Every finding on record at Radcliff Veterans Center

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. One of two medication rooms reviewed contained one box of a Covid-19 vaccine which was not labeled with the Beyond Use Date (BUD) or the thaw date.The findings include:The findings include:On [DATE], the survey team requested any policies regarding storage and labeling of drugs and biological requiring a thaw date. The facility did not provide these policies prior to exit on [DATE].Observation of the medication storage room in the 500 Neighborhood, on [DATE] at 2:26 PM, revealed one box of a thawed Covid-19 vaccine in the medication refrigerator. The box was labeled with a serial number, lot number, manufacturer's expiration date of [DATE], and a pharmacy label with a prescription date of [DATE]. There was no visible thaw date noted on the box. In addition, there was no BUD noted on the box.Review of an untitled manufacturer package insert revealed the instructions for storing the vaccine were After thawing, [brand name for the Covid-19 vaccine] may be stored refrigerated between 2 C to 8 C (36 F to 46 F) for up to 90 days or up to the expiration date printed on the carton, whichever comes first.During an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 2:26 PM, he stated he was unaware the vaccine expired 90 days after thawing and did not know that a thaw date or BUD needed to be labeled on the box.During an interview with Registered Nurse (RN) 1 on [DATE] at 3:00 PM, she stated that she might have known, at one time, that there was to be a thaw date on that vaccine, but she could not recall.Interview with the facility's Infection Preventionist (IP), on [DATE] at 3:00 PM revealed that, We had been going by the manufacturer's expiration date, the boxes were not received with thaw date or beyond use date stickers to fill out. I called the pharmacy, and he educated me that the Mnexspike has a 90-day expiration date when thawed. I informed him that there are no warning stickers on the boxes and no labels to alert the receiving nurse about special handling. She further stated that she was starting education of the nursing staff about the handling and storage of the Covid -19 vaccines and the differing expiration dates of different brands. During an interview with the Director of Nursing (DON) on [DATE] at 1:20PM, she stated Once we get them (the vaccines) from pharmacy, they go in the fridge, and we go by the manufacturer's expiration date. She stated nurses were trained upon hire and whenever new vaccines came out. She verbalized that negative outcomes of items not being labeled properly were that the veterans could get the wrong medication, it could harm a veteran.

Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) within the required timeframe for one (Resident (R) 1) of three sampled residents reviewed for abuse. Staff witnessed an allegation of abuse at approximately 10:00 AM on 07/22/2025; however, the facility did not immediately (in no more than two hours, per regulation) notify the SSA.The findings include:Review of the facility's policy titled, Reporting Abuse to State Agencies, effective 09/11/2023, revealed all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were to be reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury. The policy further revealed verbal or written notice to the appropriate agencies was to be made within two hours when an occurrence involving abuse was reported, and a written report of the findings of the investigation was to be provided within five working days of the occurrence.Review of the facility's policy titled, Reporting Abuse to Facility Management, effective 09/11/2023, revealed employees were to immediately report any observed or suspected abuse or incident of abuse to the on-duty supervisor, who in turn was to immediately report it to the Administrator or Assistant Administrator. The policy further revealed the Administrator or Assistant Administrator was to be immediately notified of suspected abuse or incidents of abuse and suspected or confirmed abuse was to be immediately reported to facility management regardless of the time lapse since the incident occurred.Review of a facility document titled, admission Record, revealed the facility admitted R1 on 05/15/2023 with diagnoses including Alzheimer's disease with late onset, cognitive communication deficit, chronic kidney disease, and hypertension. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2026, revealed R1 was assessed as severely cognitively impaired. Review of a facility document, titled, Initial Report, dated 07/22/2025, revealed the facility reported an allegation from Nurse Aide State Registered ([NAME]) 2 that she witnessed NASR1 physically abuse R1. The Initial Report documented the date and time of the incident as 07/22/2025 at 12:35 PM. Review of email correspondence revealed the facility submitted the Initial Report to the Department for Community Based Services (DCBS), the ombudsman, and the Office of Inspector General (OIG-SSA) on 07/22/2025 at 2:32 PM. Review of another facility document, titled, Final Report/5 Day Follow-Up, dated 07/25/2025, revealed that no abuse was substantiated. However, review of this document revealed the alleged abuse actually occurred on 07/22/2025 at 10:00 AM (not 12:35 PM as initially reported). Based on the times listed on the Final Report/5 Day Follow-Up, the initial abuse allegation was not reported for over four hours and did not meet the immediate reporting requirement of no more than two hours required by regulation and facility policy. Review of personnel records revealed a written counseling memorandum issued by the Director of Nursing (DON) to NASR2, which documented NASR2 reported to Licensed Practical Nurse (LPN) 1 on 07/22/2025 at 12:27 PM that she had observed NASR1 inappropriately pull on R1's arm while providing a shower at approximately 10:00 AM that same day. The memorandum further documented NASR2 was counseled to report all allegations of abuse or neglect immediately in the future.Review of a letter from the Department of Veterans Affairs, dated 07/22/2025, revealed NASR1 was placed on special leave with pay pending further investigation. The letter documented NASR2 reported to LPN1 that NASR2 observed NASR1 in the bathroom with R1 at approximately 10:00 AM on 07/22/2025 and reported NASR1 allegedly inappropriately pulled on R1's arm while providing a shower.Review of an untitled facility document outlining the investigation timeline confirmed that the abuse allegation on 07/22/2025 was not immediately reported within two hours of NASR2 witnessing suspected abuse of R1 at 10:00 AM. Per this document, NASR1 remained in resident direct care until 12:32 PM, the Administrator was notified at 12:33 PM, the investigation was initiated at 12:50 PM, and the allegation of physical abuse involving R1 was reported to the OIG/SSA at 2:32 PMIn an interview on 03/19/2026 at 2:41 PM, NASR2 stated allegations of abuse or neglect were to be reported to the charge nurse or nurse on the hall as soon as possible, and the facility had two hours to report abuse to [OIG]. NASR2 stated at approximately 10:00 AM on 07/22/2025, NASR1 was pulling on [R1's] arm, R1 was trying to pull away, and she told NASR1 to sit R1 down because that was what worked to keep R1 calm. NASR2 stated she thought about it and then reported the incident to LPN1. NASR2 further stated, I know I didn't report it right then and there, and explained she was nervous about reporting because others who had reported concerns had felt retaliated against. In an interview on 03/18/2026 at 1:32 PM, LPN1 stated NASR2 reported around lunchtime that NASR1 had been rough with R1. LPN1 stated when he assessed R1, there were marks on his arm that were consistent with grabbing. LPN1 stated the incident was then reported to the nurse supervisor or Assistant Director of Nursing (ADON), and NASR1 was removed from the hallway and did not return to the floor that day.In interview with NASR1, on 03/19/2026 at 12:27 PM via telephone, NASR1 stated she recalled the incident in question but denied anything out of the ordinary occurred and there was nothing going on with the resident.In an interview on 03/19/2026 at 3:29 PM, the ADON stated incidents of alleged abuse were to be reported immediately and there was a two-hour timeframe to report abuse to [OIG]. The ADON stated LPN1 reported the incident to her, and at the time of the report, she was told the incident had occurred earlier, around 10:00 AM. The ADON stated NASR1 was then removed from the unit and placed in the Director of Nursing's (DON) office. In an interview on 03/19/2026 at 3:43 PM, the DON stated abuse allegations were to be reported immediately and the required timeframe for reporting allegations of abuse to OIG was two hours. The DON stated the ADON reported the allegation involving R1 to her after lunch, sometimes in the afternoon, and she understood the incident had happened around 10:00 AM. The DON stated when asked why the report was delayed, NASR2 said she was not sure it was abuse. The DON stated she reiterated to NASR2 to always report the allegation and allow management to determine whether abuse had occurred. In an interview on 03/19/2026 at 4:10 PM, the Administrator stated allegations of abuse were to be reported immediately. The Administrator stated notification to OIG was required within two hours if bodily injury was involved and within 24 hours if there was no bodily injury. The Administrator stated that, for this incident, she believed the report was timely because there was no injury. However, the Administrator failed to note that the regulation and facility policy also required that all allegations must be reported within two hours if the event that caused the allegation involved abuse.

