Every finding on record at Riverview Health Care Center

Based on observation, interview, and facility policy review, the facility failed to provide housekeeping services to ensure a clean and sanitary environment for 5 of 25 sampled residents (Residents (R)40, R62, R64, R67, and R81). The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed residents had a right to a safe, clean, comfortable and homelike environment. Review of the facility's policy for housekeeping titled, Housekeeping Daily Duties, dated 12/2001, revealed a schedule of what housekeeping staff were to do on each day of the week. Further review revealed the policy stated, All corners and along all baseboards must be dust mopped to prevent buildup. 1. Observation on 02/15/2026 at 11:42 AM, of R640's room, revealed a cracked ceiling tile in the bathroom, as well as holes in the corners of tiles due to the use of the incorrect size. Further observation revealed the flooring in the bathroom was sticking up approximately one inch off the floor, which created a fall hazard for residents. 2. Observation on 02/15/2026 at 11:51 AM, of R62's room, revealed a large brown stain on the ceiling tile in the bathroom. 3. Observation on 02/15/2026 at 11:58 AM, of R64's room, revealed broken ceiling tiles in the bathroom. Continued observation revealed a yellow stain around the caulking on the toilet. In interview with R64 at the time of observation, the resident stated, The stuff around the toilet is yellow and brown and it looks like someone has pissed all over it and it dried. Makes me feel dirty. 4. Observation on 02/15/2026 at 12:38PM, of R67's room, revealed chipped paint on the wall beside the resident's bed. 5. Observation on 02/15/2026 at 12:54PM, of R81's room, revealed wood chipped beside the resident's bed. Further observation revealed an approximate two inch hole in the bathroom ceiling due to the ceiling tiles being the incorrect size. 6. Observation on 02/15/2026 at 1:18 PM, of first floor door labeled, Hazardous Material revealed the door frame had multiple holes in it at the bottom. Further observation revealed a gold/yellow tape over the large holes in the doorframe. In interview on 02/16/2026 at 11:42 AM, the Maintenance Director stated staff used a book on both floors to write down any maintenance issues that needed to be addressed. He said the facility had a system called TELS (a building management and maintenance platform designed for senior living communities to streamline work orders, preventive maintenance, compliance tracking, and asset management). The Maintenance Director stated however, he just checked the books on the floors. He reported, We always check the books on both floors daily to see if there is anything that needs to be done. The State Survey Agency (SSA) Surveyor asked the Maintenance Director if he performed walk throughs of the facility checking for environmental issues, and he stated, Yes, once a month. The Maintenance Director further stated, Currently we are waiting for a part to fix the sink in the kitchen. But, that's the only thing that has been reported to me that needs to be fixed as of right now. During interview with the Housekeeping Manager on 02/16/2026 at 1:12 PM, she stated, Every resident room gets a deep clean once a week and on the days we don't deep clean, we spot clean. She said she instructed her staff to always notify maintenance of anything problems identified needing to be fixed. The Housekeeping Manager reported she went around and helped her housekeeping staff if needed. She further stated she also went around to check that certain rooms and areas got cleaned daily. In interview with the Administrator on 02/18/2026 at 9:32 AM, revealed she was new to her position and had only been in it since December 2025. She said anyone in the facility could put a work order in and it would be sent to maintenance and they would prioritize it. The Administrator reported the facility was still trying to phase out some of the old processes and initiate some new things to help the facility. She stated she expected all environmental issues to be addressed daily in the morning huddle meeting, which was her process for staying on top of issues. The Administrator explained, We use a system called TELS and anyone can place a work order (through it). She reported, My expectation is that work orders will get done in a timely manner, once they are reported to maintenance. The SSA Surveyor asked the Administrator if the facility used TELS for work orders, or the books that maintenance referenced, she stated, We do have both. But the TELS system is what is supposed to be utilized. She further stated she and the maintenance staff did a full walk through of the facility each month to identify anything needing to be fixed.

