approximately a month ago that CMT #3 administered more narcotic pain medications to residents than any other staff. Interview with LPN #4 on 07/26/2021 at 3:06 PM, revealed she had noticed that CMT #3 gave more PRN narcotic medications to residents than other staff. She stated, Most everyone saw it. However, she had not reported her concerns to the DON. Interview with the facility's Pharmacy Consultant on 07/26/2021 at 3:30 PM, revealed she had not been in the facility for over a year due to COVID 19. She stated the year she was out, she was not monitoring narcotic administration, narcotic cards, nor narcotic sheets. She stated when she came back in April 2021, she identified and reported to the Director of Nursing (DON) that CMT #3 was administering more pain medication to residents than any other staff. The Pharmacy Consultant stated after reporting to the DON in April 2021, it was up to the facility how and when to investigate the concern. Interview with the DON on 07/26/2021 at 6:22 PM, revealed the Pharmacist Consultant made her aware of CMT #3 administering more PRN narcotic pain medications in April 2021. The DON stated she randomly started reviewing narcotic sheets, but found no concerns. Continued interview revealed the CMT's passing the medications counted the narcotics on their cart. The DON stated nurses did not have keys or access to the medication carts, only the CMT's had the keys. Interview with the Administrator on 07/26/2021 at 7:56 PM, revealed she was not a nurse and could not answer anything clinically related.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of three (3) sampled residents (Resident #1). Observations conducted on 01/02/20 revealed Resident #1 had two (2) Stage 2 pressure areas to his/her right and left buttock. Further observations revealed the areas were uncovered, and interview with the Treatment Nurse revealed she was not aware that Resident #1 had pressure sores. Review of the resident's record revealed no evidence the pressure areas had been identified, assessed, or provided treatment to prevent worsening as required. The findings include: Review of the facility policy titled Skin Assessments, dated (MONTH) 2019, revealed a baseline skin assessment would be conducted upon admission and head-to-toe skin assessments would also be conducted on all facility residents weekly. The policy also stated the admission skin assessment would reflect the skin conditions that were present upon admission that required treatment measures such as wounds of any cause which included pressure. The policy also stated pressure injuries identified would be assessed by a licensed nurse when the area was initially identified and weekly until healed. The policy also directed staff to monitor the progress of the resident's wound daily. Review of Resident #1's medical record revealed the facility admitted the resident on 12/29/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was frequently incontinent of bowel and bladder, and required limited assistance of one (1) staff member for bed mobility and toileting. The MDS revealed Resident #1 had no brief interview for mental status (BIMS) score on the assessment but was able to make him/herself understood and was able to understand others. Review of Resident #1's hospital record revealed hospital staff had photographed open areas to the resident's right and left buttock on 12/23/19 (before the resident was transferred back to the nursing facility). No measurements were documented on the areas photographed on the residents' skin. Further review of Resident #1's record revealed no evidence a skin assessment was conducted when he/she was readmitted to the facility on [DATE]. Review on 01/02/20 of Resident #1's record also revealed a skin assessment was attempted by the Treatment Nurse on 12/26/19 (three days after the resident was readmitted ); however, the resident refused. There was no documented evidence that staff had attempted to evaluate the resident's skin since his/her documented refusal on 12/26/19 (a period of six days). Interview with Resident #1 was attempted on 01/02/20 at 11:15 AM; however, he/she would not respond to questions asked by the surveyor. Observations conducted of Resident #1's skin/wound assessment observed on 01/02/20 at approximately 11:20 AM, revealed he/she had one (1) open area to his/her right buttock which measured 0.3 centimeters (cm) in length and 0.4 cm in width. Continued observations revealed the resident also had an open area to his/her left buttock that measured 1.2 cm in length and 1.0 cm in width. The open areas were not covered with a dressing upon initial assessment. Interview with State Registered Nurse Aide (SRNA) #1 on 01/02/20 at 12:30 PM revealed she provided care to Resident #1 frequently. The SRNA stated she had observed the open areas on the resident's bilateral buttocks but could not recall if she had reported it to nursing staff and also stated she assumed nursing staff was aware because the areas have been there since he/she returned from the hospital. Interview with SRNA #2 on 01/02/20 at 2:00 PM revealed she had identified the open areas to Resident #1's bilateral buttocks over the past couple of weeks, but was unable to recall the date/time. She stated she had reported the resident's open areas and stated she was pretty sure it was the treatment nurse that she reported the resident's abnormal skin condition to. Interview with SRNA #3 on 01/02/20 at 2:30 PM revealed she frequently cared for Resident #1 and she had reported the open areas on Resident #1's bottom to the Treatment Nurse and to Licensed Practical Nurse (LPN) #2. The SRNA stated she had reported the resident's open areas a couple of days ago because the resident had been incontinent of bowel and the SRNA was concerned because the open areas were not covered. Interview with LPN #3 on 01/02/20 at 3:00 PM revealed she was the designated Treatment Nurse in the facility and stated staff had not informed her that Resident #1 had two (2) Stage 2 pressure areas to his/her buttocks. She stated she had not measured, assessed, or implemented treatments to Resident #1's pressure sores because she was not aware of the resident's pressure sores. LPN #3 stated she had attempted to evaluate Resident #1's skin on 12/26/19; however, the resident refused. The LPN acknowledged residents were required to have a head-to-toe skin assessment every week in the facility; however, she stated she was unable to recall if she had attempted to evaluate the resident's skin again since his/her refusal. Interview with LPN #2 on 01/03/20 at 10:20 AM revealed she was unable to recall if SRNAs had reported to her that Resident #1 had wounds (pressure sores) to his/her buttocks. However, the LPN stated she may have been in conversation with the Treatment Nurse regarding Resident #1's pressure sores, but I can't be sure. The LPN stated she was not required to measure or document anything related to the resident's skin condition if the Treatment Nurse was in the facility. Interview with LPN #1 on 01/03/20 at 3:30 PM revealed she readmitted Resident #1 to the facility from a recent hospital stay on 12/23/19. She stated she had been trained to conduct a head-to-toe skin assessment when residents were readmitted to the facility, and document the findings of the skin assessment in the resident's medical record. However, LPN #1 stated it was busy when she readmitted Resident #1 and she was unable to recall if she conducted a skin assessment. The LPN stated she was not aware that Resident #1 had pressure areas to his/her buttocks. Interview with the DON on 01/02/20 at 2:30 PM revealed Resident #1 should have received a head-to-toe skin assessment when he/she returned to the facility on [DATE]. The DON also stated licensed staff had been trained to do a wound assessment, and obtain treatment orders when a new pressure sore is reported and/or identified. She also stated staff were required to document resident refusals and ensure other attempts are made to evaluate and ensure the resident's needs were met in the facility.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to maintain an effective infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections for one (1) of three (3) sampled residents (Resident #1). Resident #1 was readmitted on [DATE] after a hospital stay. During the hospital stay, Resident #1 was diagnosed with [REDACTED]. The hospital staff had also cultured a wound to the resident's back. Although the final results were pending, the initial culture report dated 12/22/19, indicated a Heavy Growth of Gram Positive Cocci (the primary bacterial pathogen [MEDICAL CONDITION]) was present in his/her wound. There was no evidence the facility identified the resident's abnormal lab results, or that no follow-up was conducted to obtain the final results of the resident's pending abnormal wound culture. In addition, there was no evidence that any interventions had been implemented to protect other residents and/or staff from Resident #1's infection. The findings include: Review of the facility policy titled Care of the Resident with a MDRO ([MEDICAL CONDITION]), not dated, revealed staff should follow the guidelines for appropriate isolation precautions, of residents known or suspected to have a MDRO infection or colonization. The policy defined a MDRO as bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs; one example identified per the policy of an MDRO [MEDICAL CONDITION]. The policy stated residents known or suspected to have a MDRO infection or colonization would be placed on Contact Precautions. The policy also indicated the following conditions should be considered in determining the need for Contact Precautions, which included draining wounds and stool incontinence. Review of Resident #1's medical record revealed the facility admitted the resident on 12/29/17 with [DIAGNOSES REDACTED]. Review of the resident's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she required limited assistance of one (1) staff member for bed mobility and toileting and he/she was frequently incontinent of bowel and bladder. The MDS stated Resident #1 was able to make him/herself understood and he/she understands others; however, he/she had no brief interview for mental status (BIMS) score recorded on the assessment. Interviews with staff revealed Resident #1 had no BIMS score conducted because he/she would not participate in the resident interview process. Interview with Resident #1 was attempted on 01/02/20 at 11:15 AM; however, the resident would not respond to questions asked by the surveyor. Observations conducted of Resident #1 as well as a skin assessment observed during initial tour of the facility on 01/02/20 at 11:20 AM, revealed he/she had an open area to his/her upper back and a moderate amount of light yellow drainage was observed to the resident's wound. Observations also revealed no evidence that Contact Precautions had been implemented for the resident. Review of Resident #1's nurse's notes dated 12/22/19 at 4:00 PM revealed the resident complained of severe pain and itching to his/her body. The documentation also revealed Resident #1 had an open area to his/her back which was observed to have a scant amount of clear to blood-tinged drainage. Resident #1 was transferred to a local hospital on [DATE] at 4:20 PM, and later admitted with a [DIAGNOSES REDACTED]. Review of Resident #1's hospital record revealed the resident was evaluated at a local emergency room (ER) on 12/22/19 at approximately 5:00 PM. Resident #1's record revealed open areas were observed to his/her upper back in the ER and wound cultures were obtained at 8:13 PM. Review of Resident #1's hospital record also revealed staff had collected a nasal swab on 12/22/19, to screen the resident for [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Review of the resident's laboratory results dated [DATE] at 5:02 AM revealed the nasal swab was positive [MEDICAL CONDITION]. Review of the preliminary (early) report of the resident's wound culture dated 12/23/19 at 8:47 AM indicated a Heavy Growth of Gram Positive Cocci. Review of Resident #1's final wound culture report dated 12/24/19 at 10:47 AM revealed the resident had a Heavy Growth of [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) and Moderate Growth of Diptheroids in his/her wound. Interview with Licensed Practical Nurse (LPN) #1 on 01/03/20 at 3:30 PM revealed she readmitted Resident #1 to the facility on [DATE]. The LPN stated she had been trained to review lab tests conducted while residents were in the hospital. However, LPN #1 had not reviewed any of Resident #1's laboratory tests when he/she was readmitted because it was crazy and busy when the resident returned to the facility. The LPN stated she should have identified that the resident had tested positive [MEDICAL CONDITION] and had an abnormal preliminary wound culture, which was pending a final result, and ensured someone followed up to obtain the resident's results. She also stated if she had identified that Resident #1 had been diagnosed with [REDACTED]. Interview with the Infection Control Nurse on 01/03/20 at 3:00 PM revealed she maintained a log of residents with MDROs in the facility, and Resident #1 had not been previously diagnosed with [REDACTED]. stay. She stated she should have been notified of Resident #1's abnormal lab results and Contact Precautions should have been implemented when he/she was readmitted to the facility. She also stated she would have contacted the hospital and obtained the final wound culture report if she had been made aware one was pending for the resident. Interview with the DON on 01/02/20 at 2:30 PM revealed the nurse that readmitted Resident #1 should have reviewed laboratory results conducted while the resident was at the hospital. However, the DON stated Contact Precautions should not have been implemented for Resident #1 when he/she was readmitted to the facility, even though the resident was newly diagnosed with [REDACTED]. The DON stated she should have been notified that a wound culture had been conducted so someone could have followed up to ensure the final results were obtained.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary treatment and care related to non-pressure wounds for one (1) of three (3) sampled residents (Resident #1). Observations conducted on 01/02/20 revealed Resident #1 had an open area to his/her upper back and a foul odor was observed. In addition, light yellow drainage was observed on the resident's pillowcase. The facility failed to identify the wound to the resident's back upon readmission on 12/23/19, and failed to monitor the wound and implement actions when the wound showed signs and symptoms of infection. The findings include: Review of the facility policy titled Skin Assessments, dated (MONTH) 2019, revealed a baseline skin assessment would be conducted upon admission and head-to-toe skin assessments would also be conducted on a weekly basis, on all facility residents. The policy also stated the admission skin assessment would reflect the skin conditions that were present upon admission that required treatment measures such as wounds, regardless of the cause. The policy also stated wound assessments would be conducted by a licensed nurse when the area was identified and at least weekly until the area was healed. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was frequently incontinent of bowel and bladder, and he/she required limited assistance of one (1) staff member for bed mobility and toileting. Resident #1 had no brief interview for mental status (BIMS) score on the assessment; however, the assessment indicated he/she was able to make him/herself understood and was able to understand others. Review of Resident #1's hospital record revealed hospital staff had photographed open areas to the resident's upper back area on 12/23/19 (before the resident was transferred back to the nursing facility). No measurements were documented on the areas photographed on Resident #1's skin at the hospital. Review of Resident #1's medical record revealed no evidence a skin assessment was conducted when he/she was readmitted to the facility on [DATE]. Review of Resident #1's physician orders dated 12/24/19 revealed staff had been directed to apply [MEDICATION NAME] Foam dressing to the area on the resident's upper back. Observations conducted of Resident #1's skin assessment observed on 01/02/20 at approximately 11:20 AM, revealed he/she had an open area with a foul odor on the resident's upper back. Further observations revealed light yellow drainage, dry in appearance, on the resident's pillowcase. Review of Resident #1's wound assessment documented by Licensed Practical Nurse (LPN) #3 dated 01/02/20 at 4:17 PM revealed the wound to the resident's back was measured as six (6) centimeters (cm) in length and eight (8) cm in width. The LPN also documented that the resident's wound had a light amount of exudate (drainage) with a foul odor observed. Interview with SRNA #2 on 01/02/20 at 2:00 PM revealed she had identified the open areas to Resident #1's upper back over the past couple of weeks but was unable to recall when. The SRNA also stated she had observed a foul odor to the resident's wound and had reported the concern to nursing staff, and she stated she was pretty sure it was the treatment nurse that she reported the concern to. Interview with SRNA #3 on 01/02/20 at 2:30 PM revealed she had observed open areas to Resident #1's back, and drainage with a foul odor was observed a few days ago, but she was unable to recall the date/time. The SRNA also stated she had reported the abnormal findings to the Treatment Nurse. The SRNA stated she had provided care to the resident since reporting the abnormal findings to the treatment nurse; however, she stated the condition of the resident's wound to his/her back remained unchanged. Interview with LPN #3 on 01/02/20 at 3:00 PM revealed she was the Treatment Nurse in the facility and she stated she was aware that Resident #1 had open areas to his/her back since he/she had returned to the facility on [DATE]. However, she stated she had not measured the resident's wound until requested to obtain wound measurements by the surveyor. The LPN stated she had not measured the wound before today but I should have. The LPN also stated staff had not informed her of the drainage or odor that was observed to the resident's wound. LPN #3 also stated she observed the resident's wound yesterday and I didn't notice the drainage or the odor. Interview with Licensed Practical Nurse (LPN) #1 on 01/03/20 at 3:30 PM revealed she readmitted Resident #1 to the facility on [DATE]. LPN #1 also stated she was required to conduct a head-to-toe skin assessment on residents when they were readmitted to the facility. However, the LPN stated it was busy when Resident #1 was readmitted and she was unable to recall if she conducted a skin assessment. The LPN stated she was not aware that Resident #1 had an open area to his/her upper back that had a foul odor. Interview with the DON on 01/02/20 at 2:30 PM revealed staff should have conducted a head-to-toe skin assessment and documented any abnormal findings for Resident #1 when he/she returned to the facility on [DATE]. She also stated licensed staff had been trained to complete a wound assessment when open areas are identified in the facility. The DON stated Resident #1's open wound should have been assessed and an accurate description of the resident's skin condition should have been documented in the medical record, as outlined by the facility policy.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to review/revise the resident's plan of care to address the resident's medical, physical, mental, and psychosocial needs for one (1) of three (3) sampled residents (Resident #1). The facility readmitted Resident #1 on 12/23/19 after a hospital stay. Upon readmission, the resident was diagnosed with [REDACTED]. The facility failed to revise the resident's plan of care and address the newly diagnosed infection and pressure sores. The findings include: Review of the facility policy titled Development of a Care Plan, not dated, revealed staff were directed to utilize a care-planning checklist to ensure a comprehensive care plan was developed, which included information related to special treatment to wounds or any infections that was pertinent to the resident. The policy also stated care plans should be reviewed/revised per the RAI manual and with significant changes. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was frequently incontinent of bladder and bowel, and he/she required limited assistance of one (1) staff member for toileting and bed mobility. Resident #1 had no brief interview for mental status (BIMS) score on the assessment but was able to make him/herself understood and was able to understand others. Review of Resident #1's nurse's notes dated 12/22/19 at 4:00 PM revealed the resident complained of severe pain and itching to his/her body and was transferred to a local hospital on [DATE] at 4:20 PM. Review of Resident #1's hospital record revealed the resident was evaluated at a local emergency room (ER) on 12/22/19 at approximately 5:00 PM. The hospital record also indicated the resident was admitted on [DATE] at 8:01 PM with [DIAGNOSES REDACTED]. Review of Resident #1's hospital record (located in the medical record at the facility) revealed a nasal swab was obtained to screen the resident [MEDICAL CONDITION] on 12/22/19. Further review of the resident's laboratory results (located in the medical record at the facility) dated 12/23/19 at 5:02 AM revealed he/she tested positive [MEDICAL CONDITION]. Further review of Resident #1's hospital record revealed hospital staff had photographed open areas to the resident's right and left buttock on 12/23/19 (before the resident was transferred back to the Nursing Home). No measurements were documented on the open areas photographed on the resident's skin. Further review of Resident #1's medical record revealed no evidence a skin assessment was conducted when he/she was readmitted to the facility on [DATE]. Observations conducted of Resident #1's skin/wound assessment observed on 01/02/20 at approximately 11:20 AM, revealed Resident #1 had one (1) open area to his/her right buttock which measured 0.3 centimeters (cm) in length and 0.4 cm in width. Continued observations revealed the resident also had an open area to his/her left buttock that measured 1.2 cm in length and 1.0 cm in width. The open areas were not covered with a dressing upon initial assessment. Review of Resident #1's comprehensive care plan revealed no evidence staff had reviewed/revised the resident's care plan related to the resident's pressure sores or his/her newly diagnosed [MEDICAL CONDITION] infection. Interview with Licensed Practical Nurse (LPN) #1 on 01/03/20 at 3:30 PM revealed she readmitted Resident #1 to the facility on [DATE]. She stated she was required to conduct a head-to-toe skin assessment and evaluate all paperwork returned with the resident from the hospital when they were readmitted . However, LPN #1 stated it was busy when she readmitted Resident #1 and she was unable to recall if she conducted a skin assessment or not. LPN #1 stated she was not aware that Resident #1 had pressure areas to his/her buttocks. She also stated she was required to review lab tests conducted while residents were in the hospital. However, she acknowledged she had not reviewed any of Resident #1's laboratory tests when he/she was readmitted because it was crazy and busy when the resident returned to the facility. The LPN stated she should have identified that the resident had tested positive [MEDICAL CONDITION] and had pressure areas to his/her buttocks and notified administrative staff so the resident's care plan could have been reviewed/revised. Interview with State Registered Nurse Aide (SRNA) #2 on 01/02/20 at 2:00 PM revealed she identified the open areas to Resident #1's bilateral buttocks over the past couple of weeks, but was unable to recall the date/time. SRNA #2 stated she reported Resident #1's open areas and stated she was pretty sure it was the treatment nurse that she reported the resident's abnormal skin condition to but was unable to recall when. Interview with SRNA #3 on 01/02/20 at 2:30 PM revealed Resident #1 had open areas to his/her buttocks and she had reported the resident's skin condition to facility nurses, which included the Treatment Nurse. The SRNA stated she had reported the resident's open areas a couple of days ago because the resident had been incontinent of bowel and she was concerned because the open areas were not covered. Interview with LPN #3 on 01/02/20 at 3:00 PM revealed she was the designated Treatment Nurse in the facility and acknowledged Resident #1 had two (2) Stage 2 pressure areas to his/her left and right buttocks. She stated she was not aware that Resident #1 had pressure sores therefore she had not measured, assessed, or implemented treatments to the resident's pressure sores. LPN #3 stated she was not responsible to review/revise care plans for residents with pressure sores in the facility. Interview with the Minimum Data Set (MDS) Coordinator on 01/03/20 at 12:15 PM revealed she was not aware that Resident #1 had been diagnosed with [REDACTED]. She also stated both clinical conditions should have been included in the resident's care plan. Interview with the DON on 01/03/20 at 2:30 PM revealed staff should have conducted a head-to-toe skin assessment and reviewed Resident #1's laboratory results when he/she returned to the facility on [DATE]. The DON also stated resident care plans were reviewed/revised as a team effort, and the resident's pressures sores, as well as his/her newly diagnosed infection, should have been included in Resident #1's plan of care.

