Every finding on record at River Oaks Health & Rehabilitation

The findings include:Review of an undated facility policy, Food Safety Sanitation Guidelines revealed dietary staff were to wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food. During observation of the lunch meal preparation in the main kitchen on 07/08/2025 at 11:59 AM, [NAME] 16 had an approximately 3-inch black beard. Continued observation revealed [NAME] 16 did not have the beard covered while he placed covers on residents' food trays and then placed the meal trays in the cart for delivery. During interview on 07/08/2025 at 2:01 PM, [NAME] 16 stated he did not have a beard restraint (cover) in place because he could not find one to put on. During interview on 07/09/2025 at 11:07 AM, the Dietary Director stated all dietary staff were expected to wear hair and beard coverings as required. During interview on 07/09/2025 at 2:35 PM, the Director of Nursing (DON) stated she expected all staff who entered the kitchen to wear a hair/beard covering as required. During interview on 07/09/2025 at 2:33 PM, the Administrator stated he expected all staff to wear an appropriate hair covering as required while in the kitchen.

Based on interview, document review, and facility policy review, the facility failed to notify each resident and/or their representative when their resident trust account balance was within $200 of the social security income (SSI) resource limit for 7 of 12 residents whose current balance was over $1,800.00 (Resident (R) 47, 52, 54, 57, 65, 72, 87).The findings included:Review of an undated facility policy, Management of Resident Personal Funds guidelines indicated 3. Notice of Certain Balances a. The facility must notify each resident that receives Medicaid benefits: When the amount in the resident's account reached $200 less than the SSI resource limit for one person and; If the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.Review of an untitled document dated 05/21/2024, indicated Proactive Oversight: The Business Officer Manager's [BOM] Role in Safeguarding SNF [skilled nursing facility] Resident Trust Accounts in skilled nursing facilities, managing resident finances is a critical responsibility, especially concerning resident trust accounts. These accounts hold personal funds for residents who often rely on public assistance programs like Medicaid, which imposes strict resource limits to determine eligibility. A robust internal policy, therefore, is not just good practice - it's essential for compliance and maintaining residents' access to vital care. One such crucial policy dictates the actions a Business Officer Manager (BOM) takes when a resident's trust account approaches, but has not yet exceeded, the Medicaid resource limit. Specifically, when a resident trust account reaches $1,800 - $200 under the typical $2,000 resource limit - it triggers a set of predefined, proactive measures. The document specified, The Business Officer Manager's Protocol at the $1,800 Mark: When a resident's trust account balances reaches $1,800, our company policy directs the Business Officer Manager to initiate the following steps: 1. Immediate Notification and Education: The BOM's first action is to inform the resident and/or their legally authorized representative. This notification is usually in writing, followed by direct conversation. Per the document, 3. Documentation of Communication and Actions: Every step taken - the date of notification, the content of the discussion, any advice given, and the resident/representative's response - is meticulously documented in the resident's financial file. This documentation is crucial for audit purposes and demonstrates the facility's due diligence in managing resident funds according to regulations.Review of facility document, Trial Balance with balances as of 07/07/2025, indicated the facility managed the 71 resident trust accounts. Continued review revealed 12 accounts with a current balance of greater than $1,800. Per the Trial Balance, Resident #87 had a current balance of $1,824.78; Resident #52 had a current balance of $2,439.38; Resident #57 had a current balance of $2,583.92; Resident #72 had a current balance of $1,864.87; Resident #54 had a current balance of $2,490.56; Resident #47 had a current balance of $2,053.08; and Resident #65 had a current balance of $2,592.02.During an interview on 07/09/2025 at 8:11 AM, the BOM stated several resident fund balances exceeded Medicaid asset limit and described ongoing efforts to address the issue.Review of facility documents revealed no evidence to indicate the resident and/or their representative had been notified their resident trust account balance was over $1,800,00.During an interview on 07/09/2025 at 12:15 PM, the Director of Nursing (DON) stated the BOM had been working on the necessary documentation related to resident fund balances. The DON stated the facility expectation was to notify the resident and/or their representative when a resident's funds exceeded allowable limits.During an interview on 07/09/2025 at 1:15 PM, the Administrator stated there was recent transition of staff in the BOM position, which contributed to significant operational issues. Per the Administrator, the current BOM was working to rectify the issue with resident fund balances and acknowledged that the situation could impact the facility's financial stability.

Based on interview, record review, and document review, the facility failed to issue a Notice of Medicare Non-coverage (NOMNC) - Form CMS-10123 to 1 of 3 sampled residents reviewed for beneficiary notification (Resident (R) 60).The findings included:Review of a facility admission Record revealed the facility admitted Resident #60 on 10/31/2024. According to the admission Record, the resident had a medical history that included difficulty in walking, lack of coordination, weakness, and cervical disc degeneration.Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 01/22/2025, revealed the facility assessed Resident #60 with a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. The MDS indicated the resident had not receive any therapy services during the seven-day assessment period.Review of a facility provided list of residents discharged from a Medicare Part A stay with benefit days remaining during the past six months revealed Resident #60 was discharged from a Medicare covered Part A stay on 01/14/2025 but remained in the facility. Resident #60's SNF [skilled nursing facility] Beneficiary Notification Review completed by the facility, revealed the facility initiated Resident #60's discharge from Medicare Part A services when the resident's benefit days were not exhausted. The form indicated the facility issued a SNF Advance Beneficiary Notice (SNF ABN) - Form CMS-10055, but not a NONMC - Form CMS-10123.During an interview on 07/08/2025 at 8:27 AM, the Director of Social Services (DSS) stated he had been providing the NOMNC and the SNF ABN forms to the residents at the facility for the past year. The DSS stated Resident #60 only received the SNF ABN form, as he thought Resident #60 was going to be discharged home, but then Resident #60 decided to remain in the facility. According to the DSS, if he knew Resident #60 was going to remain in the facility, he would have issued both the SNF ABN and the NOMNC.During an interview on 07/08/2025 at 8:43 AM, the Director of Nursing (DON) stated she expected the appropriate forms to be issued when a resident discharged from skilled services and remained in the facility. Per the DON, there was confusion as to whether Resident #60 was going to discharge or remain in the facility.During an interview on 07/09/2025 at 11:10 AM, Administrator stated he expected the appropriate notices to be given to the residents.

Based on observation, interview, and facility policy review, the facility failed to ensure a resident's room had an environment that was safe and homelike environment for 2 of 13 residents sampled for environment (Resident (R) 2 and R57).The findings include:Review of facility policy, Maintenance Service revised 12/2009, revealed Maintenance services shall be provided to all areas of the building, grounds, and equipment. Further review of the section noted as Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Review of an undated facility policy, Preventative Maintenance guidelines, revealed under number 5 The designated staff will ensure repairs/replacements are completed within a reasonable time.During observation on 07/09/2025 at 11:10 AM, a missing ceiling tile was observed in R2's room.During a concurrent observation and interview on 07/09/2025 at 10:39 AM, a hole was observed in the wall of R57's room, which exposed the underlying white sheetrock. Certified Nurse Aide (CNA) 11 confirmed the presence of the hole in R57's wall and stated she had noticed the hole previously. CNA 11 stated she believed the damage to R57's wall might have resulted from the resident's bed being moved up and down.During observation on 07/09/2025 at 11:38 AM, the hole in the wall of R57's room measured approximately two feet in width and had a length with an estimated diameter of four to five centimeters.During interview on 07/09/2025 at 10:43 AM, Registered Nurse (RN) 1 stated when a repair was needed, staff were expected to place a note in the maintenance binder located at the nurses' station. RN 1 stated while it was not the nursing staff's responsibility to inspect residents' rooms for maintenance issues, they were required to report any problems they observed. He stated the hole in the wall in R57's room had been damaged for several weeks. RN 1 further stated the damage occurred with the resident's bed being moved. He reported noting the issue of the hole in R57's room in the maintenance log.During interview on 07/09/2025 at 11:12 AM, the Maintenance Aide stated there had not been a work order completed for the missing ceiling tile in R2's room or for the hole in the wall in R57's room. He said there was also no plan in place to repair those areas, and he had not been made aware of those concerns. Review of the facility's maintenance log for the timeframe 11/25/2024 through 07/09/2025, revealed no documented evidence of a missing ceiling tile in R2's room or of the hole in the wall of R57's room.During interview on 07/09/2025 at 12:00 PM, the Director of Nursing (DON) stated she was not aware of any residents who had missing ceiling tiles and had not been made aware of the hole in the wall in R57's room. She reported the recent resignation of the facility's Maintenance Director contributed to the ongoing challenges of maintaining the facility's repair needs. The DON further stated the issues identified in the resident's room should be addressed and repaired in a timely manner.During interview on 07/09/2025 at 12:52 PM, the Administrator explained the facility had experienced instability with its maintenance department. He said two Maintenance Directors had left the position unexpectedly. The Administrator reported staff were to submit a maintenance request, either verbally or in writing, and maintenance staff were expected to assess the issue and complete the necessary repairs. He stated all staff were trained to report structural issues so that any damage could be promptly repaired. He further stated he expected all resident rooms to be maintained in good repair. In addition, the Administrator said he believed the missing ceiling tile in R2's room had been removed to repair the ceiling and was never replaced. He also stated the hole in R57's room should have been addressed immediately.

Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts was kept locked when not in the line of sight of the person administering medications. The findings include: Review of an undated facility policy, Medication & Biologicals Storage guidelines, revealed, Guidelines: The facility will ensure all medications will be stored in the medication rooms/carts according to the manufacturer's recommendations and security. Per review, all medications and biologicals were to be stored in locked compartments under proper temperature controls. Continued review revealed only authorized staff were to have access to the keys to locked compartments. Further review revealed during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.During observation on 07/07/2025 at 11:29 AM, a medication cart was observed left unlocked and parked between rooms [ROOM NUMBERS]. Per observation, the residents' room doors were closed. Further observation revealed two packages of medications were noted lying on top of the medication cart.During interview on 07/07/2025 at 11:36 AM, Certified Medication Aide (CMA) 4 stated the medications (lying on top of the cart) were for the residents in room [ROOM NUMBER]. The CMA reported the medication cart should have been locked. CMA 4 further stated anyone could have gotten into the medication cart while it was unlocked and unobserved. During interview on 07/08/2025 at 8:34 AM, the Director of Nursing (DON) stated she expected the nurses and CMAs to lock the medication carts when they did not have the carts in their line of sight. The DON further stated when a nurse or CMA was in a resident's room with the door shut, the medication cart would not be in their line of sight. During interview on 07/09/2025 at 3:55 PM, the Administrator stated staff were trained so much on how to care for medications and knew medication carts were to be locked at all times. The Administrator stated a medication cart would not be in a nurse's or CMA's line of sight if they were in a resident's room with the door closed, even if the medication cart was directly in front of the room.

Based on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 2 sampled residents (Resident (R) 31) reviewed for urinary catheters. In addition, the facility further failed to ensure a resident's urinary catheter drainage bag was not touching the floor for 2 of 2 residents sampled for urinary catheters (R31 and R93).The findings include: 1. Review of the undated facility policy, Enhanced Barrier Precautions, revealed under Guidelines the facility was to use the guidelines for the prevention of transmission of multidrug-resistant organisms (MDRO). Per review, Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of MDROs that employed targeted gown and glove use during high contact resident care activities. Continued review revealed High-contact resident care activities included: dressing; bathing; transferring; and providing hygiene for residents. Further review revealed additional high-contact resident care activities included: changing linens; changing residents' briefs or assisting them with toileting; device care or use; and urinary catheter use. Review of the admission Record for R31 revealed the facility admitted the resident on 10/26/2024, with a medical history that included diagnoses of chronic kidney disease and retention of urine. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/12/2025, revealed the facility assessed R31 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Continued review of the MDS revealed the facility assessed R31 as having an indwelling catheter and to require substantial/maximal assistance with toileting hygiene. Review of R31's Care Plan Report revealed a focus area initiated 09/24/2024, that noted the resident was on enhanced barrier isolation related to having an indwelling urinary catheter. Continued review revealed the interventions included for staff to implement enhanced isolation precautions per the facility's guidelines (initiated 09/24/2024). Observation on 07/08/2025 at 2:06 PM, revealed Certified Nurse Aide (CNA) 13 transferred R31 from a wheelchair to the bed without wearing a gown as required for EBP. During interview on 07/08/2025 at 2:12 PM, CNA 13 stated she was not aware R31 required EBP. The CNA acknowledged the only personal protective equipment (PPE) she had worn during R31's transfer was gloves. During interview on 07/09/2025 at 12:19 PM, the Director of Nursing (DON) stated if close contact occurred during a resident transfer, as identified as on EBP, staff should wear appropriate PPE, which included a gown and gloves. During interview on 07/09/2025 at 12:43 PM, the Administrator stated he expected staff to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for all types of precautions. 2. Review of the admission Record for R93 revealed the facility admitted the resident on 05/08/2025, with a medical history that included a diagnosis of benign prostatic hyperplasia. Review of the admission MDS Assessment, with an ARD of 05/15/2025, revealed the facility assessed R93 as having a BIMS score of four out of 15, which indicated severe cognitive impairment. Further review of the MDS revealed the facility assessed R93 to have an indwelling catheter and to require substantial/maximal assistance with toileting hygiene. Review of R93's Care Plan Report revealed a focus area initiated 05/20/2025, that noted the resident had potential for complications related to an indwelling urinary catheter. Further review revealed the interventions included staff to provide catheter care as per the facility's policy (initiated 05/20/2025). During observation on 07/06/2025 at 10:23 AM and 10:51 AM, R93's catheter bag was observed in a privacy bag that was lying on the floor next to the right side of the resident's bed. During interview on 07/06/2025 at 10:52 AM, CNA 8 confirmed R93's catheter drainage bag was lying on the floor. The CNA explained the hook to hang R93's catheter drainage bag broke on 07/05/2025, was not replaced and that was why the catheter drainage bag was lying on the floor. CNA 8 stated R93 could obtain an infection from the catheter bag lying on the floor. During interview on 07/06/2025 at 11:38 AM, Licensed Practical Nurse (LPN) 7 stated she was not aware R93's catheter drainage bag was lying on the floor. The LPN further stated R93 could get an infection from the catheter drainage bag being left lying on the floor. During interview on 07/08/2025 at 9:02 AM, CNA 9 stated if the hook to hang R93's catheter drainage bag was broken, she would use a hook and loop fastener on the catheter drainage bag to secure it up off the floor and then notify a nurse. During interview on 07/08/2025 at 2:07 PM, the DON stated she expected a resident's catheter drainage bag to be up off the floor and it should never be left lying on the floor. The DON reported if a CNA found a resident's catheter drainage bag on the floor, they should report that information to a nurse since it could cause a potential for an infection. The DON further stated the facility did not have a policy that addressed placement of a resident's urinary catheter drainage bag. During interview on 07/08/2025 at 4:18 PM, the Administrator stated he would be concerned if a resident's catheter drainage bag was left lying on the floor. He reported he expected every staff member that entered a resident's room to ensure a resident's catheter drainage bag was not lying on the floor and notify a clinical staff member if it was on the floor so that issue could be corrected. During interview on 07/09/2025 at 5:45 PM, the Staff Development Coordinator (SDC) reported she also functioned as the facility's Infection Preventionist. She stated she would not expect a resident's catheter drainage bag to be left lying on the floor. The SDC said if staff found a resident's catheter drainage bag lying on the floor, she expected staff to pick it up and alert a nurse to have the drainage bag replaced. She further stated if the hook on the drainage bag was broken, she expected staff to also alert a nurse regarding that concern.