Based on observation, interview, record review, and policy review, the facility failed to establish and maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 25 sampled residents (Residents (Rs)38, R57, R96, and R102). The findings include: Review of the facility policy titled, Infection Control, revised on 01/30/2026, revealed the facility must maintain infection control practices intended to provide a safe, sanitary, and comfortable environment and to prevent, detect, investigate, and control infections. Per policy review, infection control practices were to apply equally to all residents, personnel, visitors, and volunteers. Continued review revealed the facility was to establish and implement guidelines for Standard Precautions and Transmission-Based Precautions (TBP), including ensuring the availability and accessibility of supplies and equipment necessary to follow those precautions. Further review revealed staff were to be trained upon hire and periodically thereafter on infection control practices appropriate to their job duties. In addition, the facility was to ensure infection control policies and practices were implemented, monitored, and followed through the Quality Assurance and Performance Improvement (QAPI) and Infection Control Committees. Review of the facility policy titled, Enhanced Barrier Precautions, last reviewed on 01/31/2026, revealed the facility was to implement Enhanced Barrier Precautions (EBP) as additional infection control measures to reduce the transmission of multidrug-resistant organisms. Per review, the facility's infection control practices, including EBP, to apply equally to all residents, personnel, consultants, visitors, and volunteers. Continued review revealed when a resident was placed on EBP appropriate signage was to be posted at the resident's room entrance. Policy review revealed the signage was to be posted to inform staff and visitors of the need for and type of precautions, including instructions regarding the use of personal protective equipment (PPE) prior to entering the room. Further policy review revealed residents with chronic wounds and/or indwelling medical devices were required to have EBP regardless of multidrug-resistant organism (MDRO) status. Review of the facility policy titled, Hand Hygiene Policy, effective 06/27/2025, revealed the facility required hand hygiene to be performed by all stakeholders (staff) to reduce the transmission of infectious agents and healthcare-associated infections. Continued review revealed the policy defined hand hygiene as handwashing with soap and water or the use of alcohol-based hand rub. Further review revealed staff were to perform hand hygiene before and after resident contact, before performing aseptic tasks, after removing gloves, in accordance with resident-specific isolation guidelines when indicated, and when hands were visibly soiled. 1). Review of R38's Electronic Health Record (EHR) revealed active physician's orders for EBP, including orders dated 02/10/2026, noting EBP to be followed every shift, days and nights, with nursing staff instructed to provide education and maintain required isolation precautions for the duration ordered. Continued record review revealed R38 was transferred to room [ROOM NUMBER] on 02/13/2026 at approximately 12:00 AM. However, observation on 02/15/2026 revealed despite the ongoing EBP orders, there was no EBP signage or required PPE present outside of room [ROOM NUMBER]. In interview, on 02/15/2026 at 1:15 PM, Unit Manager (UM) 1 stated R38 had been moved to room [ROOM NUMBER] on 02/13/2026 at 12:00 AM. The UM said however, staff failed to move the EBP signage and required PPE products to the resident's new room. The UM further stated staff had been providing care to R38 without following the necessary EBP and PPE requirements from 02/13/2026 through 02/15/2026 at approximately 1:15 PM. In interview, on 02/18/2026 at 10:38 AM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated EBP and PPE should have been transferred immediately when R38 was moved to the new room. The ADON/IP acknowledged uncertainty regarding how that oversight occurred. In interview, on 02/18/2026 at 11:27 AM, the Director of Nursing (DON) stated the EBP signage and required PPE for R38 should have been transferred immediately at the time of the resident's room change. She said she was unable to identify why the EBP signage and necessary PPE had not been moved as required upon the room change. 2). Review of R102's EHR revealed active physician's order for EBP, with an order start date of 03/29/2024, listed as open-ended. Continued review revealed the physician's order directed EBP be followed every shift, days and nights. Further record revealed the EBP order were related to wound care needs, requiring staff to follow infection control practices to reduce the risk of transmission of infectious organisms during resident care. Observation on 02/15/2026 at 12:45 PM, revealed State Registered Nurse Aide (SRNA) 3 entering resident room [ROOM NUMBER] (R102's room) and exiting the room without performing hand hygiene. Continued observation revealed the SRNA then proceeded to enter resident room [ROOM NUMBER] to open a soft drink for that resident. Further observation revealed SRNA 3 handed the soft drink to that resident, and exited room [ROOM NUMBER] without performing hand hygiene. In interview, on 02/15/2025 at 12:50 PM, SRNA 3 stated she had not performed the proper hand hygiene before entering and after exiting residents' rooms. The SRNA reported she should have washed her hands and proper hand hygiene was necessary to prevent the spread of germs from one resident to another. She further stated failure to perform hand hygiene could result in residents becoming sick. 3). Review of R57's EHR revealed an active physician's order for EBP with instructions for every shift, days and nights and the precaution order was active and open-ended. Observation on 02/17/2026 at 10:10 AM revealed however, the signage posted outside R57's room noted the resident was on Contact Precautions and not the ordered EBP. Continued observation revealed Environmental Services (EVS) staff 2 exiting resident room [ROOM NUMBER] (R57's room) and place the cleaning equipment used in that room onto the housekeeping cart without sanitizing or disinfecting the equipment prior to placement on the cart. In interview, on 02/17/2026 at 10:10 AM, EVS 2 stated she had forgotten to sanitize the mop handle after exiting the contact precaution room (room [ROOM NUMBER]). She reported sanitizing the cleaning equipment after use in a contact precaution room was important to ensure the equipment remained clean when used in other residents' rooms. EVS 2 further stated sanitizing the equipment was also important to prevent the spread of germs and potential illness to other residents. 