Based on observation, interview, record review, and a review of facility policy, it was determined the facility failed to provide care and services when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). Interviews and record reviews revealed Resident #1 complained of pain and staff observed [MEDICAL CONDITION] to the resident's left arm on 06/17/19. However, staff also failed to assess/monitor the resident's arm for further changes. On 06/27/19, ten days later, Therapy Staff reported to Licensed Practical Nurse (LPN) #1 that Resident #1's arm was bruised and didn't look right. The therapist also reported Resident #1 was unable to tolerate range of motion (ROM) to his/her left arm due to complaints of pain. However, Resident #1's physician was not notified of the continued change in the resident's condition until 06/28/19. On 06/28/19, an x-ray was ordered and Resident #1 was diagnosed with [REDACTED]. The findings include: Interview with the Director of Nursing on 07/09/19 at 4:10 PM revealed the facility did not have a policy related to assessing/monitoring residents when a change in condition was identified. However, the DON stated staff had been trained and were required to monitor the resident once a shift for seventy-two (72) hours when a change in condition occurred. Review of the facility policy titled Pain Management Policy and Procedure, not dated, revealed residents would receive a Clinical Pain Assessment upon admission, quarterly, and with any significant change in their behavior or activity level. The policy stated that staff were also directed to monitor the effectiveness of any pain management therapy provided to facility residents. Review of the facility policy titled Physician/Legal Representative Notification, last revised in (MONTH) 2012, revealed staff were to immediately inform the resident, and consult with the resident's physician and the resident's legal representative or an interested family member, when there was an accident that resulted in injury and had the potential to require physician intervention. The policy also stated notifications should be made immediately when there was a significant change in the resident's physical, mental, or psychosocial status or when there was a need to alter treatment significantly (discontinue existing treatment or to commence a new form of treatment). Review of Resident #1's medical record revealed the facility admitted the resident on 02/08/12 with [DIAGNOSES REDACTED]. Review of the resident's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was totally dependent on two (2) staff members for bed mobility, transfers, toileting, and bathing. The resident's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated the resident was interviewable. An interview was attempted with Resident #1 on 07/08/19 at 1:45 PM and again on 07/09/19 at 1:00 PM; however, the resident responded inappropriately to questions. A skin assessment was also attempted on two different occasions on 07/09/19; however, Resident #1 refused to allow the surveyor to observe his/her skin and stated, My arm hurts. Review of Resident #1's nurse's notes revealed on 06/17/19 [MEDICAL CONDITION] was identified to the resident's left upper extremity (LUE) and staff were to elevate the resident's LUE as much as possible. Review of Resident #1's physician's orders dated 06/17/19 at 10:15 AM revealed Occupational Therapy (OT) was ordered to evaluate and treat the resident, if indicated, for [MEDICAL CONDITION] to the residents' left upper extremity. Review of the initial Occupational Therapy (OT) evaluation completed by OT #1 on 06/17/19 revealed the resident had a new onset of [MEDICAL CONDITION], pain, and limited range of motion (ROM) to the left upper extremity. The evaluation also revealed Resident #1 was guarding his/her left upper extremity and was observed to have facial grimacing and loudly stated OW during the assessment. OT #1 also documented that the resident was resistant to all movement and/or passive ROM and severe [MEDICAL CONDITION] was observed to Resident #1's left upper arm from the shoulder to his/her mid-forearm. Interview with OT #1 on 07/09/19 at 12:20 PM revealed she evaluated Resident #1 on 06/17/19 for complaints of pain and [MEDICAL CONDITION] to his/her left arm. She stated the resident could barely tolerate movement to the left arm and that the resident was unable to tolerate any external rotation. The OT stated Resident #1 was also observed to guard the left arm during the initial evaluation. OT #1 stated she reported the concerns to LPN #2. Further interview revealed the OT had treated Resident #1 under the assumption that the resident's [MEDICAL CONDITION] was related to [MEDICAL CONDITION]. Interview with LPN #2 on 07/09/19 at 10:35 AM revealed Resident #1 complained of pain and she observed [MEDICAL CONDITION] to the front part of the resident's shoulder area on 06/17/19. LPN #2 stated she did not assess any other part of the resident's arm to evaluate for bruising or any other signs of injury. LPN #2 stated she notified Nurse Practitioner (NP) #1 that the resident had [MEDICAL CONDITION] on 06/17/19; however, she did not inform the NP of the resident's complaints of pain. The LPN stated, We thought it was [MEDICAL CONDITION] ([MEDICAL CONDITION] refers to swelling that generally occurs in one of your arms or legs and is most commonly caused by the removal of or damage to lymph nodes as a part [MEDICAL CONDITION] treatment) so we recommended therapy staff to evaluate and treat the resident. Interview with LPN #1 on 07/08/19 at 3:15 PM revealed on 06/17/19 she was Resident #1's primary nurse and she observed [MEDICAL CONDITION] to Resident #1's left elbow, which continued to the lower part of the resident's arm and the resident was guarding his/her left upper extremity due to pain. She stated LPN #2 notified the resident's physician and due to the previous [PR[NAME]EDURE] to his/her left breast, We thought it was [MEDICAL CONDITION] and we recommended therapy. However, LPN #1 stated she did not do any further assessment of the resident. She stated she should have implemented monitoring for Resident #1 every shift for seventy-two hours to monitor for further changes in the resident's condition. Interview with State Registered Nurse Aide (SRNA) #1 on 07/09/19 at 11:20 AM revealed she had assisted another staff member with obtaining Resident #1's weight by using a mechanical lift on 06/18/19 and 06/25/19. She stated the resident complained of pain to his/her left arm when the resident was lifted off the bed and when staff lowered the resident back onto the bed on both dates. SRNA #1 stated she did not notify the resident's nurse of the resident's complaints of pain because they told us the doctor already knew about it. Further review of Resident #1's OT notes revealed on 06/26/19 (9 days later) Resident #1 allowed the therapist to range his/her shoulder to seventy degrees flexion and to neutral end range (ER) but complained of severe pain at end range. There was no documented evidence that nursing staff or the resident's physician was notified of the resident's complaints of pain on 06/26/19. Review of the OT notes for Resident #1 dated 06/27/19 (10 days later) revealed the therapist attempted passive ROM to the resident's left shoulder and the resident was unable to tolerate the exercise. OT #1 documented that she notified LPN #1 of her concerns with Resident #1's left upper extremity. Continued review of Resident #1's nurse's notes revealed no documented evidence that staff assessed Resident #1's left upper extremity. Interview with OT #1 on 07/09/19 at 12:20 PM revealed on 06/27/19, Resident #1's left arm didn't look right and it wasn't bending at the shoulder. OT #1 stated the resident was unable to tolerate range of motion exercises to his/her left arm and purple bruising was observed to the resident's arm from the left axilla region (armpit) to the elbow area. The OT stated she notified LPN #1 of the resident's condition. Interview with LPN #1 on 07/08/19 at 3:15 PM revealed on 06/27/19, OT #1 reported, and the LPN observed, that Resident #1 had increased pain, dark purple bruising to the left upper arm, and bruising to the elbow. However, the LPN stated she did not notify the resident's physician until the next day, 06/28/19. Interview with Resident #1's Responsible Party (RP) on 07/08/19 at 9:30 PM revealed she accompanied Resident #1 to the hospital on [DATE], and the resident was moaning and groaning with complaints of pain to his/her left arm. She stated that the resident was diagnosed with [REDACTED]. The RP stated that if she had known the resident was having pain on 06/17/19, she would have made sure his/her arm was x-rayed instead of them giving him/her therapy and manipulating an arm that had been broke for a week. The RP stated that as a result of the fracture, the facility would no longer transfer the resident from bed. Interview with the Director of Nursing on 07/09/19 at 4:10 PM revealed staff should have assessed Resident #1's arm on 06/17/19 when [MEDICAL CONDITION] was observed to the resident's shoulder. The DON also stated staff should have implemented ongoing assessments/monitoring for Resident #1 when the resident voiced complaints of pain and when [MEDICAL CONDITION] was identified to the resident's left upper extremity on 06/17/19. The DON stated the resident's physician should have been notified on 06/17/19 related to complaints of pain and decrease in ROM that was identified by the OT. Further interview revealed the DON stated staff should have notified the physician on 06/27/19 when increased pain, bruising, and decreased ROM was identified to the resident's left upper extremity. Review of Resident #1's x-ray report completed at the hospital on [DATE] revealed Resident #1 was diagnosed with [REDACTED].

Based on observation, interview, record review, and a review of facility policy it was determined the facility failed to review/revise the resident's care plan after a change in condition was identified for one (1) of three (3) sampled residents (Resident #1). Interviews and record reviews revealed Resident #1 complained of pain and [MEDICAL CONDITION] was observed to the resident's left arm on 06/17/19. The facility revised the resident's care plan with an intervention to provide occupational therapy due to [MEDICAL CONDITION]; however, the facility failed to revise the resident's care plan with interventions to address the patient's pain/guarding or with interventions to monitor/assess the resident. There was no documentation that the facility assessed the patient again until 06/28/19, after the resident was diagnosed with [REDACTED]. The findings include: Review of the facility policy titled Development of a Care Plan, not dated, revealed all residents would have a comprehensive care plan developed in the facility. The policy also stated the resident's care plan would be reviewed and revised when significant changes in the resident's condition occurred. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/08/12 with [DIAGNOSES REDACTED]. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on two (2) staff members for bathing, bed mobility, transfers, and toileting. Further review revealed Resident #1's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated the resident was interviewable. Review of Occupational Therapist (OT) #1's initial evaluation on 06/17/19 revealed the resident had a new onset of [MEDICAL CONDITION], pain, and limited range of motion (ROM) to the left upper extremity. The note stated Resident #1 was guarding his/her left upper extremity, was observed to have facial grimacing, and loudly stated OW during the assessment. The OT also documented that the resident was resistant to all movement and/or passive ROM and severe [MEDICAL CONDITION] was observed to Resident #1's left upper arm from the shoulder to the mid forearm. Review of Resident #1's nurse's notes revealed on 06/17/19 [MEDICAL CONDITION] was identified to the resident's left upper extremity (LUE) and staff were to elevate the resident's LUE as much as possible. Review of Resident #1's care plan revealed the facility revised the resident's care plan on 06/17/19, with an intervention to provide therapy related to left extremity [MEDICAL CONDITION]. However, there was no documented evidence that the facility revised the resident's care plan with interventions to address/monitor the resident's arm or to address the resident's pain and guarding of the extremity. Interview with LPN #1 on 07/08/19 at 3:15 PM revealed she observed [MEDICAL CONDITION] to Resident #1's left elbow, and also observed the resident to guard his/her left arm on 06/17/19. According to LPN #1, she did not revise Resident #1's care plan because she had not been trained to revise the resident's care plan to reflect changes in the resident's condition. Interview with LPN #2 on 07/09/19 at 10:35 AM revealed Resident #1 complained of pain and had [MEDICAL CONDITION] to the front part of the resident's shoulder area on 06/17/19. LPN #2 stated she did not update the resident's care plan to reflect the change in the resident' condition because she had not been trained to do so. Further review of Resident #1's medical record revealed there was no documentation that Resident #1's left arm was assessed/monitored after [MEDICAL CONDITION] was discovered to the resident's left arm on 06/17/19. Further review of Resident #1's OT notes revealed on 06/26/19 (9 days later) Resident #1 had severe pain during range of motion to the left upper extremity. Further review revealed on 06/27/19 (10 days later) the resident was unable to tolerate range of motion to the left upper extremity and LPN #1 was notified. Review of Resident #1's x-ray report completed at the hospital on [DATE] revealed Resident #1 had a spiral-type [MEDICAL CONDITION] third of the resident's humerus. Interview with MDS Coordinator #1 on 07/09/19 at 1:10 PM revealed she was responsible to ensure care plans were updated/revised to reflect changes that occurred in the resident's condition. She stated she depended upon physician orders and nursing documentation to ensure care plans were updated to reflect the condition of facility residents. The MDS nurse stated that since there was no documentation related to the resident's complaints of pain, the care plan was not revised as required. Interview with the Director of Nursing on 07/09/19 at 4:10 PM revealed Resident #1's care plan should have been revised and staff should have implemented ongoing assessments/monitoring due to pain and [MEDICAL CONDITION].