Based on interview, personnel record review, review of website Kentucky Online Offender Lookup (Kentucky Offender Search - Kentucky Department of Corrections - Offender Online Lookup System, review of the Kentucky Statutes (https://apps.legislature.ky.gov/), review of the Kentucky Board of Nursing online licensure validation (kbn.ky.gov), and review of the facility's policy the facility failed have to have an effective system to ensure individuals contracted or hired had pre-employment checks completed for 18 of 18 personnel files. Pre-employment checks were either missing; not fully completed; completed after employment began; or the checks were not dated when completed for: the State nurse aide abuse registry, the Kentucky Adult Caregiver Misconduct Registry (KACMR), and/or criminal background checks. The findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, not dated, revealed the facility provided protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Staff included employees and contractors who provided care and services to residents on behalf of the facility. The facility's abuse prohibition plan included: screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. Screening included background checks should be conducted on potential employees and contracted staff and the facility would maintain documentation of proof that the screening occurred. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long-term care facility was to, Query as to whether the prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel files for completion of the criminal background checks revealed the facility did not complete criminal background checks for 14 of 18 employees: agency Certified Nurse Aide 9 (CNA9) hired 10/01/2024; CNA10 hired 03/05/2024; CNA11 hired 11/12/2024; CNA12 hired 08/28/2024; Certified Medication Technician (CMT) re-hired 11/28/2023; Licensed Practical Nurse (LPN) 5 hired 10/29/2024; Registered Nurse (RN)1 hired 10/29/2024; Physical Therapist (PT2) hired 10/25/2024; Admissions Director hired 08/05/2024; Laundry Aide (LA)1 hired 08/13/2024; LA2 hired 09/17/2024; Transitional Care Coordinator (TCC) hired 10/15/2024; Activities Assistant hired 11/12/2024; and, the Activities Director hired 04/01/2024. 2. Additionally, the facility did not complete criminal background checks for other states of residence for two of 18 employee files reviewed: CNA11 for Ohio, and the Activities Director for Indiana. 3. Review of the personnel files for completion of the State Nurse Aide (NA) Abuse Registry checks revealed checks were not completed for nine of 18 files reviewed: Activities Assistant, Activities Director, Admissions Director, LA1, LA2, PT2, TCC, CMT, and LPN5. 4. Additionally, the NA Abuse Registry checks completed for Unit Manager (2) hired 10/10/2023 was not completed until 11/21/2023. 5. Continued review of the NA Abuse Registry checks revealed the checks completed were not dated for the date of the check for five of 18 personnel files reviewed: agency CNA9, CNA11, CNA12, RN1, and the Housekeeper. 6. Review of the personnel files revealed the facility did not complete the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks for three of 19 employees: CMT, agency LPN1, and CNA10. 7. Additionally, the KACMR checks were completed late for two of 18 files reviewed: UM2's (hired 10/10/2023) KACMR check was dated 11/21/2023; and the Housekeeper's (hired 01/09/2023) KACMR check was dated 04/26/2023. 8. Continued review of the personnel files revealed the KACMR checks completed did not have the date of completion for 12 of 18 employees: agency CNA9, CNA11, CNA12, LPN5, RN1, Activities Assistant, Activities Director, Admissions Director, LA1, LA2, TCC, and PT2. In interview with the Human Resource (HR) Manager on 11/19/2024 at 8:28 AM with the Administrator present, the HR Manager stated she began employment at the facility on 01/18/2024 as the HR Manager. She stated the facility transitioned to another company on 05/01/2024. She stated she was unsure the reason the date did not print on the KACMR checks. The HR Manager stated if an employee lived in another state such as CNA11, she checked their background on the MyCase website. In continued interview with the HR Manager, on 11/19/2024 at 8:28 AM, she stated she did not print the results of the checks for Ohio or Indiana, including CNA11's check. She stated she could not validate that the checks were completed before she began employment with the facility. Additionally, the HR Manager stated employees who were not nurse aides, including PT2 and the Activities Assistant, did not have the State NA Abuse Registry checks. She stated she was not aware of how to complete the NA abuse registry checks and thought it was completed through the OIG Exclusions List. She stated the purpose of the NA abuse registry checks was to ensure (employment applicants) had not hurt anybody. She also stated the purpose of the KACMR checks was to ensure an applicant did not have abuse of any kind. The HR Manager stated the purpose of the background checks was to make sure the facility had qualified applicants to serve residents the best way they could. She stated if any of the checks were not completed, the facility could hire unqualified applicants, and somebody could get hurt. Observation during interview with the HR Director on 11/19/2024 at 8:28 AM, revealed the surveyor checked a State NA abuse registry check on the website with the HR Director. The search returned results with the current date visible on the website. Additionally, the results could be printed or downloaded. Both options also reflected the date of the search. In continued interview with the HR Manager on 11/21/2024 at 1:08 PM, she stated that when she began employment, she received about a day and half of training, and was told the [NAME] President of HR and Corporate Director were also new. In interview with the Administrator on 11/21/2024 at 1:53 PM, he stated when the HR Manager began employment with the facility there was no corporate HR director in the role. The Administrator stated the HR Manager knew not to hire anyone with a criminal background. He stated the pre-hire employment checks were extremely significant as we do not know the people who applied. He also stated the pre-hire checks provided insight to who the individuals were, what they had done and who they were in the past. He further stated the pre-hire checks should be completed before orientation with the facility. 37182

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to implement care plan interventions to prevent falls for two of three sampled residents, Resident (R)1 and R2. Both R1 and R2 falls prevention interventions included colored tape on the resident's call light, however the call lights did not have colored tape for multiple days of the survey. The findings include: 1. Review of the facility policy Fall Prevention & Management Program not dated, revealed if a high fall risk was identified, the facility would develop a care plan to address the risk. Interventions would be monitored for effectiveness. Review of the facility policy Post Fall Management Guidelines not dated, revealed the Program would provide applicable interventions to prevent falls. If a fall occurred other interventions would be executed to prevent another fall as much as possible. The program included implementation of person-centered interventions to decrease the incidence of falls. Review of the clinical record for Resident (R)1 revealed the facility admitted the resident on 01/22/2021 and readmitted the resident on 04/10/2024. Diagnoses included dementia, depression, impulse disorder, and repeated falls. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of nine out of 15 and determined the resident was cognitively intact. Review of facility care plan for R1 revealed after the resident fell on [DATE] a new falls intervention added for bright orange tape to call light, dated 10/10/2024. Observation of R1 on 10/16/2024 at 10:16 AM and 10/17/2024 at 9:48 AM, revealed no colored tape on the resident's call light. In interview on 10/16/2024 at 10:20 AM with R1, he stated the call light never had colored tape on it. In interview on 10/17/2024 at 11:02 AM, with Licensed Practical Nurse (LPN)1 revealed colored tape on R1's call light was to keep the call light more visible, for the resident to see it. The LPN stated if the resident did not have tape on his call light according to the care plan, the resident could fall. On 10/17/2024 at 11:35 AM, interview with Certified Nurse Aide (CNA)4 revealed she was unsure when she last saw the tape on the R1's call light, however there was no tape on the call light today. She stated she was unsure who put the tape on the call light. She stated the colored tape was to get the resident's attention to use the call light. The CNA stated if the tape was not on the call light, the resident would not use the call light and try to get up by himself. In interview on 10/17/2024 at 1:38 PM, with CNA6 revealed the tape on R1's call light was so the call light would stand out. She stated if the tape was not on the call light the resident might not see the call light. She stated she did not receive in report when she came on duty the resident was to have tape on his call light. On 10/17/2024 at 3:47 PM, interview with the MDS Coordinator revealed if a resident fell the intervention put in place at the time of the fall was completed by the Unit Manager (UM) and entered into the care plan. She stated the bright tape helped identify the call light and if the tape was not present the call light would not stand out to the resident. In interview on 10/18/2024 at 8:43 AM, UM1 stated when R1 fell on [DATE] she placed the orange tape on the resident's call light as a new fall intervention. She stated the tape was for R1 to see the call light more and as a reminder to use the call light. She stated although she rounded on residents she was not able to look at every resident's interventions and relied on the nurses to catch if the tape was missing. She stated she was informed yesterday by staff the tape was not on the call light, which increased R1's risk for falls. The UM further stated the tape was put in place to prevent a fall or reduce the risk of falling. In interview on 10/18/2024 at 9:41 AM, the Director of Nursing (DON) stated after R1 fell on [DATE] tape was placed on his call light so the resident could see the call light and prompt him to use it before getting up. She stated if the tape was not on the call light, the intervention would not be effective as the resident would not have the prompt to use the call light. She stated the tape was a care plan intervention to prevent a fall and was the nurse's responsibility to ensure the intervention was in place. The DON stated the Unit Managers completed rounds to check falls interventions were in place, although the rounds were not documented. The DON further stated R1 was impulsive and hoped the tape prompted him to use the call light. In interview on 10/17/2024 at 10:41 AM, the Executive Director stated if the tape was not on the resident's call light, the resident may not see the call light and may not use it. He stated the resident's care plan included interventions to try to prevent falls. 2. Review of the facility policy Fall Prevention & Management Program not dated, revealed the facility would develop a care plan to address a high fall risk if identified. Interventions would be monitored for effectiveness. Review of the facility policy Post Fall Management Guidelines not dated, revealed the Program provided interventions to prevent falls. If a fall occurred, other interventions would be used to prevent another fall. The program included implementation of person-centered interventions to decrease the incidence of falls. Review of the clinical record for Resident (R)2 revealed the facility admitted the resident on 02/28/2024 with diagnoses of pain in left hip, low back pain, urinary tract infection (UTI), and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 13 out of 15, and determined the resident was interviewable. Review of the facility investigation for a fall on 06/20/2024 revealed a new intervention for bright tape to call light. Review of the care plan for falls revealed an intervention for bright tape to call light, dated 07/25/2024. Observation of Resident (R)2, on 10/16/2024 at 10:20 AM, 10/17/2024 at 10:57 AM and 2:56 PM, revealed the resident's call light did not have colored tape on it. In interview on 10/16/2024 at 10:20 AM and 2:56 PM, R2 stated his call light never had tape on it. In interview on 10/17/2024 at 1:21 PM, Certified Nurse Aide (CNA)5 stated she never saw colored tape on R2's call light in the several weeks she was working at the facility. She stated no one informed her R2 should have tape on his call light. She stated if the tape was not on the resident's call light the resident would not be able to see the call light. On 10/17/2024 at 2:14 PM, interview with Licensed Practical Nurse (LPN)2 revealed R2's care plan intervention for bright tape to his call light was for the resident to easily find the call light. She stated if the resident did not see the call light he could not use it and would not be able to notify staff when he needed assistance. In interview on 10/17/2024 at 3:11 PM, LPN3 stated she did not recall seeing tape on R2's call light. She stated the care plan intervention for tape was for the resident to see it easily. She stated if the call light did not have the tape, the resident might not see the call light as easily and would not be able to use it when he needed something. She stated she could not recall if she was told in report if the resident had the tape on his call light. In interview on 10/17/2024 at 3:47 PM, the MDS Coordinator stated residents who fell were discussed in the clinical meeting. She stated she could not recall if R2 was discussed after his fall. She stated the interventions were also discussed in the clinical meeting. The MDS Coordinator also stated if a resident fell a new intervention was put in place at the time of the fall and placed on the resident's care plan. She stated bright tape was to help identify the resident's call light. She further stated if the tape was not on the call light, the call light would not stand out to the resident to use. On 10/18/2024 at 9:41 AM, interview with the Director of Nursing (DON) revealed the tape was placed on R2's call light in June so the resident would see the call light to use it. She stated the facility did not have any audits regarding resident's call lights and the tape on it. She stated if the tape was not on the call light the resident the intervention would not be effective to prevent another fall. She also stated the nurses were responsible to ensure the tape was in place. In interview on 10/18/2024 at 10:41 AM, the Executive Director stated the facility did not have a procedure in place to ensure the tape was on R2's call light. He stated if the tape was not on the call light the resident might not see the call light and could not use it. In interview on 10/18/2024 at 11:11 AM, Unit Manager (UM)2 stated after the resident fell an intervention for color tape to the call light was to make the call light more visible to the resident so he would not try to just get up and walk. She stated if the tape was not on the call light, it would not be as visible to the resident as intended. She also stated once an intervention was in place and added to the care plan, we assume once the intervention was in place there would not be a reason for the intervention to not be in place unless removed. UM2 stated she did not know why the tape was not on the resident's call light.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure access to complete resident clinical records for two of three sampled residents (Residents (R)2, and R3). The facility transitioned 07/01/2024 to a new computer software system and did not have the residents' prior clinical information available for R1 and R2 for information in their electronic health records from the time of their initial admission to the facility until 07/01/2024. The findings include: 1. Review of the facility policy titled Fall Prevention & Management Program not dated, revealed upon admission the nurse would complete a fall risk assessment with the admission assessment to determine the resident's level of fall risk. The nurse would document the resident's fall risk in the resident's records and initiate interventions on the resident's baseline care plan. Review of the facility policy titled Post Fall Management Guidelines not dated, revealed a fall was documented in the clinical record. Review of the clinical record for Resident (R)1 revealed the facility admitted the resident on 01/22/2021 and readmitted the resident on 04/10/2024. R1's diagnoses included Dementia and repeated falls. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of nine out of 15 and determined the resident was cognitively intact. Review of the care plan for R1, dated 07/25/2024, revealed falls interventions were initiated on 06/23/2024. Review of the resident's electronic health record revealed the earliest documentation in the resident's progress notes began 06/26/2024. Observation of R1 on 10/15/2024 at 8:34 AM revealed the resident sat on the side of the bed, with non-skid strips on the floor at the side of the bed. In interview on 10/15/2024 at 8:34 AM, R1 stated he had a few falls at the facility and did not want to discuss them further. In interview on 10/17/2024 at 3:32 PM, the Medical Records (MR) Specialist stated she was not involved in the computer switch over and was not provided any instruction to prepare for the change. She stated the facility was told resident records and information would be available after 05/01/2024 when the facility switched over to another computer system. She further stated the facility was not told they would not have access, otherwise she would have printed information to enter into the new system. She stated any resident who was at the facility before June would not have prior information in the current clinical record. She further stated the medical record was not complete without access to the old system. On 10/17/2024 at 3:47 PM, interview with the MDS Coordinator revealed nothing the facility had in the prior computer system carried over to the new clinical records. She stated she thought records were supposed to carry over to the new system when the facility transitioned. She further stated when the facility transitioned to the new system, there were some resident records that were incomplete and did not have the documentation necessary to complete the MDS during the look- back period, although she could not recall specific residents who were affected. The MDS Coordinator stated the resident's clinical record was incomplete if the information did not carry over from the older system. She stated the medical record's purpose was for the resident's ongoing care. She stated she was not involved to prepare for the transition from one system to another and was not instructed what to do in preparation for the transition. In interview on 10/18/2024 at 8:38 AM, interview with Unit Manager (UM)1 revealed R1's care plan prior to the transition was not copied and uploaded into the new computer system when the facility transitioned from the prior clinical record. She stated R1 admitted to the facility in 2021, however with the transition she was not able to access the record prior to the transition and the record was then incomplete. UM1 also stated if the clinical record was not complete, all the resident's risks and every intervention the facility tried to put into place specialized to the resident was not available and could be harmful to the resident. In interview on 10/17/2024 at 9:41 AM, the Director of Nursing (DON) stated the facility did not have a way to find previous information for a resident prior to the transition to a new computer system. She stated the medical record ensured staff knew what a resident's care was and was provided. She stated if the record was not complete resident care may not be correct or safe. The DON also stated R1's care plan prior to the transition did not transition to the new system and his medical record was not complete. The DON stated the facility was not involved with the transition as it was completed by a third party. On 10/17/2024 at 10:41 AM, interview with the Executive Director revealed the corporate office had the contracts and negotiations for the transition from one computer record to another. He stated the facility was supposed to have information needed to perform their jobs. He stated R1's care plan did not carry over and the facility no longer had access to the prior system. 