Based on observation, interview, record review, review of the facility's policies, and review of video camera footage, it was determined the facility failed to have an effective system in place to ensure residents at risk for elopement received the necessary supervision to maintain their safety and prevent elopement for one (1) of three (3) sampled residents, (Resident 1). The facility assessed Resident (R) 1 to be at low risk for elopement on [DATE]. Registered Nurse (RN) 8 noted that R1 was exit seeking on [DATE]. Continued record review revealed on [DATE], Licensed Practical Nurse (LPN) 1 noted R1 was exit seeking. However, LPN1 did not report the resident's behavior. On [DATE], at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid beneath the courtyard gate through a gap between the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. R1 stated, I am trying to get back home to pay for my stay and get my medicine. R1 was brought back inside the facility and assessed by the nurse. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. A Partial Extended Survey was initiated on [DATE] and concluded on [DATE]. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE] alleging the IJ was removed on [DATE]. The State Survey Agency validated the IJ was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at S/S of D while the facility develops and implements a Plan of Correction. An additional deficiency was cited at 42 CFR 483.90(g) Resident Call System: F919. The findings include: Review of the facility's policy, Safety and Supervision of Residents, approved date [DATE], revealed the facility strove to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. According to the policy, the facility's resident-oriented approach to safety addressed groups of residents. Safety risks and environmental hazards were identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; Quality Assurance (QA) reviews of safety and incident/accident reports; and a facility wide commitment to safety at all levels of the organization. Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Further review of the Safety and Supervision of Residents policy, approved [DATE], revealed the Interdisciplinary Care Team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. Review of the facility's policy, Elopement/Missing Resident, revised date [DATE], revealed the facility must ensure adequate supervision of residents to prevent accidents. It was the responsibility of staff to investigate and report any resident who tried to leave the premises or was suspected of elopement to Security and his/her supervisor immediately. Review of the facility's policy, Wandering Unsafe Resident, revised [DATE], revealed the facility would strive to maintain a safe environment while maintaining the least restrictive environment for residents who were at risk for elopement or unsafe wandering. The resident's care plan would indicate identified risk for elopement or wandering into areas that exposed (the) resident to other safety issues. The Interdisciplinary Team would utilize interventions to maintain safety such as a personalized monitoring plan, application of wander-prevention band and/or consideration for resident to move to a more secure location. A Medical Provider order would be written should the need for a wander-prevention band be identified. Review of the Admission Record, in Resident 1's (R1) clinical record revealed the facility admitted R1 on [DATE] with diagnoses that included unspecified dementia, mixed conductive and sensorineural hearing loss; bilateral, unspecified visual loss, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R1 scored eight (8) of fifteen (15) on the Brief Interview for Mental Status (BIMS). This score indicated the resident was assesses as moderately cognitively impaired. Review of the Quarterly Elopement Risk Assessment, dated [DATE], revealed the facility assessed R1 to be at Low Risk for Wandering. Additionally, item G, History of Wandering indicated the facility assessed R1 not to be a known wanderer/history of wandering. During an interview, on [DATE] at 5:22 PM, the MDS Coordinator stated interventions for Low Risk for Wandering would be to just monitor the resident with hourly rounding, meaning staff would check on residents every hour and provide any needed care to those residents. She stated if she heard a resident say something like he/she wanted to leave the facility, a progress note would be entered into the clinical record for the IDT to review. During an interview, on [DATE] at 3:50 PM, the MDS Coordinator stated a resident would have a history of wandering if there were several documented attempts of that resident seeking a way out of the facility, or the resident verbalized he/she wanted to get out of the facility, or wanted to go away. She stated more than one documented assessment of exit seeking behavior would be needed for the MDS Coordinator to check Known wanderer/history of wandering on the resident's Elopement Risk Assessment. Additionally, the MDS Coordinator stated the designated safe area while outside and the external facility grounds included the outdoor gated and locked courtyard adjacent to the indoor unit where R1 lived. Review of R1's elopement risk care plan revealed on [DATE] the facility initiated a care Focus that R1 wished to exercise his/her right to be independent in the pursuit of outdoor activities on the external facility grounds. The Goal was that R1 would enjoy self-directed activities while maintaining his/her personal safety on the external facility grounds. The Intervention was that R1 was to remain in the designated safe area while outside. Review of an untitled care plan document revealed on [DATE] the facility initiated a care Focus, that R1 was at risk for elopement, with a Goal that R1 would continue to walk safely within the unit/facility. Nursing Interventions/Tasks included assessing unit as needed for potential hazards, cueing, and redirecting as needed, and identifying any triggers that increased need for wandering and intervene as necessary. During an interview, on [DATE] at 11:35 AM, Nurse Aide State Registered ([NAME]) 9 stated she knew R1, and he/she often spoke of wanting to go back to his/her hometown. During an interview, on [DATE] at 9:02 AM, LPN3 stated she was familiar with R1 and had cared for him/her. LPN1 recalled that she and R1 had quite a few conversations about people coming to pick him/her up and R1 had asked LPN3 how far it was to his/her hometown. LPN3 stated R1 was confused. Although it was the facility's policy to immediately report any suspicion of elopement to her supervisor, LPN3 stated she did not report to her supervisor R1's questions about the distance to his/her hometown, and R1's statements about people coming to pick him/her up, but was sure she gave it in report. Further interview revealed LPN3 did not think R1 was going to leave the facility, and she felt R1 was confused about where [he/she] was staying. During an interview, on [DATE] at 3:07 PM, LPN2 stated she was familiar with R1, but it had been a while since she took care of him/her, and that was probably during this past summer. LPN2 stated R1 was usually walking around looking for his/her car, and he/she liked to go out to the facility's 500 C Unit outdoor courtyard. LPN2 stated at night R1 would walk around looking for his/her car and would say I gotta find my car and get home. Review of Progress Notes, dated [DATE] at 1:36 PM, revealed LPN1 documented R1 noted to be exit seeking at this time. During an interview, on [DATE] at 2:24 PM, LPN1 stated he had written R1 noted to be exit seeking at this time. LPN1 stated exit seeking most likely meant R1 had been pushing on doors, or was probably talking about going home. LPN1 stated his note did not say R1 was attempting to leave the facility, and that was why he did not report it to his supervisor, although the facility's Elopement/Missing Resident policy stated staff were to report any suspicion of elopement to their supervisor immediately. LPN1 stated if a resident said they wanted to go to Florida, it was one thing. Actually going there was another. Further interview revealed when asked if LPN1 implemented R1's Elopement Risk nursing care plan Interventions/Tasks to Identify any triggers that increase need for wandering and intervene as necessary, LPN stated he did not understand that care plan intervention. During an interview, on [DATE] at 11:30 AM, Charge Nurse (CN) 1 stated R1 had a wander-prevention band when he/she was first admitted to the facility, but it aggravated him/her, and R1 took off the wander-prevention band. CN1 stated the facility assessed R1 to be better than when he/she first came into the facility, and after he/she had been in the facility awhile R1 did not seem to need the wander-prevention band. CN1 stated the day R1 eloped he/she had a moment of dementia. Review of the facility's video footage of the event, which was recorded by a camera located on the facility's 500 C unit outdoor courtyard where Resident #1 had eloped, revealed on [DATE] at 4:04:49, R1 could be seen exiting the unlocked door of the 500 C Unit where he/she resided. R1 was then seen walking toward the gated section of the iron fence which surrounded the 500 C unit's courtyard. At 4:05:04 PM, R1 was no longer in the view of the courtyard camera. Review of the facility's Initial Report of their investigation, dated [DATE] at 6:15 PM, revealed the facility described the incident as R1 was identified going outside to the residence's secured courtyard at 4:05 PM. At approximately 4:10 PM R1 was observed by Visitors (V1 and V2) who had parked to come in to visit. R1 was observed to be on his/her knees having crawled under the outside courtyard gate on the unit. R1 stood and held onto the fence. V1 and V2 came immediately to the door to inform staff. Staff went immediately to R1 and escorted him/her into the unit at approximately 4:15 PM. CN1 and LPN1 asked R1 to follow them to his/her room so that they could check for any injuries. Further review of the Initial Report, dated [DATE] at 6:15 PM, revealed the steps taken after R1's elopement to protect him/her were described as R1 was placed on 15 minute checks for forty-eight (48) hours and would reassess. All household courtyard doors have been locked with signage to ask for assistance to be in the outside courtyard. Maintenance was contacted. Wander-prevention band was applied to R1's right wrist with his/her consent. During an interview, on [DATE] at 9:55 AM, CN1 stated she assessed R1's skin after he/she eloped on [DATE] and observed superficial scratches on R1's back. Review of a statement by LPN1, dated [DATE], revealed that on [DATE] at approximately 4:15 PM, LPN1 was made aware that R1 had crawled beneath the gate in the courtyard on the unit. LPN1 then exited the facility and noted R1 standing on the other side of the gated courtyard. When LPN1 approached R1, he/she stated I was headed to [his/her hometown] to get money to pay for my stay [at the facility] last night. Review of the facility's investigation Interview of R1 at 3:28 PM on [DATE], revealed R1 stated he/she was out in the courtyard walking around, was going to hitchhike home [be]cause he/she was out of money. [I] just looked at the distance and skid [sic] right under the gate to outside of the courtyard. I walked over there around the courtyard and the main road is on out from here to where you would need to hitchhike. During an interview, on [DATE] at 3:10 PM, Safety/Security (S/S) Staff 1 stated he was going to the unit (where R1 resided) to deliver food to another resident when he looked out the window of the corridor and saw two (2) staff members and R1. S/S1 stated R1 was on the outside of the gate with other staff. S/S1 delivered the food and then went back outside and saw staff walking R1 back to the gate of the courtyard. S/S1 stated staff told him/her R1 got out of the secured courtyard by crawling under the gate. Observation, on [DATE] at 10:44 AM, revealed R1 had walked approximately eighty-one (81) feet away from the facility's courtyard gate, as measured by the Maintenance Branch Manager and as reported by S/S1. During an interview, on [DATE] at 4:26 PM, V1 stated he and his brother (V2) visited their relative on the weekends. V1 stated, on [DATE], he and V2 signed in at the facility's front desk and drove around to the 500 C Unit's entrance. V1 stated he noticed a person (R1) on his/her knees facing the gate. V1 stated he and V2 pulled in and saw R1 stand up and R1 had a cane. V1 stated he said to V2, I think that is a resident. V1 saw R1 turn around and V1 stated he recognized him/her, and R1 waved when he/she saw V1 and V2 in the facility's parking lot. V1 stated he went to the door of the 500 C Unit, rang the doorbell, and told a man who was working there (LPN1) that he thought a resident was outside. During the interview, on [DATE] at 4:26 PM, V1 stated R1 had to have just walked around the edge of the fence. V1 stated he thought he heard someone saying something about a space under the gate, but he could not believe it. V1 stated he would have never thought that would have happened. He stated he had never noticed the gap until after it happened and could not believe R1 crawled under there. Review of the Progress Notes, dated [DATE], revealed LPN1 documented at 4:15 PM that he had been made aware R1 had crawled beneath the gate in the courtyard of the facility. LPN1 exited the facility and noted R1 standing on the other side of the gated courtyard; when approaching R1 he/she stated that he/she was headed home to get money to pay for his/her stay last night; LPN1 explained to R1 that he/she did not need to pay for his/her stay at the facility as insurance took care of it. Continued review revealed R1 was redirected inside of facility and his/her skin was assessed where he/she had crawled under the fire exit gate in courtyard - scattered abrasions to upper back noted; R1 denied complaints of (c/o) pain