4). Review of R 96's EHR revealed an active physician's order for EBP with instructions for every shift, days and nights. Continued review revealed the precaution order was active and open-ended. Observation on 02/17/2026 at 3:00 PM, revealed SRNA 8 entered resident room [ROOM NUMBER] (R96's room) which displayed an EBP sign. Continued observation revealed SRNA 8 entered and exited room [ROOM NUMBER] without performing hand hygiene. In interview, on 02/16/2026 at 9:04 AM, the Administrator stated failure to follow EBP and proper PPE use could result in the spread of infection to residents. In interview, on 02/16/2026 at 10:45 AM, the DON stated failure to follow EBP and proper PPE use could place residents at risk for acquiring an infection. The DON further stated facility staff were expected to follow all infection prevention and control policies to prevent the spread of germs and potential infection to residents and staff. In continued interview, on 02/18/2026 at 10:38 AM, the ADON/IP stated staff were required to perform hand hygiene upon entering and exiting EBP rooms to prevent the spread of germs, particularly due to the unknown nature of infections that might be present in resident wounds. In additional interview, on 02/18/2026 at 11:46 AM, the Administrator stated when a resident was transferred to a different room, all EBP signage and required PPE were expected to be transferred with the resident. She reported facility staff were expected to know and comply with all applicable policies and regulatory requirements. The Administrator further stated it was the responsibility of facility administration to ensure staff were educated on and adhered to infection prevention and control policies.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain an effective system for documenting the receipt, storage, disposition, and reconciliation of controlled medications in sufficient detail to allow accurate reconciliation for 1 of 25 sampled residents (Resident (R)11).The findings include: Review of facility policy titled, Clinical Medication Controlled Medication, dated [DATE], revealed controlled medications was to remain in the facility after the order had been discontinued or due to residents being discharged . Per review, the controlled medication was retained in the facility in a securely locked area with restricted access until destroyed by two nurse leaders and/or one nurse leader and a consultant pharmacist. Review of the policy, Consultant Pharmacist Services Provider Requirements, dated 01/2023, revealed the consultant was to assist the provider pharmacy to establish a system of records of receipt and disposition of all controlled substance. Per review, the established system produced an accurate reconciliation and account of controlled substance use on a periodic basis. Further review revealed the system assisted in the accounting, destruction and reconciliation of unused controlled substances and non-controlled substances as required by state and federal law. Observation on [DATE] at 9:20 AM, during inspection of the nursing storage room refrigerator located in the first-floor nurses' station, revealed a locked and chained black box contained one vial of Ativan injectable solution labeled for R11. During interview on [DATE] at 9:22 AM Registered Nurse (RN) 2 stated the Ativan medication order for R11 had been discontinued on [DATE]. RN 2 reported the medication should have been sent back to the pharmacy. The RN further stated if the medication had been given it could have caused harm, such as making the resident ill or being ineffective in controlling the resident's seizures. During interview on [DATE] at 9:30 AM, Unit Manager (UM) 8 stated discontinued medications were to be given to the Director of Nursing (DON). She further stated failure to remove discontinued and expired controlled medications created the potential for administration of those medications. She reported which might be ineffective or potentially harmful if given to a resident. In interview on [DATE] at 10:10AM, the DON stated the Ativan medication should have been given to her to put in a locked cabinet until the narcotic medication could have been destroyed as per facility policy. She reported discontinued and expired narcotic medication should not be given to residents, as if given, the medication could be less effective. The DON further stated if not given to her the narcotic medication could have been diverted from the facility. In interview on [DATE] at 10:50AM, UM 1 stated discontinued narcotic medication were to be discarded with two people signing the narcotic sheet and disposing of the medication. UM 1 further reported she was currently trying to get the policy and was not sure what the policy was for disposal of discontinued narcotic medications. She further stated R11's Ativan medication could have been given to another resident, or administered to the resident who could have experienced an adverse reaction because the medication was expired. She further stated the Ativan medication could have been taken out of the facility by someone. In interview, on [DATE] at 11:00AM, the Administrator stated she expected narcotic medication that were discontinued or expired to be destroyed. The Administrator further stated however, she was unaware of the facility's policy and exact time frames for holding and destroying medications. In interview, on [DATE] at 9:23AM, the Pharmacy Consultant (PC) stated he came to the facility monthly to spot check medication carts, medication storage room refrigerators and locked boxes. PC reported however, he did not know the last time he checked the narcotic box in the medication refrigerators. He further stated discontinued and expired narcotic medications were to be added to a control sheet and given to the DON for her to destroy in a reasonable amount of time.