2. Review of the facility policy titled Fall Prevention & Management Program not dated, revealed upon the nurse would complete a fall risk assessment with the admission assessment to determine the resident's level of fall risk on admission of a resident. The nurse would document the resident's fall risk in the resident's records and initiate interventions on the resident's baseline care plan. Review of the facility policy titled Post Fall Management Guidelines not dated, revealed a fall was documented in the clinical record. Review of the clinical record for Resident (R)2 revealed the facility admitted the resident on 02/28/2024 with diagnoses of pain and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 13 out of 15 and interviewable. Review of the resident care plan revealed the resident at risk of falls with interventions noted. In interview on 10/17/2024 at 3:11 PM, Licensed Practical Nurse (LPN)3 stated the purpose of the resident's medical record was for the facility to know correct dates, documentation, and multiple information for resident safety. She stated there was no way to look back before the change in computer systems to know what the resident may need for care. In interview with the Medical Records (MR) Specialist on 10/17/2024 at 3:32 PM. She stated she was not involved in the computer switch to a new system for resident clinical records. She stated the facility was not told they would no longer have access to the prior records. She further stated R2 had 3 months of records in the prior system and his clinical record was not complete without it. On 10/17/2024 at 3:47 PM, interview with the MDS Coordinator revealed she was not aware the clinical records from the prior system would not be available with the new system. She also stated the purpose of the clinical record was for a resident's ongoing care. She stated if the information did not carry over, the resident's clinical record was not complete. In interview on 10/18/2024 at 9:41 AM, the Director of Nursing (DON) stated R2's clinical record was not complete. She stated there was no way to find previous information when the facility transitioned from one computer system to another. The DON stated the purpose of the medical record was to ensure care was provided to the resident. She also stated if the record was not complete, resident care could be incorrect, or unsafe. In interview on 10/18/2024 at 10:41 AM, the Executive Director stated the current company hired another company to assist in the transition from one record system to another. He stated the system changed on 07/01/2024 to the current computer system. He further stated the facility needed items from the previous record and should be available to the facility. On 10/18/2024 at 11:11 AM, interview with Unit Manager (UM)2 revealed resident clinical records in the prior system included previous doctor appointments and continuation of the resident's care plan. She stated she expected to have access to the resident's notes. The UM stated if the clinical record was not complete the facility would not be able to reference previous falls, see previous progress notes, care plan, or have a baseline of how the resident came to the facility.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards, including expiration dates, and with appropriate accessory and cautionary instructions for two of five medication carts. Observation revealed medications for Resident (R) 66 and R42 were not labeled with an opened date, and medications labeled for R12, R26, and R77 contained different medications than what the medications were labeled for. The findings include: Review of the facility policy titled, Labeling & Storage, undated, revealed all medications and biologicals were to be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. Further review of the policy revealed labels for individual drug containers must include the resident's name, prescribing Physician, name of the medication, prescribed dose, strength and quantity, date drug was dispensed, appropriate instructions and precautions, route of administration and when applicable the expiration date. 1. Review of the face sheet for R12 revealed the facility admitted the resident on 08/10/2015, with diagnoses of dementia, heart disease with a pacemaker and peripheral vascular disease. Review of the medication orders for R12 revealed the resident was prescribed Potassium chloride (medicine used to treat low potassium) extended release (ER) 20 milliequivalent (mEq) two tablets oral, once a day; and Furosemide (medicine used to treat extra fluid in the body) 10 milligram (mg) 1 tablet oral, once a day. Observation on 06/07/2024 at 12:59 PM of R12's medication box labeled potassium chloride 20 mEq (mEq) revealed it contained two individual packaged pills identified on the packaging as Furosemide 20 milligrams (mg), with no resident label. 2. Review of the face sheet for R26 revealed the facility admitted the resident on 10/13/2014, with diagnoses of chronic respiratory failure, cerebral infarction, and heart failure. Review of the medication orders for R26 revealed the resident was prescribed Benzonatate (a medicine used for cough) 100 mg capsule as needed, three times a day; and Carvedilol (a medicine used to treat high blood pressure and heart failure) 12.5 mg tablet, two times a day. Observation on 06/07/2024 at 12:59 PM, of R26's medication box labeled for Benzonatate 100 mg revealed it contained two individual packaged pills identified on the packaging as Carvedilol 25 mg, with no resident label. 3. Review of the face sheet for R42 revealed the facility admitted the resident on 01/18/2022, with diagnoses of dementia, type 2 diabetes, and high blood pressure. Review of the medication orders for R42 revealed the resident was prescribed Admelog SoloStar insulin pen, four times a day via subcutaneous injection based on a sliding scale for blood sugar results. Observation on 06/07/2024 at 12:59 PM, of R42 Admelog SoloStar insulin pen revealed no opened date documented on the pen or its packaging. 4. Review of the face sheet for R66 revealed the facility admitted the resident on 08/27/2021, with diagnoses of type 2 diabetes, and dementia. Review of R66's medication profile revealed the resident was prescribed Flonase nasal spray, one spray, one time a day. Observation on 06/07/2024 at 4:25 PM, of R66's medications revealed the resident had a Fluticasone nasal spray dated as opened on 01/24/2024. 5. Review of the face sheet for R77 revealed the facility admitted the resident on 12/28/2023, with diagnoses of cerebral infarction, high blood pressure, and atrial fibrillation. Review of R77's medication orders revealed the resident was prescribed acetaminophen 325 mg, two tablets every four hours as needed; and folic acid one mg tablet every morning. Observation on 06/07/2024 at 12:59 PM, of R77's medication box labeled acetaminophen 325 mg revealed it contained two individual packaged pills identified on the packaging as folic acid 1 mg, with no resident label. In an interview with Certified Medication Technician (CMT) 1 on 06/07/2024 at 3:00 PM, she stated the facility switched pharmacy providers in the past couple of weeks, and the medication from the previous pharmacy was still being used due to the abundance of supply. She stated it was important to label medications when opened so residents did not receive expired medications that could cause them adverse problems. In an interview with Licensed Practical Nurse (LPN) 5 on 06/07/2024 at 1: 24 PM, she stated two weeks ago the facility switched pharmacies and went to a new method of medication administration by using timed dose packs with all the medications contained in them. LPN 5 stated it had been confusing during medication administration because the facility still had an abundance of medication from the previous pharmacy that was in boxes and packaged individually and the new rolls all together. She stated it was important to check each individual packaged resident medication to ensure the resident was receiving the right medication. LPN 5 further stated she attended training on the new medication system, but it was still confusing at times because the facility still had the old system too. In an interview with Registered Nurse (RN) 1 on 06/07/2024 at 3:20 PM, she stated she was an agency nurse and had not worked at the facility for a while but had worked there previously. RN 1 stated she received training on the facility's new medication administration process from the floor manager, and if she had any questions, she could ask a fell ow staff nurse or go to the floor manager. She stated it was important for all medications to be labeled when opened so the nurse could determine the expiration date, which was important for resident safety. In an interview with the Unit 2 Manager on 06/06/2024 at 10:52 AM, she stated the facility had changed pharmacies and the previous supplier had sent a 90-day supply of medications leaving an abundance of medications that were currently being stored in the medication storage room in sealed bags. The Unit 2 Manager stated the facility had contacted the previous pharmacy twice to come pick up the medications; however, they had not done so yet. She stated staff received extensive training from the new pharmacy, and there was a resource book on the unit for reference. The Unit 2 Manager stated staff also had access to a 24-hour help desk if questions or problems with medications arose. She further stated to date she had only heard positive comments from staff using the new pharmacy system and was unaware of any concerns with the new medication administration process. In an interview with the Director of Nursing (DON) on 06/07/2024 at 4:20 PM, she stated the facility was working with a new pharmacy and there had been an adjustment period due to the previous supplier having done a 30-day supply of residents' medications, and now the new supplier did a seven day supply. She stated prior to the end of the previous supplier's contract, they had completed a 90-day refill for residents' medications, meaning the new supplier could not refill the medications until the 90 days was complete. The DON stated the new medication administration went into effect on 06/01/2024, and all staff received extensive training the two weeks leading up to the launch of it. In an interview with the facility's Administrator on 06/07/2024 at 2:40 PM, he stated the previous pharmacy was expected to send a courier to pick up the remaining medications on 05/27/2024, and they had not arrived to do so yet. He stated the facility had contacted the pharmacy regarding the medications and still had not been given a date for reconciliation. The Administrator stated currently the medications were being contained in a locked medication storage room in sealed bags until the previous supplier collected them. He stated the new pharmacy sent a trainer to the facility, and they had completed staff training on an individual basis that was very extensive. In addition, the Administrator stated there was a 24-hour help line and the nighttime nurse supervisors and the unit managers received additional training and were a resource if medication issues arose.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety related to ensuring all food and drinks were checked for timely use and expiration dates. Observation on [DATE] revealed approximately 45 milk cartons in two milk crates dated [DATE]. The findings include: Review of the facility's Dietetic Solutions Operations Policy dated [DATE], under the Cold Storage Areas, revealed staff were to store cold foods until their used by date or expiration date. Observation during the kitchen tour on [DATE] at 11:55 AM, revealed two milk crates with approximately 45 milk cartons dated [DATE] stored in it. In interview with the Dietary Manager (DM), at the time of observation, she stated she had no concerns regarding the milk stored in the walk-in cooler. The State Survey Agency (SSA) Surveyor showed the approximately 45 cartons of out-of-date milk to the DM. She stated milk was delivered to the facility on a weekly basis, sometimes more often if needed. The DM stated she expected staff to rotate the milk on a First In - First Out method to ensure freshness. She said she had several new employees and felt that might have been part of the problem. The SSA Surveyor witnessed the DM create a laminated sign to hang on future crates of returnable products in order for the mistake not to happen again. During interview on [DATE] at 12:04 PM, the [NAME] stated any out of date products were to be removed immediately and the DM notified for direction related to gaining the credit for damaged goods. During an interview with the Administrator on [DATE] at 2:45 PM, he stated the process to ensure fresh food was to rotate the product using the First In - First Out method. He stated a potential for adverse reaction to an expired food or drink could exist. The Administrator stated his expectation of lower level staff was for them to report any concerns to their Dietary Manager.

Based on observation, interview, record review, review of facility policy, and the Center for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent and control the development and transmission of communicable diseases and to implement interventions for protection for three of twelve (12) sampled residents (R), R71, R234, and R238. R71 had an indwelling medical device, a gastrostomy tube (G-tube). Observation revealed however, no Enhanced Barrier Precautions (EBP) signage posted on R71's room door and no Personal Protective Equipment (PPE) supplies available outside the resident's room. R234 had an indwelling medical device, a PEG tube. Observation revealed Licensed Practical Nurse (LPN) 6 turned R234 to his/her side without donning the appropriate PPE. Additionally, observation revealed no EBP signage posted on the resident's door and no PPE supplies located outside the door. R238 had an indwelling medical device, a percutaneous endoscopic gastrostomy (PEG) tube. Observation revealed however, no EBP signage posted on R238's room door and no PPE supplies available at the entrance of the resident's door. The findings include: Review of the facility policy titled, Isolation Precautions Guidelines undated, revealed the facility would take appropriate precautions to prevent transmission of pathogens. Further review revealed upon initiation of isolation precaution, signage for the use of specific PPE was to be placed in a conspicuous location outside the resident's room. Review of the facility policy titled, Enhanced Barrier Precautions, (EBP) undated, revealed precautions were to be taken to reduce transmissions of Multidrug-resistant organisms (MDROs) to staff hands and clothing during high contact care activities. Continued review revealed EBP were indicated for residents with open wounds that required a dressing and for indwelling medical devices regardless of colonization. Per review, the guidelines included an order was to be obtained for EBP precautions for residents with wounds, and/or indwelling medical devices such as feeding tubes, urinary catheters, and tracheostomies even if the resident was not known to be infected or colonized with a MDRO. Further review revealed PPE was necessary when performing high contact care activities such as: dressing; bathing; transferring; providing hygiene; changing linens and briefs; and wound and device care. In addition, review further revealed PPE was to be available immediately near or outside a resident's room. Review of the facility's signage for Enhanced Barrier Precautions revealed providers and staff must wear gloves and a gown for high contact resident care activities. 1. Review of R71's face sheet revealed the facility admitted the resident on 07/22/2022, with diagnoses to include cerebral infarction (stroke), dysphagia (difficulty swallowing), and high blood pressure. Review of R71's order set revealed EBP isolation precautions started on 04/04/2024. Review of R71's Comprehensive Care Plan (CCP) dated 04/04/2024, revealed the facility identified a problem for the resident for risk of infection related to having a G-tube. Continued review revealed the interventions included staff were to utilize appropriate PPE when providing personal and G-tube care for the resident. Observation on 06/07/2024 at approximately 1:35 PM, revealed however, revealed no signage posted on the resident's door, nor of PPE supplies stored outside the room. 2. Review of R234's face sheet revealed the facility admitted the resident on 12/22/2023, with diagnoses to include cerebral infarction (stroke), and dysphagia (difficulty swallowing). Review of R234's order set revealed no documented evidence of an order for EBP. Review of R234's CCP undated, revealed the facility had identified a problem for the resident as risk of infection due to having a PEG tube with a goal date of 09/07/2024. Further review revealed the interventions included staff were to utilize PPE when providing care for the resident, with status listed as current. Observation on 06/05/2024 at 2:15 PM, revealed LPN 6 turning R71 to his/her right side with no gown donned, and only wearing gloves. Additional observation revealed R71's G-tube site to the upper abdominal area had feeding solution and water infusing through the tube per pump. Further observation revealed no signage posted to the resident's room door, not of PPE supplies stored at the door. 3. Review of R238's face sheet revealed the facility admitted the resident on 05/28/2024, with diagnoses to include chronic obstructive pulmonary disease (COPD), and dysphagia (difficulty swallowing). Review of R238's order set dated 05/28/2024, revealed no documented evidence of an order for EBP. Review of R238's CCP undated, revealed the facility had identified a problem for the resident for EBP due to having a peg tube. Continued review revealed the interventions included staff were to utilize appropriate PPE when providing the resident's care. Observation on 06/07/2024 at approximately 1:35 PM, revealed however, no EBP signage posted on R238's room door, nor of PPE stored next to the resident's room door. Further observation revealed PPE stored in proximity at the resident room next door. During interview with Certified Nursing Assistant (CNA) 8 on 06/06/2024 at 1:55 PM, he stated he could not recall receiving any training on EBP from the facility. Further interview revealed CNA 8 was unable to state/identify conditions when EBP precautions were to be taken. During interview with CNA 5 on 06/07/2024 at 1:55 PM, she stated the facility had not provided any training on EBP; however, she had received that training through the agency she worked for. CNA 5 further stated if a resident had a feeding tube there was no need to put on PPE. During an interview with CNA 6 on 06/07/2024 at 2:30 PM, she stated she had received infection control training through the agency she worked for. She further stated it was important to follow signage for isolation, including EBP to prevent transmission of germs to other residents and to protect oneself. During an interview with LPN 4 on 06/07/2024 at 1:50 PM, he stated the facility gave on the spot trainings for new admissions or if a resident's status changed. LPN 4 stated however, he could not really recall receiving EBP training at the facility. Continued interview revealed LPN 4 was unable to identify instances for when a resident was to be on EBPs. He stated, when asked why it was important to follow isolation protocol, that it was important to prevent contamination. Interview with the 200 Hall Unit Manager (UM) on 06/06/2024 at 2:05 PM, she stated it was important to follow EBP isolation for prevention of spreading infection. She stated staff were to follow the in-house training given by the facility. In an addition interview on 06/07/2024 at 2:20 PM, the 200 Hall UM stated signage on residents' room doors let staff know what type of PPE to wear, which not only protected staff but residents as well. During an interview with the Infection Preventionist (IP) on 06/06/2024 at 10:40 AM, she stated it was important to have signage on isolation residents' room doors so staff knew what PPE to wear for resident care, and they received trainings on isolation from her or the Staff Development Coordinator. During an interview with the Director of Nursing (DON) on 06/06/2024 at 10:40 AM, she stated residents were to be placed on EBP if they had any type of medical line or device and R71, R234, and R238 should have been on EBP. In additional interview on 06/07/2024 at 3:20 PM, she stated infection control trainings were performed as needed if any concern was identified. She stated there were scheduled trainings on the facility's computer-based training program. The DON stated all agency staff were given educational packets to review prior to working at the facility. She stated her concern if staff were not following signage for isolation, there would be a risk for spreading infection. The DON further stated her expectation was that staff should know what PPE to use for a resident's care. In an interview with the facility's Administrator on 06/07/2024 at 2:55 PM, he stated his expectations were for staff to stay up to date on all trainings and to follow the trainings and procedures for all isolation precautions, including the use of signage on the residents' door. He stated his concern if staff were not following precaution signage and training, was that they were placing themselves and residents at risk for harm from possible infection.