Based on observation, interview, record review, and a review of facility policy it was determined the facility failed to notify the resident's physician and an interested family member when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). Interviews and record reviews revealed Resident #1 complained of pain and [MEDICAL CONDITION] was observed to the resident's left arm on 06/17/19. However, the resident's physician or his/her responsible party (RP) was not notified as required. In addition, Occupational Therapist (OT) #1 reported to Licensed Practical Nurse (LPN) #1 on 06/27/19, that bruising was observed to Resident #1's left arm, and she also reported that the resident's arm didn't look right. OT #1 also reported Resident #1 was unable to tolerate range of motion (ROM) to his/her left arm, due to complaints of pain on 06/27/19. However, the facility failed to notify Resident #1's physician of the continued change in the resident's condition until 06/28/19. An x-ray was ordered and completed on 06/28/19 and the x-ray results revealed Resident #1 had an acute fracture to his/her left humerus (long bone in the arm that runs from the shoulder to the elbow). The findings include: Review of the facility policy titled Physician/Legal Representative Notification, last revised in (MONTH) 2012, revealed staff were to immediately inform the resident, and consult with the resident's physician and the resident's legal representative or an interested family member, when there was an accident that involved the resident which resulted in injury and had the potential to require physician intervention. The policy also stated notifications should be made immediately when there was a significant change in the resident's physical, mental, or psychosocial status or when there was a need to alter treatment significantly (discontinue existing treatment or to commence a new form of treatment). The policy directed nursing staff to make two (2) attempts to notify the attending physician and if those attempts were unsuccessful, the physician on call or the Medical Director should be notified. Review of Resident #1's medical record revealed the facility admitted the resident on 02/08/12 with [DIAGNOSES REDACTED]. Resident #1's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was totally dependent on two (2) staff members for bathing, bed mobility, transfers, and toileting. Continued review revealed Resident #1's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated the resident was interviewable. Review of an Occupational Therapy (OT) evaluation for Resident #1 dated 06/17/19 revealed the resident had a new onset of [MEDICAL CONDITION], pain, and limited range of motion (ROM) to the left upper extremity. The evaluation stated Resident #1 was guarding his/her left upper extremity, was observed to have facial grimacing, and loudly stated OW during the assessment. The OT also documented that the resident was resistant to all movement and/or passive ROM and severe [MEDICAL CONDITION] was observed to Resident #1's left upper arm from the shoulder to his/her mid forearm. OT #1 stated she reported the concerns to Licensed Practical Nurse (LPN) #2. Review of Resident #1's nurse's notes dated 06/17/19, revealed LPN #2 documented that [MEDICAL CONDITION] was identified to Resident's #1 left upper extremity (LUE). However, there was no documentation of the resident's complaints of pain, or that the resident's physician was notified of the resident's complaints of pain on 06/17/19. Interview with LPN #2 on 07/09/19 at 10:35 AM revealed Resident #1 complained of pain and [MEDICAL CONDITION] was observed to the front part of the resident's shoulder area on 06/17/19. LPN #2 stated she notified Nurse Practitioner (NP) #1 of the observed [MEDICAL CONDITION] on 06/17/19; however, she did not inform the NP of the resident's complaints of pain. LPN #2 stated she should have informed the resident's provider of his/her complaints of pain and should have ensured the resident's RP was notified of the resident's change in condition on 06/17/19. Further review of Resident #1's OT documentation revealed on 06/26/19 (9 days later) Resident #1 allowed the therapist to range his/her shoulder to seventy degrees flexion and to neutral end range (ER) but complained of severe pain at end range. There was no evidence that nursing staff or the resident's physician was notified of the resident's complaints of severe pain on 06/26/19. Continued review of OT #1's documentation revealed on 06/27/19 (10 days later) Resident #1 was unable to tolerate passive ROM to his/her left shoulder. OT #1 documented that she notified LPN #1 of her concerns with Resident #1's left upper extremity. Further review of Resident #1's medical record revealed no documented evidence that the resident's physician/provider was notified of the pain/inability to tolerate ROM on 06/26/19 or 06/27/19. Interview with LPN #1 on 07/08/19 at 3:15 PM revealed on 06/27/19, OT #1 reported, and the LPN observed, that Resident #1 had increased pain, dark purple bruising to the left upper arm, and bruising to the elbow. However, the LPN stated she did not notify the resident's physician until the next day, 06/28/19. Review of Resident #1's x-ray report completed at the hospital on [DATE] revealed Resident #1 was diagnosed with [REDACTED]. Interview with Resident #1's Responsible Party (RP) on 07/08/19 at 9:30 PM revealed she accompanied Resident #1 to the hospital on [DATE]. She stated the resident was moaning and groaning with complaints of pain to his/her left arm. She stated the facility did not notify her that the resident was having pain or swelling on 06/17/19. The RP stated if she had known, I would have made sure his/her arm was x-rayed instead of them giving him/her therapy and manipulating an arm that had been broke for a week. The RP stated that after the facility determined the resident's arm was broken, the facility informed her that Resident #1 would no longer be able to be transferred out of bed, for any reason, due to the fracture. She stated the resident enjoyed getting his/her hair done on Tuesdays, but now that simple pleasure is gone for him/her. In addition, she stated the resident would no longer be able to receive a shower if the resident could not get out of bed. The RP further stated that the resident hurts every time he/she is moved, and it broke the RP's heart. Interview with NP #1 on 07/09/19 at 12:50 PM revealed staff informed her on 06/17/19 that Resident #1's left upper arm was [MEDICAL CONDITION]. She stated staff did not notify her that the resident had pain, but stated they should have. NP #1 stated if staff had informed her that Resident #1 had complained of pain, the resident's treatment plan would have included diagnostic testing in attempts to determine the etiology of his/her discomfort, prior to initiating any type of therapy for the resident.

Based on interview, record review, facility policy review, and review of the facility's investigations, it was determined the facility failed to revise the care plans for one (1) of four (4) sampled residents (Resident #1) who was assessed to be at risk for elopement. Resident #1 exited the facility on 09/13/15, 10/23/15, 11/02/15, and 11/03/15, causing the alarm to sound and staff immediately returned the resident. On 12/11/15 and again on 12/22/15, the resident eloped (exited) from the facility without staff knowledge. Staff interviews revealed Resident #1 routinely (1-2 times per shift) set off the West Hall exit door alarm by pushing the exit bar, often until the door opened, requiring frequent redirection from staff. Interviews also revealed Resident #1 routinely demonstrated this behavior in the hours after supper. Review of Resident #1's care plan, initiated on 09/01/15, revealed interventions for wandering which included to check promptly when the alarm system goes off, verify resident's safety/whereabouts, and redirect the resident's attention as needed. However, after the resident exited the building, the facility failed to assess the resident's behavior and revise the resident's care plan to put interventions in place to address his/her daily exit-seeking behaviors to prevent further elopements. The facility's failure to revise residents' care plans and implement interventions to ensure adequate supervision and monitoring for residents who were at risk for elopement was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16 which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Accident Prevention and Management, dated 2014, revealed staff members should assess all residents for their risk of unsafe wandering and elopement. The assessment should occur upon admission, readmission, quarterly, when there has been a significant change in status, or if the resident elopes. The care plan should focus on minimizing the issues identified during the assessment. The care plan interventions should also be resident-focused. Further review revealed unsafe wandering can lead to elopement. The policy instructed staff in the event of a resident's elopement, after the resident was returned to a safe environment, to complete a physical assessment. The policy stated after staff members assess the resident for injury, they must reassess the resident immediately for factors that led to the elopement. If they determine the root cause was a failure in measures to prevent an elopement, or there were no measures in place, they should adjust the care plan immediately to prevent reoccurrence. Review of the facility's policy, Development of a Care Plan, date unknown, revealed the care plan should be reviewed/revised as per the Resident Assessment Instrument (RAI) manual with significant changes, and changes in orders as received by the Minimum Data Set (MDS) Coordinator. Review of Resident #1's medical record revealed the facility admitted the resident on 08/17/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/24/15, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was severely cognitively impaired and was not interviewable. Further review of the MDS Assessment revealed the resident had presented with behaviors of wandering that had occurred on one (1) to three (3) days during the seven (7) day look back period. The facility assessed the resident to require limited assistance with transfers and extensive assistance with walking in his/her room and corridor, and locomotion on and off the unit. Review of the facility's Social Progress Notes and Evaluation, dated 08/17/15, revealed the resident was transferred from another facility and had a history of [REDACTED]. Review of the Nurse's Notes, dated 08/18/15, revealed the resident had a Wander Risk Assessment completed that day which indicated the resident was at moderate risk for wandering. Further review revealed a wander risk safety bracelet was placed on the resident after the assessment was completed. Review of the resident's Comprehensive Plan of Care, initiated on 09/01/15, revealed the resident was at risk for wandering from the facility unattended. Further review of the care plan revealed the goals included that the resident would not wander from the facility unattended and would move about freely in a monitored and safe environment. The interventions on the care plan for wandering included checking promptly when the alarm system goes off to verify the resident's safety/whereabouts and to redirect the resident's attention as needed. Review of the resident's Mood and Behavior Pattern Logs for September 2015 through December 2015 revealed the resident frequently exhibited behaviors of wandering. Interviews with Certified Medication Aide (CMA) #1 on 01/07/16 at 10:14 AM, Licensed Practical Nurse (LPN) #4 on 01/05/16 at 1:55 PM, the Environmental Services Supervisor (ESS) on 01/05/16 at 2:25 PM, LPN #3 on 01/05/16 at 3:55 PM, LPN #2 on 01/05/16 at 4:23 PM, LPN #6 on 01/05/16 at 5:05 PM, CMA #3 on 01/05/16 at 5:45 PM, State Registered Nurse Aide (SRNA) #2 on 01/06/16 at 1:56 PM, LPN #1 on 01/06/16 at 2:20 PM, CMA #2 on 01/06/16 at 3:36 PM, SRNA #1 on 01/06/16 at 5:36 PM, CMA #1 on 01/07/16 at 10:14 AM, and Laundry Aide #1 on 01/07/16 at 11:15 AM revealed Resident #1 routinely (1-2 times per shift) set off the West Hall exit door alarm by pushing the exit bar, often until the door opened, requiring frequent redirection from facility staff. Interviews with CMA #1, LPN #4, and Registered Nurse (RN) #1 revealed Resident #1 routinely demonstrated this behavior in the hours after supper. Review of the facility's Event Report Investigations revealed Resident #1 exited the facility on 09/13/15, 10/23/15, 11/02/15, 11/03/15, and 12/11/15. Review of the facility's Increased Monitoring Logs revealed the resident was placed on increased supervision (to verify the resident's whereabouts every fifteen {15} minutes for eight {8} hours, then every thirty {30} minutes for twelve {12} hours, then hourly for four {4} hours) for 24 hours following each exit event. Review of the Event Report Investigation, dated 12/22/15, revealed the resident eloped from the facility at approximately 4:50 PM, and was located approximately 450 feet away from the facility. Resident #1 was returned to the facility at 5:00 PM by a non-staff person. The resident was placed on 1:1 supervision (staff person is with the resident at all times) until 12/29/15. Review of the Event Report Investigation, dated 01/02/16, revealed Resident #1 was witnessed to exit the facility. The resident was returned to the facility and was found to have sustained two (2) skin tears. The resident was witnessed to exit out of the West Hall door by LPN #3. Further review revealed the resident was followed out the door by the LPN, resisted redirection, and proceeded down the hill outside of the facility. The resident fell and sustained two (2) skin tears. Review of the Event Report Investigation revealed the facility determined the possible causative factors to be Dementia and Delusional Disorders. Although the facility placed the resident on increased supervision following each exit, they failed to assess the elopement to determine the root cause in order to revise the resident's care plan to develop and implement individualized interventions to provide supervision after the 24-hour monitoring was discontinued to prevent further elopements. In addition, the facility failed to review/revise the resident's plan of care to reflect the resident's daily exit-seeking behaviors and add interventions to prevent additional elopements. The facility failed to follow its policy to implement resident focused interventions to prevent further elopements. Interview with the MDS Coordinator Assistant on 01/05/16 at 2:15 PM revealed the MDS Coordinator and the MDS Coordinator Assistant were responsible to ensure resident care plans were reviewed and revised following an event and should include supervision interventions for residents at risk for wandering. Further interview revealed interventions to prevent exit-seeking behavior should have been included on Resident #1's care plan. Interview with the Administrator and Director of Nursing (DON) on 01/07/16 at 1:10 PM revealed care plan interventions to prevent wandering were put into place after each time the resident exited from the facility. However, further interview with the Administrator revealed the facility had been unable to meet the supervision needs for Resident #1. The Administrator stated the resident should have been more closely monitored. Further interview revealed supervision interventions to prevent the exit-seeking behaviors should have been included in the care plan. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supervision. Observation on 01/19/16 at 1:50 PM revealed Resident #1 was provided 1:1 supervision by Activity Assistant #1, with no reported concerns at the time of the observation. Review of Resident #1's Increased Monitoring Logs, dated 01/02/16 through 01/19/16 revealed the resident had been on 1:1 supervision since 01/02/16. Interviews with Certified Medication Aide (CMA) #4 on 01/19/16 at 1:12 PM, State Registered Nurse Assistant (SRNA) #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #1 had been on 1:1 supervision since 01/02/16. Observation on 01/19/16 at 2:10 PM revealed Resident #4 was sitting up in a wheelchair wearing a wander safety bracelet on his/her right shoe. Review of Resident #4's Increased Monitoring Logs, dated 01/07/16 through 01/19/16, revealed the resident had been placed on 30-minute checks since 01/07/16. Interviews with CMA #4 on 01/19/16 at 1:12 PM, SRNA #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #4 had been on 30-minute supervision checks since 01/07/16. 2) Review of the Wander Risk Assessments, dated 01/11/16, revealed all residents' Wander Risk Assessments were reviewed by the DON and MDS. Residents #2, #3, and #5 were identified by the facility to be at high risk for wandering. Interviews conducted on 01/19/16 with the MDS Coordinator and the MDS Assistant at 3:08 PM, and the DON at 4:05 PM confirmed all resident wander risk assessments were reviewed on 01/11/16 and no changes were made. The staff also confirmed all care plans for residents identified at high risk for wandering were reviewed and revised on 01/12/16. Review of Resident #2's Event Report Investigation, dated 01/09/16, revealed the resident was found standing at an exit door and the alarm was sounding. Further review revealed the resident was redirected away from the door. Review of Resident #2's Increased Monitoring Logs, dated 01/09/16, revealed the resident was placed on increased monitoring for twelve (12) hours. Review of the resident's care plan, revision date 01/12/16, reflected exit-seeking behaviors exhibited on 01/09/16, included wander risk interventions and 30-minute checks x 30 days. Interview with the MDS Coordinator on 01/19/16 at 3:08 PM, revealed the resident's care plan was reviewed/revised after the incident occurred to include exit-seeking behavior and interventions. 3) Interview with the DON on 01/19/16 at 4:05 PM and the Administrator on 01/19/16 at 4:10 PM confirmed the unsupervised exit investigations were reviewed and addendums were added to include missing information. Further review of the Event Report Investigations dated 09/13/15, 10/23/15, 11/02/15, 11/03/15, 12/11/15, 12/22/15, and 01/02/16 for Resident #1 revealed addendums were added to the facility's investigation forms to include missing exit and return times. Review of the Event Report Investigation, dated 09/12/15, for Resident #4 revealed an addendum was added to include the time the resident was missing. 4) Interview with the DON on 01/19/16 at 4:05 PM revealed she reviewed all Incident/Event Reports for the last thirty (30) days and identified no concerns with inadequate documentation of elopements. 5) Review of the contracted vendor's Statement/Work Order revealed the vendor inspected the facility's wander alert and maglock systems on 01/11/16 and 01/13/16 and adjustments were made to the facility's exit doors, wander alert, and maglock systems. Interview with the Environmental Services Supervisor (ESS) on 01/19/16 at 1:03 PM confirmed the wander alert and maglock systems were inspected and adjusted by the contract vendor. Observations on 01/19/16 at 1:00 PM, revealed the facility's exit alarms were audible throughout the facility. Interviews conducted on 01/19/16 with the ESS at 1:03 PM, CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, SRNA #5 at 2:10 PM, and Charge Nurse #1 at 3:22 PM confirmed the exit door alarms were adjusted and were audible throughout the facility. Observations on 01/19/16 at 1:00 PM, revealed each exit door alarm was activated when pressure was applied to the door for three (3) seconds, or if a wander bracelet remained within three (3) feet of the door for more than 60 seconds. Further observation confirmed the doors were enabled with a 30-second delay for opening. 6) Observations made on 01/19/16 at 1:00 PM revealed the keypads outside the exit doors were inactive when the alarm was sounding and/or a resident wearing a wander bracelet was within three (3) feet of the door. 7) Review of documentation revealed residents' Wandering Risk Bracelets were checked on 01/11/16 to ensure they were functioning. Interview with the ESS on 01/19/16 at 1:03 PM confirmed all wander risk bracelets were checked on 01/11/16 to determine proper functioning. 8) Review of the facility's documentation dated 01/08/16, revealed the MDS Nurses were in-serviced by the contract Nurse Consultant on 01/08/16, and by the DON on 01/11/16. Interview with the MDS Coordinator and MDS Assistant on 01/19/16 at 3:08 PM, confirmed they received the in-services and would assess each resident for Wander Risk potential upon admission, with each required MDS, and with a change in condition. If the resident was determined to be high risk for wandering/exit-seeking, the MDS Nurse would alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed after being alerted by the MDS Nurse that a resident was at high risk for wandering/exit-seeking, she was responsible to implement wander risk precautions. 9) Review of the facility's In-service Records, dated 01/08/16, revealed the Corporate Nurse Consultant and Vice President of Operations in-serviced the Administrator and DON regarding the facility's wander risk policy/procedure and forms, and the necessary components of the AOC. Interview with the Corporate Quality Control Nurse on 01/19/16 at 2:38 PM confirmed the Administrator and DON were in-serviced on 01/08/16. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM confirmed they received the education. A. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed if a resident not previously identified at risk starts to exhibits behaviors of wandering/exit-seeking, she was responsible to implement wander risk precautions. The Charge Nurse stated she would also complete a New Wander Risk Resident UDA (User Defined Assessment) in the resident's medical record. B. Review of the facility's policy and procedure titled Wandering Resident revealed the steps facility staff was to take to respond to an exit door alarm sounding. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, SRNA #5 at 2:10 PM, Charge Nurse #1 at 3:22 PM, and LPN #5 at 3:49 PM verified knowledge of the facility's procedure to respond to the Wander Guard System Alarm. C. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed all residents who demonstrate exit-seeking behaviors would be placed on increased monitoring and facility staff would utilize the Increased Monitoring Log Form. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Increased Monitoring Form and assigning staff responsibility for monitoring throughout the shift. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed the Increased Monitoring Logs Form became part of the resident's medical record and was filed after its completion. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and the IDT through the medical record Alert/High Risk Progress Note System. Interview with the DON on 01/19/16 at 4:05 PM revealed if a resident met two (2) of the Alert/High Risk criteria, facility staff would place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it should be stopped. D. Review of the facility's Elopement Investigation Form revealed the Form included the exit/return times and the investigative findings for an event. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the information obtained from the completed Elopement Investigation Forms will be used to determine the causative factor(s) of the elopement and implement a corrective action plan, revise the resident's plan of care, educate staff, and the QAPI review/evaluation. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the completed Elopement Investigation Form and the resident's medical record would be reviewed by the IDT and administrative staff the next day (M-F). If the event occurred on the weekend, the House Supervisor and/or Administrative Nurse on duty should review the investigation/medical record and consult via phone with the Administrator or DON as indicated; and, then the IDT and administrative staff will follow up with a review on Monday morning. Review of the In-service Training Report, date