Based on observation, interview, and review of facility documentation, the facility failed to ensure menus were updated and accurately reflected the meals served and failed to ensure residents were informed of meal selections, for 4 of 25 sampled residents (Residents (Rs)4, 17, 48, and 101) and had the potential to affect all residents consuming meals in the facility.The findings include: On 02/17/2026 at 3:00 PM, the State Survey Agency (SSA) Surveyor asked the Administrator to provide a policy regarding menu posting and food substitutions; however, no such policy or procedure was provided. Review of the posted menu available for resident viewing revealed it was dated 07/14/2025 at 10:11 AM. Observation on 02/17/2026 at 10:45 AM, revealed menus were posted on the first-floor bulletin board across from the nurses' station and on hallway bulletin boards. Continued observation on 02/17/2026 at 10:50 AM, revealed the menus were posted on the second-floor bulletin board across from the nurses' station and on hallway bulletin boards. Further observation on 02/17/2026 at 10:55 AM, of the posted menus, revealed the lunch meal was listed as beef soft tacos with flour tortilla, shredded lettuce, diced tomatoes, and shredded cheese. In addition, observation of the menus revealed the alternative meal listed was garlic baked pork chop with sauteed peppers and onions, sliced parsley carrots, Mexican corn, potato wedges, dinner roll, and pineapple tidbits. However, further observation on 02/17/2026 at 11:02 AM, of the meal being served, revealed it was lasagna with meat sauce, cauliflower, dinner roll, and deluxe fruit salad. Continued observation revealed the alternative meal being served was breaded chicken on a bun with mayonnaise, lettuce, and tomato, oven browned potatoes, and deluxe fruit salad. Therefore, the posted menus did not reflect the meal being served on that date. 1). In interview on 02/16/2026 at 11:00 AM, R48, who was bedbound, stated she did not receive menus and was never informed by staff of what meals being served were. She further stated when she asked a Certified Nursing Assistant (CNA), she was always told, I don't know. 2). In interview on 02/16/2026 at 11:12 AM, R101's spouse stated she did not know where to find menus. She further stated she did not know what the meal being served to R101 until it was delivered. 3). In interview on 02/16/2026 at 11:18 AM, R4 stated she did not receive a menu; however, would like to know what the meals being served were before they were delivered to her room. 4). In interview on 02/17/2026 at 9:50 AM, R17 stated he was admitted in December 2025. R17 further stated what was listed on the posted menus were not always what was being served. In interview on 02/17/2026 at 11:35 AM, the Dietary Manager (DM) stated she was responsible for posting menus. She further stated, I am supposed to switch them, and I have not. I guess I just forgot. In interview on 02/17/2026 at 2:40 PM, the Regional Dietitian (RD) stated the facility did not rely on posted menus because department heads were informed of daily meals during the morning huddle. The RD said the unit managers (UMs) were expected to inform staff and residents of what was being served daily. The RD reported if the residents did not know what meals were being served it was because of a breakdown in communication due to staff being informed in the morning huddle. When the SSA Surveyor asked the RD why the correct menus had not been posted, the RD stated the current Dietary Manager (DM) had taken on that role in September 2025, and it was an oversight. In interview on 02/17/2026 at 4:00 PM, Registered Nurse (RN) 1, the Unit Manager (UM) stated she did not post menus on the unit. RN 1 reported she did inform residents sitting near the nurses' station of what the daily meals were. She stated however, she sometimes forgot to inform other nurses and CNAs of that information. She further stated therefore, some residents might not receive the information on the meals being served.