Based on interview, record review, and review of facility policy, it was determined the facility failed to immediately notify and consult the resident's physician when there was a significant change in the resident's physical status for one (1) of nine (9) sampled residents (Resident #6). Resident #6 complained of sore toes bothering him/her on 11/08/2021 and on 11/27/2021; however, the facility's nursing staff failed to notify the physician of that information. Resident #6 was diagnosed with [CONDITION(S)] of the left great toe on 12/16/2021. The findings include: Review of the facility's policy titled, Change of Condition, dated 11/01/2017, revealed it was the facility's policy to respond to a noted resident change of condition, which included but was not limited to a change in vital signs, blood pressure (BP), pulse, respirations, pulse oximetry, and pain. Further review revealed the physician and resident's representative were to be notified of findings and actions. Review of the document titled, Face Sheet dated 04/07/2022, revealed the facility admitted Resident #6 on 05/16/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #6 had an Attending/Primary Care Physician and an Advanced Practice Registered Nurse (APRN) noted as his/her medical providers. In addition, review further revealed Resident #6 was an established patient of a Doctor of Podiatric Medicine (DPM). Review of Resident #6's Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #6 to have a Brief Interview for Mental Status (BIMS) score of two (2) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the facility also assessed Resident #6 as totally dependent on staff for dressing and personal hygiene. Review of the document, Care Plan Report printed on 04/13/2022 and noted as effective from 05/26/2017 through the present date, revealed the facility care planned Resident #6 to be at risk for impaired skin integrity related to his/her impaired mobility, episodes of incontinence and history of refusing care, history of chronic arterial wound to right heel and vascular wound to top of left foot. Interventions for this problem were noted as staff to observe for and report any signs/symptoms of skin breakdown, [CONDITION(S)], etc. Review of the document, Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review dated 11/09/2021, revealed CNA #9 noted Resident #6 complained of his/her heels and sore toes bothering him/her. Further review of the document revealed it had been signed by CNA #9 and by Licensed Practical Nurse (LPN) #7. Review of the document, Clinical Notes Report printed 04/08/2022 revealed a Nursing Daily Note dated 11/27/2021 completed by LPN #7, which noted Resident #6 was did not feel like getting up in his/her chair due to left foot pain. Interview with CNA #9 on 04/12/2022 at 11:50 AM, revealed Resident #6 had not complained much of pain or anything else. Continued interview revealed Resident #6 had not complained of pain in his/her toes until CNA #9 first noted it on the shower sheet on 11/09/2021. CNA #9 clarified the shower sheet was the unofficial name of the facility's document titled Skin Monitoring: Comprehensive CNA Shower Review on which she had documented Resident #6's complaints of toe pain. Interview with LPN #7 on 04/12/2022 at 11:40 AM, revealed she could not remember whether she reported Resident #6's toe pain to the nurse practitioner or not. She stated usually if something was abnormal (with a resident) she documented it, and then if it happened again, she told the nurse practitioner. Interview with the facility's Director of Nursing (DON) on 04/18/2022 at 12:15 PM, revealed the types of changes in condition which were to be reported to the physician included any new skin areas, and pain. She stated that residents could suffer if the facility missed something and did not report a change in a resident's condition to the physician. Interview with the facility's Executive Director (ED) on 04/18/2022 at 12:25 PM, revealed he expected the nurses to report changes of condition to the residents' medical providers. He stated not reporting a change of condition to the provider could cause the condition to worsen.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure an allegation of misappropriation of the property was thoroughly investigated for one (1) of nine (9) sampled residents, Resident #4. Resident #4 reported his/her debit card as missing to the facility. The facility notified local law enforcement; however, failed to ensure the allegation of the missing debit card was fully investigated. The findings include: Review of the facility policy, Abuse Reporting and Prevention, revised 12/09/2019, revealed the Executive Director was responsible for ensuring the facility's compliance with all applicable provisions of KRS Chapter 209.092 and 483.13. Per review of the policy, as soon as possible, all information related to a report of abuse, neglect, misappropriation of property was to be obtained in writing from all persons with knowledge of the reported incident. Continued review revealed pertinent interviews were to be conducted in a confidential, professional manner with need to know priority of information. Review revealed the interviews might include the resident if possible, the individual reporting the event, all staff on duty at the time of the event, with any probable first-hand information, and other individuals present in the area at the time of the reported incident. Further review revealed the interviews were to be noted in writing and discussed only by those with the responsibility for determining substantiation of the report. Record review revealed the facility admitted Resident #4 on 11/12/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quaterly Minimum Data Set (MDS) Assessment, dated 01/12/2022, revealed the facility assessed Resident #4 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was cognitively intact. Interview with Resident #4 on 04/05/2022 at 10:00 AM, revealed the resident kept his/her debit card in a little wallet in the night stand next to his/her bed. Per interview, Resident #4 stated had probably been gone for a few days before he/she noticed it as missing. According to Resident #4, the bank told him/her the debit card had been used at a hair shop, where the person spent two hundred and thirty dollars ($230.00) of his/her money. Interview revealed the bank reimbursed Resident #4 the money spent at the hair shop. Resident #4 further stated at the time his/her debit card was stolen, he/she had not had a lock box to put important personal things in. Interview additionally revealed Resident #4 had now been provided a lock box and he/she was the only person who had a key to the box, and had not had any further missing items. Interview with the facility's Staff Development Coordinator (SDC), on 04/07/2022 at 9:00 AM, revealed during the investigation of Resident #4's missing debit card, she was not working at the facility, but if she had been, she would try to obtain information from the Certified Nursing Assistants (CNAs) and other people with knowledge of the incident. She stated however, it was important to conduct a thorough investigation to make sure the staff were honest and did not take things from the residents. Further interview revealed it was also important to investigate incidents immediately. Interview with the Social Services Director (SSD), on 04/07/2022 at 9:34 AM, revealed she was not sure if written statements were obtained during the investigation of Resident #4's allegation of his/her missing debit card. The SSD stated the in-house investigations were important to protect residents' rights, rule out the perpetrator, and keep residents safe. She said if in-house investigations were not conducted, the problem would continue to occur and become problematic. Interview revealed the facility still had the responsibility to conduct an in-house investigation regardless of the local law enforcement's involvement. Per the SSD, it had been the responsibility of the facility's previous Executive Director to conduct investigations into incidents/events, and ensure the necessary written statements, and interviews were conducted as required. Further interview revealed the facility started to conduct the investigation into Resident #4's missing debit card; however, once the local law enforcement became involved they told the facility not to interfere with their investigation into the missing debit card. The SSD further revealed therefore, the facility failed to conduct a thorough investigation. In addition, the SSD stated staff talked to Resident #4 and then left it in the hands of the local law enforcement officers. Interview with the Director of Nursing (DON) on 04/07/2022 at 10:07 AM, revealed it was important to obtain the story, investigate, report, and educate the staff to make sure residents were safe. She stated the event regarding Resident #4's alleged missing debit card was reported to the local police department and they created a case. Per the DON, the police interviewed the facility's employees. The DON revealed after the facility released the case to the local police department, the facility did not interview the staff, as the police told the facility not to interfere with their investigation. Continued interview revealed the facility potentially should have investigated employees and not relied on the local police to investigate. According to the DON, it was important the facility investigated the incident to make sure the facility did not have a problem and ensure residents were free from abuse. The DON stated it would have helped the investigation if the facility had taken statements from anyone who knew anything about the incident. Interview revealed if the incident was not investigated thoroughly, the perpetrator could still be employed by the facility and residents would be in jeopardy. Per the DON, the daughter of Resident #4 had informed her of the resident's missing debit card, which she reported to the Administrator. She revealed she then worked with the Social Worker and they asked residents generalized questions. Further interview revealed the facility had not interviewed any of the CNAs because they were told by the police officers it was a criminal investigation, and the police would be interviewing the facility's employees. In addition, the DON revealed the facility unsubstantiated the allegations related to Resident #4's missing debit card based on its limited investigation. Further interview with the DON on 04/13/2022 at 2:10 PM, revealed an in-house investigation had been initiated on 01/25/2021 after the facility became aware of the incident, with interviews of residents and their families initiated; however, facility employee interviews were left in the hands of the local police. The DON stated the facility interviewed Resident #4 and the residents that surrounded his/her unit. According to the DON, the facility did not have any individualized statements other than Resident #4's statement. Continued interview revealed after the incident occurred all alert and oriented residents had been asked if they would like a lock box for their important personal items by Social Services. The DON stated those resident who wanted a lock box were provided a lock box. Per interview with the DON, the facility's previous ED had been responsible for obtaining the statements and interviews necessary for a thorough investigation. She revealed however, the previous ED had not ensured all the necessary interviews and statements were documented. Further, interview revealed the Social Worker asked other residents standardized questions about the abuse which had questions such as had anyone been mean to them, were they afraid to be in the facility, were they mad at anyone at the facility. The DON additionally revealed the interviewable residents had made no complaints related to the standardized questions. Interview with the Executive Director (ED) on 04/07/2022 at 11:00 AM, revealed that; although, he was not employed by the facility when the incident happened, and if he had been, he would open an investigation, obtain statements from the residents and all staff that had been associated with the resident. He stated he would also call the police to come and then follow their suggestions, and call the facility's corporate office personnel. Continued interview revealed the investigation process was important to determine if there was a bad apple in the facility, and discover whether employees had the ability/opportunity to steal. The ED stated he would suspend employees found to have stolen residents' personal items in order to send a message that stealing would not be tolerated. Further, interview revealed the potential if the investigation was not conducted would be whoever had caused the incident would feel it was okay to do it again. The ED further stated he would open an investigation and saw it through to the end, and it would be his investigation and his conclusion. Interview with the facility's Director of Clinical Support Services (DCSS) on 04/13/2022 at 3:20 PM, revealed the initial in-house investigation initiated on 01/25/2021, they looked at the staffing schedules and cameras to see if anyone went in and out of Resident #4's room. Per interview, the schedules reviewed revealed an agency CNA had been assigned to Resident #4 during the time Resident #4's debit card went missing, and the camera video revealed no other people other than staff going in and coming out of the resident's room. She stated the CNA, who had been assigned to Resident #4, was an agency employee and the facility had ensured she did not return to work at the facility. According to the DCSS, the facility and Resident #4 had suspected the agency CNA had been the person who had taken the debit card. The DCSS revealed the facility interviewed Resident #4 and other interviewable residents, therapy and housekeeping staff; however, had not interviewed interviewed the CNAs. Continued interview revealed a police officer interviewed the facility's employees, and did not have concerns. The DCSS stated however, the police officer had not wanted the previous Executive Director to interview the facility's employees because that would interfere with their police investigation. Interview revealed the DCSS thought if the police told the facility staff not to interfere then they could not interfere and the police had better experience in investigation matters like that. Further interview revealed after the incident the facility implemented a full plan of correction, re-educated the facility's employees on abuse and neglect, checked residents' lock boxes and ensured each lock box had a key. The DCSS revealed the facility was not able to provide written evidence of interview of Resident #4 and other interviewable residents, therapy, and housekeeping staff; however, those interviews should have been in writing. In addition, the DCSS stated the bank issued a new debit card to Resident #4.