or discomfort at that time; courtyard doors were to remain locked for the remainder of the shift; Supervisor made aware; Nurse Practitioner (NP) made aware; responsible party made aware. LPN1 would continue to update R1's chart as necessary that shift. During an interview, on [DATE] at 1:37 PM, RN3 stated she was working as an aide on Sunday [DATE] and saw R1 outside within the unit's locked and gated courtyard between 4:00 PM and 4:05 PM. She stated she took another resident, R2, to the bathroom. RN3 stated she then heard a visitor say they saw someone on their hands and knees by the gate. She went out the door to the courtyard and saw R1 outside of the locked and gated courtyard. RN3 stated R1 had walked along the fence outside of the courtyard and could have had the intention of leaving the facility. During an interview, on [DATE] at 3:10 PM, the Director of Nursing (DON) stated R1's elopement was avoidable and could have been prevented if the gap in the courtyard gate, where R1 exited the courtyard, had been identified during environmental rounds of the facility. The DON stated maintenance walked through and around the building to check the environment for problems and hazards. She stated she could not point her finger at maintenance because all facility staff were responsible for residents' safety. During further interview, on [DATE] at 3:10 PM, the DON said R1's elopement could have been a bad situation and she was thankful visitors pulled in and saw R1 getting up from his/her knees. The DON stated she expected staff to keep the facility's environment as safe as possible and provide supervision to prevent any unforeseeable accidents from occurring. During an interview, on [DATE] at 5:30 PM, the Administrator stated she would never have thought R1's elopement could have ever happened. The facility was responsible for the safety of the residents. The Administrator stated R1 got out and to her that went along with why so many children died in pools in the summertime. It took that one moment that you never expected, and this was that one moment. She stated she now thought differently about assessing the facility's environment since R1's elopement, she had created a subcommittee for environmental safety. The subcommittee would look at R1's incident and determine if we have enough eyes to adequately supervise residents. The Administrator said she was not aware of any preventative maintenance plan prior to R1's elopement, but there was now a plan. The facility alleged it had taken the following actions to remove the Immediate Jeopardy: 1. Corrective action included on [DATE] at approximately 4:12 PM, R1 was cued and redirected inside by Licensed Practical Nurse (LPN)1. Corrective action also included on [DATE] at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. Corrective action included on [DATE] at 4:30 PM, LPN1 initiated 15 minute checks for R1, and continued until [DATE], by licensed staff assigned to R1. DON, ADON, NS or CN ensured 15 minute checks were documented/completed on a 24-hour Q15-minute checks form. 3. Further corrective action included on [DATE] and [DATE], licensed or certified nursing staff documented hourly rounds on Daily Hourly Rounding forms for all residents when in the courtyard. 4. Corrective action included on [DATE] at approximately 4:45 PM, all courtyard doors on 400 and 500 households were secured by locking the door and only able to open by staff with a badging system card, and signs were posted. 5. Further corrective action included on [DATE], after the event, [DATE] and [DATE], residents assessed to be at risk for elopement were provided 1:1 supervision by licensed or certified nursing staff, when in the courtyards, until the gates were modified to include metal plates on the bottom. 6. Corrective action included, on [DATE] at approximately 5:00 PM, the courtyards in the 500 and 400 households were assessed by the Administrator for potential hazards. Work orders were placed for maintenance to address the gap between the ground and secured gate on each courtyard. Additional corrective action was on [DATE] at approximately 4:30 PM, 500 household courtyard gates were modified to include metal plates on the bottom by the Maintenance Branch Manager (MBM), Maintenance Supervisor (MS), Maintenance Technician (MT) I, or Maintenance Worker (MW) I. Also, on [DATE] at approximately 4:30 PM, 400 household courtyard gates were modified to include metal plates on the bottom by MBM, Maintenance Supervisor (MS), Maintenance Technician I, or Maintenance Worker I. 7. Further corrective action included on [DATE], R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention band and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of [DATE]. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing of verification and validation on [DATE]. 8. Corrective action included on [DATE], R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention band and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of [DATE]. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing of verification and validation on [DATE]. Staff was alerted verbally directly after R1's elopement of the changes to the care plan for fifteen (15) minute checks, EPLAS applied, and household courtyard door secured and locked. The Charge Nurse for buildings 400 and 500 made all staff aware of the incident and changes to secure locked household door and the elopement. 9. Further corrective action included on [DATE] DON added an order for licensed nursing staff to check placement and function every shift for R1's wander-prevention band. 10. Corrective action included on [DATE] between 8:00 AM and 12:00 PM, LPN1 reassessed elopement risk for all veterans in the facility, including the previous nine (9) who had already been identified as requiring safety using the wander-prevention band. No necessary changes were identified. Census for [DATE] was 57 residents. 11. Corrective action included on [DATE], all residents in the facility's CCP, based on elopement risk, were reviewed by the Certified Social Worker (CSW) 12. Further corrective action included, on [DATE], licensed and certified nursing staff continued with hourly rounding for R1, documented on Daily Hourly Rounding forms. 13. Corrective action included on [DATE], MDS Coordinator revised CCP to include certified nursing staff to complete documentation on checking placement and ensuring function of wander-prevention bands. 14. Further corrective action was Training: [DATE]-[DATE], one hundred (100) percent of licensed or certified nursing staff were in-serviced by the DON, ADON, NS, or CN, on ensuring the residents' environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Identifying and addressing risks, including the potential for accidents, included consideration of the environment. All staff can identify, report, and implement interventions for resident risk and environmental hazards. Communicate potential hazards to supervisors. Attestation of acknowledgement and understanding of the in-service provided was contained on the In-service Training Sheet. New staff would be in-serviced by the DON, ADON, NS, or CN, before accepting and reporting to direct care assignment. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, DON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on [DATE]-[DATE]. 15. Corrective action included, on [DATE], training was provided to all staff with one hundred percent of licensed or certified nursing staff received education by DON, ADON, NS, CN, or CSW on wandering, goal directed wandering and exit seeking definitions. Additionally, in-serviced on following an event of wandering or exit seeking, licensed nursing staff should complete a Progress Note to describe specifics of what occurred. Documentation should include the event, implementation of care planned interventions or initiation of a new intervention and effectiveness of the intervention. Notification to nursing supervisor; reassessment of elopement risk with exit seeking; review/revision of care plan to include event and any new intervention used. Attestation of acknowledgement and understanding of the in-service provided was contained on the In-service Training Sheet. All staff would be trained upon hire and before reporting to his/her shift and before providing direct care. Any staff member currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator would notify the DON, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on [DATE]. 16. Further corrective action included on [DATE], training was provided to all staff with 100 percent of non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) received education by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management, on wandering, goal directed wandering and exit seeking definitions and reporting wandering and/or exit seeking to a licensed nurse. Attestation of acknowledgement and understanding of the in-service provided was contained on the in-service training sheet. All staff will be trained upon hire and before reporting to his/her shift and before providing direct care. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. On [DATE], training was provided to all staff with 100 percent of licensed certified nursing staff and 100 percent of non-clinical facility staff completed post-testing on [DATE] and [DATE] related to the above training by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management. All staff will complete a post in-service test with 100 percent pass rate. All staff will be trained upon hire and before reporting to his/her shift and before providing direct care and take the post test with a 100 percent pass rate. Any staff currently on leave was contacted via phone to complete all in-servicing and post-test. Any staff that may be on leave that was identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 17. Corrective action included on [DATE], an Ad Hoc QAPI meeting was held to review Policy #33 Accidents and Incidents and Policy #44 Safety and Supervision. Staff in attendance were the Administrator leading the meeting the DON, CSW, NS ADON, APRN (Medical Director designee), Chaplain, Infection Preventionist, Associate Business Manager (ABM) MBM, Administrative Specialist III, HIM, Admissions Coordinator, Activities Director, Rehab Program Director, and the Registered Dietician. 18. Further corrective action included on [DATE] an Ad Hoc QAPI meeting was held to review Immediate Jeopardy removal plans to include training on auditing the CCP, the Progress Notes, and the Behavior Report by DON, ADON, NS, CN and/or the CSW. Attendance consisted of: Chaplain, AD, SDC, DON, FM, Administrator, QA Nurse led the meeting. Admissions Coordinator, Administrative Specialist III, CSW, ADON, Housekeeping/Laundry Director, IP, ABM, NS, MDS Coordinator, and MD joined by telephone. 19. Corrective action included: [DATE] daily ongoing, the DON, ADON, NS, CN, or CSW will review Progress Notes and Behavior Reports to ensure wandering and exit seeking behaviors were assessed and care planned appropriately. If issues were identified based on monitoring, immediate corrective action (revision to CCP, assessment/reassessment, notification to licensed nursing supervisor, documentation and/or education to staff) will be provided by the DON, ADON, NS, SDC, IP, MDS Coordinator, CN, or CSW. Upon completion of in-servicing for wander/goal directed wandering and exit seeking and expectation following documentation of wandering/exit seeking, beginning [DATE], audits will be completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW. 20. Further corrective action included the audits completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW will be reported by the DON to the QA committee for review on [DATE]. The State Survey Agency validated the facility had taken the alleged actions. 1. During an interview, on [DATE] at 9:30 AM, LPN1 stated on the day R1 eloped from the facility, afterwards he walked with R1 back to the facility, wrote the Progress Note, and notified his supervisor and the NP. 2. During an interview, on [DATE] at 9:30 AM, LPN1 stated on [DATE] he initiated 15 minute checks for R1. 3. Record review of the document titled 24-Hour Q-15 Minute Check, dated [DATE] revealed 15 minute checks were initiated for R1 at 4:30 PM that day and continued until [DATE] at 4:30 PM. Observation, on [DATE] at 11:00 AM, revealed Daily Hourly Rounding forms were filed in the Nurse Supervisor's office. 4. Observation, on [DATE] at 4:30 PM, revealed a sign was posted on the inside of the courtyard door notifying residents to Please let staff know if [they] wanted to go outside. 5. During an interview, on [DATE] at 9:30 AM, LPN1 stated he and other staff provided 1:1 supervision to residents at risk for elopement when they were outside in the courtyard until the courtyard gates were fixed. 6. Review of theMaintenance Work Order #22437 revealed, on [DATE] at 6:20 PM, a work order request was added that stated, Administrator requests all courtyard gates be checked and a correction be implemented so [R1's elopement] does not happen again. Observation, on [DATE] at 9:00 AM, revealed a metal plate was installed to the bottom of the 500 C Unit's outdoor courtyard gate. The metal plate extended to within three (3) inches of the ground which eliminated the gap which R1 slid under on [DATE]. Observation, on [DATE] from 9:10 AM until 9:25 AM revealed any gaps in the facility's courtyard gates had been modified with metal plates to eliminate any gap between the bottom of the gate and the ground. 7. During an interview, on [DATE] at 9:30 AM, LPN1 stated he revised R1's care plan after he/she eloped from the facility. Review of a document titled std_intervention_id revealed on [DATE] the nursing intervention of I [R1] wear a [Wander-prevention band]. Check placement and function each shift. had been initiated on R1's care plan. 8. Review of an untitled, undated document revealed the DON documented, On [DATE], when reviewing R1's care plan, she saw that LPN1 had revised R1's care plan to include interventions; wander-prevention band and 15 minute checks. Further, the care plan was printed to include in the follow up investigation, indicating LPN1 had revised R1's care plan after R1 eloped on [DATE] and before [DATE]. 9. Review of R1's Treatment Administration Record for [DATE] revealed staff began to check R1 for his/her wander-prevention band's placement and function every shift beginning at 7:00 PM on [DATE]. Obser [TRUNCATED]