Based on observation, interview, and facility policy review, the facility failed to ensure daily nurse staffing information was posted and updated daily as required.The findings include: Review of the facility policy titled, Posting of Nurse Staffing, last revised 01/31/2025, revealed the facility was to post nurse staffing information on a daily basis at the beginning of each shift. Per review of the policy, the posted information was to include the facility name, current date, resident census, and the total number and actual hours worked by registered nurses (RNs), licensed practical/vocational nurses, and certified nurse aides (CNAs) per shift. Policy review further revealed it was required for the nurse staffing information to be posted in a clear, readable format in a prominent location readily accessible to residents and visitors. Observation on 02/15/2026 at 11:26 AM, revealed the facility's posted daily staffing information was dated Wednesday, 02/11/2026 (four days prior), and did not reflect the current staffing for 02/15/2026. Continued observation revealed the daily nurse staffing sheets posted at the time clock, at the first-floor nurses' station, and the second-floor nurses' station, were all dated Wednesday, 02/11/2026. In interview, on 02/15/2026 at 11:31 AM, State Registered Nurse Aide (SRNA) 5 stated it was the responsibility of the Assistant Director of Nursing (ADON) or Director of Nursing (DON) to post the daily staffing schedules. In interview, on 02/15/2026 at 11:33 AM, RN 4 also stated it was the responsibility of the ADON or DON to post the daily staffing schedules. In interview, on 02/15/2026 at 11:47 AM, the DON stated she or the ADON were responsible for posting the daily staffing schedules. She reported however, the ADON had been off work the previous week so the responsibility had fallen solely on her to post the schedules. The DON further stated she was unsure when she last posted the daily nurse staffing. In interview, on 02/18/2026 at 10:38 AM, the ADON stated she was primarily responsible for posting the daily staffing information. She further stated however, she had been off the previous week and the DON would have been responsible for posting the daily nurse staffing schedule while she was off. In interview, on 02/18/2026 at 11:46 AM, the Administrator stated that she knew posting the daily nurse staffing schedule was a regulation. She stated she expected her staff to follow all policies and regulations. The Administrator further stated the staffing schedule should have been updated daily.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to implement the plan of care for one (1) of nine (9) sampled residents (Resident #1) to prevent accidents. The facility identified Resident #1 was at risk for elopement due to dementia and developed a plan of care with interventions for elopement to monitor and provide supervision to the resident. Interviews with staff revealed on the evening of 04/18/2022, Resident #1 was wandering, attempted to exit the building by pushing on doors, and made statements of wanting to go home. The staff failed to implement the resident's plan of care interventions. On 04/18/2022, at approximately 8:24 PM, Resident #1 exited a facility window without staff knowledge, traveled approximately two-tenths (0.2) of a mile from the facility, and was found beside a major highway by a police officer. The facility's failure to ensure the resident's plan of care was implemented to provide supervision/monitoring has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/04/2022 and was determined to exist on 04/18/2022 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 05/04/2022. An acceptable removal plan was received on 05/10/2022, which alleged removal of the Immediate Jeopardy on 04/21/2022. The State Survey Agency (SSA) validated removal of the IJ, on 04/21/2022, as alleged, the facility corrected the deficient practice prior to the start of the abbreviated survey initiated on 04/26/2022. The findings include: A review of the facility's policy titled, Comprehensive Care Plans, dated 07/19/2018, revealed the comprehensive care plan was based on a thorough assessment and incorporated identified problem areas. Further review revealed the plan of care was maintained for each resident to ensure the highest level of functioning of the resident. A review of the facility's policy titled, Elopement/Wandering Resident, dated 05/30/2018, revealed that any resident displaying significant wandering behavior would be assessed for elopement/wandering risk. Further review of the policy revealed the facility would provide safety within the facility, reduce risk from exit-seeking behavior, and increase supervision as deemed necessary to prevent elopement. A review of Resident #1's medical record revealed the facility admitted the resident on 04/05/2022 with diagnoses of Dementia, Altered Mental Status, Type II Diabetes Mellitus and Generalized Weakness. A review of the resident's Admission Minimum Data Set (MDS) Assessment, dated 04/10/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident was cognitively impaired. Further review revealed Resident #1 required staff supervision, oversight, and encouragement or cueing for ambulation in his/her room and on the unit, with no mobility devices. Continued review of Resident #1's MDS revealed wandering behavior was not exhibited by the resident at the time of the assessment. Further review of the medical record revealed the resident was discharged home with family, on 04/19/2022, because the resident did not want to stay at the facility. Review of Resident #1's