Based on interview, record review, and review of facility policies, it was determined the facility failed to implement the resident's Comprehensive Person-Centered Care Plan for one (1) of nine (9) sampled residents (Resident #5). Resident #5 was care planned to be in sitting area while up in wheelchair (w/c); however, the facility failed to ensure staff implemented the resident's care plan intervention. Therefore, Resident #5 sustained three (3) falls from his/her w/c within a thirty (30) day period as a result of being left sitting alone and unattended in his/her room. The findings include: Review of the facility's policy, Care Plan dated 01/23/2012, revealed it was the policy of the facility for all residents to have care plans. Review revealed the resident's care plan provided guidance for all staff caring for the resident and communicated changes in care to all the direct care staff. Further review revealed the resident's care plan was to be initiated at the time of admission. Review of the facility's policy, Falls Prevention undated, revealed through assessment and intervention the facility would provide supervision and assistance to residents in an effort to avoid falls and minimize injury which might result from a resident falling. Additionally, residents identified as being at risk for falls were to have a falls care plan initiated based on each of the individual's risk factors. Review of Resident #5's medical record revealed the facility admitted the resident on 01/31/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the document titled Initial Fall Risk Evaluation dated 02/01/2022 revealed the facility had assessed Resident #5 with a total score of twenty (20), the document noted a resident who scored ten (10) or higher on the Evaluation was at risk. Review of Resident #5's Comprehensive Minimum Data Set (MDS) Admission assessment dated [DATE] revealed the resident required physical assistance of one (1) person to self-perform when transferring. Per review, the Comprehensive MDS Assessment defined transfer as how the resident moved between surfaces. In addition, review of the Comprehensive MDS revealed the resident was totally dependent on others for toileting. Further review of the MDS Assessment revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status score of five (5), indicating the resident was severely impaired cognitively. Review of the document, Clinical Notes Report printed on 04/05/2022 revealed a Nursing Daily Note dated 02/13/2022 at 5:25 PM by Registered Nurse (RN) #1 revealed Resident #5 required assist of one (1) to transfer to bed and to walk with his/her walker to the bathroom. Review of the document, Care Plan Report printed on 04/05/2022 and noted as effective from 02/16/2022 through the present date revealed the facility care planned Resident #5 as at risk for falls related to his/her impaired mobility, and history of falls. Further review revealed the active interventions included were for Resident #5 to be assisted with transfers and ambulation as applicable, and for the resident to be in the sitting area while up in his/her w/c. Review of the document, Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 02/25/2022 at 1:57 PM revealed Resident #5 was found lying on the floor on the right side of his/her w/c which had been facing the television in the resident's room. Continued review of the Nursing Daily Note revealed Resident #5's w/c was noted as directly behind the resident which had been locked with call light on arm of chair. Further review revealed Resident #5's call light had not been on, and the resident stated, I was going to the rest room. Review of the document, Investigation Date dated 02/28/2022 revealed the facility's investigation identified Resident #5 lost his/her balance when getting out of the w/c without assistance. Continued review revealed the facility's investigation determined Resident #5's fall on 02/25/2022 likely occurred due to his/her physical health problems of [CONDITION(S)] and critically low Hemoglobin (Hgb) which had increased Resident #5's confusion. Per review, the facility determined that issue would likely resolve itself as Resident #5's physical health conditions improved. Continued review of the document, Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 03/08/2022 at 2:20 PM by the Staff Development Coordinator (SDC) noting Resident #5 experienced a second unwitnessed fall as Resident #5 was found on the floor in his/her room. Per review, when staff asked Resident #5 how he/she managed to fall, Resident #5 stated he/she scooted to the front of the chair then wiggled his/her way down. Review of the document, FSI - Fall Scene Investigation Report, undated, revealed on 03/08/2022 at 12:45 PM Resident #5 was found on the floor while alone and unattended in his/her room. Further document review revealed just prior to the fall Resident #5 had attempted a self-transfer and slid out of his/her w/c. Continued review of the document, Clinical Notes Report printed on 04/05/2022 revealed a Nursing Clinically at Risk Note dated 03/14/2022 at 5:10 PM by Director of Nursing (DON) revealed the DON would encourage Resident #5 to sit in common area when up to w/c and would continue to monitor. Review of the document Clinical Notes Report printed on 04/05/2022 revealed a Nursing Daily Note dated 03/19/2022 at 5:58 PM revealed RN #1 placed Resident #5 in the common area to finish dinner once his/her granddaughter left. Continued review of the document Clinical Notes Report printed on 04/05/2022 revealed RN #1's 03/19/2022 5:58 PM Nursing Daily Note was the only documented evidence a staff member placed Resident #5 in the common sitting area when up in his/her w/c since Resident #5's facility admission on 01/31/2022 through 03/31/2022. Continued review of the document Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 03/26/2022 at 10:06 AM by RN #1 revealed Resident #5 was loudly calling for help and was found lying on the floor in his/her room. Further review of the 04/05/2022 Nursing Fall Note revealed Resident #5 told staff he/she had been trying to get back into his/her bed. Observation of Resident #5 on 04/01/2022 at 10:30 am and on 04/04/2022 at 7:10 PM revealed Resident #5 was sitting in his/her w/c alone and unattended in his/her room (although the resident had been care planned to be in the sitting area when up in his/her w/c). Interview with Resident #5 on 04/04/2022 at 6:05 PM revealed the resident could not remember falling while residing at the facility. Resident #5 stated his/her memory was not the best. Interview on 04/05/2022 at 11:30 AM with Certified Nursing Assistant (CNA) #2 revealed the place called the sitting area was where a television for residents was located in the community area. Interview on 04/05/2022 at 11:50 AM with CNA #4 revealed she thought residents were placed in the community sitting area near the nurses' station because those residents needed the supervision. CNA #4 stated Resident #5 must be watched because the resident would try to get up out of his/her w/c unassisted. Further interview revealed CNA #4 stated she had seen Resident #5 sitting in his/her w/c in his/her room alone while eating before. In addition, CNA #4 stated Resident #5 got confused, would turn on his/her call light, and then forgot why he/she turned on the call light. Interview on 04/06/2022 at 11:17 AM with RN #1 revealed she told her CNA's if Resident #5 was in his/her room alone and wanted to stay sitting up in his/her w/c, then they should assist the resident to the common sitting area. RN #1 stated she highly recommended that Resident #5 needed someone in his/her room when the resident was tired or in bed as he/she fell when fatigued. Interview on 04/06/2022 at 3:54 PM with the RN Unit Manager (UM) revealed the facility's Interdisciplinary Team (IDT) reviewed residents' falls for the root cause after a resident experienced a fall. The RN UM stated the facility's nursing management was responsible for adding any care plan interventions to prevent further falls for residents after a fall occurred. She stated the nurses knew about any new interventions which were added by the IDT because the nurses signed off on the new interventions and care plan updates when they worked and that indicated their awareness of the new interventions. Further interview revealed the RN UM was aware Resident #5 was at a high risk for falls related to his/her impaired mobility and history of falls and was also aware of the resident's care plan intervention to be in the sitting area when up in his/her w/c. Interview on 04/06/2022 at 4:33 PM with the SDC revealed she was aware of Resident #5 being at a high risk for falls related to the resident's history of falls and impaired mobility. The SDC stated she was also aware of Resident #5's care plan intervention for the resident to be in sitting area when up in his/her w/c. Interview on 04/14/2022 at 2:10 PM with the DON revealed the purpose of the intervention for Resident #5 to be in sitting area when up in his/her w/c in order for staff to supervise the resident. The DON stated she had never personally placed Resident #5 in the sitting area, nor did she recall ever seeing the resident in his/her w/c in the common sitting area. Further interview revealed the DON was not sure the facility would be able to prevent Resident #5 from falling without eyes on him/her twenty-four (24) hours a day seven (7) days a week. Interview on 04/18/2022 at 12:25 PM with the Executive Director (ED) revealed it was the responsibility of his staff to be aware of potential hazards to the facility's residents on a daily basis and to try to mitigate those hazard possibilities. Further interview revealed if the facility staff did not implement a resident's care plan interventions related to falls, then the resident could experience further falls.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure each resident received the necessary supervision and assistance required to prevent accidents for one (1) of nine (9) sampled residents (Resident #5). The facility care planned Resident #5 to be in the sitting area when sitting up in his/her wheelchair (w/c). However, Resident #5 sustained three (3) falls within a thirty (30) day period from his/her w/c when being left alone in his/her room. The findings include: Review of the facility's policy Falls Prevention, undated, revealed its policy was to provide supervision and assistance to residents through assessment and intervention in an effort to avoid falls and minimize injury which might result from a resident experiencing a fall. Additionally, policy review revealed residents identified as at risk for falls were to have a falls care plan initiated based on their individual risk factors. Review of the facility's policy titled Incident Reporting, undated, revealed all incidents that occurred in the facility were to be investigated to ensure appropriate actions were taken to minimize reoccurrence and/or reduce risk of injury. Further review revealed a root cause analysis was to be conducted with the goal of improving resident care/services by preventing or minimizing the chance of reoccurrences. Review of the document Face Sheet dated 04/05/2022 revealed the facility admitted Resident #5 on 01/31/2022 with diagnoses which included: Altered Mental Status, Age-Related Physical Debility, Ataxic Gait, Unsteadiness on Feet, Weakness, History of Falling, Unspecified Dementia, Cognitive Communication Deficit, and Post COVID-19 Condition, unspecified. Review of the document titled Initial Fall Risk Evaluation dated 02/01/2022 revealed a total score of twenty (20) for Resident #5. Further review revealed the document stated, A resident who scored a 10 or higher is at risk. Review of Resident #5's Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 required one (1) person physical assist for self-performance when he/she transferred. Per review, the Comprehensive MDS Assessment defined transfer as how the resident moved between surfaces and to or from the bed, chair, w/c, and standing position; however, excluded to and from the bath/toilet. Continued review of the Comprehensive MDS revealed Resident #5 required total dependence on others for his/her self-performance using the toilet. Further review revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Review of the facility document titled, Care Plan Report, printed on 04/05/2022 and noted as effective from 02/16/2022 through the present survey date, revealed the facility had care planned the resident as at risk for falls related to his/her impaired mobility and history of falls. Further review revealed the active interventions included were for Resident #5 to be assisted with transfers and ambulation as applicable, and for the resident to be in the sitting area while up in his/her w/c. Observation of Resident #5 on 04/01/2022 at 10:30 AM, and on 04/04/2022 at 7:10 PM, revealed the resident sitting up in his/her w/c in his/her resident room alone and unattended with oxygen donned. Interview with Resident #5 on 04/04/2022 at 6:05 PM revealed the resident could not remember falling while living at the facility. Continued interview revealed Resident #5 stated his/her memory was not the best. Review of the document titled Clinical Notes Report printed on 04/05/2022 revealed a Nursing Daily Note dated 02/13/2022 at 5:25 PM by Registered Nurse (RN) #1 revealed Resident #5 required assist of one (1) to transfer to bed and to walk with his/her walker to the bathroom. Review of the document titled Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 02/25/2022 at 1:57 PM revealed Resident #5 was found lying on the floor on the right side of his/her w/c which had been facing the television in the resident's room. Continued review of the Nursing Daily Note revealed Resident #5's w/c was noted as directly behind the resident which had been locked with call light on arm of chair. Further review revealed Resident #5's call light had not been on, and the resident stated, I was going to the rest room. Review of the document titled Investigation Date dated 02/28/2022 revealed the facility's investigation had identified Resident #5 lost balance when he/she got out of w/c without assistance. Continued review revealed the facility's investigation determined Resident #5's fall on 02/25/2022 likely occurred due to his/her physical health problems ([CONDITION(S)], critically low hemoglobin (Hgb) which had increased Resident #5's confusion. Per review, the facility determined this would likely resolve itself as Resident #5's physical health conditions improved. Continued review of the document titled Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 03/08/2022 at 2:20 PM by the Staff Development Coordinator (SDC) revealed a second unwitnessed fall had occurred as Resident #5 had been found on the floor in his/her room. Per review, when staff asked Resident #5 how he/she managed to fall, Resident #5 stated he/she scooted to the front of the chair then wiggled his/her way down. Review of the document titled FSI - Fall Scene Investigation Report, undated, revealed on 03/08/2022 at 12:45 PM Resident #5 was found on the floor while alone and unattended in his/her room. Further document review revealed just prior to the fall Resident #5 had attempted a self-transfer and slid out of his/her w/c. Continued review of the document titled Clinical Notes Report printed on 04/05/2022 revealed a Nursing Clinically at Risk Note dated 03/14/2022 at 5:10 PM by the Director of Nursing (DON) revealed the DON would encourage Resident #5 to sit in common area when up to w/c, and would continue to monitor. Continued review of the document titled Clinical Notes Report printed on 04/05/2022 revealed a Nursing Fall Note dated 03/26/2022 at 10:06 AM by RN #1 revealed Resident #5 was awake and loudly calling for help and was found in his/her room on the floor lying on his/her right side between his/her w/c and the bathroom the opposite direction from the bed, however he/she stated he/she was trying to get back into bed. Interview with CNA #4 on 04/05/2022 at 11:50 AM revealed when residents were placed in the community sitting area near the nurses' station it was because those residents' needed supervision. Per interview, CNA #4 stated Resident #5 had to be watched when up in his/her w/c as he/she would attempt to get up unassisted. According to CNA #4, she had observed Resident #5 sitting up in his/her w/c alone in his/her room while eating. Further interview revealed Resident #5 got confused sometimes and turned on his/her call light, and then forgot why when staff answered the call light. Interview with Registered Nurse (RN) #1 on 04/06/2022 at 11:17 AM, revealed she informed the CNA's working under her to take Resident #5 to the common sitting area if he/she was sitting up in his/her w/c in his/her room alone. Further interview revealed RN #1 highly recommended that Resident #5 needed a person with him/her when in his/her room if the resident was tired or in bed as that was when he/she experienced falls due to being fatigued. Interview with the RN Unit Manager (UM) on 04/06/2022 at 3:54 PM, revealed the facility's Interdisciplinary Team (IDT) reviewed all resident's falls to determine the root cause and nursing management had the responsibility of adding any new interventions to assist in preventing further falls for residents. Per interview, the nurses signed off on any new interventions and care plan updates which indicated their awareness of the new interventions and updates. The RN UM stated she knew Resident #5 was at a high risk for falls related to his/her impaired mobility and a history of falls and was aware of the intervention for the resident to be in community sitting area when he/she was up in the w/c. Interview with the SDC on 04/06/2022 at 4:33 PM, revealed she knew Resident #5 was at a high risk for falls related to his/her history of falls and impaired mobility. Further interview revealed the SDC was aware of the intervention for Resident #5 to be placed in the community sitting area while up in his/her w/c. Interview with the DON on 04/14/2022 at 2:10 PM, revealed the purpose of Resident #5's intervention for the resident to be in the sitting area when sitting up in his/her w/c was in order for staff to be able to supervise the resident. Per interview, the DON stated she had never assisted Resident #5 to the sitting area when up in his/her w/c. The DON stated she could not recall ever seeing Resident #5 in the common sitting area when up in his/her w/c. The DON further stated she was not sure the facility could prevent Resident #5 from experiencing further falls without eyes on the resident twenty-four (24) hours a day seven (7) days a week. Interview with the Executive Director (ED) on 04/18/2022 at 12:25 PM revealed it was his staff's responsibility to be aware of potential hazards to the facility's residents on a daily basis and to mitigate those hazard possibilities.

Based on observation, interview, and facility policy review it was determined the facility failed to implement proper infection control practice to prevent the potential transmission of Covid-19 for eight (8) of nine (9) sampled residents, Residents #1, #3, #4, #5, #6, #7, #8, and #9. A Certified Nursing Assistant (CNA) failed to perform hand hygiene during resident care and staff failed to implement social distancing during a group activity. The findings include: Review of the policy Facility Guidance during Coronavirus Outbreak revealed it was the guidance of the facility to follow resident current care plans, dining and preferences to the ability possible while following Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) Guidance regarding group activities, communal dining and social distancing. Review of CDC guidance Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, reviewed 04/15/2020, revealed facilities should encourage residents to remain in their room when there were COVID-19 cases in their facility or sustained transmission in the community. If there were cases in the facility, the facility should restrict residents (to the extent possible) to their rooms except for medically necessary purposes. The guidance further revealed if residents left their room they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others). Review of the policy Standard Precautions revealed standard precautions were designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized source of infection in healthcare facilities. The policy revealed standard precautions were used for the care of all residents. Further review of the policy revealed hands should be washed immediately after gloves were removed, between residents, when removing a soiled gown, and when otherwise necessary to avoid transfer of microorganisms to other residents or the environment. Observation, on 04/14/2020 at 1:43 PM, revealed the Activities Director seated at a table playing Bingo with three (3) residents, Resident #7, #8, and #9. Resident #6 was seated next to the table eating a snack. Further observation revealed the Chaplain seated at a table in the living room playing Bingo with two (2) residents, Resident #4 and #5. Neither the staff nor residents practiced social distancing. Interview with the Activities Director, on 04/15/2020 at 10:20 AM, revealed all activities should be 1:1 with residents in their rooms. She stated she tried to play bingo in the common area with only Resident #9; however, other residents came to the table and she could not keep explaining why they could not play. The Director revealed the group activity was an infection control issue because of the potential for exposure to COVID-19. Interview with the Chaplain, on 04/15/2020 at 2:45 PM, revealed residents should should maintain a six (6) foot distance from each other to stop the potential spread of coronavirus. The Chaplain revealed the facility held only 1:1 activities for residents; however, additional residents joined the bingo activity on 04/14/2020. He stated he did not try to redirect the residents or get assistance from other staff because it was easier to continue than to tell the residents they could not play. Interview with CNA #3, on 04/14/2020 at 3:05 PM, revealed residents should be seated six (6) feet apart to prevent potential cross contamination of the COVID-19 virus. Interview with CNA #4, on 04/15/2020 at 11:14 AM, revealed she was trained on COVID-19 and infection control and stated staff tried to maintain social distancing among residents by keeping them 6 feet apart and avoid large gatherings. She stated the facility stopped doing group activities, but every now and then the Activity Director tried to do an activity with a smaller group. Interview with the 1st floor Unit Manager (UM), on 04/15/2020 at 1:53 PM, revealed the majority of residents stayed in their rooms and stated staff tried to ensure residents were six (6) feet apart in common areas to prevent the potential spread of the COVID-19 virus. Further interview with the UM revealed she noticed the group of residents that were not social distancing during bingo. According to the UM, the staff and residents were too close together and she asked the Activities Director to wrap it up. She stated the facility normally tried to keep the number of residents in an activity to a minimum. Interview with the Staff Development Coordinator (SDC), on 04/15/2020 at 3:13 PM, revealed the CDC recommended social distancing of six (6) feet as an intervention to prevent the potential spread of COVID-19, and included no communal dining or activities. He stated staff were responsible for ensuring residents were spaced out as best they could. Further interview with the SDC revealed he was aware an issue with infection control during bingo, because residents were seated closer than six feet together. He stated he addressed issues with social distancing and mask adornment with the Activity Director afterwards. According to the SDC, the activity did not coincide with the facility's social distancing practice. Interview with the Director of Nursing (DON), on 04/16/2020 at 7:53 AM, revealed the facility eliminated group activities and communal dining to reduce the potential spread of COVID-19. The DON revealed two (2) residents with dementia [DIAGNOSES REDACTED]. He revealed the facility tried to adhere to CDC guidelines by maintaining a six-foot radius between residents and stated the group activity was an isolated incident. The DON revealed he was not aware of any prior issues related to social distancing during activities. Interview with the Administrator, on 04/16/2020 at 9:48 AM, revealed he noticed the group bingo activity when the surveyor entered the building; however, it was not standard operating procedure. He stated the facility cancelled communal dining and activities, held 1:1 activities in resident rooms, and tried to ensure residents were social distancing six (6) feet apart. The Administrator revealed staff should have redirected the residents who were attending bingo to ensure they were social distancing. 2. Observation, on 04/14/2020 at 2:13 PM, revealed CNA #1 made Resident #3's bed with her bare hands, failed to perform hand hygiene, exited the room, and entered Resident #1's room. The CNA moved Resident #1's over bed table with her bare hands and exited the room pushing the resident in his/her wheelchair to the spa room. Further observation, on 04/14/2020 at 2:22 PM, revealed CNA #1 exited the spa room and returned Resident #1 to his/her room. CNA #1 handed the call light to the resident and adjusted the air conditioner with her bare hands. She failed to perform hand hygiene, exited the room, walked to the nurses station, picked up a binder, and documented care. Interview with the CNA #1, on 04/14/2020 at 2:25 PM, revealed hand hygiene should be performed when entering a resident room, before leaving the room, between resident care, when passing meal trays, and before going to and returning from break. She stated it was important to perform hand hygiene to reduce the risk of cross contamination of germs because residents could get sick. CNA #1 stated she did not perform hand hygiene before she exited Resident #3's room because she was going to toilet Resident #1. She further revealed she did not perform hand hygiene when she exited Resident #1's room because she was getting ready to leave for the day. Interview with CNA #3, on 04/14/2020 at 3:05 PM, revealed staff should wash their hands for at least 20 seconds before entering/exiting a resident's room, between glove changes, and after providing care. She revealed hand hygiene was important for infection control to prevent passing germs between residents. Interview with CNA #4, on 04/15/2020 at 11:14 AM, revealed staff should perform hand hygiene every time they entered/exited a room, when passing meal trays, before donning gloves, and after removing gloves. She stated the purpose of hand hygiene was to prevent cross contamination of bacteria or infection to surfaces and residents. Interview with Licensed Practical Nurse (LPN) #1, on 04/14/2020 at 2:50 PM, revealed hand hygiene should be performed before/after resident contact, before eating, when hands were soiled, and after handling items with bare hands. She stated it was important to perform hand hygiene to prevent residents or yourself from getting sick. Interview with the 1st floor Unit Manager (UM), on 04/15/2020 at 1:53 PM, revealed staff should wash their hands when they entered/exited a room, when providing care, and should utilize hand sanitizer when out and about in the facility. According to the UM, hand hygiene helped prevent the spread of the COVID-19 virus because [MEDICAL CONDITION] could live anywhere, including hands, clothing and hair. The UM revealed she rounded on the unit frequently to ensure staff performed hand hygiene and stated she had not identified any issues. Interview with the SDC, on 04/15/2020 at 3:13 PM, revealed staff should perform hand hygiene before and after resident care, after touching anything, before/after changing gloves, after removing personal protective equipment (PPE), after going to the bathroom, and before/after eating. He stated it was important to perform hand hygiene to prevent cross contamination of germs and potential spread of COVID-19. The SDC revealed he audited daily to ensure staff performed hand hygiene and stated he had not identified any concerns related to hand hygiene. Interview with the DON, on 04/16/2020 at 7:53 AM, revealed a huge part of COVID-19 prevention was hand hygiene and cough etiquette. He stated it was very important to ensure adequate hand hygiene and maintain good standard precautions to prevent the potential spread of disease, viruses, or nosocomial infection to immunocompromised residents. The DON revealed the SDC and UM's consistently audited for hand hygiene and PPE, and corrected potential issues as needed. Interview with the Administrator, on 04/16/2020 at 9:48 AM, revealed he had not identified any issues related to infection control and hand hygiene. He stated he performed walking rounds two to three times a day and felt staff were doing a very good job for the most part. The Administrator revealed it would be a concern if staff failed to perform hand hygiene because of the potential for transmission of the COVID-19 virus.