Based on observation, interview, record review, video camera footage review, and facility policy review, it was determined the facility failed to have an effective system to ensure care plans were implemented to provide proper care and supervision to residents to prevent elopement for one (1) of three (3) sampled residents (Resident 1). The facility assessed Resident 1 (R1) to be at risk for elopement after his/her admission on 12/13/2022. The facility developed a care plan component on 01/25/2023 to address the resident's risk for elopement. Interventions included assessing the resident's living spaces for potential hazards, as needed, and identifying any triggers that increased the resident's need for wandering and intervene as necessary. Per interview with Licensed Practical Nurse (LPN) 3, R1 had spoken in the past with LPN1 of people coming to pick him/her up and take him/her to his/her hometown. LPN 1 noted that on 09/23/2023, R1 was exit seeking. However, LPN3 and LPN1 did not report the resident's exit seeking behaviors to their supervisors. On 10/22/2023, at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid through a gap at the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. Staff brought R1 back inside the facility and he/she was assessed by the nurse. Immediate Jeopardy (IJ) was identified on 11/09/2023 and was determined to exist on 08/08/2023, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a J; and 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. A partial Extended Survey was initiated on 11/18/2023 and concluded on 11/18/2023. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on 11/17/2023 alleging the IJ was removed on 11/17/2023. The State Survey Agency validated the IJ was removed on 11/17/2023 as alleged, prior to exit on 11/18/2023, with remaining non-compliance at S/S of D while the facility develops and implements a Plan of Correction. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 01/01/2017, revealed each resident would have an individualized comprehensive care plan that included measurable goals and corresponding interventions developed by the Interdisciplinary Team (IDT) to meet their physical and psychosocial needs. The comprehensive care plan (CCP) would serve as a reference for daily resident care, as well as a tool for relaying each resident's personal preferences and routines. Review of the facility's policy titled, Elopement/Missing Resident, revised date 10/18/2022, revealed the facility must ensure adequate supervision of residents to prevent accidents. It was the responsibility of staff to investigate and report any resident who tried to leave the premises or was suspected of elopement to Security and his/her supervisor immediately. Record review revealed on 10/22/2023, at approximately 4:05 PM, R1 exited the facility to the outdoor fenced courtyard. R1 slid through a gap at the bottom of the gate and the ground. Visitors alerted facility staff that someone was outside on their knees by the gate. Staff responded and found R1 standing by the fence outside of the gated courtyard. R1 stated, I am trying to get back home to pay for my stay and get my medicine. Observation, on 10/30/2023 at 10:44 AM, revealed on 10/20/2023, when R1 left the facility, he/she walked approximately eighty-one (81) feet away from the courtyard gate, as measured by the Maintenance Branch Manager and as reported by S/S1. Review of Resident 1's (R1) Admission Record, revealed the facility admitted R1 on 12/13/2022 with diagnoses that included unspecified dementia, cognitive communication deficit, mixed conductive and sensorineural hearing loss; bilateral, and unspecified visual loss. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2023, revealed R1 scored eight (8) of fifteen (15) on the Brief Interview for Mental Status (3.0 BIMS) examination. This score indicated the resident had moderate cognitive impairment. Review of R1's Comprehensive Care Plan (CCP) revealed the facility initiated a personal safety care plan with a care focus on 12/13/2022, that indicated R1 wished to exercise his/her right to be independent in the pursuit of outdoor activities on the external facility grounds. The CCP's goal was that R1 would enjoy self-directed activities while maintaining his/her personal safety on the external facility grounds. Nursing interventions included that R1 was to remain in the designated safe area while outside. During an interview, on 11/07/2023 at 4:15 PM, the MDS Coordinator stated outdoor activities were care planned for all residents, and the external facility grounds included the outdoor gated and locked courtyard adjacent to the indoor unit where R1 lived. She stated R1 was allowed to be on the courtyard by himself/herself according to R1's outdoor personal safety care plan. The MDS Coordinator stated all residents were allowed in the facility's courtyards by themselves but were rounded on or checked on frequently. She stated, We do not take things away. If [residents] want to go out, we do not stop them. Continued review of R1's CCP revealed the facility initiated a care focus on 01/25/2023, that R1 was at risk for elopement. The CCP's goal was that R1 would continue to walk safety within the unit/facility. Nursing interventions included to assess the resident's unit as needed for potential hazards, cue and redirect as needed, and identify any triggers that increased need for wandering and intervene as necessary. During an interview, on 11/07/2023 at 4:15 PM, the MDS Coordinator stated she could not say if R1's unit was assessed for potential hazards prior to R1's elopement from the facility. She stated if she had looked at the gap in the 500 C unit's courtyard gate, she would not have thought someone could get under the gate. The MDS Coordinator stated, in any case we do not know what is going to happen, that is how crazy it is to me that [R1's elopement] happened. She stated R1 was rounded on and when staff round, they are supervising, indicating staff made routine rounds when they observed the residents' whereabouts. During further interview the MDS Coordinator stated it was hard to tell if someone is exit seeking or if they are just walking. She stated triggers that increased R1's need for wandering were that R1 had said he/she had wanted to leave the facility. The MDS Coordinator stated, Here was a red flag, that maybe [the facility] should not have let [him/her] outside. She stated the facility did not keep R1 safe. In interview she stated the resident's care plan was implemented until the moment he/she slid under the gate. The MDS Coordinator stated she would not have thought the gap in the 500 C Unit's courtyard gate was a hazard. During an interview, on 11/08/2023 3:50 PM, the MDS Coordinator stated interventions for Low Risk for Wandering would be to just monitor the resident with hourly rounding. She stated she did not like the word wander because walking from unit to unit was not considered exit seeking. Wandering was subjective, and exit seeking was less subjective. If a resident verbalized he/she wanted to go away from the facility, or was going, that should be reported so the next staff person knew what had happened. The MDS Coordinator stated if she heard a resident say something like he/she wanted to leave the facility, she would enter a progress note in the clinical record for review by the IDT at a later date. She stated it would take more than one documented attempt of a resident seeking a way out of the facility, or verbalizing they wanted to leave, for the MDS Coordinator to assess the resident as known wanderer/history of wandering during an Elopement Risk Assessment. However, the facility's policy required staff to investigate and report any resident who tried to leave the premises, or who was suspected of elopement to security and his/her supervisor immediately. During further interview, on 11/08/2023 at 3:50 PM the MDS Coordinator stated if staff identified any triggers indicating R1 wanted to get out of the facility, like [he/she] came out with bags packed and shoes on, then staff would intervene, and redirect the resident. The MDS Coordinator stated, there was no staff present to redirect R1 from the trigger of a gap in the gate. During an interview, on 10/26/2023 at 1:37 PM, RN3 stated she was working as an aide (on Sunday 10/22/2023) and saw R1 outside within the unit's locked and gated courtyard between 4:00 PM and 4:05 PM. She then took another resident, R2, to the bathroom. RN3 stated she then heard a visitor say they saw someone on their hands and knees by the gate. She went out the door to the courtyard and saw R1 outside of the locked and gated courtyard. RN3 stated R1 had walked along the fence outside of the courtyard and could have had the intention of leaving the facility. During an interview, on 10/27/2023 at 2:41 PM, the Maintenance Branch Manager (MBM) stated the maintenance crew rounded and checked everything at the facility. Doors and gates were check daily by security and maintenance. The MBM stated the maintenance crew usually went through all the courtyard gates with the mowing crew, and no one ever noticed the gap in the courtyard gate. He stated he never would have thought somebody could ever slide underneath the courtyard gate like R1 had, and it floored me when he got the phone call. The MBM did not even know there was a gap in the courtyard gate, and it was not a big gap, was the odd thing, he said. During an interview, on 11/07/2023 at 3:30 PM, Nurse Aide State Registered ([NAME]) 4 stated she had cared for R1 and knew R1 tended to wander, that he/she was confused, and needed to be reoriented by staff. [NAME] 4 stated R1 would talk to her about looking for his/her car and wanting to go to his/her hometown. She stated prior to R1's elopement, his/her environment was probably not assessed to be as safe as possible for the resident because there needed to be more safeguards for going out on the courtyard, such as closer monitoring and clearer guidelines for going outside. NASR4 stated she wanted to see those guidelines on the care plan because the nurse may not always be available. When LPN1 heard R1 speak of going to Florida and was asked, during an interview on 11/08/2023 at 2:24 PM, if that was an exit seeking trigger, LPN1 stated he did not think he understood the wording of the question. When asked if LPN1 implemented R1's Elopement Risk nursing care plan Interventions/Tasks to Identify any triggers that increase need for wandering and intervene as necessary, LPN stated he did not understand that care plan intervention. During an interview, on 11/07/2023 at 4:00 PM, RN7 stated the facility did not keep R1 safe, and his/her care plan was implemented until the moment R1 slid under the gate. RN7 stated they were not expecting R1 to elope, were shocked that it happened, and the facility was now more aware of the surroundings. RN7 stated if R1 verbalized he/she wanted to go to his/her hometown or find his/her car, that was an exit seeking trigger which increased R1s need for wandering, and should have been reported to a supervisor, but in the past month she had not heard any exit seeking triggers from R1. During an interview, on 11/04/2023 at 4:30 PM, Nurse Supervisor (NS) stated if something like a fall or elopement happened, the IDT figured out what happened and what to place on the care plan. Then the care plan was updated, usually by MDS, and the IDT met with the nursing staff to ensure they knew about the changes. The NS stated care plan changes were communicated to nursing staff directly in huddles, which took place on Tuesdays and Thursdays, and as often as needed if something was going on. The NS stated if the care plan was not implemented or updated, and an intervention was missed, the very thing that caused the intervention to be put on the care plan could happen, such as R1's elopement. During an interview, on 11/07/2023 at 3:10 PM, the Director of Nursing (DON) stated the facility could have avoided R1's elopement if during environmental rounds when staff assessed the unit as needed for potential hazards per the CCP, the gap in the 500 C unit courtyard gate had been found. The DON stated she did not expect nursing staff to measure gaps in gates, but she could not point her finger at maintenance since all staff were responsible for residents' safety. During an additional interview, on 11/08/2023 at 8:45 AM, the DON stated resident care plans were important because care plans were the guides for staff to follow for giving daily resident care, based on the facility's assessments of the residents. The DON expected staff to follow the guide. During an additional interview, on 11/18/2023 at 5:00 PM, the Administrator stated she expected nursing staff to follow residents' care plans because they guided staff on how to meet residents' needs, and if the care plans were not followed, residents' needs might not be met, as in the case of R1. The facility alleged it had taken the following actions to remove the Immediate Jeopardy: 1. On 10/22/2023 at approximately 4:12 PM, R1 was cued and redirected inside by Licensed Practical Nurse (LPN)1. On 10/22/2023 at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. Corrective action also included on 10/22/230 at 4:30 PM, LPN1 initiated 15 minute checks for R1. 