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective quality assessment and assurance program to identify quality deficiencies, and to develop and implement appropriate plans of action to correct identified quality deficiencies related to elopements. The facility was aware Resident #1 and Resident #4 had eloped from the facility without staff knowledge but failed to develop and implement actions to prevent further elopement. Resident #1 exited the facility from the West Hall exit door six (6) times from 10/23/15 to 01/02/16 by pushing on the door for thirty (30) seconds, which released the door lock. Although the facility reviewed the resident's exit incidents during a weekly safety meeting, the facility's Quality Assurance (QA) Committee failed to identify a pattern in the resident's exit behaviors and implement increased monitoring to prevent further elopement. Additionally, the facility failed to identify that Event Report Investigations for Resident #1 and Resident #4 were not being documented accurately and completely. There was no evidence the facility's QA Committee identified accident hazards as quality concerns in the facility. Refer to F280, F323, F490, and F514. The facility's failure to ensure a Quality Assurance Committee was in place, which identified quality concerns in the facility, and implemented action plans to correct the concerns placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520), with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16, which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Continuous Quality Improvement Program, date unknown, revealed the monitoring and evaluation of resident care and services with a focus on continuous improvement are the fundamental activities of any quality improvement process. Review of the facility's policy, Risk Management Program, not dated, revealed the facility shall incorporate a Risk Management Program to ensure residents are safe from injury. Further review revealed the facility had established a risk management program as part of its Continuous Improvement Committee and the Safety Committee Program. The policy stated resident Event Reports would be reviewed daily during the week in the facility's morning meetings. Record review revealed Residents #1 and #4 were assessed by the facility to be at risk for elopement and were utilizing a wander risk safety bracelet (an electronic device worn by the resident that causes the exit door keypad to visually blink and become locked when the resident comes within a certain range of an exit door). Residents #1 and #4 were found to have exited the facility without staff knowledge. Although Resident # 1 exited the facility six (6) times from 10/23/15 to 01/02/16 from the West Hall exit door, the facility failed to identify a pattern with the resident's exit behavior and failed to implement interventions to prevent further elopements. During the 12/22/15 incident, Resident #1 eloped from the facility and was found approximately 450 feet from the facility by a non-staff person. Record review revealed on 09/12/15, Resident #4 exited the facility without staff knowledge, was gone for an undetermined amount of time, and was found outside of the facility in a rear parking lot, unsupervised. The facility's QA Committee failed to identity this incident with Resident #4 as an elopement due to the resident being located on facility grounds. However, review of the facility's policy titled Accident Prevention and Management, dated 2014, revealed the most dangerous form of wandering is elopement, which occurs when a resident leaves the facility or safe area without authorization or necessary supervision. Additionally, the facility failed to identify that the residents' Event Report Investigations were not being accurately documented to include the time the residents were returned to the facility. Interview with the Administrator on 01/07/16 at 1:10 PM revealed she was the Quality Assurance Coordinator and chaired the QA Committee. Additional interview revealed meetings were conducted weekly and monthly in the facility to review concerns and the full QA Committee met quarterly to review all concerns monitored by QA. The Administrator stated all resident Event Report Investigations were reviewed during a weekly safety meeting as part of QA. She stated although the facility had identified that Resident #1 exhibited consistent exit-seeking behavior, a corrective action plan had not been implemented by the QA Committee. Further interview revealed the facility had not identified that the Event Report Investigations did not include the time the resident was returned to the facility. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supervision. Observation on 01/19/16 at 1:50 PM revealed Resident #1 was provided 1:1 supervision by Activity Assistant #1, with no reported concerns at the time of the observation. Review of Resident #1's Increased Monitoring Logs, dated 01/02/16 through 01/19/16 revealed the resident had been on 1:1 supervision since 01/02/16. Interviews with Certified Medication Aide (CMA) #4 on 01/19/16 at 1:12 PM, State Registered Nurse Assistant (SRNA) #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #1 had been on 1:1 supervision since 01/02/16. Observation on 01/19/16 at 2:10 PM revealed Resident #4 was sitting up in a wheelchair wearing a wander safety bracelet on his/her right shoe. Review of Resident #4's Increased Monitoring Logs, dated 01/07/16 through 01/19/16, revealed the resident had been placed on 30-minute checks since 01/07/16. Interviews with CMA #4 on 01/19/16 at 1:12 PM, SRNA #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #4 had been on 30-minute supervision checks since 01/07/16. 2) Review of the Wander Risk Assessments, dated 01/11/16, revealed all residents' Wander Risk Assessments were reviewed by the DON and MDS. Residents #2, #3, and #5 were identified by the facility to be at high risk for wandering. Interviews conducted on 01/19/16 with the MDS Coordinator and the MDS Assistant at 3:08 PM, and the DON at 4:05 PM confirmed all resident wander risk assessments were reviewed on 01/11/16 and no changes were made. The staff also confirmed all care plans for residents identified at high risk for wandering were reviewed and revised on 01/12/16. Review of Resident #2's Event Report Investigation, dated 01/09/16, revealed the resident was found standing at an exit door and the alarm was sounding. Further review revealed the resident was redirected away from the door. Review of Resident #2's Increased Monitoring Logs, dated 01/09/16, revealed the resident was placed on increased monitoring for twelve (12) hours. Review of the resident's care plan, revision date 01/12/16, reflected exit-seeking behaviors exhibited on 01/09/16, included wander risk interventions and 30-minute checks x 30 days. Interview with the MDS Coordinator on 01/19/16 at 3:08 PM, revealed the resident's care plan was reviewed/revised after the incident occurred to include exit-seeking behavior and interventions. 3) Interview with the DON on 01/19/16 at 4:05 PM and the Administrator on 01/19/16 at 4:10 PM confirmed the unsupervised exit investigations were reviewed and addendums were added to include missing information. Further review of the Event Report Investigations dated 09/13/15, 10/23/15, 11/02/15, 11/03/15, 12/11/15, 12/22/15, and 01/02/16 for Resident #1 revealed addendums were added to the facility's investigation forms to include missing exit and return times. Review of the Event Report Investigation, dated 09/12/15, for Resident #4 revealed an addendum was added to include the time the resident was missing. 4) Interview with the DON on 01/19/16 at 4:05 PM revealed she reviewed all Incident/Event Reports for the last thirty (30) days and identified no concerns with inadequate documentation of elopements. 5) Review of the contracted vendor's Statement/Work Order revealed the vendor inspected the facility's wander alert and maglock systems on 01/11/16 and 01/13/16 and adjustments were made to the facility's exit doors, wander alert, and maglock systems. Interview with the Environmental Services Supervisor (ESS) on 01/19/16 at 1:03 PM confirmed the wander alert and maglock systems were inspected and adjusted by the contract vendor. Observations on 01/19/16 at 1:00 PM, revealed the facility's exit alarms were audible throughout the facility. Interviews conducted on 01/19/16 with the ESS at 1:03 PM, CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, SRNA #5 at 2:10 PM, and Charge Nurse #1 at 3:22 PM confirmed the exit door alarms were adjusted and were audible throughout the facility. Observations on 01/19/16 at 1:00 PM, revealed each exit door alarm was activated when pressure was applied to the door for three (3) seconds, or if a wander bracelet remained within three (3) feet of the door for more than 60 seconds. Further observation confirmed the doors were enabled with a 30-second delay for opening. 6) Observations made on 01/19/16 at 1:00 PM revealed the keypads outside the exit doors were inactive when the alarm was sounding and/or a resident wearing a wander bracelet was within three (3) feet of the door. 7) Review of documentation revealed residents' Wandering Risk Bracelets were checked on 01/11/16 to ensure they were functioning. Interview with the ESS on 01/19/16 at 1:03 PM confirmed all wander risk bracelets were checked on 01/11/16 to determine proper functioning. 8) Review of the facility's documentation dated 01/08/16, revealed the MDS Nurses were in-serviced by the contract Nurse Consultant on 01/08/16, and by the DON on 01/11/16. Interview with the MDS Coordinator and MDS Assistant on 01/19/16 at 3:08 PM, confirmed they received the in-services and would assess each resident for Wander Risk potential upon admission, with each required MDS, and with a change in condition. If the resident was determined to be high risk for wandering/exit-seeking, the MDS Nurse would alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed after being alerted by the MDS Nurse that a resident was at high risk for wandering/exit-seeking, she was responsible to implement wander risk precautions. 9) Review of the facility's In-service Records, dated 01/08/16, revealed the Corporate Nurse Consultant and Vice President of Operations in-serviced the Administrator and DON regarding the facility's wander risk policy/procedure and forms, and the necessary components of the AOC. Interview with the Corporate Quality Control Nurse on 01/19/16 at 2:38 PM confirmed the Administrator and DON were in-serviced on 01/08/16. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM confirmed they received the education. A. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed if a resident not previously identified at risk starts to exhibits behaviors of wandering/exit-seeking, she was responsible to implement wander risk precautions. The Charge Nurse stated she would also complete a New Wander Risk Resident UDA (User Defined Assessment) in the resident's medical record. B. Review of the facility's policy and procedure titled Wandering Resident revealed the steps facility staff was to take to respond to an exit door alarm sounding. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, SRNA #5 at 2:10 PM, Charge Nurse #1 at 3:22 PM, and LPN #5 at 3:49 PM verified knowledge of the facility's procedure to respond to the Wander Guard System Alarm. C. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed all residents who demonstrate exit-seeking behaviors would be placed on increased monitoring and facility staff would utilize the Increased Monitoring Log Form. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Increased Monitoring Form and assigning staff responsibility for monitoring throughout the shift. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed the Increased Monitoring Logs Form became part of the resident's medical record and was filed after its completion. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and the IDT through the medical record Alert/High Risk Progress Note System. Interview with the DON on 01/19/16 at 4:05 PM revealed if a resident met two (2) of the Alert/High Risk criteria, facility staff would place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it should be stopped. D. Review of the facility's Elopement Investigation Form revealed the Form included the exit/return times and the investigative findings for an event. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the information obtained from the completed Elopement Investigation Forms will be used to determine the causative factor(s) of the elopement and implement a corrective action plan, revise the resident's plan of care, educate staff, and the QAPI review/evaluation. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the completed Elopement Investigation Form and the resident's medical record would be reviewed by the IDT and administrative staff the next day (M-F). If the event occurred on the weekend, the House Supervisor and/or Administrative Nurse on duty should review the investigation/medical record and consult via phone with the Administrator or DON as indicated; and, then the IDT and administrative staff will follow up with a review on Monday morning. Review of the In-service Training Report, dated 01/11/16, revealed nursing staff was in-serviced on Missing Residents, Increased Monitoring Logs, and Elopement Investigation. Interviews conducted on 01/19/16 with Charge Nurse #1 at 3:22 PM and LPN #5 at 3:49 PM confirmed they were in-serviced by the DON regarding the completion of the Unsupervised Exit Investigation Form, the Increased Monitoring Form, and the New Wander Risk Resident UDA. Review of the In-service Training rosters revealed facility staff was in-serviced on the facility's wander risk policies and procedures, which identified residents who were wander risks, how to identify exit-seeking behavior, the need to be alert to any resident exhibiting these behaviors, the need to implement redirection interventions per care plan and what to do when an alarm sounds. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, and SRNA #5 at 2:10 PM revealed they did receive the in-service. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed all facility staff had been in-serviced as of 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed all employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Review of the facility's Elopement Drill forms, dated 01/13/16 and 01/14/16, revealed the Administrator performed elopement drills for all three (3) shifts to ensure that staff responded appropriately and in accordance with the facility's wander risk policy. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed the drills were performed and the results of the elopement drills were reviewed in the weekly QAPI Team meeting. Interview on 01/19/16 with CMA #5 at 1:47 PM confirmed the Administrator had been conducting elopement drills. 11) Review of In-service Training Reports, dated 01/11/16 and 01/12/16, revealed the QAPI Team and Medical Director received in-service training by the Administrator, on the correct completion of the QAPI indicators and the need to review the indicator information in the QAPI Committee meetings to determine compliance and to develop action plans if indicated. Interview with the Administrator on 01/19/16 at 4:10 PM, revealed she in-serviced the QAPI Team and the Medical Director. Interviews conducted on 01/19/16 with the DON at 4:05 PM, the SSD at 2:02 PM, and the MDS Coordinator at 3:08 PM confirmed the QAPI Team was in-serviced by the Administrator. Interviews with the DON and the MDS Coordinator confirmed that any indicators which fail to meet established thresholds or reoccurring issues would be addressed with the contracted consultants. 12) Review of the QAPI Agenda/Meeting, dated 01/12/16, revealed the AOC and all criteria were reviewed by the QAPI Team and Medical Director. 13) Review of the Daily-Weekly Reviews, dated January 2016, revealed daily documentation of the wander bracelet placement was monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. 14) Review of the Daily-Weekly Reviews, dated January 2016, revealed the daily documentation on the MARs of bracelet functioning check by CMAs were monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. Review of the QAPI Indicators A-10 and A-14 revealed the facility had been completing the indicators daily until 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed the A-10 and A-14 indicators were being completed daily until jeopardy was abated. 15) Review of the A-9 QAPI indicators, dated 01/14/16 and 01/18/16, revealed the indicators were completed with near elopement events and no concerns were identified. Interviews conducted on 01/19/16 with the DON at 4:05 PM and Administrator at 4:10 PM revealed the QAPI Indicator A-9 will be completed as each elopement or near elopement event occurs. 16) Review of the facility's Evaluation of the QAPI Program, dated 01/12/16, revealed the QAPI indicators for monitoring the effectiveness of the

Based on observation, interview, record review, and a review of the facility's policy it was determined the facility failed to be administered in a manner that maintained the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's Administrator failed to ensure Residents #1 and #4, who were assessed to be at risk for elopement and were utilizing a wandering risk safety bracelet (an electronic device worn by the resident that causes the exit door keypad to visually blink and become locked when the resident comes within a certain range of an exit door) received adequate supervision to prevent accidents. Resident #1 exited the facility on two (2) occasions and Resident #4 exited the facility on one (1) occasion without staff knowledge. On 12/11/15, Resident #1 exited the West Hall door of the facility and was unsupervised for approximately fifteen (15) minutes. On 12/22/15, Resident #1 exited the West Hall door of the facility without staff knowledge, was located approximately 450 feet away from the facility, and was returned to the facility ten (10) minutes later by a non-staff person. Resident #4 exited the facility on 09/12/15, was gone an undetermined amount of time, and was found in the rear parking lot of the facility. The Administrator failed to ensure the incidents were appropriately documented and failed to implement corrective action in an attempt to prevent further resident elopements. Refer to F323, F280, and F514. The facility Administrator's failure to ensure residents received adequate supervision to prevent accidents was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520), with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16 which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/15 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Administrator/Facility Objectives, date unknown, revealed the Administrator shall implement and maintain an ongoing program to promote employee and resident safety. Review of the facility's policy, Accident Prevention and Management, dated 2014, revealed The most dangerous form of wandering is elopement, which occurs when a resident leaves the facility or a safe area without authorization or necessary supervision. Further review revealed the interdisciplinary team (including the Administrator) should gather information to develop interventions that will help reduce the potential for avoidable accidents. The interdisciplinary team should attempt to fully understand the underlying causes of each hazard. Observations, interviews, and record review revealed Residents #1 and #4 exited the building without staff knowledge. Review of the facility's Event Report Investigations revealed the facility failed to document the time Resident #1 was returned to the facility on [DATE], 10/23/15, 11/02/15, and 12/11/15. Further review of the facility's Event Report Investigations, which were reviewed during the weekly safety meeting, revealed the facility also failed to document the time Resident #4 was returned to the facility after exiting on 09/12/15. Review of the facility's Increased Monitoring Logs revealed the residents were placed on 24-hour monitoring after each exit from the facility. The facility's policy stated, The most dangerous form of wandering is elopement, which occurs when a resident leaves the facility or a safe area without authorization or necessary supervision. However, review of the resident's care plans revealed the facility failed to implement interventions to provide the necessary supervision after the 24-hour monitoring ended. Interview with the Administrator on 01/07/16 at 1:10 PM revealed administrative staff had discussed the residents' exit incidents during the weekly safety meetings but had failed to implement interventions to provide routine increased supervision. The Administrator stated she was ultimately responsible to ensure Event Report Investigations were reviewed, documentation was completed, and appropriate interventions were put into place. Although the facility defined elopement as leaving the facility or a safe area, without the necessary supervision, the Administrator stated she did not consider residents leaving the facility without staff knowledge as elopement if the resident was found on facility grounds. She stated she considered an elopement to have occurred when a resident leaves facility grounds unsupervised. Further interview with the Administrator revealed she thought the exit doors locked down when a resident wearing a wander safety bracelet was within a certain range of the door. However, she was not aware that the doors did not function that way until Resident #1 exited the facility on 01/02/16. The Administrator stated she did not make rounds to check the exit door capabilities and functioning. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supervision. Observation on 01/19/16 at 1:50 PM revealed Resident #1 was provided 1:1 supervision by Activity Assistant #1, with no reported concerns at the time of the observation. Review of Resident #1's Increased Monitoring Logs, dated 01/02/16 through 01/19/16 revealed the resident had been on 1:1 supervision since 01/02/16. Interviews with Certified Medication Aide (CMA) #4 on 01/19/16 at 1:12 PM, State Registered Nurse Assistant (SRNA) #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #1 had been on 1:1 supervision since 01/02/16. Observation on 01/19/16 at 2:10 PM revealed Resident #4 was sitting up in a wheelchair wearing a wander safety bracelet on his/her right shoe. Review of Resident #4's Increased Monitoring Logs, dated 01/07/16 through 01/19/16, revealed the resident had been placed on 30-minute checks since 01/07/16. Interviews with CMA #4 on 01/19/16 at 1:12 PM, SRNA #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #4 had been on 30-minute supervision checks since 01/07/16. 2) Review of the Wander Risk Assessments, dated 01/11/16, revealed all residents' Wander Risk Assessments were reviewed by the DON and MDS. Residents #2, #3, and #5 were identified by the facility to be at high risk for wandering. Interviews conducted on 01/19/16 with the MDS Coordinator and the MDS Assistant at 3:08 PM, and the DON at 4:05 PM confirmed all resident wander risk assessments were reviewed on 01/11/16 and no changes were made. The staff also confirmed all care plans for residents identified at high risk for wandering were reviewed and revised on 01/12/16. Review of Resident #2's Event Report Investigation, dated 01/09/16, revealed the resident was found standing at an exit door and the alarm was sounding. Further review revealed the resident was redirected away from the door. Review of Resident #2's Increased Monitoring Logs, dated 01/09/16, revealed the resident was placed on increased monitoring for twelve (12) hours. Review of the resident's care plan, revision date 01/12/16, reflected exit-seeking behaviors exhibited on 01/09/16, included wander risk interventions and 30-minute checks x 30 days. Interview with the MDS Coordinator on 01/19/16 at 3:08 PM, revealed the resident's care plan was reviewed/revised after the incident occurred to include exit-seeking behavior and interventions. 3) Interview with the DON on 01/19/16 at 4:05 PM and the Administrator on 01/19/16 at 4:10 PM confirmed the unsupervised exit investigations were reviewed and addendums were added to include missing information. Further review of the Event Report Investigations dated 09/13/15, 10/23/15, 11/02/15, 11/03/15, 12/11/15, 12/22/15, and 01/02/16 for Resident #1 revealed addendums were added to the facility's investigation forms to include missing exit and return times. Review of the Event Report Investigation, dated 09/12/15, for Resident #4 revealed an addendum was added to include the time the resident was missing. 4) Interview with the DON on 01/19/16 at 4:05 PM revealed she reviewed all Incident/Event Reports for the last thirty (30) days and identified no concerns with inadequate documentation of elopements. 5) Review of the contracted vendor's Statement/Work Order revealed the vendor inspected the facility's wander alert and maglock systems on 01/11/16 and 01/13/16 and adjustments were made to the facility's exit doors, wander alert, and maglock systems. Interview with the Environmental Services Supervisor (ESS) on 01/19/16 at 1:03 PM confirmed the wander alert and maglock systems were inspected and adjusted by the contract vendor. Observations on 01/19/16 at 1:00 PM, revealed the facility's exit alarms were audible throughout the facility. Interviews conducted on 01/19/16 with the ESS at 1:03 PM, CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, SRNA #5 at 2:10 PM, and Charge Nurse #1 at 3:22 PM confirmed the exit door alarms were adjusted and were audible throughout the facility. Observations on 01/19/16 at 1:00 PM, revealed each exit door alarm was activated when pressure was applied to the door for three (3) seconds, or if a wander bracelet remained within three (3) feet of the door for more than 60 seconds. Further observation confirmed the doors were enabled with a 30-second delay for opening. 