Based on interview, record review, and a review of facility policy, it was determined the facility failed to have an effective system to ensure one (1) of four (4) sampled residents received adequate supervision to prevent accidents. On 06/20/19, Resident #1, who had a history of [REDACTED]. However, the facility's Maintenance Director unlocked the gate to the secured courtyard, allowing entrance for landscaping personnel, and left the gate unsecured to allow the landscape company access in and out of the area. Subsequently, Resident #1 exited through the unsecured gate without staff knowledge. The resident, who was independently mobile via wheelchair, went across the facility's parking lot to the sidewalk, and was wheeling down the sidewalk away from the facility. A facility staff member, who happened to be walking toward the facility on the same sidewalk, observed the resident. Staff assisted Resident #1 back into the facility and assessed the resident to have no injuries. The facility's failure to ensure residents were provided with adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/21/19, and was determined to exist on 06/20/19 at 42 CFR 483.25 Quality of Care (F689). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 11/21/19. An acceptable Allegation of Compliance was received on 11/25/19, which alleged removal of the Immediate Jeopardy on 07/23/19. The State Survey Agency verified that the facility implemented corrective actions and was in compliance on 07/23/19, as alleged, prior to the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's Elopement policy, undated, revealed the facility would conduct assessments to identify residents at risk for elopement or unsafe wandering. The facility would utilize the assessments to develop individualized approaches and interventions for residents at risk for elopement. Review of Resident #1's medical record revealed the facility admitted the resident on 05/19/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment completed on 03/25/19, revealed the facility assessed Resident #1 to have a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. The assessment also indicated Resident #1 was able to transfer self and use a walker and wheelchair for mobility, requiring only oversight and setup help. In addition, the facility assessed the resident to reject care but exhibited no wandering behaviors. Review of Resident #1's Care Plan, dated 06/14/19, revealed the facility identified Resident #1 to have a history of wandering and exit-seeking behaviors (initial onset not indicated). Interventions initiated for the resident included wearing a wander guard bracelet (an alarm system for exit doors) and for staff to monitor the whereabouts of the resident. Interview with the Assistant Director of Nursing (ADON) on 11/20/19 at 2:46 PM, revealed Resident #1 had a history of [REDACTED]. The ADON stated staff was to monitor wandering residents based on their individual needs, as determined by the facility's interdisciplinary team (IDT). The ADON stated Resident #1 often preferred to sit outside on the secured patio area and the IDT had assessed the resident to be able to do so without staff supervision. Review of a Clinical Note for Resident #1, dated 06/20/19, and the facility's investigation initiated on 06/20/19, revealed the facility readmitted Resident #1 on 06/14/19, after an acute hospital stay related to Paranoia. At the time of the readmission, the facility determined the resident was at continued risk for elopement. Further review of the note and investigation revealed on 06/20/19, Resident #1 had eaten lunch outside in the facility's secured enclosed patio area, and Licensed Practical Nurse (LPN) #2 picked up the resident's lunch tray at approximately 1:30 PM. At approximately 1:50 PM, the facility's Maintenance Director unlocked the gate to the secured patio area to allow a contracted landscaping company access to the secured patio area to work, and left the gate unlocked and unattended to allow the contract company to come and go at will. At 1:55 PM, the facility's security camera showed Resident #1 in the middle of the facility parking lot in a wheelchair going in the direction of the parking lot exit. Continued review of the note and investigation revealed at 1:57 PM, a Nurse Practitioner, who works at the facility, observed Resident #1 on the city sidewalk, approximately 150 feet from the facility, in a wheelchair wheeling away from the facility. At approximately 2:00 PM, staff assisted Resident #1 back to the facility and assessed the resident to have sustained no injury. Resident #1 was dressed appropriately, wearing shoes and a hat. Review of weather archives from Weather Underground for 06/20/19, revealed the temperature was 78 degrees Fahrenheit, and partly cloudy with no rain. The facility's investigation determined the cause of the incident was maintenance staff unlocking the gate and leaving it unsecured, without notifying nursing staff. Interview with LPN #2 on 11/25/19 at 1:45 PM, revealed she was the nurse assigned to Resident #1 on 06/20/19. LPN #2 stated that at approximately 12:00 PM on 06/20/19, she unlocked the door leading out to the secured courtyard to allow Resident #1 to eat lunch on the patio. LPN #2 stated Resident #1 frequently sat outside in the patio area when the weather was nice. The LPN stated the patio area was visible from the nurses' station and she would look out at times to check on the resident. LPN #2 stated she delivered Resident #1's lunch on 06/20/19 and later picked up the tray. The LPN stated Resident #1 continued to sit on the patio after eating lunch. LPN #2 stated the next time she observed the resident after picking up the lunch tray, was when the Nurse Practitioner was bringing the resident back to the unit. LPN #2 stated she was not aware that any landscaping or maintenance work was being done on that day or that the Maintenance Director had unlocked the gate to the patio. LPN #2 stated she thought the patio area was secure, as it normally was, and had no idea that Resident #1 had eloped through an unlocked patio gate until the resident was returned to the unit by the Nurse Practitioner. Interview with the facility Nurse Practitioner on 11/21/19 at 10:35 AM revealed the Nurse Practitioner was leaving the facility on 06/20/19 at approximately 1:45 PM, and observed Resident #1 propelling in a wheelchair on a sidewalk away from the facility. The Nurse Practitioner stated that when she approached the resident and attempted to get the resident to return to the facility, the resident refused to return. The Nurse Practitioner stated she then went back to the facility to get help. Continued interview with the Nurse Practitioner revealed that when facility staff got to Resident #1, he/she continued to refuse to return to the facility. The Nurse Practitioner stated staff had to pull the resident backwards to the facility and inside the building. The Nurse Practitioner stated staff was unaware that Resident #1 had left the secured area until she returned to the facility to obtain assistance. The Nurse Practitioner stated Resident #1 was not hurt or injured when assessed by staff after the incident. Interview with the Maintenance Director on 11/21/19 at 9:50 AM, revealed he had unlocked the gate to the facility's secured courtyard on 06/20/19 to allow landscapers to work in the patio area. According to the Maintenance Director, he was not aware that any resident was sitting in the patio area at the time he unlocked the gate and left it unlocked and unattended allowing the landscaping company access. The Maintenance Director stated therefore, he did not inform nursing staff that the gate was unlocked. The Maintenance Director stated it was routine for maintenance staff to unlock the gate and leave it unlocked for contract staff to work in the courtyard area. The Maintenance Director stated on 06/20/19, when the incident occurred, the gate only had one lock, which was located on the outside of the gate. However, the Maintenance Director stated after the incident occurred an additional lock was placed on the inside of the gate, which nursing staff has a key to, and has to unlock before the gate can be opened. Observation of the secured courtyard and patio area on 11/21/19 at 10:30 AM revealed the area was completely enclosed by a wooden privacy fence, which was equipped with one gate that exited to the facility parking lot. Continued observation revealed a lock was located on the outside of the gate and one located on the inside of the gate, both of which required a key to open. The facility's parking lot exited onto the city street, and the sidewalk, where Resident #1 was located, ran parallel to the city street. Interview with Resident #1 on 11/20/19 at 11:35 AM, revealed the resident recalled the incident that occurred on 06/20/19. The resident recounted exiting through an open gate into the facility parking lot, and down the sidewalk. When asked where he/she was going, the resident replied anywhere but here. An interview with the Administrator on 11/25/19 at 5:20 PM revealed nursing staff informed him of the incident on 06/20/19. The Administrator stated he directed staff to conduct a head count of all residents to confirm their whereabouts, assess Resident #1 for any injury, place the resident on 1:1 supervision, and immediately initiate an investigation. The Administrator stated after investigating the incident the facility determined the resident had eloped from a gate that the Maintenance Director had left unlocked and unattended to allow landscapers access to the secured courtyard. Continued interview with the Administrator revealed after the incident the facility had implemented a double lock system on the courtyard gate, which required both maintenance and nursing staff to unlock the gate before it could be opened, to prevent reoccurrence of the incident. ** The facility implemented the following actions to correct the immediate Jeopardy and deficient practice: 1. Resident #1 was returned to his/her room after the incident. Nursing staff completed a skin assessment on 06/20/19 and found no signs or symptoms of injury. The resident's vital signs were obtained and were within normal limits. The resident was appropriately attired for the weather on 06/20/19 and was wearing a hat. A new Elopement Assessment was completed by a licensed nurse on 06/20/19. The resident's care plan and nurse aide care plan were reviewed and revised on 06/20/19. 2. A licensed nurse completed a new Elopement Assessment on all residents on 06/20/19 to ensure all residents at risk had been identified. Residents identified to be at risk of elopement had their care plans reviewed and revised if needed by a licensed nurse on 06/20/19. Residents with a wander guard had their orders checked by a licensed nurse to ensure both the order to check placement every day and function every week were present on 06/20/19. 3. The Director of Nursing (DON) and Executive Director reviewed the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, and Door Alarm Safety Checks policy on 06/20/19. 4. The Executive Director (ED) developed and reviewed with the DON on 06/20/19 the Gate Policy and Procedure. The new policy and procedure was developed to ensure both Nursing and Maintenance have to be present to open the gate in the Memory Care courtyard and the Meadow courtyard. The gate is equipped with a lock on the inside of the gate and outside. Nursing has a key to the inside lock and Maintenance the outside lock. 5. The Interdisciplinary Team (IDT) was trained by the Director of Nursing prior to the beginning of staff training on 06/20/19. 6. All staff that the facility was able to contact were educated on the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, Door Alarm Safety Checks policy, and Meadow Courtyard and Gate Policy and Procedure either in person or by phone on 06/20/19 by a member of the Interdisciplinary team (IDT). The IDT included Human Resource staff, Payroll, the Dietary Manager, Maintenance, Unit Managers, Social Services, the Business Office Manager, and the Dietitian. Any staff not educated on 06/20/19 will be educated prior to working. 7. All new staff will be educated on the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, Door Alarm Safety Checks policy, Meadow Courtyard and Gate Policy and Procedure in orientation, annually, and as needed. Current staff will be educated annually and as needed. 8. The Elopement binders and picture frames at each door were checked for accuracy by the social worker on 06/20/19. 9. A copy of the Meadow Courtyard procedure was posted at the door leading to the courtyard for staff review. The door at the courtyard was posted with information stating that residents could not be in the courtyard without being monitored as per the care plan. The Licensed nurse holds the key to this courtyard. 10. Social Services or a Nurse Manager will complete the Elopement audit for currently known at risk residents weekly for 26 weeks, then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. Audits will be reviewed with the Executive Director (ED) weekly. 11. A Nurse Manager will audit all new admissions and residents with a change of cognition weekly for 26 weeks, then as recommended by the QAPI Committee. The audits will be reviewed with the DON weekly. 12. The gates in the Meadow and 1B courtyards will be checked by a licensed nurse, to ensure the lock on the inside of these gates is locked, daily for four (4) weeks, then three (3) times weekly for eight (8) weeks, then weekly for eight (8) weeks, and then as recommended by the QAPI Committee. The audits will be reviewed by the DON weekly. 13. A QAPI meeting was held on 06/20/19 related to Resident #1's elopement. Attending the meeting were the Executive Director, the DON, the Medical Director, and Social Services. The Medical Director reviewed the current and new policy and procedures, offered content, and approved the new policies. The DON and ED will present the Elopement Audits for both current and new admissions and the Meadow Courtyard Audits to the QAPI Committee for review and further recommendations monthly for six (6) months to ensure continued compliance, then as recommended by the Committee. ** The state survey agency verified the facility actions to remove the IJ and correct the deficient practice: 1. Review of Resident #1's record revealed nursing staff assessed Resident #1 on 06/20/19 when the resident was returned to the facility and no injuries were noted. Further review revealed the facility provided 1:1 supervision from 3:00 PM on 06/20/19 until 11:45 PM on 06/22/19. Review of Resident #1's care plan revealed the care plan was revised on 06/20/19 and the 1:1 supervision was added. Interview with LPN #2 on 11/25/19 at 1:45 PM and the DON on 11/25/19 at 4:40 PM confirmed that Resident #1 had no injuries after the incident and that the resident was placed on 1:1 supervision. The DON stated Resident #1's plan of care was revised on 06/20/19 and the 1:1 supervision was added. 2. Review of the Elopement assessment dated [DATE] revealed Resident #1 was reassessed by staff for risk of elopement. Further review of Elopement assessments revealed all residents were reassessed on 06/20/19 for their elopement risk. Review of documentation revealed on 06/20/19 a licensed nurse checked all residents with wander guards to ensure that orders to check placement and function were present. A review of the medical records for Residents #1, #4, #5, #6, and #7 revealed elopement risk assessments were completed for these residents on 06/20/19. Interview with RN #3 on 11/25/19 at 1:30 PM and the ADON on 11/20/19 at 2:46 PM revealed they completed the resident Elopement assessments on 06/20/19 and the resident orders for wander guards/placement of the wander guard were present for each resident. 3. Review of documentation revealed the Director of Nursing (DON) and Executive Director reviewed the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, and Door Alarm Safety Checks policy on 06/20/19. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they met on 06/20/19 to review the above policies. 4. Review of the Gate Policy and Procedure dated 06/20/19 revealed the new policy/procedure was developed and signed by the DON and Administrator on 06/20/19. The new policy and procedure stated that keys to the locks on the courtyard gate would be held by Nursing for the inside lock and by Maintenance staff for the outside lock. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they met on 06/20/19 to develop and implement the new Gate policy and procedure. 5. Review of training records revealed the Interdisciplinary Team (IDT) was trained by the Director of Nursing prior to the beginning of staff training on 06/20/19. Interview with the DON on 11/25/19 at 4:40 PM revealed he had educated the IDT on 06/20/19 on the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, Door Alarm Safety Checks policy, and the new Gate policy/procedure. Interview with the ADON on 11/20/19 at 2:46 PM and the MDS Nurse on 11/15/19 at 3:10 PM confirmed they had received education on 06/20/19 on the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, Door Alarm Safety Checks policy, and the new Gate policy/procedure. 6. Review of training records reveal all staff were educated on the Missing Person policy, Elopement policy, Care Plan policy, Door Alarm/Lock policy, Door Alarm Safety Checks policy, and Meadow Courtyard and Gate Policy and Procedure either in person or by phone on 06/20/19 and 06/21/19 by a member of the Interdisciplinary Team (IDT). Interview with LPN #2 on 11/25/19 at 1:45 PM, RN #3 on 11/25/19 at 12:30 PM, LPN #1 on 11/22/19 at 12/20 PM, State Registered Nurse Aide (SRNA) #4 on 11/25/19 at 12:50 PM, SRNA #5 on 11/25/19 at 1:00 PM, and SRNA #6 on 11/25/19 at 1:30 PM confirmed they had received the above trainings. 