3. Further corrective action included on 10/22/2023 at approximately 5:00 PM, the courtyards in the 500 and 400 households were assessed by the Administrator for potential hazards. Work orders were placed for maintenance to address the gap between the ground and secured gate on each courtyard. The Courtyard door leading from each household on neighborhoods 400 and 500 were locked with access only by staff to swipe to enter/exit with signs posted. 4. Corrective action included on 10/22/2023 at 5:34 PM, the Charge Nurse assessed R1, with new assessment score of five (5), as a moderate risk for elopement. A wander-prevention bracelet was applied to R1's wrist. 5. Further corrective action included on 10/22/2023, R1's Comprehensive Care Plan (CCP) was revised by LPN1, to include new interventions; wander-prevention bracelet and 15 minute checks as identified on the printed copy of the Care Plan Elopement section print date of 10/23/2023. Statement by LPN1 attesting the creation of the care plan intervention and the statement by Director of Nursing (DON) of verification and validation on 10/23/2023. Staff was alerted verbally directly after R1's elopement of the changes to the care plan for fifteen (15) minute checks, EPLAS applied, and household courtyard door secured and locked. The Charge Nurse (CN1) for buildings 400 and 500 made all staff aware of the incident and changes to secure locked household door and the elopement. 6. Corrective action on 10/23/2023 between 8:00 AM and 12:00 PM, LPN1 reassessed elopement risk for all veterans in the facility, including the previous nine (9) who had already been identified as requiring safety using the wander-prevention bracelet. No necessary changes were identified. Census for 10/23/2023 was 57 residents. 7. Further corrective action included, on 10/25/2023, R1 continued with hourly rounding, completed by assigned direct care nursing staff, licensed, and certified nursing staff, documented on Daily Hourly Rounding forms. 8. Corrective action included, on 11/10/2023, R1's CCP was revised by the CSW to include asking to go to home; goal directed wandering tin the household; reminiscing about hitchhiking. 9. Corrective action included, on 11/10/2023, CCPs for the nine (9) veterans assessed to be at risk for elopement were reviewed and revised by the CSW and Minimum Data Set (MDS) Coordinator to include person-centered focuses [sic]. 10. Further corrective action included new admissions after 10/22/2023 will be assessed upon admission, quarterly and as needed for risk for elopement and care plans will be revised and developed as needed in a person-centered format. 11. Corrective action included from 10/26/2023-11/04/2023, training was provided to all staff with one hundred (100) percent of nursing staff in-serviced by the Director of Nursing, Assistant Director of Nursing, Nurse Supervisors, or Charge Nurses, on developing and implementing each veteran's care plan to ensure they included measurable objectives and timeframes to meet a veteran's medical, nursing, and mental and psychosocial well-being. The care plan must be reviewed and revised by the interdisciplinary team (IDT) after assessments and as needed to include changes in residents. Developing, implementing, and revising the care plan for each resident ensures their personal needs are met/quality of care is provided. Training will be added to new hire orientation for all licensed nursing staff and certified nursing staff before reporting to his/her shift and before direct care is provided. Any staff currently on leave was contacted via phone to complete all inservicing and post-test. Any staff that may be on leave that is identified by the HR Administrator will notify the Director of Nursing, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material presented on 10/26/2023-11/04/2023. 12. Further corrective action included, on 11/10/2023, training was provided to all staff with one hundred percent of licensed or certified nursing staff received education by DON, ADON, NS, CN, or CSW on wandering, goal directed wandering, and exit seeking definitions. Additionally, in-serviced on following an event of wandering or exit seeking, licensed nursing staff should complete a Progress Note to describe specifics of what occurred. Documentation should include the event, implementation of care planned interventions, or initiation of a new intervention; and effectiveness of the intervention Notification to nursing supervisor; reassessment of elopement risk with exit seeking; review/revision of a care plan to include event, and any new intervention used. Training will be added to new hire orientation for all staff before reporting to his/her shift and before direct care is provided. Any staff currently on leave was contacted via phone to complete all inservicing and the post-test. Any staff that may be on leave that is identified by the HR Administrator will notify the Director of Nursing, ADON, NSs, CNs or CSW to receive training by DON, ADON, NSs, CNs or CSW prior to reporting to shift and providing direct care. Training related to the above was validated with all licensed or certified nursing staff via verbal acknowledgement of material present on 11/10/2023. 13. Corrective action included, on 11/15/2023, training was provided to all staff with one hundred percent of non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) received education by DON, ADON, NS, CN, CSW, Business Office Manager, Administration Specialist, or Health Information Management, on wandering, goal directed wandering and exit seeking definitions and reporting wandering and/or exit seeking to a licensed nurse. Any staff currently on leave was contacted via phone to complete all inservicing and posttest. Any staff that may be on leave that is identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 14. Further corrective action included, on 11/15/2023, training was provided to all staff with 100 percent of licensed and certified nursing staff and 100 percent non-clinical facility staff (dietary, housekeeping, laundry, maintenance, security, administration) completed post testing on 11/15/2023 through 11/16/2023 related to the above training by DON, ADON, NS, CN, CSW, Business Office Manager (BOM), Administration Specialist (AS), or Health Information Management (HIM). All staff will complete a post in-service test with a 100 percent pass rate. Any staff currently on leave was contacted via phone to complete all inservicing and posttest. Any staff that may be on leave that is identified by the HR Administrator will notify the DON, ADON, NS, CN or CSW to receive training by DON, ADON, NS, CN or CSW prior to reporting to shift and providing direct care. 15. Corrective action included, on 10/25/2023, an Ad Hoc QAPI meeting was held to review Policy #33 Accidents and Incidents and Policy #44 Safety and Supervision. Staff in attendance were the Administrator leading the meeting with the DON, CSW, NS, ADON, APRN (Medical Director [MD] designee), Chaplain, Infection Preventionist (IP), Administrative Branch Manager (ABM), Maintenance Branch Manager (MBM), Administrative Specialist (AS) III, HIM, Admissions Coordinator (AC), Activities Director (AD), Rehab Program Director, and the Registered Dietician (RD). 16. Further corrective action included, on 11/10/2023 an Ad Hoc QAPI meeting was held to review Immediate Jeopardy removal plans to include training on auditing the CCP, the Progress Notes, and the Behavior Report by DON, ADON, NS, CN and/or the CSW. Attendance consisted of: Chaplain, AD, SDC, DON, FM, Administrator, QA Nurse led the meeting. AD, ASIII, SCW, ADON, Housekeeping/Laundry Director (H/LD), IP, ABM, NS, MDS, and MD joined by telephone. 17. Corrective action included, from 10/22/2023 daily and ongoing, the DON, ADON, NS, CH, or SCW will review Progress Notes and Behavior Reports to ensure wandering and exit seeking behaviors are assessed and care planned appropriately. If issues are identified based on monitoring, immediate corrective action (revision to CCP, assessment/reassessment, notification to licensed nursing supervisor, documentation and/or education to staff) will be provided by the DON, ADON, NS, SDC, IP, MDS Coordinator, CN, or CSW. Upon completion of in-servicing for wander/goal directed wandering and exit seeking and expectation following documentation of wandering/exit seeking, beginning 11/10/2023, audits will be completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW. The audits completed daily of the Behavior Report, Progress Notes and Care Plans by the DON, ADON, NS or CSW will be reported by the DON to the QA committee for review on 11/17/2023. The State Survey Agency validated the facility had removed the IJ as alleged: 1. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on the day R1 eloped from the facility, afterwards he walked with R1 back to the facility, wrote the Progress Note, and notified his supervisor and the NP. Record review of Nursing Note, dated 10/22/2023 at 4:15 PM, revealed on 10/22/2023 at 4:15 PM, LPN1 documented R1 had crawled beneath the gate in the courtyard on the 500 C hall neighborhood. Further, LPN1 had notified the Charge Nurse and Nurse Practitioner (NP), Medical Director (MD) designee. 2. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated on 10/22/2023 he initiated 15 minute checks for R1. Review of the document titled 24-Hour Q-15 Minute Check, dated 10/22/2023 revealed 15 minute checks were initiated for R1 at 4:30 PM that day and continued until 10/24/2024 at 4:30 PM. Review of the facility's Maintenance Work Order #22437 revealed the Administrator requested all courtyard gates be checked and a correction be implemented as so this did not occur again. Staff work order was created on 10/22/2023 at 6:20 PM. 3. Review of Statement of the Administrator, undated, revealed she assessed the 500 C Unit outside courtyard gate and determined that there was enough room for R1 to elope. During an interview, on 11/18/2023 at 5:00 PM, the Administrator stated she had assessed the facility soon after R1 had eloped and asked that a work order be entered to fix the courtyard gates. 4. Review of Elopement Risk assessment dated [DATE] revealed R1 was assessed by the CN as moderate risk for wandering. Observation, on 11/18/2023 at 4:30 PM, revealed R1 was ambulating with his/her cane nearby within the unit. During an interview, on 11/18/2023 at 4:30 PM, NASR4 asked R1 if she could see his wrist. R1 agreed. Observation, on 11/18/2023 at 4:31 PM, revealed a black band, which looked similar to a watch, around R1's right wrist. 5. Review of an untitled, undated document revealed the DON documented On 10/23/2023, when reviewing R1's care plan, she saw that LPN1 had revised R1's care plan to include interventions; wander-prevention bracelet and 15 minute checks. Further, the care plan was printed to include in the follow up investigation. During an interview, on 11/18/2023 at 9:30 AM, LPN1 stated he revised R1's care plan on 10/22/2023 to include the wander-prevention bracelet and 15 minute checks. During an interview, on 11/18/2023 at 9:55 AM, CN1 stated she let all the staff in the building on 10/22/2023 know about the changes to R1's care plan for 15 minute checks, a wander-prevention band applied to his/her wrist, and about the courtyard doors being secured and locked. 6. Review of the report Assessment History Multi, dated 11/16/2023, revealed the date range of the report was 10/23/2023 to 10/23/2023. Fifty-nine (59) elopement risk assessments were completed on fifty-four (54) residents. 7. Observation, on 11/18/2023 at 11:00 AM, revealed Daily Hourly Rounding forms were filed in the Nurse Supervisor's office. Observation, on 11/18/2023 at 4:25 PM revealed a Daily Hourly Rounding form lay on the dining table of one of the facility's units. [NAME] were noted by Residents' names indicating they had been checked on by NASR7. During an interview, on 11/18/2023 at 4:30 PM, NASR7 stated, as she picked up her Daily Hourly Rounding Form from the unit's dining table, that she checked on her residents on every odd hour during her shift and was going to do so at 5:00 PM. During an interview, on 11/18/2023 at 11:00 AM, the Nurse Supervisor (NS) stated nurses and NASRs rounded hourly on residents, and that hourly rounding and the Daily Hourly Rounding forms were not a new process and that hourly rounding by certified and licensed nursing staff had been implemented before R1 eloped. 8. Review of R1's CCP revealed, on 11/10/2023, the MDS Coordinator revised R1's care plan to include talking about the resident going to his/her previous home and him/her reminiscing about hitchhiking. During an interview, on 11/18/2023 at 1:48 PM, the CSW stated she and the MDS Coordinator worked on the care plans together. The CSW reviewed the Behavior Notes, and the MDS Coordinator did the updates. 9. Review of the nine (9) veterans assessed to be at risk for elopement were reviewed and revised by the CSW and Minimum Data Set (MDS) Coordinator to include person-centered focuses [sic]. 10. Review of Elopement Risk Assessment, Effective Date 10/30/2023, revealed R15, had an Admission Wandering Risk Score of Low Risk for Wandering. Review of Elopement Risk Assessment, Effective Date 11/02/2023, revealed R16, had an Admission Wandering Risk Score of Low Risk for Wandering. 