6) Observations made on 01/19/16 at 1:00 PM revealed the keypads outside the exit doors were inactive when the alarm was sounding and/or a resident wearing a wander bracelet was within three (3) feet of the door. 7) Review of documentation revealed residents' Wandering Risk Bracelets were checked on 01/11/16 to ensure they were functioning. Interview with the ESS on 01/19/16 at 1:03 PM confirmed all wander risk bracelets were checked on 01/11/16 to determine proper functioning. 8) Review of the facility's documentation dated 01/08/16, revealed the MDS Nurses were in-serviced by the contract Nurse Consultant on 01/08/16, and by the DON on 01/11/16. Interview with the MDS Coordinator and MDS Assistant on 01/19/16 at 3:08 PM, confirmed they received the in-services and would assess each resident for Wander Risk potential upon admission, with each required MDS, and with a change in condition. If the resident was determined to be high risk for wandering/exit-seeking, the MDS Nurse would alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed after being alerted by the MDS Nurse that a resident was at high risk for wandering/exit-seeking, she was responsible to implement wander risk precautions. 9) Review of the facility's In-service Records, dated 01/08/16, revealed the Corporate Nurse Consultant and Vice President of Operations in-serviced the Administrator and DON regarding the facility's wander risk policy/procedure and forms, and the necessary components of the AOC. Interview with the Corporate Quality Control Nurse on 01/19/16 at 2:38 PM confirmed the Administrator and DON were in-serviced on 01/08/16. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM confirmed they received the education. A. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed if a resident not previously identified at risk starts to exhibits behaviors of wandering/exit-seeking, she was responsible to implement wander risk precautions. The Charge Nurse stated she would also complete a New Wander Risk Resident UDA (User Defined Assessment) in the resident's medical record. B. Review of the facility's policy and procedure titled Wandering Resident revealed the steps facility staff was to take to respond to an exit door alarm sounding. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, SRNA #5 at 2:10 PM, Charge Nurse #1 at 3:22 PM, and LPN #5 at 3:49 PM verified knowledge of the facility's procedure to respond to the Wander Guard System Alarm. C. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed all residents who demonstrate exit-seeking behaviors would be placed on increased monitoring and facility staff would utilize the Increased Monitoring Log Form. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Increased Monitoring Form and assigning staff responsibility for monitoring throughout the shift. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed the Increased Monitoring Logs Form became part of the resident's medical record and was filed after its completion. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and the IDT through the medical record Alert/High Risk Progress Note System. Interview with the DON on 01/19/16 at 4:05 PM revealed if a resident met two (2) of the Alert/High Risk criteria, facility staff would place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it should be stopped. D. Review of the facility's Elopement Investigation Form revealed the Form included the exit/return times and the investigative findings for an event. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the information obtained from the completed Elopement Investigation Forms will be used to determine the causative factor(s) of the elopement and implement a corrective action plan, revise the resident's plan of care, educate staff, and the QAPI review/evaluation. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the completed Elopement Investigation Form and the resident's medical record would be reviewed by the IDT and administrative staff the next day (M-F). If the event occurred on the weekend, the House Supervisor and/or Administrative Nurse on duty should review the investigation/medical record and consult via phone with the Administrator or DON as indicated; and, then the IDT and administrative staff will follow up with a review on Monday morning. Review of the In-service Training Report, dated 01/11/16, revealed nursing staff was in-serviced on Missing Residents, Increased Monitoring Logs, and Elopement Investigation. Interviews conducted on 01/19/16 with Charge Nurse #1 at 3:22 PM and LPN #5 at 3:49 PM confirmed they were in-serviced by the DON regarding the completion of the Unsupervised Exit Investigation Form, the Increased Monitoring Form, and the New Wander Risk Resident UDA. Review of the In-service Training rosters revealed facility staff was in-serviced on the facility's wander risk policies and procedures, which identified residents who were wander risks, how to identify exit-seeking behavior, the need to be alert to any resident exhibiting these behaviors, the need to implement redirection interventions per care plan and what to do when an alarm sounds. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, and SRNA #5 at 2:10 PM revealed they did receive the in-service. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed all facility staff had been in-serviced as of 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed all employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Review of the facility's Elopement Drill forms, dated 01/13/16 and 01/14/16, revealed the Administrator performed elopement drills for all three (3) shifts to ensure that staff responded appropriately and in accordance with the facility's wander risk policy. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed the drills were performed and the results of the elopement drills were reviewed in the weekly QAPI Team meeting. Interview on 01/19/16 with CMA #5 at 1:47 PM confirmed the Administrator had been conducting elopement drills. 11) Review of In-service Training Reports, dated 01/11/16 and 01/12/16, revealed the QAPI Team and Medical Director received in-service training by the Administrator, on the correct completion of the QAPI indicators and the need to review the indicator information in the QAPI Committee meetings to determine compliance and to develop action plans if indicated. Interview with the Administrator on 01/19/16 at 4:10 PM, revealed she in-serviced the QAPI Team and the Medical Director. Interviews conducted on 01/19/16 with the DON at 4:05 PM, the SSD at 2:02 PM, and the MDS Coordinator at 3:08 PM confirmed the QAPI Team was in-serviced by the Administrator. Interviews with the DON and the MDS Coordinator confirmed that any indicators which fail to meet established thresholds or reoccurring issues would be addressed with the contracted consultants. 12) Review of the QAPI Agenda/Meeting, dated 01/12/16, revealed the AOC and all criteria were reviewed by the QAPI Team and Medical Director. 13) Review of the Daily-Weekly Reviews, dated January 2016, revealed daily documentation of the wander bracelet placement was monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. 14) Review of the Daily-Weekly Reviews, dated January 2016, revealed the daily documentation on the MARs of bracelet functioning check by CMAs were monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. Review of the QAPI Indicators A-10 and A-14 revealed the facility had been completing the indicators daily until 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed the A-10 and A-14 indicators were being completed daily until jeopardy was abated. 15) Review of the A-9 QAPI indicators, dated 01/14/16 and 01/18/16, revealed the indicators were completed with near elopement events and no concerns were identified. Interviews conducted on 01/19/16 with the DON at 4:05 PM and Administrator at 4:10 PM revealed the QAPI Indicator A-9 will be completed as each elopement or near elopement event occurs. 16) Review of the facility's Evaluation of the QAPI Program, dated 01/12/16, revealed the QAPI indicators for monitoring the

Based on observation, record review, and review of the facility's policy and investigations, it was determined the facility failed to ensure the care plan was implemented for one (1) of four (4) sampled residents (Resident #4). The facility identified the resident was at risk for leaving the facility without staff supervision and developed a care plan for Resident #4 to wear a wander risk bracelet to ensure the resident's safety. However, on 09/12/15, the facility failed to ensure the resident was wearing a wander risk bracelet and the resident was found outside the facility unsupervised. The facility's failure to implement residents' care plans to ensure residents' safety was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16 which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Wander Monitoring System policy (not dated) revealed wander risk bracelets were to be worn by the resident 24 hours per day. The policy stated staff should check every shift to assure that the bracelet was intact. Observations on 01/06/16 revealed Resident #4 was independently mobile in a wheelchair. Review of Resident #4's medical record revealed the facility admitted the resident on 05/23/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 08/17/15, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely cognitively impaired and not interviewable. The MDS Assessment further revealed the resident required extensive assistance for transfers, locomotion on/off of the unit, and used a walker/wheelchair for mobility. According to the MDS, Resident #4 had not exhibited behaviors of wandering during the seven-day look back period. Review of Resident #4's care plan, initiated on 08/12/15, revealed the facility identified the resident was at risk for wandering from the facility unsupervised and developed goals for the resident not to wander from the facility unsupervised. Care plan interventions for wandering included verifying Resident #4's safety/whereabouts and utilizing a wander risk bracelet to ensure the resident's safety. Review of a facility Event Report Investigation, dated 09/12/15, with no documented time, revealed Resident #4 was located outside of the facility in the parking lot. Further review of the Investigation revealed the resident had last been seen at the nurses' station at 12:30 PM. Interview with State Registered Nurse Aide (SRNA) #1 on 01/06/16 at 5:36 PM revealed she discovered Resident #4 self-propelling a wheelchair outside of the facility while on break (unsure of time) on 09/12/15. The SRNA stated facility staff was unaware the resident had exited the facility. When found, the resident was not wearing the wander risk safety bracelet, and the facility exit door had not alerted facility staff that the resident had exited the facility. The SRNA stated the resident's wander risk safety bracelet was routinely kept on the resident's shoes; however, the resident's family had changed the resident's shoes prior to the incident and had not notified facility staff. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supervision. Observation on 01/19/16 at 1:50 PM revealed Resident #1 was provided 1:1 supervision by Activity Assistant #1, with no reported concerns at the time of the observation. Review of Resident #1's Increased Monitoring Logs, dated 01/02/16 through 01/19/16 revealed the resident had been on 1:1 supervision since 01/02/16. Interviews with Certified Medication Aide (CMA) #4 on 01/19/16 at 1:12 PM, State Registered Nurse Assistant (SRNA) #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #1 had been on 1:1 supervision since 01/02/16. Observation on 01/19/16 at 2:10 PM revealed Resident #4 was sitting up in a wheelchair wearing a wander safety bracelet on his/her right shoe. Review of Resident #4's Increased Monitoring Logs, dated 01/07/16 through 01/19/16, revealed the resident had been placed on 30-minute checks since 01/07/16. Interviews with CMA #4 on 01/19/16 at 1:12 PM, SRNA #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #4 had been on 30-minute supervision checks since 01/07/16. 2) Review of the Wander Risk Assessments, dated 01/11/16, revealed all residents' Wander Risk Assessments were reviewed by the DON and MDS. Residents #2, #3, and #5 were identified by the facility to be at high risk for wandering. Interviews conducted on 01/19/16 with the MDS Coordinator and the MDS Assistant at 3:08 PM, and the DON at 4:05 PM confirmed all resident wander risk assessments were reviewed on 01/11/16 and no changes were made. The staff also confirmed all care plans for residents identified at high risk for wandering were reviewed and revised on 01/12/16. Review of Resident #2's Event Report Investigation, dated 01/09/16, revealed the resident was found standing at an exit door and the alarm was sounding. Further review revealed the resident was redirected away from the door. Review of Resident #2's Increased Monitoring Logs, dated 01/09/16, revealed the resident was placed on increased monitoring for twelve (12) hours. Review of the resident's care plan, revision date 01/12/16, reflected exit-seeking behaviors exhibited on 01/09/16, included wander risk interventions and 30-minute checks x 30 days. Interview with the MDS Coordinator on 01/19/16 at 3:08 PM, revealed the resident's care plan was reviewed/revised after the incident occurred to include exit-seeking behavior and interventions. 3) Interview with the DON on 01/19/16 at 4:05 PM and the Administrator on 01/19/16 at 4:10 PM confirmed the unsupervised exit investigations were reviewed and addendums were added to include missing information. Further review of the Event Report Investigations dated 09/13/15, 10/23/15, 11/02/15, 11/03/15, 12/11/15, 12/22/15, and 01/02/16 for Resident #1 revealed addendums were added to the facility's investigation forms to include missing exit and return times. Review of the Event Report Investigation, dated 09/12/15, for Resident #4 revealed an addendum was added to include the time the resident was missing. 4) Interview with the DON on 01/19/16 at 4:05 PM revealed she reviewed all Incident/Event Reports for the last thirty (30) days and identified no concerns with inadequate documentation of elopements. 5) Review of the contracted vendor's Statement/Work Order revealed the vendor inspected the facility's wander alert and maglock systems on 01/11/16 and 01/13/16 and adjustments were made to the facility's exit doors, wander alert, and maglock systems. Interview with the Environmental Services Supervisor (ESS) on 01/19/16 at 1:03 PM confirmed the wander alert and maglock systems were inspected and adjusted by the contract vendor. Observations on 01/19/16 at 1:00 PM, revealed the facility's exit alarms were audible throughout the facility. Interviews conducted on 01/19/16 with the ESS at 1:03 PM, CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, SRNA #5 at 2:10 PM, and Charge Nurse #1 at 3:22 PM confirmed the exit door alarms were adjusted and were audible throughout the facility. Observations on 01/19/16 at 1:00 PM, revealed each exit door alarm was activated when pressure was applied to the door for three (3) seconds, or if a wander bracelet remained within three (3) feet of the door for more than 60 seconds. Further observation confirmed the doors were enabled with a 30-second delay for opening. 6) Observations made on 01/19/16 at 1:00 PM revealed the keypads outside the exit doors were inactive when the alarm was sounding and/or a resident wearing a wander bracelet was within three (3) feet of the door. 7) Review of documentation revealed residents' Wandering Risk Bracelets were checked on 01/11/16 to ensure they were functioning. Interview with the ESS on 01/19/16 at 1:03 PM confirmed all wander risk bracelets were checked on 01/11/16 to determine proper functioning. 8) Review of the facility's documentation dated 01/08/16, revealed the MDS Nurses were in-serviced by the contract Nurse Consultant on 01/08/16, and by the DON on 01/11/16. Interview with the MDS Coordinator and MDS Assistant on 01/19/16 at 3:08 PM, confirmed they received the in-services and would assess each resident for Wander Risk potential upon admission, with each required MDS, and with a change in condition. If the resident was determined to be high risk for wandering/exit-seeking, the MDS Nurse would alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed after being alerted by the MDS Nurse that a resident was at high risk for wandering/exit-seeking, she was responsible to implement wander risk precautions. 9) Review of the facility's In-service Records, dated 01/08/16, revealed the Corporate Nurse Consultant and Vice President of Operations in-serviced the Administrator and DON regarding the facility's wander risk policy/procedure and forms, and the necessary components of the AOC. Interview with the Corporate Quality Control Nurse on 01/19/16 at 2:38 PM confirmed the Administrator and DON were in-serviced on 01/08/16. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM confirmed they received the education. A. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed if a resident not previously identified at risk starts to exhibits behaviors of wandering/exit-seeking, she was responsible to implement wander risk precautions. The Charge Nurse stated she would also complete a New Wander Risk Resident UDA (User Defined Assessment) in the resident's medical record. B. Review of the facility's policy and procedure titled Wandering Resident revealed the steps facility staff was to take to respond to an exit door alarm sounding. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, SRNA #5 at 2:10 PM, Charge Nurse #1 at 3:22 PM, and LPN #5 at 3:49 PM verified knowledge of the facility's procedure to respond to the Wander Guard System Alarm. C. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed all residents who demonstrate exit-seeking behaviors would be placed on increased monitoring and facility staff would utilize the Increased Monitoring Log Form. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Increased Monitoring Form and assigning staff responsibility for monitoring throughout the shift. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed the Increased Monitoring Logs Form became part of the resident's medical record and was filed after its completion. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and the IDT through the medical record Alert/High Risk Progress Note System. Interview with the DON on 01/19/16 at 4:05 PM revealed if a resident met two (2) of the Alert/High Risk criteria, facility staff would place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it should be stopped. D. Review of the facility's Elopement Investigation Form revealed the Form included the exit/return times and the investigative findings for an event. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the information obtained from the completed Elopement Investigation Forms will be used to determine the causative factor(s) of the elopement and implement a corrective action plan, revise the resident's plan of care, educate staff, and the QAPI review/evaluation. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the completed Elopement Investigation Form and the resident's medical record would be reviewed by the IDT and administrative staff the next day (M-F). If the event occurred on the weekend, the House Supervisor and/or Administrative Nurse on duty should review the investigation/medical record and consult via phone with the Administrator or DON as indicated; and, then the IDT and administrative staff will follow up with a review on Monday morning. Review of the In-service Training Report, dated 01/11/16, revealed nursing staff was in-serviced on Missing Residents, Increased Monitoring Logs, and Elopement Investigation. Interviews conducted on 01/19/16 with Charge Nurse #1 at 3:22 PM and LPN #5 at 3:49 PM confirmed they were in-serviced by the DON regarding the completion of the Unsupervised Exit Investigation Form, the Increased Monitoring Form, and the New Wander Risk Resident UDA. Review of the In-service Training rosters revealed facility staff was in-serviced on the facility's wander risk policies and procedures, which identified residents who were wander risks, how to identify exit-seeking behavior, the need to be alert to any resident exhibiting these behaviors, the need to implement redirection interventions per care plan and what to do when an alarm sounds. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, and SRNA #5 at 2:10 PM revealed they did receive the in-service. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed all facility staff had been in-serviced as of 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed all employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Review of the facility's Elopement Drill forms, dated 01/13/16 and 01/14/16, revealed the Administrator performed elopement drills for all three (3) shifts to ensure that staff responded appropriately and in accordance with the facility's wander risk policy. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed the drills were performed and the results of the elopement drills were reviewed in the weekly QAPI Team meeting. Interview on 01/19/16 with CMA #5 at 1:47 PM confirmed the Administrator had been conducting elopement drills. 11) Review of In-service Training Reports, dated 01/11/16 and 01/12/16, revealed the QAPI Team and Medical Director received in-service training by the Administrator, on the correct completion of the QAPI indicators and the need to review the indicator information in the QAPI Committee meetings to determine compliance and to develop action plans if indicated. Interview with the Administrator on 01/19/16 at 4:10 PM, revealed she in-serviced the QAPI Team and the Medical Director. Interviews conducted on 01/19/16 with the DON at 4:05 PM, the SSD at 2:02 PM, and the MDS Coordinator at 3:08 PM confirmed the QAPI Team was in-serviced by the Administrator. Interviews with the DON and the MDS Coordinator confirmed that any indicators which fail to meet established thresholds or reoccurring issues would be addressed with the contracted consultants. 12) Review of the QAPI Agenda/Meeting, dated 01/12/16, revealed the AOC and all criteria were reviewed by the QAPI Team and Medical Director. 13) Review of the Daily-Weekly Reviews, dated January 2016, revealed daily documentation of the wander bracelet placement was monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. 14) Review of the Daily-Weekly Reviews, dated January 2016, revealed the daily documentation on the MARs of bracelet functioning check by CMAs were monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. Review of the QAPI Indicators A-10 and A-14 revealed the facility had been completing the indicators daily until 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed the A-10 and A-14 indicators were being completed daily until jeopardy was abated. 15) Review of the A-9 QAPI indicators, dated 01/14/16 and 01/18/16, revealed the indicators were completed with near elopement events and no concerns were identified. Interviews conducted on 01/19/16 with the DON at 4:05 PM and Administrator at 4:10 PM revealed the QAPI Indicator A-9 will be completed as each elopement or near elopement event occurs. 16) Review of the facility's Evaluation of the QAPI Program, dated 01/12/16, revealed the QAPI indicators for monitoring the effectiveness of the QAPI program were completed daily until jeopardy was abated. The indicators were reviewed by the QAPI team and Medical Director on 01/12/16. Interviews conducted on 01/19/16 with the Social Services Director (SSD) at 2:02 PM, the MDS Coordinator at 3:08 PM, the DON at 4:05 PM, and the Administrator at 4:10 PM confirmed the completed indicators were reviewed by the QAPI Team on 01/12/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed the QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate action plan, and make any necessary changes. 17) Interview with the Administrator on 01/19/16 at 4:10 PM revealed she would review QAPI Evaluation Tools as outlined in the AOC daily and would review the QAPI Minutes and action plans from each meeting. The Administrator also stated that she would provide oversight and education to QAPI Team members as needed.