7. Review of the Education Calendar for the facility revealed that education related to resident elopement had been added to the calendar for all staff. Interview with the Staff Development Nurse on 11/25/19 at 3:25 PM revealed he had started work at the facility on 07/15/19 and his orientation training had included the elopement procedures. 8. Review of documentation revealed the Social Worker checked the Elopement binders and picture frames at each door for accuracy on 06/20/19. Observations of the facility exit doors on 11/25/19 at 2:00 PM revealed residents who had been assessed to wander had pictures in a frame by the door and elopement binders with resident information were at each exit. 9. Observation on 11/25/19 at 2:00 PM revealed a copy of the Meadow Courtyard procedure was posted at the door leading to the courtyard. The door also included signage that residents could not be in the courtyard without being monitored as per their care plan. Interview with LPN #2 on 11/25/19 at 1:45 PM, RN #3 on 11/25/19 at 12:30 PM, LPN #1 on 11/22/19 at 12/20 PM, State Registered Nurse Aide (SRNA) #4 on 11/25/19 at 12:50 PM, SRNA #5 on 11/25/19 at 1:00 PM, and SRNA #6 on 11/25/19 at 1:30 PM revealed all were trained on the courtyard procedure. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they reviewed the audits weekly and no other problems had been identified. 10. Review of audits revealed the facility completed the Elopement audit for all residents at risk for elopement beginning on 06/20/19 and had continued the audits weekly. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they reviewed the audits weekly and no other problems had been identified. 11. Review of audits revealed the facility had used the Elopement audit form to audit new admissions and residents with a change in cognition at least weekly. Interview with RN #3 on 11/25/19 at 1:30 PM revealed he had completed the Elopement audits on new admissions. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they reviewed the audits weekly and no other problems had been identified. 12. Review of the Courtyard Gate audit revealed the gates in the Meadow and 1B courtyards were checked by a licensed nurse, to ensure the locks on the inside of these gates are locked, daily since 06/20/19. Interview with RN #3 on 11/25/19 at 1:30 PM and LPN #2 on 11/25/19 at 1:45 PM, revealed both had checked the gate locks for the courtyard when they were working the Meadow Unit. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM revealed they reviewed the audits weekly and no other problems had been identified. 13. Review of documentation revealed a QAPI meeting was held 6/20/19 related to Resident #1's elopement. Attending the meeting were the Executive Director, the DON, the Medical Director, and Social Services. Continued review of the QAPI documentation revealed meetings were held on 06/18/19, 07/23/19, 08/27/19, and 09/24/19. Review of the 07/23/19 QAPI Meeting Minutes revealed the documentation of the implemented corrective action plan and audit results. The minutes indicated no further concerns had been identified. Interview with the DON on 11/25/19 at 4:40 PM and with the Administrator on 11/25/19 at 5:20 PM confirmed the QAPI meetings were held per the plan with no additional problems identified.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the transmission of communicable diseases and infections for four (4) of six (6) sampled residents, Resident #3, #43, #102, and #261. Observations revealed staff failed to wear Personal Protective Equipment (PPE) in isolation rooms and failed to perform hand hygiene during wound care. The isolation rooms did not have designated receptacles to dispose linens and PPE. Continued observation revealed staff failed to perform hand hygiene when administering medication and the facility failed to ensure staff was supplied with the necessary items needed to perform hand hygiene, such as soap and paper towels. Further observation revealed the facility failed to ensure residents in contact isolation cohabitated with like residents with the same infection, per their policy. In addition, the facility failed to monitor infections in the facility. The findings include: Review of the facility's policy, Transmission Based Precautions, dated 08/08/17, revealed contact precautions were utilized for residents who transmitted disease through contact. PPE equipment used prior to entering the room was gown and gloves, and was to be removed prior to leaving the room. Residents may cohabitate with like diagnoses; otherwise, residents were to be assigned a single room. Review of the facility's policy, Clean Dressing Technique, dated 02/01/12, revealed hands were to be washed before starting, and before/after glove changes, and a non-porous material was to be placed to protect the surface of the wounds. Contamination of supplies was to be avoided through an organized procedure and to ensure items used for the wound treatment were prevented from coming in contact with the bedside table. Further review revealed the procedure was to ensure contaminate of the wound was minimized. Review of the facility's policy, Hand Washing, revised 01/23/12, revealed staff was to perform hand hygiene to prevent the spread of infections. Staff was to perform hand hygiene before and after care of a resident. The noted equipment for hand hygiene was water, soap, detergent, and a disposable towel. 1. Review of Resident #43's clinical record revealed the resident was in contact isolation due to [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA-contagious bacteria) of the sacrum, and was treated with intravenous (IV) [MEDICATION NAME] (antibiotic) 750 Milligram (mg) twice a day. In addition, the resident had wounds to both feet with dressing changes. Observation, on 03/13/19 at 9:11 AM, revealed Resident #43 was in contact isolation and Registered Nurse (RN) #5 entered the resident's room to administer an IV antibiotic without washing her hands. The RN donned gloves after she entered the room but did not don a gown and her shirt came in contact with the resident's arms, sheet, and blankets. RN #5 touched the IV pole, IV machine, table, linens, and the resident with gloved hands and touched her shirt up and down to identify an object in her pocket, reached into her pocket, obtained supplies, and proceeded to clean the rubber port of the IV. RN #5 removed her gloves, washed her hands, and proceeded to touch the handle to the bathroom, touched the door and doorframes, left the room and did not wash or sanitize her hands after having touched the objects. There was no designated receptacle for linen and PPE disposal in Resident #43's room, and RN #5 discarded her soiled gloves in the regular garbage can that was lined with a clear plastic bag. Interview with RN #5, on 03/13/19 at 9:31 AM, revealed hand hygiene was to be performed before and after care with residents in contact isolation. She stated the floor supervisor instructed her that gowns did not have to be worn unless staff had physical contact with the resident in contact isolation. She stated the facility did not have isolation containers to use in resident rooms and normal garbage cans were used to dispose of PPE. She stated she received minimal orientation on infection control, did not complete online training for infection control, and the Staff Development Supervisor (SDS)/Infection Preventionist (IP) did not audit her care and practices. She further stated cross contamination could occur with poor handwashing and not following contact isolation precautions, which could cause other residents to get sick. She further stated staff was responsible to follow handwashing precautions and PPE use for contact isolation at all times, and with every resident, to prevent other residents from getting ill. Observation of Resident #43's wound care, on 03/14/19 at 1:30 PM, revealed RN #2, CNA #3, and CNA #4 donned gowns and gloves, and entered the room and placed dressing supplies of gauze, gauze wrapping, scissors, saline bottle, and a [MEDICATION NAME] bottle on the over bed table that was not cleaned nor was a barrier placed on the table. Resident #43's foot with a dressing that was soiled with a green, brown, and yellow odorous exudate on the outside, laid on the bare mattress. RN #2 placed two (2) white towels under the resident's feet/ankles bilaterally and CNA #3 placed an empty red biohazard bag on the mattress at the foot of the bed. Scissors, which laid on the unclean table, were used to cut off the dressings and RN #2 replaced the scissors onto the resident's table after cutting through the soiled dressings. The soiled dressings were placed into the red biohazard bag on the bed. RN #2 proceeded to clean the heel wounds with saline and gauze without performing hand hygiene and glove change after removing the soiled foot dressings. RN #2 proceeded with soiled gloved hands and placed [MEDICATION NAME] on a sterile gauze and placed the gauze onto the wound bed, and wrapped the [MEDICATION NAME] soaked gauze with the gauze wrap. RN #2 placed the red biohazard bag on the floor, removed the now soiled white towels, and placed them on the floor against the wall, as there was no receptacle in the room for the linen. Resident #43's over the bed table was not sanitized after the treatment was completed. Prior to the dressing change, CNA #3 and #4 changed Resident #42's soiled brief and utilized the restroom to empty the resident's urinary catheter bag into the toilet, which included flushing the toilet using the handle with soiled gloves. Staff did not sanitize the bathroom after use and Resident #43's roommate, Resident #3, used the restroom to toilet. After toileting, Resident #3 washed his/her hands, used a wet paper towel to wipe off the sink, re-wiped his/her hands with the same paper towel, wiped off the handles to his/her walker, placed his/her hands down into the garbage can that contained used PPE and pushed the PPE down into the can, repositioned the garbage can, and placed his/her hands onto the walker handlebars and proceeded to leave the room. Interview with Resident #3, on 03/14/19 at 2:10 PM, whom the facility deemed interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) on 03/02/19, revealed he/she use the bathroom and sink in the room multiple times a day. Resident #3 stated he/she was instructed to wash his/her hands and stated housekeeping cleaned the room once a day. Resident #3 stated he/she was able to take care of his/her own needs with minimal help from staff and frequented all areas of the facility. Resident #3 further stated he/she was unaware [MEDICAL CONDITION] was or if he/she was diagnosed with [REDACTED]. Interview with RN #2, on 03/14/19 at 4:22 PM, revealed she forgot to clean the table before she placed the dressing supplies on it and after, in addition, she stated she never used a barrier, as stated in the policy. She stated the resident's foot should not have been in contact with the mattress due to the drainage, as it contaminated the mattress and she should have cleaned the mattress but did not. She stated she should have sanitized the scissors and should have changed her gloves and performed hand hygiene. The RN revealed if the CNA touched the handle, and it was not cleaned, then Resident #3 could have been contaminated. RN #2 stated she was trained on infection control and contact precautions. She stated it was important to have good infection control techniques in order to prevent the spread of infection. Interview with Unit Manager (UM) #2, on 03/14/19 at 2:45 PM, revealed Resident #3 did not [MEDICAL CONDITION], was independent, actively walked around the facility, attended activities, and ate in the cafeteria. She stated Resident #3 was in a contact isolation room with Resident #43 because Resident #43 was on bedrest and was unable to get out of bed to cause cross contamination. 2. Observation during medication administration, on 03/15/19 at 7:45 AM, revealed RN #7 attempted to wash her hands in room [ROOM NUMBER] but the soap dispenser was empty and she went into the shower room to perform hand hygiene. At 8:08 AM, RN #7 placed a resident's medication tablet into the palm of her hand from the bubble pack, picked up the medication with her fingers, and placed the tablet into a medication cup. RN #7 hands were not sanitized and she was not wearing gloves when she handled the tablet. At 8:30 AM, after medication administration, RN #7 attempted to perform hand hygiene in room [ROOM NUMBER]; however, the paper towel dispenser was empty. RN #7 turned off the faucet with wet hands, obtained paper towels from the shower room, and dried her hands. Continued observation at 8:36 AM, revealed after medication administration in room [ROOM NUMBER], RN #7 was unable to complete hand hygiene in the room due to an empty soap and paper towel dispenser. RN #7 went across the hall to room [ROOM NUMBER]; expressed to the resident she needed to wash her hands, and completed hand hygiene in room [ROOM NUMBER]. Further observation at 8:40 AM, revealed RN #7 wiped her sweaty brow with a paper towel, which soaked through the towel onto her fingertips; however, RN #7 did not complete hand hygiene afterwards and continued medication pass until notified by the surveyor to sanitize her hands after contact with her sweaty brow. Interview with RN #7, on 03/15/19 at 10:06 AM, revealed the facility educated her to complete hand hygiene before and after each resident interaction and stated several rooms were without supplies to complete proper hand hygiene. She stated the environmental department was to provide supplies for hand hygiene but the environmental staff was not present to ask for supplies. The RN stated the medication cart was not equipped with hand sanitizer to use for hand hygiene in between residents. She stated the facility in-services did not include hand hygiene during medication pass. Per interview, medications were not to be touched with bare hands during medication pass, but she placed the tablet in her hand and administered it to the resident. She further stated cross contamination could occur with poor hand hygiene and infection control issues, which could cause the residents to become ill. She further stated it was everyone's goal to keep the residents healthy. Interview with Housekeeper #1, on 03/15/19 at 2:05 PM, revealed she cleaned isolation rooms once a day. She stated the Charge Environment Supervisor checked the levels of the soaps once a week and she ensured paper towels were available. She stated she worked first shift and the facility did not employee second or third shift environmental staff. Interview with the Director of Environment, on 03/15/19 at 3:15 PM, revealed the facility did not have a waste and linen disposal system for the isolation rooms. He stated the linen was put in a regular bag and taken to the linen room by staff and PPE was disposed in the regular garbage cans in the rooms. He stated isolation rooms were cleaned once a day and nursing staff did not have access to the cleaning supplies. He further stated environmental services were not available on the second and third shifts. The Director stated the Lead Supervisor audited availability of hand hygiene supplies once a week for resident rooms, bathrooms, hallways, and general public areas; however, the audits were not recorded and he stated once a week probably was not effective to maintain the needed supplies for infection control in the facility. Per interview, without the proper supplies to perform hand hygiene, the transfer of infections could occur and the residents could become ill. Review of the facility's Routine Housekeeping Audit Tool, undated, revealed the audit tool did not identify supplies readily available, such as paper towels, hand soap, and hand sanitizer to be checked and stocked. Review of the New Admission/Empty Room Check List, undated, revealed the stock of paper towels was audited; however, the hand soap and hand sanitizer was not. Observation of medication administration, on 03/15/19 at 9:20 AM, revealed LPN #1 administered medication to multiple residents without performing hand hygiene before, during, or after each resident contact. LPN #1 took scissors from the left jacket pocket to cut open medication packages without sanitizing the scissors prior to use, and replaced the scissors back in the jacket pocket each time. Interview with LPN #1, on 03/15/19 at 9:40 AM, revealed in-services and annual education on infection control and hand hygiene practices were not completed recently and she was not audited on infection control practices. She stated using scissors to cut open medication packages was an acceptable practice and was not an infection control issue. The LPN further stated everyone was responsible to keep infections from spreading and poor hand hygiene with medication pass could cause residents to become ill. Interview with the UM #3, on 03/15/19 at 10:08 AM, revealed she completed impromptu audits of staff infection control practices during medication administration and general duties. However, she stated it was a long time since any audits occurred and she did not complete education to staff for medication pass. UM #3 stated hand hygiene was to be completed before medications were obtained, before and after medication administration, and touching medication with bare hands contaminated the medication. She stated scissors were to be sanitized before and after use especially if kept in a nurse's pocket. According to the UM, poor infection control practices put all residents at risk for an infection. She stated she was responsible to ensure proper infection control practices were completed and to report issues to the Director of Nursing (DON) so it could be addressed immediately to protect the residents and the facility from infection. Interview with the UM #1, on 03/15/19 at 10:55 AM, revealed hand hygiene was to be completed before and after resident care, and before and after medications were administered. She stated there were no audits conducted to monitor staff's infection control practices during care and medication pass. She stated staff was to maintain proper infection control practices at all times to prevent the spread of infection to other residents and cause a facility outbreak of a disease. She further stated supplies on the unit for hand hygiene was reported to the Environmental Manager. Interview with the SDS/IP, on 3/15/19 at 3:00 PM, revealed staff was educated on hand hygiene, PPE, contact isolation precautions, proper infection control during medication pass, and infection control during wound care, and no issues had been identified during staff audits. The SDS/IP stated annual courses and in-services were provided to staff on infection control practices, and staff was expected to follow the techniques at all times. She stated poor infection control practices were the major cause of infections in facilities and stated residents could die from an infection acquired from a facility. Interview with the Director of Nursing (DON), on 03/15/19 at 12:00 PM, revealed she expected all nursing staff, and staff in general, to perform hand hygiene during medication pass and wound care, and isolation precautions were to be followed at all times to prevent infection. She stated she identified issues with staff's infection practices but was unable to fully address it with staff. 