11. Review of Employee Sign-In Record; Title: Care Plans; Target Audience: Nursing Staff, revealed in-services were held between 10/26/2023 and 11/04/2023 regarding development and implementation for each resident care plan which included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in assessments for licensed and certified nursing staff. During an interview, on 11/18/2023 at 11:35 AM, RN4 stated she had training recently on care plans. She stated she would update a resident's care plan if she assessed a resident to be at risk for elopement, and enter a progress note in the resident's clinical record, which described the resident's exit-seeking behavior, and she would report it immediately to her supervisor. RN4 stated a supervisor was always available to help her if she had any questions about updating the care plan. In an interview, on 11/18/2023 at 1:30 PM, SDC Nurse Consultant #2 stated she had provided care plan education to facility staff that all licensed nursing staff could enter for residents' care plan interventions, and the IDT team met to review them for quality of care. 12. Review of Employee Sign-In Record; Title: Wandering and Exit Seeking; Target Audience: Nursing Staff revealed in-services were held on 11/10/2023 between 10/26/2023 and 11/04/2023 regarding wandering and exit seeking definitions, and the requirement of licensed nursing staff to complete a Progress Note to describe the specifics of what occurred following an event of wandering or exit seeking. Documentation should include the event, implementation of care planned interventions or initiation of a new intervention, and effectiveness of the intervention. Licensed nursing staff were to also notify their supervisor and re-assess the resident for elopement risk. During an interview, on 11/18/2023 at 11:15 AM, [NAME] 10 stated she had training recently about on wandering and exit seeking. She stated residents walking around, or wandering, was different than exit seeking. NASR10 stated if she saw signs that made her think the resident wanted to leave the facility, she would ensure the resident's safety and immediately tell the nurse. 13. During an interview, on 11/18/2023 at 11:40 AM, the Cosmetologist stated she knew the residents and talked with them often when she cut their hair. She stated she had training recently and if she heard a resident talking about wanting to home she would immediately tell the nurse. 14. Record review of Wandering/Goal Directed Wandering and Exit Seeking Post Test revealed a post test was administered to therapy, nursing, and non-clinical staff on 11/15/2023, some via telephone. During an interview on 11/18/2023 at 2:30 PM the HR Administrator stated the pink marks on the employee roster indicated staff members who took the posttest while in the facility. Those who were not working that day were contacted by telephone. 15. During an interview, on 11/18/2023 at 5:15 PM, the DON stated they had QAPI meetings on 10/25/2023, 11/10/2023 and on 11/17/2023. 16. During an interview, on 11/18/2023 at 1:30 PM, the Chaplain stated she attended the QAPI meeting on 11/10/2023. She stated she was not clinical and could not update care plans but knew if a resident talked about wanting to get out of the facility, she would immediately tell the nurse. The Chaplain stated she would also try to engage the resident and try to figure out what was going on with him/her so that he/she could be redirected from exit seeking. (Did you review sign-in sheets for those meetings? If so, add here.) Completed below Review of QAPI QAA Committee Meeting Attendance Record/Sign In Sheet, dated 11/10/2023, revealed a QAPI meeting was held at 11:30 AM on 11/10/2023. Documentation of the meeting revealed the Immediate Jeopardy notifications delivered to the facility on [DATE] were reviewed and a plan for the removal of the facility's Immediate Jeopardy status was discussed. 17. Review of the audit sheet, titled ADON, revealed the ADON audited the facility residents' Nursing Progress Notes daily from 10/22/2023 through 11/17/2023. Audits revealed 13 o [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain an effective call system to allow residents to call for staff assistance. On 09/19/2023, the Director of Nursing (DON) became aware that the facility's wireless system was not properly operating on three (3) of the facility's six (6) residential units. The DON created a work order on 09/19/2023 at 9:24 AM to initiate repair of the wireless call system. The findings include: Review of the facility's policy, Call Light Failure, dated 06/19/2022, revealed staff would immediately notify the Charge Nurse (CN) if the call system was not working properly. The Charge Nurse would immediately call the Maintenance Person (MP) on call and the Maintenance Branch Manager (MBM). The MP would give the CN instructions of what action to take such as resetting the system. If resetting the system did not work then the Administrator or designee and the DON would be notified. The CN would hand out bells to staff who would place the bells in the residents' rooms. Staff were to ensure the bells remained within residents' reach. Further review revealed the MP would contact a contractor to service the call lights. Review of Maintenance Work Order #21974, dated 09/21/2023, revealed the DON created a work order on 09/19/2023 at 9:24 AM. The work order indicated the call light system pagers were not working and there were no beeps. The work order also stated the call light system's status was On Hold - Contractor. During an interview, on 10/27/2023 at 2:41 PM, the Maintenance Branch Manager (MBM) stated the call light system computer chip board was broken on the 500 Hall. He stated the DON had put in a work order in late September that the system had been broken for a few weeks. The MBM stated the broken parts were obsolete and the contractor had to find the replacement parts. During an interview, on 10/27/2023 at 3:05 PM, the Maintenance Supervisor (MS) stated his maintenance team did not perform regular preventative maintenance on the facility's call system. However, nursing would change the batteries when indicated in the call system pagers. The MS stated the main communication board light of the system still functioned properly, and the lights still lit up above the residents' rooms when they pushed their call light, but the pager system that notified the nurses and nurse aides state registered ([NAME]) was broken. During an interview on 11/13/2023 at 3:10 PM, [NAME] 8 stated she carried a pager in her pocket and when the facility's call light system worked, the pager would ring. She stated there was a screen on the pager that indicated which resident's room number the page had come so she could go check on that resident. The [NAME] stated when she came on duty the nurse told her to watch out for lights and look for them. NASR8 stated she checked on her residents more often when the call system was broken. During an interview on 11/13/2023 at 3:16 PM, NASR7 stated when she returned to work, during the morning huddle meeting and in report, the Charge Nurse told her the call system was broken. NASR7 stated residents had a bell in their bathroom and at their bedside. During an interview on 11/13/2023 at 4:20 PM, NASR6 stated once the call system broke, staff put little bells in residents' rooms. During an interview, on 11/13/2023 at 2:20 PM, NASR5 stated when she came back from leave in mid-October the call system was broken. She explained that a light came on above the door when the resident pushed his/her call bell. She stated when the call system broke, residents were given two (2) bells. One bell was placed on the resident's sink by the toilet and another bell was placed within the resident's reach. NASR5 stated she could hear the bells ringing, but not too well unless you were standing close by the resident's room. NASR5 stated residents did not complain about waiting extra-long for help because usually if a resident needed something they would shout out. NASR5 stated she kept the television volume low so she could hear the bells better and did hourly rounding unless the resident was on fifteen (15) minute checks. NASR5 also stated as far as maintaining the call system, nursing replaced the pager batteries when needed, and if the call system was broken nursing would call maintenance and they would repair it. During an interview, on 11/14/2023 at 2:00 PM, Resident (R) 12 stated he/she remembered when the call system broke. R12 stated it was a major issue and he/she had to use his/her personal phone a couple of times to call security to get help. The resident stated staff gave them little bells to use to ring for assistance. R12 stated he/she used the bell, but when his/her door was closed and he/she rang the bell, he/she got frustrated and threw the bell on the floor. During the interview, the resident stated there were three (3) occasions he/she had to call security for help. R12 stated if he/she had not had his/her phone with him/her, he/she would have been shit out of luck. During an interview, on 11/14/2023 at 3:00 PM, R13 stated when the facility's call system failed, the unit went bonkers. The resident stated when he/she pushed the little bell he/she had been given by staff, it took them longer to get to him/her. He/she stated if staff members were in another resident's room, they could not hear the little bell ringing. During an interview, on 11/14/2023 at 11:05 AM, the DON stated she could not recall who reported to her that the facility's call light system was broken , or exactly what day it was reported, but it was at the end of September 2023. The DON stated staff gave residents bells to use until the call light system was repaired. During an interview on 10/27/2023 at 3:30 PM, the Administrator stated there was no regular preventative maintenance performed on the facility's electronics. She stated the batteries on the call light system's pagers were changed when the pagers stopped sounding. The Administrator stated it was important for the facility's call light system to be operational so that residents' needs could be met, and if the call system was broken, residents' needs may not be met. During an interview, on 11/07/2023 at 5:30 PM, the Administrator stated the facility was responsible for the safety of the residents.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure all allegations of misappropriation of property were reported to State agencies within 24 hours in accordance with established procedures, and failed to report within five (5) working days of the incident the results of an investigation to the State Survey Agency as per regulations and facility policy. Resident #4 reported to staff on 08/10/2020 that his wallet was missing. The facility did not submit a report of the allegation until 08/25/2020, 15 days after the wallet was reported missing. The facility did not complete written findings of the five (5) day follow-up of the investigation to the State agency until 08/30/2020, 20 days after the initial report of the missing wallet. The findings include: Observation of Resident #4 on 04/28/2021 at 11:15 AM revealed the resident sitting in a recliner in his/her room eating breakfast. The resident informed surveyor he/she always slept late and contacted staff upon waking and requested breakfast. When asked by surveyor if the resident had any issues with missing property, the resident replied he/she reported a missing wallet, but later found it. The resident stated he/she displaced the wallet, found it later and it was not staff's fault. Review of the facility's policy, Abuse Policy and Procedures, revised 10/07/2020, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported no later than 24 hours if the events that caused the allegation did not involve abuse and did not involve serious bodily injury, to the Administrator of the facility and to State Survey agency and Adult Protective Services. The facility Administrator promptly notified the State licensing/certification agency, Ombudsman, the resident's legal representative, Adult Protective Services, law enforcement, the resident's physician, and the facility Medical Director. The Administrator provided the appropriate agencies with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status was intact with a Brief Mental Status Interview (BIMS) score of 15, and the resident required supervision with Activities of Daily Living (ADL). Review of the resident's care plan with revision date 04/20/2020 revealed the resident was able to make decisions regarding his care and required supervision with ADL's. Review of Grievance/Service Recovery Case Report Form, dated 08/10/2020 revealed documentation a wallet was reported missing from Resident #4's room. The resident reported the wallet contained identification card, medical cards, social security card and six (6) 50 dollar bills. Review of the Summary of Investigation for Misappropriation of Property of Resident #4, documented on 08/24/2020, the Social Services director received a directive from the facility administrator to initiate an investigation regarding Resident #4's reported missing wallet, which the resident reported on 08/10/2020. According to the document the facility administrator was initially informed of misappropriation of property, the resident's missing wallet, on 08/10/2020 at approximately 6:30-6:45 AM. Further review of faxed documentation revealed the facility contacted the State Survey Agency on 08/25/2020 of Resident #4's allegation of misappropriation of property, 15 days after the resident reported an allegation of misappropriation of property. The Social Services Director (SSD) stated during an interview on 04/28/2021 at 3:10 PM she was a certified investigator and responsible for conducting facility investigations. She said the administrator contacted her when a facility investigation needed initiated and reported to the State agencies. The SSD said on 08/24/2020 the administrator directed her to start an investigation regarding Resident #4's missing wallet. The SSD stated she was aware the contacts to state agencies and the implementation and completion of the investigation were late. An interview with the Administrator, on 04/28/2021 at 2:00 PM revealed he was informed of the allegation of misappropriation of property regarding Resident #4's missing wallet on 08/10/2020. He stated he forgot that misappropriation of property was included in the 24 hour reporting requirement. The Administrator said he could not recall when he realized he should have reported the allegation of misappropriation of property. He said once he made the connection, he realized the facility would be late with reporting the allegation of misappropriation of property and of conducting and completing the investigation for the five (5) day follow-up requirement to the State agencies.