elopement risk assessment, dated 04/05/2022, revealed the resident exhibited making statements of leaving or questioning the need to stay at the facility. Further review of the assessment revealed the resident was assessed to display behaviors that would indicate an attempt to leave and that elopement may be forthcoming. According to the assessment, the resident was determined to be at risk for exit seeking/elopement. Review of the Comprehensive Care Plan developed for Resident #1, dated 04/05/2022, revealed the facility identified problems the resident was at risk for wandering/elopement because the resident ambulates independently and wanders at times, had impaired cognition, and would make statements he/she wanted to go home. Approach interventions were developed to keep the resident safe within the environment assess for needs of the resident, complete elopement observations with changes, increase involvement in activities, monitor behavior for recent changes, statements of leaving, exiting, or pushing on exit doors, conduct visual checks of the resident every thirty (30) minutes. Review of the nurse's notes, dated 04/18/2022 at 8:45 PM, revealed the facility received a call from 911 dispatch that Resident #1 had been found walking near the middle school. Further review revealed the resident was brought back to the facility by a police officer. According to the note, the resident was found to be in no distress with a pleasant demeanor. Further review revealed the resident was dressed in long pants shirt jacket socks shoes, and a cowboy hat. A skin assessment was conducted, and no issues were identified. The resident was placed on one-to-one supervision. Observation of the facility video camera footage for 04/18/2022 revealed Resident #1 was observed on 4/18/2022 at 8:23 PM ambulating by Licensed Practical Nurse (LPN) #1 in the hallway. At 8:24 PM the resident was observed to enter room [ROOM NUMBER], an unoccupied room, when the nurse had her back turned to the resident. Further review of the footage revealed Resident #1 exited the window of the room at 8:28 PM on 04/18/2022 and was observed to ambulate in the direction of the highway in front of the facility before going out of view of the camera. Observation of the area the resident was found by the police officer conducted on 04/27/2022 at 12:45 PM revealed the location of the area near the school was two tenths (0.2) of a mile from the facility on a major highway and within approximately three hundred (300) yards of a river. Interview with State Registered Nurse Aide (SRNA) #1, on 04/27/2022 at 3:34 PM, revealed on the night of 04/18/2022 at approximately 8:00 PM the SRNA was on lunch break in the facility dining area when Resident #1 entered the dining area and was pushing on the exit doors attempting to open the doors. Additional interview with SRNA #1 revealed the resident ask SRNA #1 how he/she could go home. Further interview revealed the resident left the dining room area and went back to the unit. According to the SRNA, she did not see the resident again until the resident was brought back to the facility by the police officer at approximately 8:50 PM, on 04/18/2022. According to the SRNA, she did not inform the resident's nurse of the resident's behavior, as per the resident's care plan, to prevent the resident from elopement. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM, revealed the LPN was assigned to care for Resident #1 and was monitoring the resident's elopement/exit-seeking behavior by conducting visual checks of the resident every thirty (30) minutes. Further interview revealed she last checked the resident's whereabouts at 8:10 PM when the resident was ambulating in the hallway. Further interview with LPN #1 revealed she was not aware the resident had eloped from the facility until contacted by the 911 dispatcher at 8:45 PM on 04/18/2022. According to LPN #1, she was not aware Resident #1 was pushing on the facility's exit doors in the dining room or had made statements to SRNA #1 that he/she wanted to go home. LPN #1 stated if she had been made aware the resident was exit seeking by pushing on doors or making statements of wanting to go home she would have monitored the resident more frequently or increased the resident's supervision. Interview with the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed she was notified Resident #1 had eloped from the facility by LPN #1 on 04/18/2022 immediately after the incident occurred. Continued interview revealed she contacted the Interim Administrator to inform him of the elopement. The DON stated she directed staff to place the resident on one-to-one (1:1) supervision. Interview with the Interim Administrator on 05/11/2022 at 12:30 PM revealed he had been at the facility filling in while the Administrator was on maternity leave. Per the interview, the Interim Administrator was contacted by the Director of Nursing about the elopement. The Interim Administrator stated he contacted maintenance to check all the facility exit doors to ensure the doors locked and were functioning. He further revealed he thought the resident may have exited through a door. Continued interview revealed the next day, 04/19/2022, during his review of the events that led to the resident ' s elopement, it was discovered, that while reviewing the facility ' s video camera footage, Resident #1 exited the building through a window in a vacant room. Interview with the Administrator, on 05/12/2022 at 10:54 AM, revealed she was made aware of the elopement by the Interim Administrator after she had returned from maternity leave on 04/19/2022. She stated the resident was on one-to-one supervision at that time. The Administrator revealed the facility implemented a plan of correction to ensure all the windows, with uncommon screws, were checked and maintenance ensured the screws were not easily removed. She further stated that the facility residents were assessed for wandering behaviors and their care plans were reviewed and revised. The facility implemented the following actions to remove the Immediate Jeopardy as follows: 1. Resident #1 was placed on one-to-one supervision immediately upon being brought back into the facility on [DATE]. Resident # 1 remained on one-to-one supervision from the time of his/her return to the facility on [DATE] until Resident # 1's planned discharge to home with family on 04/19/2022. 