Based on observation, interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to have an effective system in place to ensure two (2) of four (4) sampled residents (Resident #1 and Resident #4) received adequate supervision and monitoring to prevent accidents. Resident #1 exited the facility on two (2) occasions (12/11/15 and 12/22/15) and Resident #4 on one (1) occasion (09/12/15) without staff knowledge. The facility assessed Resident #1 to be at risk for elopement on 08/18/15 and placed a wander risk safety bracelet (an electronic device worn by the resident that causes the exit door keypad to visually blink and become locked when the resident comes within a certain range of an exit door) on the resident. Review of the facility's Event Report Investigations dated 12/11/15 and 12/22/15 revealed Resident #1 exited the facility without staff knowledge. Record review revealed the facility assessed Resident #4 to be an elopement risk on 08/12/15 and a wander risk safety bracelet was placed on the resident. Review of the facility's Event Report Investigation dated 09/12/15, revealed Resident #4 exited the facility without staff knowledge. The facility failed to address and investigate how the residents were able to get out of the facility unsupervised to prevent further elopements. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents who were at risk for elopement was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520), with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16 which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Wandering Monitoring System, date unknown, revealed it was the facility's intent to assure that all residents with wandering behavior would be provided safety and supervision and would remain free of harm. Review of the facility's policy, Accident Prevention and Management, dated 2014, revealed, The most dangerous form of wandering is elopement, which occurs when a resident leaves the facility or a safe area without authorization or necessary supervision. Further review revealed facility staff should assess all residents for their risk of unsafe wandering and elopement. The policy stated the assessments should occur upon admission, readmission, quarterly, when there was a significant change in status, or if the resident eloped. Continued review revealed the policy stated the care plan should focus on minimizing the issues identified during the assessment. This may include the need for environmental modifications. Further review of the policy revealed if staff members have noticed a pattern of behaviors of elopements occurring at particular times of the day, increased supervision during these periods may be helpful. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 08/17/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/24/25, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was severely cognitively impaired and not interviewable. Further review of the MDS Assessment revealed the resident had presented with behaviors of wandering that had occurred one (1) to three (3) days during the seven (7) day look back period. Further review revealed the facility assessed the resident to require limited assistance with transfers and extensive assistance with walking in his/her room and corridor, and locomotion on/off the unit. Review of the Social Progress Notes and Evaluation, dated 08/17/15, revealed the resident was transferred from another facility and had a history of [REDACTED]. Review of the nurse's notes revealed the facility completed a Wander Risk Assessment on 08/18/15, which indicated the resident was at moderate risk for wandering. Further review revealed a wander risk safety bracelet was placed on the resident after the assessment was completed. Review of the resident's Comprehensive Plan of Care, initiated on 09/01/15, revealed the resident was at risk for wandering from the facility unattended. Further review of the care plan revealed the goals included the resident will not wander from the facility unattended and will move about freely in a monitored and safe environment. The care plan interventions for wandering included checking promptly when the alarm system goes off to verify the resident's safety/whereabouts and to redirect the resident's attention as needed. Review of the resident's Mood and Behavior Pattern Logs for September 2015 through December 2015 revealed the resident frequently exhibited behaviors of wandering, approximately three to five times per week. Review of the facility's Event Report Investigations revealed Resident #1 exhibited exit-seeking behaviors and exited the facility on 09/13/15, 10/23/15, 11/02/15, and 11/03/15. According to staff interviews, facility staff observed the resident exit the facility on 10/23/15, 11/02/15, and 11/03/15 and found the resident outside immediately after hearing the alarm on 09/13/15. Review of Resident #1's Increased Monitoring Logs revealed the facility placed the resident on increased supervision (verified the resident's whereabouts every 15 minutes for eight hours, then every 30 minutes for twelve hours, then hourly for four hours) for 24 hours after each incident when the resident exited the facility. Further review of the investigations revealed the resident exited the facility via the same (West Hall) door on three (3) of these occasions (10/23/15, 11/02/15, and 11/03/15). Interviews with Certified Medication Aide (CMA) #1 on 01/07/16 at 10:14 AM, Licensed Practical Nurse (LPN) #4 on 01/05/16 at 1:55 PM, Environmental Services Supervisor (ESS) on 01/05/16 at 2:25 PM, LPN #3 on 01/05/16 at 3:55 PM, LPN #2 on 01/05/16 at 4:23 PM, LPN #6 on 01/05/16 at 5:05 PM, CMA #3 on 01/05/16 at 5:45 PM, State Registered Nurse Aide (SRNA) #2 on 01/06/16 at 1:56 PM, LPN #1 on 01/06/16 at 2:20 PM, CMA #2 on 01/06/16 at 3:36 PM, SRNA #1 on 01/06/16 at 5:36 PM, CMA #1 on 01/07/16 at 10:14 AM, and Laundry Aide #1 on 01/07/16 at 11:15 AM revealed Resident #1 routinely (1-2 times per shift) set off the West Hall exit door alarm by pushing the exit bar, often until the door opened, and required frequent redirection from facility staff. Interviews with CMA #1, LPN #4, and RN #1 revealed the resident routinely demonstrated this behavior in the hours after supper. Review of the facility's Event Report Investigation, dated 12/11/15, no time documented, revealed Resident #1 was last seen in the dining room at 5:30 PM. The investigation report stated the West Hall exit door was sounding an alarm. The time staff initially heard the alarm sounding was not included on the report. Further review of the Event Report Investigation revealed no documented evidence of the time the resident was returned to the facility. The report included documentation that the resident was wearing a wanderguard bracelet and that it was functioning properly. Review of archived weather reports revealed the weather in the facility's area on 12/11/15 at 5:35 PM was 67.5 degrees Fahrenheit, overcast and dark. Interview with CMA #1 on 01/07/16 at 10:14 AM revealed Resident #1 was located outside of the West Hall exit door and returned to the facility at approximately 5:45 PM. CMA #1 reported that the resident told her that he/she fell down. The resident was assessed and noted to have scattered abrasions to his/her hands, knee, and upper back. Interviews with CMA #1 on 01/07/16 at 10:14 AM and Laundry Aide #1 on 01/07/16 at 11:15 AM revealed at the time of the incident on 12/11/15, they both were in other residents' rooms on the East Hall and did not hear the West Hall exit door alarm sounding until they returned to the hallway. Further interview revealed neither staff member could determine how long the alarm had been sounding when they were alerted to the West Hall exit door being open. Review of the facility's Event Report Investigation, dated 12/22/15, no time documented, revealed Resident #1 was last seen on the West Hall at approximately 4:50 PM. Further review revealed the resident exited the West Hall door without staff knowledge, left facility grounds, and was returned to the facility by a non-staff person at approximately 5:00 PM. The report indicated the resident was found near Pizza Hut. Observations with Maintenance Worker #1 on 01/07/16 at 11:20 AM revealed Resident #1 was found approximately 450 feet away from the facility. The resident was assessed by facility staff and no injuries were noted. Review of archived weather reports revealed the weather in the facility's area on 12/22/15 at 4:55 PM was 57.6 degrees Fahrenheit, dark, and mostly cloudy. Interview with LPN #2 on 01/05/16 at 4:24 PM revealed on 12/22/15 at approximately 4:50 PM, another resident (Resident #4) exited the facility with a family member out the front door. The resident was assessed by the facility to be at risk for wandering and was wearing a wander risk safety bracelet. The LPN stated the exit door alarm began to sound when Resident #4 exited the facility due to the wander risk safety bracelet and staff thought the alarm was sounding due to Resident #4 exiting the facility. Further interview revealed after the front exit door alarm was reset, facility staff was made aware that the West Hall exit door alarm was also sounding. The LPN stated facility staff began to look for Resident #1 because the resident pushes on the doors a lot and we have to watch (Resident #1) close. The LPN stated Resident #1 was . the only one down there that actually tries to get out. Review of Resident #1's medical record revealed the resident exited the facility six (6) times from 09/12/15 to 12/22/15. Review of Resident #1's Increased Monitoring Logs revealed the facility placed the resident on increased supervision for 24 hours after each incident when the resident exited the facility. Review of the facility's Event Report Investigations for each exit revealed the facility determined the causative factors to include Dementia, Confusion, and Wandering/Pacing. Interview with LPN #3 on 01/05/16 at 3:55 PM, LPN #2 on 01/05/16 at 4:23 PM, LPN #6 on 01/05/16 at 5:05 PM, SRNA #3 on 01/05/16 at 5:28 PM, SRNA #2 on 01/06/16 at 1:56 PM, LPN #1 on 01/06/16 at 2:20 PM, CMA #2 on 01/06/16 at 3:36 PM, Registered Nurse (RN) #1 on 01/06/16 at 4:55 PM, and SRNA #1 on 01/06/16 at 5:36 PM revealed residents assessed for wandering were not routinely monitored more closely than residents who did not wander. Although staff interview revealed Resident #1 exhibited daily exit-seeking behavior, review of Resident #1's care plan, initiated 09/01/15, revealed the facility failed to address interventions to prevent this behavior. Review of Resident #1's Increased Monitoring Logs revealed following the resident's elopement on 12/22/15 revealed the resident was placed on 1:1 supervision (facility staff member with resident at all times) until 12/29/15. Interview with the Administrator on 01/07/16 at 1:10 PM revealed Resident #1 was taken off 1:1 supervision on 12/29/15 because facility staff thought the facility exit doors had been revised to lock down when a resident wearing a wander risk bracelet was in close proximity. Review of the facility's Event Report Investigation, dated 01/02/16, revealed Resident #1 exited the facility from the West Hall door at 10:30 AM, and was followed outside by a facility staff member. Interview with LPN #3 on 01/05/16 at 3:55 PM revealed the LPN followed the resident out the West Hall door at the time of the incident and attempted to redirect the resident back into the facility; however, the resident proceeded down the hill outside of the exit door and fell resulting in two (2) skin tears. Further interview with the Administrator on 01/07/16 at 1:10 PM revealed the facility contracted an alarm company and the contractor was at the facility on 12/28/15 and 12/29/15 to inspect the doors and enable all facility exit doors with a wander bracelet alarm system. When a wander bracelet comes within three (3) feet of the exit door the keypad becomes locked and begins to blink. The Administrator stated she and facility staff thought the exit doors would automatically lock down when a wander bracelet was within range of the door. The Administrator stated that the Environmental Services Supervisor did a walking round with the alarm safety company and checked the functioning of each exit door on 12/29/15 and identified no concerns with the functioning of the exit doors. The Administrator stated maintenance staff was responsible to check the functioning of the exit doors daily during the week and no concerns had been identified. Interview with the ESS on 01/05/16 at 2:25 PM revealed she was not aware the doors did not lock when a wander bracelet was in close proximity until Resident #1 exited from the facility on 01/02/16. The ESS stated she had misunderstood what the alarm system company had instructed her on how the facility exit doors functioned. Review of the Preventive Maintenance Checklist for September through December 2015 revealed no concerns had been identified by facility staff regarding the wander alarm system. Observations and interview with Maintenance Worker #1 on 01/07/16 at 10:30 AM revealed facility exit doors did not sound an alarm until the exit bar was pushed for five (5) seconds, then the audible alarm sounded, and the door would open after thirty (30) seconds. Observations revealed when a wander bracelet was within range of the sensor, the keypad would flash yellow instead of green, indicating the keypad was locked down; however, the door alarm did not sound until the exit bar was pushed for five (5) seconds. Interview with the Maintenance Worker on 01/07/16 at 10:30 AM revealed the facility's exit door alarms have never sounded when a wander bracelet came into range and only sounded when the exit door bar was pushed. Interview with the Administrator on 01/07/16 at 1:10 PM revealed she thought the exit doors with the wander bracelet sensors would lock down and the alarms begin sounding when a resident wearing a wander bracelet came close to the sensor; however, she did not make rounds with the maintenance worker to ensure the door alarm system was working to her understanding. Interview with the DON and the Administrator on 01/07/16 at 1:10 PM revealed although the facility had identified Resident #1 exhibited consistent exit-seeking behavior, the facility had only increased supervision for 24 hours after each incident of the resident exiting the facility until the resident eloped from the facility on 12/22/15. The Administrator and DON stated that Resident #1's Event Report Investigations were reviewed during a weekly meeting; however, no patterns or trends had been identified. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 05/23/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/17/15, revealed the facility assessed the resident's BIMS score to be three (3), indicating the resident was severely cognitively impaired and not interviewable. Further review of the MDS Assessment revealed the resident required extensive assistance for transfers, locomotion on/off of the unit, and used a walker/wheelchair for mobility. Further review revealed the resident had not exhibited behaviors of wandering during the seven-day look back period. Review of the resident's care plan, initiated on 08/12/15, revealed the resident was at risk for wandering from the facility unattended. Care plan goals for wandering included the resident would not wander from the facility unattended and would move about freely in a monitored and safe environment. Care plan interventions for wandering included checking promptly when the alarm system went off to verify the resident's safety/whereabouts and a wander risk bracelet was placed to ensure resident safety. Observations made on 01/06/16 revealed Resident #4 was independently mobile in a wheelchair. Review of the facility's Event Report Investigation, dated 09/12/15, not timed, revealed Resident #4 was seen at the nurses' station at 12:30 PM and was located outside of the facility in the parking lot. Further review of the Investigation revealed the time the resident was found in the parking lot was not documented on the report and there was no documentation of the time the resident returned inside the facility. Interviews with the Administrator and the Director of Nursing (DON) on 01/07/16 at 1:10 PM revealed increased monitoring logs were put into effect if a resident exhibited exit-seeking behavior or after an exit had been attempted. Further interview confirmed residents assessed for wandering were not routinely monitored more closely than other residents. Interview with SRNA #1 on 01/06/16 at 5:36 PM revealed she discovered Resident #4 outside of the facility while on break (unsure of time) on 09/12/15. The resident was found to be self-propelling in a wheelchair. The SRNA stated she immediately assisted the resident back inside the facility, where the resident was assessed to have sustained no injuries. Further interview with the SRNA revealed facility staff was unaware the resident had exited the facility. The SRNA stated the resident's wander risk safety bracelet was located on the resident's shoes; however, the resident's family had changed the resident's shoes prior to the incident and had not notified facility staff. The resident was found to not be wearing the wander risk safety bracelet at the time of the incident and the facility exit door had not alerted facility staff that the resident had exited the facility. Review of the archived weather records revealed the weather in the facility's area at 12:35 PM on 09/12/15 was 68.0 degrees Fahrenheit with scattered clouds. The SRNA could not remember what the resident was wearing on the day of the incident. Interview with the DON and Administrator on 01/07/16 at 1:10 PM revealed the facility had failed to document the time the resident was returned to the facility and they were not able to determine the length of time the resident had been outside of the facility unsupervised. The Administrator stated the incident was not considered an elopement because the resident had not left facility grounds. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supe