Based on observation, interview, record review, and facility policies review, it was determined the facility failed to develop a comprehensive plan of care for three (3) of thirty (30) sampled residents (Residents #14, #18 and #67) to address urinary catheter care and securing urinary catheters to prevent trauma or injury. In addition, the facility failed to develop a care plan to address respiratory care for Resident #18 regarding respiratory secretions. The findings include: Review of the facility policy, Using the Care Plan, revised 07/10/18, revealed the facility used the care plan for developing the resident's daily care routines and was available to staff who provided care or services to the resident. Further review revealed clinical documentation must be consistent with the resident's care plan. Review of the facility policy, Care Plans-Goals and Objectives, dated 01/01/17, revealed the facility incorporated goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. Further review revealed goals and objectives were included on the resident's care plan so that all disciplines had access to such information and were able to report whether or not the desired outcomes were being achieved. Review of the facility policy, Urinary Catheter Care, dated 12/27/16, revealed the purpose of catheter care was to promote hygiene, comfort and decrease risk of infection for catheterized residents. Further review revealed residents with an indwelling catheter received catheter care every shift and as needed (PRN) for soiling and the catheter will be secured to avoid tension and in-and-out movement. 1. Review of the medical record for Resident #14 revealed the facility admitted the resident on 06/15/17, with [DIAGNOSES REDACTED]. Review of Resident #14's Physician's Orders revealed an order to change Foley catheter every month on the 17th day of the month and use an eighteen (18) French Coude catheter with a ten (10) millimeter (ml) balloon. Review of the Annual Minimum Data Set (MDS) assessment for Resident #14, dated 07/29/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), and determined the resident was interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Review of Resident #14's comprehensive plan of care dated 06/15/19 revealed the resident had no interventions developed to address performing catheter care or securing the resident's indwelling urinary catheter to prevent trauma or injury. Observation of indwelling urinary catheter care for Resident #14, on 10/17/19 at 1:42 PM, revealed an indwelling urinary catheter present with tubing secured to the resident's leg. Registered Nurse (RN) #1 provided urinary catheter care. 2. Review of the medical record for Resident #67 revealed the facility admitted the resident on 04/02/19, with [DIAGNOSES REDACTED]. Review of the Physician's orders for Resident #67, dated 04/22/19, revealed an order for [REDACTED]. Review of the Quarterly MDS assessment for Resident #67, dated 09/23/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of thirteen (13) out of fifteen (15) and determined the resident was interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Review of Resident #67's comprehensive plan of care with a revision date of 07/05/19 revealed the resident had no interventions developed to address performing catheter care or securing the resident's indwelling urinary catheter to prevent trauma or injury. Interview with State Registered Nurse Assistant (SRNA) #9, on 10/18/19 at 11:02 AM, revealed he/she performed catheter care for Resident #67 at 7:00 AM and the catheter was secured to the resident's right leg. Further interview revealed the intervention to perform catheter care and secure the catheter to the leg were not listed on the care plan. Additionally, SRNA #9 stated the catheter tubing should be secured to prevent trauma to the resident. Interview, on 10/18/19 at 10:00 AM, with the Minimum Data Set (MDS) Coordinator, revealed it was his/her responsibility to develop and revise a resident's care plans and he/she was not familiar with the care plan policy. Continued interview revealed staff, including nurses and SRNA's used the care plan to communicate the specific interventions for each resident regarding the resident's care and preferences. The MDS Coordinator stated no interventions to provide catheter care every shift and to secure the catheter were listed on the care plan. Interview with the Director of Nursing (DON), on 10/18/19 at 2:03 PM, revealed the MDS Coordinators developed the resident's care plan upon admission and all nursing staff had the ability to update a care plan. Continued interview revealed the care plan guided the care provided to the residents and a resident's care plan should include indwelling catheter care interventions including providing catheter care each shift and securing the catheter. 3. Record review revealed the facility admitted Resident #18 on 04/25/2019 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment for Resident #18, dated 05/01/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of fifteen (15) and determined the resident was interviewable. The MDS revealed the resident had muscular dystrophies, dysarthria and anarthria, and dysphagia, oropharyngeal phase. Review of Resident #18's Respiratory assessment, dated 04/24/19 at admission, revealed the resident had copious amounts of secretions, coughed and spit a lot, and asked for beside suction. The assessment further noted a suction machine was requested with oral hand held suction, as the resident wanted to do per self. Review of Resident #18's Physician's order, dated 04/25/19, revealed an order to perform oral suctioning as needed (PRN), may suction at the bedside and perform per self. Review of Resident #18's comprehensive plan of care, dated 04/25/19, revealed the resident had no interventions developed to address respiratory care or performing self-care for oral suctioning. Observation of Resident #18, dated 10/14/19 at 2:26 PM, revealed resident used an oral suction machine at bedside without nursing staff present. Interview with the Staff Development Coordinator (SDC) on 10/18/19 at 3:17 PM, revealed Resident #18 wanted to be involved with his/her care. The SDC stated he/she did not provide education to Resident #18 regarding the [MEDICATION NAME] or Vac-Assist Suction Aspirator Respiratory Machine and assumed the nursing staff provided the education. The SDS further stated staff used care plans to provide care to residents, including those such as for respiratory care. Interview with Resident #18 on 10/18/19 at 3:50 PM, revealed he/she wanted to be involved in his/her care and was educated/trained on the equipment on admission but could not recall who provided the training/education on the [MEDICATION NAME] or suction machine. Interview with Licensed Practical Nurse (LPN) #2, on 10/18/19 at 3:59 PM, revealed Resident #18 demonstrated he/she could use the [MEDICATION NAME] and Vac-Assist Suction Aspirator Respiratory Machine safely. Interview with SRNA #4, on 10/18/19 at 4:11 PM, revealed Resident #18 used the [MEDICATION NAME] and Vac-Assist Suction Aspirator Respiratory Machine independently but did not know if the facility educated the resident prior to use. Additionally, she stated resident care plans provided staff with the care needs of the residents, and if not followed, or if a need is not listed, care may be missed which may harm the resident. Interview with the Director of Nurses (DON), on 10/18/19 at 4:25 PM, revealed staff should initiate a care plan and interventions and follow through. Interview with the Administrator, on 10/18/19 at 5:01 PM, revealed the facility had not identified concerns regarding care plans development.