2. Resident #1 received a head-to-toe assessment by a Licensed Practical Nurse (LPN), on 04/18/2022, with no new concerns identified. 3. The resident ' s Physician and family were notified of the elopement on 04/18/2022. 4. The Facility reviewed the Emergency and Disaster Plan for missing residents on 04/19/2022, 04/20/2022, and 04/21/2022 during the Quality Assurance meeting. 5. On 04/18/2022, the Director of Nursing (DON) reviewed staffing and schedules to include monitoring during breaks and lunch. The staffing and schedules were reviewed by the Director of Nursing, Administrator, and Assistant Director of Nursing daily, Monday through Friday, in clinical meetings and revised as needed based on the needs of the facility, or any newly identified resident needs. The staffing and the Schedule were reviewed on Saturday and Sunday by one of the following Nurse Manger's on Call: the Director of Nursing, the Assistant Director of Nursing, the RN Unit Manager, or the Staff Development Coordinator and reviewed with the Administrator as needed. 6. On 04/19/2022, thirteen (13) residents that had already been identified to be an elopement risk were reviewed for any new wandering, statements, or signs of exit seeking behavior and validation ensuring thirty (30) minute visual elopement checks were in place, elopement binder up to date, elopement assessment and care plan were up to date. This was completed by the Social Services Director, Director of Nursing, and Signature Care Consultant. 7. Elopement risk evaluation was completed on one-hundred percent (100%) of residents on 04/19/2022 by the Staff Development Coordinator, Restorative Nurse, Minimum Data Set Nurses, Unit Manager, Administrator, and Care Consultant. One additional resident was identified to be at risk for elopement and was placed into the elopement binder. The resident's care plan was updated and he/she was placed on thirty (30) minute visual elopement checks. During this review, all residents who were identified as an elopement risk were validated to have thirty (30) minute visual elopement checks in place, and none of the identified residents were identified to need increased supervision. 8. The facility completed an audit to review and revise current residents' care plans who were at risk for exit seeking/elopement. The State Registered Nurse Aides (SRNA) point of care plans, based on the latest elopement risk evaluations were completed by Staff Development Coordinator, Restorative Nurse, Minimum Data Set Nurses, Unit Manager, Administrator, and the Care Consultant. This was completed on 04/19/2022. A census audit sheet was used to ensure and verify one-hundred percent (100%) of residents' care plans were reviewed to have elopement risk assessments, up-to-date personalized care plans, and Point of Care SRNA Care plans. If the resident was previously or newly identified as an elopement or wandering risk, they were verified to have personalized elopement care plans in place, reviewed for any new or increased behaviors, the need for increased supervision was reviewed, and all elopement books were up to date with any newly identified concern. 9. On 04/18/2022 Licensed Practical Nurse and Maintenance checked all doors and alarms. All doors and door alarms were in working order. On 04/19/2022 security camera footage was reviewed, and it was identified Resident #1 climbed out of an unoccupied resident room window on the first floor at the approximate time of 8:24 PM. Upon inspection of the room the window was closed; however, the window screen, a hairbrush, and the device that prevented the window from being raised (greater than a few inches) were found on the ground outside of the room. There were sixty-two (62) resident windows in the facility and on 04/19/2022, the Assistant Plant Ops checked all sixty-two (62) resident's room windows to ensure the brackets that prevented the windows from being raised more than a few inches were in place and re-secured. On 04/20/2022, the Assistant Plant Ops, Plant Ops Director, and Regional Plant Ops Director further re-secured the brackets in all sixty-two (62) resident's room windows with tamper-proof specialty wood screws; a type of screw that has a non-traditional type of screw head that would require a specialty screwdriver to unscrew these screws. The Administrator reviewed the past thirty (30) day window checks completed by Plant Ops on 04/19/2022 and found no concerns. All facility resident room windows would be checked Monday-Friday by the facility's maintenance and the same checks would be done on Saturday and Sunday by the facility's Manager on Duty. 10. The Care Consultant educated the Administrator, Staff Development Coordinator, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Minimum Data Set nurse on 04/18/2022 and 04/19/2022 on the following Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, behavior management of residents at risk for elopement and wandering and Comprehensive Care Plan Policy related to elopement. 