Based on interview, record review, and review of the facility's investigations it was determined the facility failed to maintain clinical records for two (2) of four (4) sampled residents (Resident #1 and Resident #4) that were complete and accurate in accordance with accepted professional standards and practices. Review of the facility's Event Report Investigations and Resident #1's medical record revealed the facility failed to document when the resident was returned inside the facility after the resident exited unattended on 09/13/15, 10/23/15, 11/02/15, and 12/11/15. Review of the facility's Event Report Investigation dated 09/12/15 and the clinical record for Resident #4 revealed the facility failed to document the time the resident was returned inside the facility after the resident had exited without supervision. The facility was unable to determine how long the resident was unsupervised due to its failure of not documenting the time the resident was returned. The facility's failure to maintain complete clinical records for residents exiting the facility without supervision was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 12/11/15 at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520), with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/07/16. An acceptable Allegation of Compliance was received on 01/15/16 which alleged removal of the Immediate Jeopardy on 01/15/16. A partial extended survey was conducted on 01/19/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/15/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280 and F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490, F514, and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on 01/07/16 at 5:40 PM, revealed the facility did not have a policy regarding maintaining accurate records. The Administrator stated charts were randomly audited and Event Investigations were reviewed during weekly safety meetings, which consisted of the Director of Nursing (DON), Social Services Director, Restorative Coordinator, Therapy Director, Minimum Data Set (MDS) Coordinator, Assistant Director of Nursing (ADON), House Supervisor, and the Administrator. Review of the facility policy titled Missing Resident, undated, revealed The resident's nurse should document all events, including contacting the physician and family. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 08/17/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment revealed the resident exhibited the behavior of wandering one (1) to three (3) days during the seven-day look back period. Review of the facility's Social Progress Notes and Evaluation, dated 08/17/15, revealed the resident had a history of [REDACTED]. Further review of the Nurse's Notes, dated 08/18/15, revealed the resident had a Wander Risk Assessment which indicated the resident was at moderate risk for wandering and a wander risk safety bracelet was placed on the resident after the assessment was completed on 08/18/15. Review of the facility's Event Report Investigations for Resident #1 dated 09/13/15, 10/23/15, 11/02/15, and 12/11/15 revealed the resident exited the facility on these days. Staff assisted the resident back into the facility; however, there was no evidence staff documented the time the resident returned inside the facility or how long the resident was outside unsupervised. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 05/23/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be three (3), indicating the resident was severely cognitively impaired and not interviewable. Further review of the MDS assessment revealed the resident required extensive assistance for transfers, locomotion on/off of the unit, and used a walker/wheelchair for mobility. Review of the resident's care plan, initiated on 08/12/15, revealed the resident was at risk for wandering from the facility unattended. Further review of the care plan revealed interventions for wandering included investigating, reporting, and documenting an elopement in accordance with facility policy. Review of the facility's Event Report Investigation, dated 09/12/15, revealed Resident #4 was located outside of the facility in the parking lot. Further review of the investigation revealed the facility failed to document the time the resident was found outside the facility unsupervised and the time the resident was assisted inside the facility. Review of the Nurse's Notes, dated 09/12/15, revealed the facility failed to ensure the time the resident was last seen, the time the resident was located outside, and the time the resident was returned inside the facility was documented. Interview with the Director of Nursing (DON) and Administrator on 01/07/16 at 1:10 PM, revealed the facility failed to document the time Resident #4 was assisted inside the facility and they were not able to determine the length of time the resident had been outside of the facility unsupervised. Interview with the DON and Administrator on 01/07/16 at 5:40 PM, revealed although it was a group effort to review the facility's Event Report Investigations, ultimately the Administrator was responsible to ensure documentation was completed accurately. Further interview revealed Resident #1 and Resident #4's Event Report Investigations had been reviewed; however, they had not identified the failure to document the time the residents were returned to the facility. During Interview with the Administrator at this time, she stated she should have ensured the exit events (elopements) were documented accurately and completely in the medical record. She stated, Hindsight is 20/20. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/15/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) A wander risk assessment was completed by the Minimum Data Set (MDS) Nurse on 01/11/16 for Residents #1 and #4. The assessments were reviewed by the Director of Nursing (DON) for accuracy. Residents #1's and #4's wander risk care plans were reviewed/revised by the MDS Nurse on 01/12/16 to determine if they addressed the residents' current wander risk status and interventions to reduce the potential for unsupervised exit from the facility. Resident #1 remained on 1:1 supervision with no other incidents reported. Resident #4 was placed on 30-minute checks on 01/07/16 and will remain on 30-minute checks until 30 days have passed with no exit-seeking behaviors. 2) Wander risk assessments of all residents were reviewed by the DON and MDS Nurse on 01/11/16 to determine that they reflected each resident's current wander risk status. No changes in Wander Risk scoring were identified. Three (3) residents were identified as high risk for wandering (in addition to Residents #1 and #4). One of the residents identified exhibited exit-seeking behavior on 01/09/16 and was placed on increased monitoring for twelve (12) hours. The resident's care plan was revised to reflect recent exit-seeking behaviors and 30-minute checks x 30 days. The care plans for all residents identified as high risk for wandering, based on the Wander Risk Assessment, were reviewed/revised by the MDS Nurses and the DON on 01/12/16 to ensure interventions were addressed on their care plans. The Wander Risk Books were reviewed by the DON on 01/11/16 to determine that all residents identified as high risk were identified in the books. 3) Record review for Residents #1 and #4, regarding the unsupervised exits, were reviewed by the DON and Administrator to determine if adequate documentation was present. An addendum was added to facility's internal investigation form to include the missing information (the exit and return times) for Resident #1 and Resident #4's unsupervised exit incidents. 4) On 01/11/16, the DON reviewed the Incident/Event reports for the past thirty (30) days, to determine if there were any resident medical records that would need to be reviewed for adequate documentation of elopement; none was identified. 5) The wander alert and maglock systems were inspected by the contracted vendor on 01/11/16 and 01/13/16 to verify that the equipment at each exit door was functioning properly. The volume of exit alarms located at all exit doors and at both nurses' stations were adjusted on 01/11/16 to be audible throughout the facility. Each exit door alarm was adjusted on 01/11/16 to become activated when a minimum of fifteen (15) pounds of pressure was applied to the door for three (3) consecutive seconds; or if a resident wearing a wander bracelet remains within three (3) feet of an exit door for more than sixty (60) seconds. After applying at least fifteen (15) pounds of pressure to an exit door for three (3) consecutive seconds, the door has an approximate thirty (30)-second delay for opening. 6) To prevent visitors from opening the exit doors and allowing residents to exit, the outside keypad (or entry button) used to enter through each exit door will be rendered inactive when the alarm is sounding and/or a resident wearing a wander bracelet is within three (3) feet of the door. 7) All wander alert bracelets were checked on 01/11/16 by the Environmental Services Director to determine if they were functioning properly. 8) The MDS Nurses were in-serviced by the contracted Nurse Consultant on 01/08/16 and by the DON on 01/11/16, on the need to address the indicated interventions for all residents identified as a wander risk and to update the care plans with the necessary interventions to address all exit-seeking event investigations. Each resident will be assessed for Wander Risk potential upon admission, with each required MDS assessment, and with a change in condition by the MDS nurse. If the resident is determined to be at high risk for wandering/exit-seeking, the MDS Nurse shall alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. 9) The Administrator and DON were in-serviced by the Corporate Nurse Consultant and Vice President of Operations on 01/08/16 regarding the facility's wander risk policy, procedure, and forms and the necessary components of the allegation of compliance to address the wander risk deficiencies. The facility revised/implemented the following system changes: A. If a resident previously determined not to be a wander risk starts exhibiting increased wandering and/or exit-seeking behavior, the charge nurse on duty will implement Wander Risk Precautions including, but not limited to, application of a wander alert bracelet, revising the resident's care plan, adding the resident to the Wander Risk Book, and communicating changes to staff. The nurse will also complete a 'New Wander Risk Resident' UDA (User Defined Assessment) in the resident's EMR (Electronic Medical Record). With the completion of the UDA, the resident's care plan will be updated and an alert will be generated by the PCC (Point Click Care) software to communicate this change to all nursing staff, administrative staff, and IDT members. B. When an exit door alarms, facility staff should do the following: -Immediately determine which door has been breached by looking at the annunciator panel located at the nurses' station. -Go to that door in search of how/who could have caused it to sound. -Open the door and step outside and check the immediate area for the resident. -As the above is being done, another staff person must check on the whereabouts of the specified Wander Risk Residents. -If no resident can be found, report to the charge nurse so that the Missing Resident Procedure can be implemented. C. All residents who demonstrate exit-seeking behaviors will be placed on increased monitoring and facility staff will utilize the Increased Monitoring Log form. This form directs the documentation of the monitoring of the resident for a 12-hour period beginning with 15-minute increments, and concluding with the determination to discontinue the increased monitoring, or to continue for another 12 hours. Any resident exhibiting exit-seeking behaviors beyond this time will be placed on 30-minute checks until 30 days have passed with no exit-seeking behaviors. The charge nurse on duty will be responsible for initiating the increased monitoring form and assigning staff responsibility for monitoring throughout the shift. The Increased Monitoring form becomes part of the resident's medical record. Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and IDT through the medical record Alert/High Risk Progress Note System. If a resident meets two (2) of the Alert/High Risk criteria, facility staff will place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it can be stopped. D. An Elopement Investigation Form was developed and will be used to investigate all unsupervised exits. The form will include the exit and return times, and the investigation findings for the event. The information collected on the Elopement Investigation Form shall be used to determine the causative factor(s) of the elopement, implement a corrective action plan, revise the resident's plan of care, educate staff, and Quality Assurance and Performance Improvement (QAPI) review/evaluation. The charge nurse on duty will be responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. The Elopement Investigation and resident's medical record will be reviewed by the IDT and administrative staff the next day (M-F). In case of a weekend occurrence, the House Supervisor and/or Administrative Nurse on duty shall review the investigation/medical record and consult via phone with the Administrator or DON as indicated. The IDT and administrative staff will follow up with a review on Monday morning. Licensed nurses were in-serviced on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 by the DON regarding the completion of the unsupervised exit investigation form, the increased monitoring form, and the New Wander Risk Resident UDA. All facility staff received in-service education on 01/11/16, 01/12/16, 01/13/16, and 01/14/16 as provided by the Administrator, DON, and the Nursing Staff Educator on the facility's wander risk program policies and procedures. A list of staff members that did not receive the appropriate education by 01/14/16 (due to vacation, leave of absence, extended days off) was compiled by the Staff Development Coordinator. Staff on the list was required to report to the DON/ADON/Staff Development Coordinator and receive education prior to beginning their assigned duties. Approximately 92 percent of the staff received the education as of 01/14/16. All employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Elopement drills were conducted by the Administrator on 01/13/16 and 01/14/16 for all three (3) shifts to determine if staff responds in accordance with the facility's wander risk policy. These drills will continue three (3) times weekly (once on each of the different shifts) until jeopardy has been abated. Results of the Elopement drills will be reviewed in the weekly QAPI Team meeting. 11) The QAPI Team received in-service education by the Administrator on 01/11/16 and 01/12/16 on the correct completion of the QAPI indicators and the need to review completed indicator information in the QAPI Committee Meetings to determine compliance and to develop action plans if indicated. Any indicators which fail to meet the established threshold, or that indicate recurrence of issues that have already been addressed in the prior month, will be reviewed with the contracted consultants for assistance in developing and implementing additional interventions. 12) The AOC and all criteria were reviewed by the facility's QAPI Team with the Medical Director on 01/12/16 and 01/14/16, to determine completion and compliance. 13) The DON/ADON/MDS Nurse monitored daily to ensure Certified Nurse Assistants (CNAs) were documenting resident bracelet (wander alert) placement checks and Certified Medication Assistants (CMAs) were documenting resident bracelet functioning. Findings were reported in the weekly QAPI meeting. 14) On 01/12/16, the Administrator and MDS Nurse used QAPI indicators A-10 and A-14 to monitor and audit all components of the facility's wander risk systems and audit the documentation. The QAPI indicators will be completed daily until jeopardy has been abated. Any concerns identified were addressed immediately. 15) QAPI indicator A-9 will be completed as each elopement or near elopement event occurs on an ongoing basis. Any concerns identified will be addressed immediately. 16) The completed QAPI indicators were reviewed by the QAPI Team with the Medical Director on 01/12/16 to determine the effectiveness of the implemented interventions. The QAPI Team will meet weekly to determine compliance by reviewing QAPI indicator tools and monitoring logs, evaluate the action plan, and make any necessary changes. 17) The Administrator will review the QAPI Evaluation Tools as outlined in the AOC daily and will review the QAPI Minutes and action plans from each meeting. The Administrator will provide assistance in writing and/or revising of QAPI Action Plans and will provide education as needed to QAPI team members. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of the Wander Risk Assessments for Resident #1 and Resident #4, dated 01/11/16, revealed the assessments were completed by the MDS Coordinator. Interview with the DON on 01/19/16 at 4:05 PM, verified the Wander Risk Assessment for Resident #1 was reviewed for accuracy. Review of Resident #1's and Resident #4's care plans verified review/revisions were made by the MDS Nurses on 01/12/16 to include interventions to reduce the potential for unsupervised exit from the facility and the increased supervision. Observation on 01/19/16 at 1:50 PM revealed Resident #1 was provided 1:1 supervision by Activity Assistant #1, with no reported concerns at the time of the observation. Review of Resident #1's Increased Monitoring Logs, dated 01/02/16 through 01/19/16 revealed the resident had been on 1:1 supervision since 01/02/16. Interviews with Certified Medication Aide (CMA) #4 on 01/19/16 at 1:12 PM, State Registered Nurse Assistant (SRNA) #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #1 had been on 1:1 supervision since 01/02/16. Observation on 01/19/16 at 2:10 PM revealed Resident #4 was sitting up in a wheelchair wearing a wander safety bracelet on his/her right shoe. Review of Resident #4's Increased Monitoring Logs, dated 01/07/16 through 01/19/16, revealed the resident had been placed on 30-minute checks since 01/07/16. Interviews with CMA #4 on 01/19/16 at 1:12 PM, SRNA #4 on 01/19/16 at 1:18 PM, Charge Nurse #1 on 01/19/16 at 3:22 PM, the DON on 01/19/16 at 4:05 PM, and the Administrator on 01/19/16 at 4:10 PM confirmed Resident #4 had been on 30-minute supervision checks since 01/07/16. 2) Review of the Wander Risk Assessments, dated 01/11/16, revealed all residents' Wander Risk Assessments were reviewed by the DON and MDS. Residents #2, #3, and #5 were identified by the facility to be at high risk for wandering. Interviews conducted on 01/19/16 with the MDS Coordinator and the MDS Assistant at 3:08 PM, and the DON at 4:05 PM confirmed all resident wander risk assessments were reviewed on 01/11/16 and no changes were made. The staff also confirmed all care plans for residents identified at high risk for wandering were reviewed and revised on 01/12/16. Review of Resident #2's Event Report Investigation, dated 01/09/16, revealed the resident was found standing at an exit door and the alarm was sounding. Further review revealed the resident was redirected away from the door. Review of Resident #2's Increased Monitoring Logs, dated 01/09/16, revealed the resident was placed on increased monitoring for twelve (12) hours. Review of the resident's care plan, revision date 01/12/16, reflected exit-seeking behaviors exhibited on 01/09/16, included wander risk interventions and 30-minute checks x 30 days. Interview with the MDS Coordinator on 01/19/16 at 3:08 PM, revealed the resident's care plan was reviewed/revised after the incident occurred to include exit-seeking behavior and interventions. 3) Interview with the DON on 01/19/16 at 4:05 PM and the Administrator on 01/19/16 at 4:10 PM confirmed the unsupervised exit investigations were reviewed and addendums were added to include missing information. Further review of the Event Report Investigations dated 09/13/15, 10/23/15, 11/02/15, 11/03/15, 12/11/15, 12/22/15, and 01/02/16 for Resident #1 revealed addendums were added to the facility's investigation forms to include missing exit and return times. Review of the Event Report Investigation, dated 09/12/15, for Resident #4 revealed an addendum was added to include the time the resident was missing. 4) Interview with the DON on 01/19/16 at 4:05 PM revealed she reviewed all Incident/Event Reports for the last thirty (30) days and identified no concerns with inadequate documentation of elopements. 5) Review of the contracted vendor's Statement/Work Order revealed the vendor inspected the facility's wander alert and maglock systems on 01/11/16 and 01/13/16 and adjustments were made to the facility's exit doors, wander alert, and maglock systems. Interview with the Environmental Services Supervisor (ESS) on 01/19/16 at 1:03 PM confirmed the wander alert and maglock systems were inspected and adjusted by the contract vendor. Observations on 01/19/16 at 1:00 PM, revealed the facility's exit alarms were audible throughout the facility. Interviews conducted on 01/19/16 with the ESS at 1:03 PM, CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, SRNA #5 at 2:10 PM, and Charge Nurse #1 at 3:22 PM confirmed the exit door alarms were adjusted and were audible throughout the facility. Observations on 01/19/16 at 1:00 PM, revealed each exit door alarm was activated when pressure was applied to the door for three (3) seconds, or if a wander bracelet remained within three (3) feet of the door for more than 60 seconds. Further observation confirmed the doors were enabled with a 30-second delay for opening. 6) Observations made on 01/19/16 at 1:00 PM revealed the keypads outside the exit doors were inactive when the alarm was sounding and/or a resident wearing a wander bracelet was within three (3) feet of the door. 7) Review of documentation revealed residents' Wandering Risk Bracelets were checked on 01/11/16 to ensure they were functioning. Interview with the ESS on 01/19/16 at 1:03 PM confirmed all wander risk bracelets were checked on 01/11/16 to determine proper functioning. 