3. Record review revealed Resident #102 was diagnosed with [REDACTED]. Record review revealed Resident #261 was suspected of [MEDICAL CONDITION]; however, laboratory results revealed the resident was negative for [MEDICAL CONDITION]. Observation, on 03/15/19 at 7:35 AM, revealed Resident #102 and #261 resided together in room [ROOM NUMBER]. The center curtain was pulled and Resident #102's area contained a bedside commode, and Resident #261's area was without a bedside commode. Signage at the door noted the room was under contact precautions with PPE available outside of the room. A red biohazard bag was in the regular garbage can. Interview with Resident #102 and #261, on 03/15/19 at 10:45 AM, revealed the residents were told to keep the curtain closed and Resident #102 was told to use the bedside commode for toileting. Resident #261 was instructed to use the normal toilet in the room and to ensure his/her hands were washed well after using the bathroom. Resident #102 stated staff emptied the bedside commode bucket into the regular toilet and he/she continued to have loose stools. Resident #102 stated he/she was on some sort of antibiotic to treat the loose stools and he/she was to stay in the room. Resident #261 stated staff told him/her he/she could leave the room. Interview with UM #1, on 03/15/19 at 11:15 AM, revealed she was aware Resident #102 was positive for [MEDICAL CONDITION] and Resident #261 was negative. She stated she reported this information to the DON and asked for direction and the DON and Administrator stated the residents were to remain together in the room and the curtain pulled to act as a barrier. She stated she was told as long as the residents utilized separate toilets, they could remain together; however, she stated she informed the DON and Administrator the bedside commode would be emptied into the toilet and both residents utilized the same sink. She did not instruct either resident regarding precautions. She further stated a single room was available when she left on 03/14/19 after 7:00 PM; however, the facility expected an admission to the room and held it open. Interview with RN #1, on 03/15/19 at 11:30 AM, revealed she took care of Resident #102 and #261 the past several days and informed the DON of the isolation needs of Resident #102 and her concerns of cohabitation of the residents. She stated on 03/14/19, she was instructed to use the curtain as a barrier and educated the residents on hand hygiene. She stated housekeeping cleaned the room once a day and the residents utilized the same sink. According to RN #1, staff emptied the bedside commode into the toilet and it surely splashed on the surfaces of the toilet, which was an infection nightmare. She stated Resident #261 used the toilet, was frail, and was at a high risk for infection. Per RN #1, she reiterated this to the DON and further stated the family came to visit Resident #261 and were instructed on PPE use and hand hygiene. She further stated she came to the room and found four (4) family members not wearing PPE and one (1) family member sitting on Resident #102's bed eating food. She continued to state the Director of Clinical Support walked onto the floor at the time and she walked her to the room to observe the situation. The RN stated Resident #261 was being moved immediately, and the family was instructed to wash their hands, and instructed on the signs and symptoms of [MEDICAL CONDITION] infection. Interview with the DON, on 03/15/19 at 12:00 PM, revealed she was aware Resident #102 was positive for [MEDICAL CONDITION] and Resident #261 was negative. She stated both were placed in precautionary isolation while awaiting lab results. The DON further stated she directed the curtain for separation and felt this was adequate, and staff instructed the residents on hand hygiene. She stated both residents utilized one sink and supervision was not in place to ensure the residents maintained good practices. Per interview, the DON did not think to move Resident #261 to a separate room after the resident's culture returned as negative. 4. Review of the facility's policy, The Infection Control (IC) Program, dated 05/09/17, revealed the program was to prevent the development and transmission of disease and infection. An objective was to maintain a record of infections and corrective actions taken, and to maintain compliance with Federal regulations. The program was to review and analyze infections, control the spread, and determine corrective actions. Review of the facility's IC Program Packet, undated, revealed the IC Committee was responsible to review and analyze Facility Acquire Infections (FAI), and review and recommend control issues and appropriate action. The Committee was to meet once a month, and review the tracking and make recommendations based on the data acquired with the ongoing monitoring. Further review revealed the facility designated an IC Professional to perform ongoing surveillance, and investigate and document the FAI. Periodic rounds were required to monitor IC practices related to resident care delivery and compliance. Continued interview with the SDS/IP, on 03/15/19 at 3:00 PM, revealed she printed a clinical report daily to review for new infections in the facility. However, she failed to transfer the information to the tracking form on a daily basis to review for trends and locations of infections. She stated she was educated by the Director of Clinical Support to review and track daily on the audit tool for ongoing infection control monitoring for the facility. She stated she did not start the (MONTH) 2019 tracking audit tool and partially completed (MONTH) and (MONTH) 2019 tools. The SDS/IP stated the tracking audit log was a surveillance device to be completed and reviewed daily and she was trying to fill in the sections. She further stated the infection control surveillance was ineffective for the facility. Continued interview with the DON, on 03/15/19 at 12:00 PM, revealed the facility administration was suspicious of cross contamination techniques, issues with infection control, and there was a failure in infection control practice monitoring. She stated cross contamination and exposure to infections placed all residents at risk, as the residents were frail which increased the risk of infection and even death. She stated she looked at the 24 hour reports and clinical summaries written daily, and reviewed diagnosed infections in the facility. However, she stated she did not monitor the Infection Preventionist to ensure she was completing daily monitoring of infections in the facility, and therefore ongoing infection control monitoring was not complete. Interview with the Director of Clinical Support, on 03/14/19 at 11:08 AM, revealed infection control monitoring was incomplete, as it was not completed for January, February, and (MONTH) 2019. She stated therefore, the Infection Prevention and Control Program for the facility was not monitored and the facility was not tracking infections. She stated the SDS was assigned as the IP, but the facility was not monitoring the SDS as the IP. The Director further stated the SDS/IP also failed to report to anyone in the facility that the Infection Prevention Control Program surveillance was not being completed, which put residents at risk and the facility was at risk for infection control issues. Interview with the Administrator and DON, on 03/14/19 at 12:30 PM, revealed neither he nor the DON monitored the SDS/IP for infection control monitoring, progress, and did not review daily or monthly written reports. The Administrator stated the Infection Prevention Control Program surveillance book was not reviewed weekly or reviewed in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The Administrator stated the facility identified issues with infection control practices, which placed residents at risk; however, the facility did not identify issues until the survey was initiated.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective Antibiotic Stewardship Program (ASP) for tracking antibiotic use using the Antibiotic Tracking Tool (ATT), and failed to ensure supervision of the Infection Preventionist (IP) who was responsible for the ASP. The IP did not complete the ATT for January, February, and (MONTH) 2019, and was not supervised for ongoing and accurate account of antibiotic use in the facility. In addition, the facility failed to review antibiotic use monthly at the Quality Assurance Performance Improvement (QAPI) meeting, per policy. The findings include: Review of the facility's policy, Antibiotic Stewardship Policy and Procedure, revised (MONTH) (YEAR), revealed the purpose of the program was to reduce the use of antibiotics, reduce adverse effects, and to improve resident outcomes. The facility was to use the Antibiotic Tracking Tool (ATT) as an ongoing review to analyze the use of antibiotics in the facility and the provider. Further review revealed the antibiotic use was to be reviewed monthly at the Quality Assurance Performance Improvement (QAPI) meeting. Review of the facility's policy, The Infection Control Program (ICP), dated 05/09/17, revealed the objective was to maintain a record of infections, antibiotic use and review, and corrective actions taken to maintain compliance with Federal regulations. The program was to review infections, type of antibiotics used, control the spread, and analyze gathered information daily and monthly. Review of the facility's Infection Control Surveillance Policy, undated, revealed the IC Nurse was to complete the Infection Control Surveillance and the ATT for tracking infections and use of antibiotics. Review of the facility IC Program Policy Packet, undated, revealed the Infection Control Committee (ICC) included an Infection Control Professional (ICP) who was designated to perform ongoing surveillance, investigate and document facility acquired infections (FAI), and track the antibiotic appropriateness prescribed. Review of the Centers for Disease Control and Prevention Core Checklist for Antibiotic Stewardship in Nursing Homes, dated 01/04/19, revealed the leadership support included monitoring whether the antibiotic stewardship policies were followed. The facility's tracking and monitoring use of antibiotics was to include monitoring of clinical assessment documentation, prescribing documentation, and point performance surveys of antibiotic use, and monitor rates of [MEDICAL CONDITIONS], antibiotic resistant organisms, and adverse events due to antibiotic use. Review of the Facility's Assessment Tool, review date 12/31/18, revealed the facility accepted residents with complex medical care that included residents with infectious diseases. The facility offered services and care based on resident needs, which included infection prevention and control. Further review revealed the facility resources to provide competent care daily included ongoing review of the Infection Control and Prevention (ICP) Program. Furthermore, daily and monthly infection rates and antibiotic use was to have ongoing monitoring and review. Interview with the Infection Preventionist (IP), on 03/13/19 at 10:30 AM, revealed when the surveyor requested to review the ASP as part of the IC Program, she stated she was currently updating the information. Interview with the Director of Clinical Support (DCS), on 03/14/19 at 11:08 AM, revealed the ASP tracking of ongoing infections with antibiotic use was incomplete for January, February, and (MONTH) 2019, and therefore the ASP for the facility was not completed daily per the policy for ongoing review and tracking. She stated the Infection Preventionist (IP) was to complete and track, on a daily basis, the use of antibiotics prescribed in the facility. She stated the Antibiotic Tracking Tool (ATT) was to be updated on a daily basis, and reviewed and monitored for tracking and trends. She further stated the Director of Nursing (DON) was to supervise the IP and monitor ATT for ongoing surveillance and completion. However, she stated the DON's lack of supervision contributed to the ASP lack of ongoing surveillance. She stated incomplete tracking and monitoring of the ASP put residents at risk in the facility. She further stated the IP was educated on the IC Program and process as well as the ASP requirements for daily review. The DCS stated the current documentation for antibiotic use was not up to date and was she unsure of the tracking accuracy. Review of the facility's ATT revealed several columns to fill in, which included the resident's name/identifier; room number; admitted ; admit from; onset date; type of infection; signs and symptoms; diagnostic tool used and whether criteria were met; acquired infection source; lab results; x-ray; other contributing factors; prescribing clinician; prescription date; prescription duration; antibiotic name; dose/ change of antibiotic (if needed); follow-up with PC; follow-up with family/resident; and comments/notes. Review of the ATT with the DCS revealed for (MONTH) 2019, the ATT was incomplete. Documentation was not completed for the onset date, signs and symptoms, indicated criteria met, acquired infection source, lab result, x-ray, contributing factors, prescription duration, and type of infection. Review of the ATT, dated (MONTH) 2019, revealed the tracking forms were incomplete. Missing documentation included the type of infection, signs and symptoms, if criteria was met, acquired infection source, lab results, x-ray, contributing factors, prescribing physician, prescription date, duration, antibiotic prescribed, dose, change of antibiotic required, follow-up with PC, and follow-up with family/resident. Review of the ATT forms, dated (MONTH) 2019, revealed the tracking forms were incomplete. Missing documentation included the room number, admitted , admitted from, onset date, type of infection, signs and symptoms, if criteria was met, acquired infection source, lab results, x-ray, contributing factors, prescription date, duration, antibiotic prescribed, dose, change of antibiotic required, follow-up with PC, and follow-up with family/resident. Interview with the IP, on 03/15/19 at 3:00 PM, revealed she relied on a daily clinical report print out for tracking antibiotic use in the facility. However, she stated to properly track and monitor antibiotic use, the information was to be documented on the ATT on a daily basis to review for trends, locations, and proper use of antibiotics. The IP stated the ATT was the facility's surveillance tool and was to be completed and reviewed daily. She stated she did not start the (MONTH) 2019 ATT, and was attempting to catch up and complete (MONTH) 2019, when the surveyor called and requested the information. Per interview, the ATT was partially completed for (MONTH) and (MONTH) 2019. She further stated she was responsible to audit and track antibiotic use daily and report trends immediately to the DON and Administrator for the protection of the residents. The Director of Clinical Support had educated her to review and track daily on the audit tool for the ASP. She further revealed the lack of, or late audit and review of, antibiotic use could cause the residents to become resistant, miss trends of infection control issues, and cause the resident population to become ill. In addition, the IP stated the QAPI committee reviewed the end number audit report but the ATT was not reviewed at the monthly QAPI meetings. Interview with the Administrator and DON, on 03/14/19 at 12:30 PM, revealed neither the Administrator nor the DON supervised the IP to ensure the ASP was up to date and monitored on a daily basis. The Administrator stated at the monthly QAPI meeting, the end of the month audit reports, which contained percentages and numbers on infection rates and antibiotic use, were reviewed. However, the ASP documentation was not brought to the meeting for review and oversight. The DON stated she did not meet with the IP for review to ensure ongoing ASP was appropriately monitored. The Administrator stated ongoing antibiotic surveillance was required to ensure residents were not at risk for harm. The Administrator further stated the facility did not identify issues with ongoing review and surveillance of the ASP until the surveyor requested the ASP information for review. Interview with the Administrator, on 03/15/19 at 4:26 PM, revealed the ASP tracking tool (ATT) was not reviewed daily, weekly, or monthly. He stated the facility relied on the end of the month reports for antibiotic tracking, use, and review; however, he stated the monthly report did not track trends, patterns, residents, or physicians who prescribed. He stated the IP was not adequately supervised to ensure ongoing tracking and monitoring of the antibiotic use in the facility and therefore, the ASP was not fluid, ongoing, or accurate.