Based on interview, record review, and facility policy review it was determined the facility failed to have an effective system to ensure staff immediately reported allegations of neglect or abuse to the administrator or state agencies within two (2) hours for one (1) of thirty (30) sampled residents, Resident #53. Interview and record review revealed Certified Nursing Assistant (CNA) #8 reported Resident #53's allegation of neglect to the Unit Manager (UM); however, the Unit Manager failed to report the allegation immediately and the facility became aware of the allegation eight (8) days after the resident's allegation. The findings included: Review of facility policy, Abuse Policy and Procedures, revised 03/05/18, revealed facility staff were to report an allegation of abuse or neglect immediately to a supervisor who was to notify the facility administration immediately. Review of facility policy, Reporting Abuse to State Agencies and Other Entities/Individuals, revised (MONTH) 2009, revealed all suspected violations of abuse were immediately reported to appropriate agencies and other entities or individuals as required by law. Review of Resident #53's clinical record revealed the facility admitted the resident on 12/06/18 with [DIAGNOSES REDACTED]. Review of Resident #53's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) exam and assessed the resident with a score of fifteen (15) and determined the resident was interviewable. Further review revealed the facility assessed Resident #53 for bed mobility as total dependence for all transfers and required extensive assistance. Observations, on 10/15/19 at 12:04 PM, revealed Resident #53 sat in an electric wheelchair and appeared unable to communicate verbally. Continued observation revealed Resident #53 utilized a visual command computer board on an electronic keyboard to spell words out and form sentences. Interview with Resident #53, on 10/15/19 at 12:04 PM, revealed staff placed him/her onto the toilet at the change of shift around 2:50 PM. The resident stated staff forgot he/she was on the toilet and it was one (1) and a half (1/2) hours before a housekeeper discovered the resident and alerted staff the resident remained on the toilet. Resident #53 stated he/she was unable to transfer and was dependent on staff for care. The resident stated he/she reported the incident to facility staff the next day and after about a week the Social Service Director (SSD) came and interviewed the resident regarding the reported incident. Interview with CNA #8, on 10/16/19 at 3:47 PM, revealed she placed Resident #1 onto the toilet as reported just before change of shift at 3:00 PM on 07/31/19. The CNA stated Resident #53 reported to her the next day he/she sat on the toilet for more than an hour and a half and staff did not check on him/her. The CNA stated the resident reported a housekeeper discovered him/her and reported to staff the need to assist the resident from the toilet. The CNA further stated she immediately reported the resident's concern to the supervisor on duty who was the UM. The CNA stated the UM referred she would take care of the resident's report. CNA #8 stated no one from administration interviewed her about her report so when CNA #8 returned to work about a week later, she reported the concern to the Infection Control Preventionist (ICP). The CNA further stated the Administrator interviewed her about a week after the incident was initially reported to the UM. The CNA stated she was concerned the resident would be left on the toilet for a long period of time again. Interview with Certified Nursing Assistant (CNA) #6, on 10/16/19 at 3:25 PM, revealed staff from the previous shift placed Resident #53 on the toilet and she assisted with returning Resident #53 to bed without complaints from the resident. The CNA stated one (1) week later she completed an interview with the Administrator and provided a written statement. CNA #6 stated all staff were to report any allegation of abuse or lack of care to the house supervisor on duty and then the report was to go up the chain of command immediately. The CNA stated this was to prevent further abuse or neglect. Interview with the UM, on 10/17/19 at 10:39 AM, revealed CNA #8 reported Resident #1 complained of being left on the toilet an excessive amount of time, about two (2) hours, the day before. The UM stated she forgot to tell the Assistant Director of Nursing (ADON) or anyone after learning of the resident's complaint as she continued to provide resident care. The UM stated she believed the ADON learned of the complaint from staff several days later. The UM stated the Administrator interviewed her the next week and she reported receiving the report from a CNA several days prior. The UM stated the facility expected all staff to report up the chain any concern for resident abuse and each person on the administration chain were to report the incident immediately to the next in line. Attempts to reach the housekeeper indicated by the resident, on 10/17/2017 at 11:31 AM, 02:12 PM, and on 10/18/19 at 12:30 PM were unsuccessful. The facility reported they no longer employed the housekeeper. Interview with CNA #7, on 10/17/19 at 3:40 PM, revealed staff were to report any concern or complaint of abuse to the supervisor on duty immediately. The CNA stated the supervisor was to report up the chain of command the incident immediately and all staff were aware of this requirement. The CNA further stated if a concern was not reported immediately residents may be subjected to further abuse or neglect. Interview with the Infection Control Preventionist, on 10/18/19 at 9:43 AM, revealed CNA #8 approached her to inquire about her report to the UM of Resident #1's concerns as no one had interviewed CNA #8 about her report. The ICP stated she immediately informed the ADON who informed the DON. Interview with Registered Nurse (RN) #9, on 10/18/19 at 10:32 AM, revealed if staff failed to report suspected abuse or neglect the residents were at risk for continued abuse or neglect. Interview with the Staff Development Coordinator (SSD), on 10/18/19 at 03:17 PM, revealed staff were expected to notify their supervisor immediately when they learned of alleged abuse. She further stated if notification of an issue is delayed the safety of the resident as well as other residents were at risk for continued neglect and abuse. Interview with the DON, on 10/18/19 at 4:42 PM, revealed she was aware of the incident and stated all staff were expected to report to their immediate supervisor when abuse or neglect was reported or suspected. The DON further stated residents were at risk for further abuse and neglect if the issue was not reported immediately to the next person up the chain of command. Interview with the Administrator, on 10/18/19 at 3:35 PM, revealed the ADON notified him of the resident's complaint on 08/09/19. He stated he began an investigation and interviewed staff and reported to state agencies. He further stated he and the facility expected all staff to follow the abuse policy and report immediately to a supervisor. He stated the facility was responsible to protect the residents from harm.

Based on observation, interview and facility policy review, it was determined the facility failed to ensure scheduled medications were stored securely in one (1) of three (3) medications rooms. Observation of the 400 neighborhood medication room refrigerator revealed the locked box for scheduled medications was not permanently affixed to the refrigerator. The findings include: Review of facility policy Medication Storage in the Facility, revealed medications and biologicals were stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Schedule II, III, IV, and V controlled medications were stored separately from other medications in a double locked (key or code) drawer or compartment designated for that purpose. Observation, on 10/16/19 at 2:56 PM, revealed the unit medication refrigerator contained a tan, locked medication box; however, it was not affixed to the inside of the refrigerator. Registered Nurse (RN) #3 removed the tan box from the refrigerator, placed it on the counter and unlocked it. The box contained one (1) thirty (30) milliliter (ml) bottle of two (2) milligrams (mg)/ml of [MEDICATION NAME] Oral Concentrate. Interview, on 10/18/19 at 3:45 PM, with Registered Nurse (RN) #8 revealed registered nurses had to swipe their badge to enter the medication room, must have a key to unlock the refrigerator and unlock the tan medication box in the refrigerator that contains scheduled medications. Further interview revealed that the locked box was not affixed to the refrigerator. Interview with the Nurse Manager (NM), on 10/16/19 at 3:00 PM, revealed that the tan locked medication box contained the narcotic medications for all of the neighborhoods in the facility (200, 400 and 500) and the box was under a double lock system, the refrigerator and the lock box, at all times; however, the locked medication box was not affixed to the refrigerator. He/she further stated only registered nurses had access to the medication room and only the nurses administering medications had access to the refrigerator and locked medication box. Interview with Assistant Director of Nursing (ADON), on 10/18/19 at 3:31 PM, revealed the facility was unaware the refrigerated medication box had to be affixed to the refrigerator. The ADON stated only nurses had keys to the refrigerator and medication box. Further interview revealed, the facility was not auditing the narcotic count sheets in the binder daily. Interview with the Director of Nursing (DON), on 10/18/19 at 3:23 PM, revealed he/she was not aware that refrigerated scheduled medications was to be stored in a medication box affixed to the refrigerator. He/she stated that ensuring the locked box is affixed to the refrigerator is important so that staff won't steal the resident's medications.

Based on interview, record review, facility policy review, and review of a facility investigation, it was determined the facility failed to investigate an allegation of abuse thoroughly for one (1) of two (2) sampled residents, Resident #1. An allegation of abuse by staff towards Resident #1 was reported to Administration. Review of the investigation revealed Resident #1 was not assessed for injuries, other residents were not assessed or interviewed, and the only staff interviewed was staff involved in the incident. The findings include: Review of facility's policy, Abuse Policies and Procedures, revised 03/05/18, revealed the facility defined physical abuse toward a resident as hitting, slapping, pinching, kicking, etc. and included controlling behavior through corporal punishment. The policy included investigation of abuse allegations, particularly when, who, and whom to interview related to allegations, witness reports, and all events leading up to the alleged event. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 08/28/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility completed a staff assessment for a Brief Interview for Mental Status (BIMS) and determined the resident was severely impaired and not interviewable. Review of a facility investigation, dated 10/26/18, revealed Certified Nursing Assistant (CNA) #4 reported to the Social Worker (SW) on 10/26/18, that a nurse held Resident #1's hands down while the resident's brief was changed. The SW notified the Assistant Administrator and he initiated an investigation. Review of Progress Notes, dated 10/26/18, revealed no documentation regarding the incident. Interview with CNA #3, on 02/01/19 at 1:20 PM, via telephone, revealed Resident #1 had been aggressive the night of the alleged incident, swinging and punching at staff, cursing, screaming, and behaving violently. She stated between 1:00 AM - 2:00 AM the morning of 10/26/18, she and Licensed Practical Nurse (LPN) #3 changed the resident's brief. During the brief change, the resident tried to tear his/her brief off, started cussing, and the CNA struggled to put the resident's fresh brief on. She stated LPN #3 assisted her by holding Resident #1's hands over his/her stomach as she hurried up to complete the brief change. During shift change, she talked about the brief change with oncoming CNA #4. CNA #3 stated she went home after her shift ended and later received a call from the Assistant Administrator who told her she was on administrative leave, but she had no idea what was going on. When she was interviewed by the facility the following Monday, she was educated and encouraged by the facility to report any abuse; however, she did not deem the holding of hands on the resident's stomach as abuse. Interview with LPN #3, on 02/01/19 at 12:52 PM, via telephone, revealed during Resident #1's brief change, the resident swung at CNA #3 and he held the resident's hands on his/her stomach for about twenty (20) to thirty (30) seconds while the brief change was completed. The LPN stated later he found out someone had reported the occurrence as possible abuse. He stated he received a call from the facility and gave a statement about the incident. Continued review of the facility investigation revealed the only staff interviews conducted was with staff directly involved with the alleged abuse, CNA #3 and LPN #3. In addition, there was no assessment completed on Resident #1 to determine if injuries were present, and there were no assessments of other cognitively impaired residents that resided on the unit to assess for possible abuse. There were no interviews with cognitively intact residents, who resided on the same unit, to determine if abuse issues had occurred. Interview with the Assistant Director of Nursing (ADON), on 02/01/19 at 10:47 AM and 5:07 PM, revealed Resident #1 was aggressive and combative with nursing staff because staff had reported this to her; however, she could not recall if the abuse allegation was reported to her. She stated she could not locate Resident #1's skin assessment; however, the resident should have been assessed to see if he/she had any injury or marks on him/her. The ADON further stated other residents residing on Resident #1's unit should have been interviewed regarding abuse. She was not aware other staff interviews should have been conducted. Interview with the Director of Nursing (DON), on 02/01/19 at 3:46 PM, revealed she had been on vacation during the time the alleged abuse occurred and she found no documentation of the incident in the progress notes. She stated other staff and other residents should have been interviewed to find out if residents felt safe in the facility and if any other similar incidents had occurred; however, there were no resident interviews nor interviews with other staff. She stated nursing staff should have completed a skin assessment on Resident #1 to assess for injury. The DON stated the investigation into alleged staff abuse of Resident #1 was not thorough enough because there was a lack of interviews from residents and other staff. Interview with the Assistant Administrator, on 02/01/19 at 11:11 AM and 5:23 PM, revealed he suspended staff and directed nursing staff to conduct a physical assessment of Resident #1 to determine if any harm had occurred to the resident. He then started the investigation of the alleged abuse, determined a hierarchy of staff to be interviewed, and began the reporting to authorities. He stated the investigation was not thorough, as he did not interview other residents regarding the care they received and he should have followed up to ensure Resident #1's assessment was completed. Interview with the Administrator, on 02/01/19 at 2:23 PM, revealed he understood the abuse investigation process; however, he stated no interviews were conducted with other residents residing on Resident #1's unit. The resident had cognitively declined since his/her admission to the facility, which did not allow for an interview with him/her. The Administrator was unsure why nursing staff had not documented the incident in the resident's clinical record. He stated the investigation could have been more thorough and late entry progress notes were possible.