8) Review of the facility's documentation dated 01/08/16, revealed the MDS Nurses were in-serviced by the contract Nurse Consultant on 01/08/16, and by the DON on 01/11/16. Interview with the MDS Coordinator and MDS Assistant on 01/19/16 at 3:08 PM, confirmed they received the in-services and would assess each resident for Wander Risk potential upon admission, with each required MDS, and with a change in condition. If the resident was determined to be high risk for wandering/exit-seeking, the MDS Nurse would alert the IDT and Charge Nurse on duty to implement Wander Risk precautions. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed after being alerted by the MDS Nurse that a resident was at high risk for wandering/exit-seeking, she was responsible to implement wander risk precautions. 9) Review of the facility's In-service Records, dated 01/08/16, revealed the Corporate Nurse Consultant and Vice President of Operations in-serviced the Administrator and DON regarding the facility's wander risk policy/procedure and forms, and the necessary components of the AOC. Interview with the Corporate Quality Control Nurse on 01/19/16 at 2:38 PM confirmed the Administrator and DON were in-serviced on 01/08/16. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM confirmed they received the education. A. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM confirmed if a resident not previously identified at risk starts to exhibits behaviors of wandering/exit-seeking, she was responsible to implement wander risk precautions. The Charge Nurse stated she would also complete a New Wander Risk Resident UDA (User Defined Assessment) in the resident's medical record. B. Review of the facility's policy and procedure titled Wandering Resident revealed the steps facility staff was to take to respond to an exit door alarm sounding. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, SRNA #5 at 2:10 PM, Charge Nurse #1 at 3:22 PM, and LPN #5 at 3:49 PM verified knowledge of the facility's procedure to respond to the Wander Guard System Alarm. C. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed all residents who demonstrate exit-seeking behaviors would be placed on increased monitoring and facility staff would utilize the Increased Monitoring Log Form. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Increased Monitoring Form and assigning staff responsibility for monitoring throughout the shift. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed the Increased Monitoring Logs Form became part of the resident's medical record and was filed after its completion. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed Progress Notes in the medical record should reflect the exit-seeking behavior and actions taken and be communicated to administrative staff and the IDT through the medical record Alert/High Risk Progress Note System. Interview with the DON on 01/19/16 at 4:05 PM revealed if a resident met two (2) of the Alert/High Risk criteria, facility staff would place the resident on 1:1 supervision. The resident will remain on 1:1 supervision until the IDT and the DON/ADON decide it should be stopped. D. Review of the facility's Elopement Investigation Form revealed the Form included the exit/return times and the investigative findings for an event. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the information obtained from the completed Elopement Investigation Forms will be used to determine the causative factor(s) of the elopement and implement a corrective action plan, revise the resident's plan of care, educate staff, and the QAPI review/evaluation. Interview with Charge Nurse #1 on 01/19/16 at 3:22 PM revealed she was responsible for initiating the Elopement Investigation Form, documenting applicable information in the medical record, and reporting the event to the Administrator or DON immediately. Interviews conducted on 01/19/16 with the DON at 4:05 PM and the Administrator at 4:10 PM revealed the completed Elopement Investigation Form and the resident's medical record would be reviewed by the IDT and administrative staff the next day (M-F). If the event occurred on the weekend, the House Supervisor and/or Administrative Nurse on duty should review the investigation/medical record and consult via phone with the Administrator or DON as indicated; and, then the IDT and administrative staff will follow up with a review on Monday morning. Review of the In-service Training Report, dated 01/11/16, revealed nursing staff was in-serviced on Missing Residents, Increased Monitoring Logs, and Elopement Investigation. Interviews conducted on 01/19/16 with Charge Nurse #1 at 3:22 PM and LPN #5 at 3:49 PM confirmed they were in-serviced by the DON regarding the completion of the Unsupervised Exit Investigation Form, the Increased Monitoring Form, and the New Wander Risk Resident UDA. Review of the In-service Training rosters revealed facility staff was in-serviced on the facility's wander risk policies and procedures, which identified residents who were wander risks, how to identify exit-seeking behavior, the need to be alert to any resident exhibiting these behaviors, the need to implement redirection interventions per care plan and what to do when an alarm sounds. Interviews conducted on 01/19/16 with CMA #4 at 1:12 PM, SRNA #4 at 1:18 PM, CMA #5 at 1:47 PM, and SRNA #5 at 2:10 PM revealed they did receive the in-service. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed all facility staff had been in-serviced as of 01/19/16. Interview with the Administrator on 01/19/16 at 4:10 PM revealed all employees hired after 01/14/16 will receive the education outlined above during their new hire orientation. This will be verified on an education requirement list included in their employee file. 10) Review of the facility's Elopement Drill forms, dated 01/13/16 and 01/14/16, revealed the Administrator performed elopement drills for all three (3) shifts to ensure that staff responded appropriately and in accordance with the facility's wander risk policy. Interview with the Administrator on 01/19/16 at 4:10 PM confirmed the drills were performed and the results of the elopement drills were reviewed in the weekly QAPI Team meeting. Interview on 01/19/16 with CMA #5 at 1:47 PM confirmed the Administrator had been conducting elopement drills. 11) Review of In-service Training Reports, dated 01/11/16 and 01/12/16, revealed the QAPI Team and Medical Director received in-service training by the Administrator, on the correct completion of the QAPI indicators and the need to review the indicator information in the QAPI Committee meetings to determine compliance and to develop action plans if indicated. Interview with the Administrator on 01/19/16 at 4:10 PM, revealed she in-serviced the QAPI Team and the Medical Director. Interviews conducted on 01/19/16 with the DON at 4:05 PM, the SSD at 2:02 PM, and the MDS Coordinator at 3:08 PM confirmed the QAPI Team was in-serviced by the Administrator. Interviews with the DON and the MDS Coordinator confirmed that any indicators which fail to meet established thresholds or reoccurring issues would be addressed with the contracted consultants. 12) Review of the QAPI Agenda/Meeting, dated 01/12/16, revealed the AOC and all criteria were reviewed by the QAPI Team and Medical Director. 13) Review of the Daily-Weekly Reviews, dated January 2016, revealed daily documentation of the wander bracelet placement was monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were reported in the weekly QAPI meeting. 14) Review of the Daily-Weekly Reviews, dated January 2016, revealed the daily documentation on the MARs of bracelet functioning check by CMAs were monitored daily by the DON/ADON/MDS Nurse until jeopardy was abated. Interview with the DON on 01/19/16 at 4:05 PM revealed the findings were re

Based on interview and record review it was determined the facility failed to ensure one of three sampled residents (resident #1) received adequate supervision and assistive devices to prevent accidents. The facility assessed resident #1 to require the use of a Hoyer lift for all transfers. However, staff transferred resident #1 without the use of a Hoyer lift on February 20, 2011. The resident complained of right knee pain during the transfer, and was diagnosed with [REDACTED]. Review of the resident's medical record and staff interview revealed staff was required to utilize a Hoyer lift when transferring resident #1 to ensure safe transfers for this resident. The findings include: Review of the medical record for resident #1 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS) for resident #1 dated April 8, 2010, revealed the facility assessed the resident to require total assistance of two or more staff persons for transfers. A review of the care plan for resident #1 revealed an intervention for the use of a mechanical lift dated April 5, 2010, and that a gait belt assisted transfer had been discontinued from the care plan on June 29, 2010. A review of the physician's orders [REDACTED].#1. A review of nurse's notes for resident #1 revealed on February 22, 2011, at 12:45 p.m., resident #1 was noted to be in pain and was noted with redness and edema to the right leg and right knee. The nurse's notes stated resident #1 was transferred to the hospital for evaluation and treatment. Resident #1 returned to the facility on [DATE], at 4:30 p.m., with a [DIAGNOSES REDACTED]. Review of the facility investigation completed on February 25, 2011, revealed the fractures to resident #1's right leg were determined to be caused when resident #1 was transferred by CNAs #1, #2, and #3 without the use of a Hoyer lift during a bath on February 20, 2011. Interview conducted with the Advanced Registered Nurse Practitioner (ARNP) on March 24, 2011, at 11:00 a.m., revealed if the mechanical lift had been utilized to transfer resident #1 the resident would have been less likely to have been injured. The ARNP stated the use of the mechanical lift would have applied more even pressure during the transfer. Per interview, it would be difficult for three staff persons to lift a resident with even pressure because staff could not lift at the exact same time. An interview conducted with CNA #1 on March 23, 2011, at 2:35 p.m., revealed on February 20, 2011, CNA #1 assisted CNAs #2 and #3 with the transfer of resident #1 from a geri-chair to a bath/lift chair. CNA #1 stated resident #1 complained during the transfer by saying, "Oh, my knee." However, resident #1 did not complain at any other time during care or when the resident was transferred back to the geri-chair after the bath was completed. CNA #1 was aware that resident #1 required a Hoyer lift for transfers. However, CNA #1 stated resident #1 was always transferred for bathing with the use of a gait belt and three staff persons. An interview conducted with CNA #3 on March 23, 2011, at 2:48 p.m., revealed CNA #3 was primarily responsible for resident bathing. CNA #3 provided a bath to resident #1 on February 20, 2011, and had transferred resident #1 with the assistance of CNAs #1 and #2. CNA #3 stated a gait belt was utilized to provide a sitting transfer from a geri-chair to a bath/lift chair for resident #1 on February 20, 2011, without the use of a Hoyer lift. CNA #3 was aware that resident #1 was assessed to require the use of a Hoyer lift for all transfers. However, a Hoyer lift had never been used to transfer resident #1 during bathing according to CNA #3. In addition CNA #3 stated that resident #1 had always been transferred with the use of three staff persons and a gait belt. CNA #3 further stated a lift could be utilized, but the shower room was small. However, CNA #3 stated the concern regarding the shower room size had not been reported to the facility's administrative staff. An interview conducted with CNA #2 on March 23, 2011, at 3:06 p.m., revealed on February 20, 2011, CNAs #1, #2, and #3 transferred resident #1 from a geri-chair to a bath/lift chair utilizing a gait belt. CNA #2 stated when resident #1 was turned during the transfer resident #1 said, "Oh, my knee." CNA #2 stated resident #1 had no further complaints after the transfer, during the bath, or when transferred after the bath was completed. CNA #2 stated a Hoyer lift had never been utilized for resident #1 during bathing transfers. An interview conducted with LPN #1 on March 23, 2011, at 1:50 p.m., revealed resident #1 was assessed to require a lift for transfers because the resident was heavy and pulling on the resident could cause injury to the resident. Further interview revealed the LPN was required to make rounds each shift to ensure the CNAs were providing resident care as required. However, the LPN was not aware staff was not utilizing a lift to transfer resident #1 for bathing. LPN #1 became aware staff was not utilizing a lift for transfers during bathing on February 20, 2011, when the CNAs requested that an order be obtained for showers for resident #1 instead of a tub bath because of the resident's size. LPN #1 informed the CNAs that a lift was to be utilized to transfer resident #1 for bathing. The LPN informed the Director of Nursing (DON) that staff was not utilizing the lift on February 21, 2011. An interview conducted with the Director of Nursing (DON) on March 23, 2011, at 3:15 p.m., revealed the nurses at each station were required to make rounds daily to monitor resident care and to ensure that CNAs were providing resident care as ordered/planned. The DON stated the CNAs were checked off by a preceptor for resident bathing and transfers upon hire and annually to ensure the CNAs were knowledgeable regarding resident care. The DON was not aware staff was not following the care plan for resident #1 by utilizing a Hoyer lift for all transfers, until LPN #1 informed the DON that the CNAs had not used a lift for resident #1 on February 20, 2011. An interview conducted with the facility Administrator on March 23, 2011, at 5:15 p.m., revealed facility administrative staff made rounds on all stations daily to ensure care provided to residents was appropriate. The Administrator stated administrative staff and nurses monitored resident bathing. However the Administrator was not aware staff had not utilized the use of a Hoyer lift while transferring resident #1 to ensure safe transfers. Resident #1 sustained a fractured tibia and fibula during this incident according to the facility investigation.

Based on interview and record review it was determined the facility failed to provide services in accordance with each resident's plan of care for one of three sampled residents (resident #1). The facility failed to utilize a mechanical lift to transfer resident #1 for bathing on February 20, 2011, in accordance with the resident's plan of care, resulting in pain and injury to the resident's right knee. Resident #1 was diagnosed with [REDACTED]. The findings include: A review of the medical record for resident #1 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident #1's annual Minimum Data Set (MDS) dated [DATE], revealed the facility assessed resident #1 to require total assistance of two or more staff persons for transfers. A review of the resident's comprehensive care plan revealed on April 5, 2010, an intervention for the use of a Hoyer lift for all transfers was added to the resident's plan of care. A review of the Certified Nurse Aide (CNA) Care Plan record for February 2011 revealed two staff persons were to use a mechanical lift for all transfers for resident #1. A review of nurse's notes dated February 22, 2011, at 12:45 p.m., revealed resident #1 was yelling in pain and was noted to have redness and [MEDICAL CONDITION] to the right leg and right knee. The physician and responsible party were notified and orders were received to transfer resident #1 to the hospital for evaluation and treatment. Resident #1 returned to the facility on [DATE], at 4:30 p.m. Review of the hospital record revealed resident #1 was diagnosed with [REDACTED]. A review of the facility's investigation regarding resident #1's fractures dated February 23, 2011, revealed the facility had determined resident #1's leg was injured during a transfer conducted by CNAs #1, #2, and #3 when the CNAs did not use a Hoyer lift to transfer the resident. The resident was reported to state, "Oh, my knee," when the three CNAs transferred resident #1 without the use of a lift on February 20, 2011. An interview conducted with CNA #1 on March 23, 2011, at 2:35 p.m., revealed on February 20, 2011, CNA #3 requested assistance from CNA #1 and CNA #2 to transfer resident #1 to a lift chair for bathing. CNA #1 stated a sitting transfer with the use of a gait belt from a geri-chair to a bath chair/lift was completed for resident #1 with the assistance of CNAs #1, #2, and #3. During the transfer resident #1 was noted to complain by saying, "Oh, my knee." However, the resident did not complain at any other time or when the resident was transferred back to the geri-chair after the bath was complete. Additional interview with CNA #1 revealed this method of transfer was always utilized for resident #1 for bathing and that a Hoyer lift was utilized for all other transfers for resident #1. An interview conducted on March 23, 2011, at 2:48 p.m., with CNA #3, whose primary duty was to bathe residents, revealed on February 20, 2011, CNA #3 requested the assistance of CNAs #1 and #2 to transfer resident #1 from a geri-chair to a bath/lift chair for bathing. CNA #3 stated a gait belt and three-person assist was utilized to transfer the resident. CNA #3 was not aware of any complaints from resident #1 during the transfer. CNA #3 was aware resident #1 was assessed to require a mechanical lift for all transfers. However, staff had never utilized a Hoyer lift when transferring resident #1 for bathing. CNA #3 stated the lift could be utilized but the shower room was small and resident #1 had always been transferred with the use of three staff persons. An interview conducted with CNA #2 on March 23, 2011, at 3:06 p.m., revealed on February 20, 2011, CNAs #1, #2, and #3 transferred resident #1 from a geri-chair to a bath/lift chair by utilizing a gait belt. CNA #2 stated when resident #1 was turned during the transfer resident #1 said, "Oh, my knee." CNA #2 stated resident #1 had no further complaints after the transfer, during the bath, or when transferred after the bath was completed. CNA #2 reported a Hoyer lift had never been utilized for resident #1 during bathing transfers. An interview conducted with LPN #1 on March 23, 2011, at 1:50 p.m., revealed that a lift was required to be utilized when transferring resident #1 because the resident was dead weight and pulling on the resident may hurt the resident. LPN #1 made rounds each shift to monitor bathing and ensure resident care was provided according to each resident's plan of care. However, the LPN was not aware staff was not utilizing a lift to transfer resident #1 for bathing. LPN #1 became aware staff was not utilizing a lift for transferring resident #1 during bathing on February 20, 2011, when the CNAs requested that an order be obtained for showers instead of a tub bath for resident #1 because of the resident's size. Further interview revealed the LPN informed the CNAs on February 20, 2011, that a lift was to be utilized for resident #1 when transferring the resident for bathing. The LPN also informed the Director of Nursing (DON) that staff was not utilizing the lift on February 21, 2011. An interview conducted with the Director of Nursing (DON) on March 23, 2011, at 3:15 p.m., revealed resident #1 was assessed to require the use of a mechanical lift for all transfers because of the resident's severe [MEDICAL CONDITION]. The DON stated the nurses were required to monitor resident baths daily when making rounds to ensure the care was provided according to the resident's plan of care. Further interview revealed the CNAs were checked off on bathing and transfers by a preceptor upon hire and annually to ensure the CNAs were knowledgeable regarding resident care. The DON was not aware staff was not utilizing the Hoyer lift to transfer resident #1 for bathing per the resident's plan of care until February 21, 2011. Resident #1 sustained a fractured tibia and fibula during this incident according to the facility investigation.