11. Re-education started on 04/19/2022 and was completed by 04/20/2022 on Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement by the Staff Development Coordinator, Unit Manager, Assistant Director of Nursing and Director of Nursing for all staff and nurses for comprehensive care plans and what to include, behavior management of residents at risk for elopement and wandering. Post-tests were completed with staff during education to ensure that knowledge of the policies was retained. All stakeholders working on 04/19/2022 were educated on that day and all stakeholders were educated from then on before they worked. As of 04/20/2022, eighty-five (85) out of one-hundred and thirty-five (135) stakeholders had been educated. Stakeholders who have not received the re-education by the start of shift 04/21/2022 would be expected to complete the education before the next shift they work by the Staff Development Coordinator, Assistant Director of Nursing, and Director of Nursing. This education would include orientation for all new staff. 12. Elopement drills were completed on 04/19/2022 and 04/20/2022, and reviewed during Quality Assurance meetings on 04/19/2022, and 04/20/2022. Moving forward, on 04/21/2022, elopement drills were conducted daily for five (5) days starting on 04/21/2022 through 04/25/2022. Elopement drills were completed by Social Services Director or Plant Operations. Following the elopement drills for five (5) days then elopement drills would be conducted three (3) times a week on different shifts for thirty (30) days and two (2) times a week for the next thirty (30) days and one (1) time a week for the next thirty (30) days. Any issues identified would be immediately corrected, re-education provided, up to and including disciplinary action as deemed necessary by the Director of Nursing and Administrator. 13. All residents ' progress notes were reviewed daily during the clinical meeting for monitoring of any exit seeking behavior by the interdisciplinary team starting on 04/19/2022 by (the Director of Nursing, Unit Manager, and Assistant Director of Nursing) for seven (7) days a week for thirty (30) days, Monday through Friday during the clinical whiteboard meeting and on Saturday and Sunday the progress notes would be reviewed by the Director of Nursing and/or Administrator. Then for five (5) days a week for the next thirty (30) days and then for three (3) days a week for the next thirty (30) days. Any resident identified as an elopement risk would have an elopement assessment completed and if determined to be at risk, would have personalized intervention(s) put into place, appropriate care plans updated, and the elopement binders updated. All resident windows would have monitoring seven (7) days per week, Monday-Friday by facility maintenance and Saturday and Sunday by the facility Manager on Duty. 14. Staff education was initiated on 04/18/2022 regarding following the comprehensive care plan and SRNA Point of Care policy in the event a resident expresses or displays exit seeking or wandering risk behaviors. Re-education was initiated by the Director of Nursing with staff on 04/18/2022 regarding immediate reporting of any identified behaviors related to exit seeking and wandering. One-to-one education regarding following the care plan interventions, and reporting residents who display or express exit seeking and wandering behaviors, were reviewed with State Registered Nurse Aide (SRNA) #1 upon returning to work completed by the Administrator, Director of Nursing, and the Care Consultant. 15. Quality Assurance Meeting was conducted on 04/19/2022 reviewing all proposed education and action plans with the Medical Director, Administrator, Director of Nursing, and Care Consultant. On 04/20/2022, the Quality Assurance committee meeting consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Care Consultant, Staff Development Coordinator, and Social Service Director was held to review all added interventions and the plan moving forward. It was determined that the Assistant Director of Nursing, Staff Development Coordinator, or Director of Nursing would educate all stakeholders who had not yet worked and would be serviced before they worked on 04/21/2022 forward. 16. Quality Assurance would review elopement drills, staff education, and daily clinical meeting audits for completion and accuracy as outlined in this plan. Quality Assurance committee reviewed elopement drills from 04/19/2022 and 04/20/2022 on 04/21/2022. The committee determined to continue moving forward with the plan. The Quality Assurance Committee met weekly for the first thirty (30) days, two (2) times a month for the next thirty (30) days, and monthly thereafter. Any further action would be as determined by the Quality Assurance committee as needed. 17. Regional oversight was in place daily for this plan since 04/19/2022. The Regional oversight occurred on-site or by phone from the Care Consultant, the Regional [NAME] President, or a member of the Regional Team. This would continue until immediate jeopardy was abated. The State Survey Agency validated the removal of Immediate Jeopardy as follows: 1. A review of the closed medical record for Resident #1 revealed the resident was placed on one-to-one supervision immediately upon being brought back into the facility on [DATE] and remained on one-to-one supervision until the resident's planned discharge home on 04/19/2022. Interviews with State Registered Nurse Aide (SRNA) #1, on 04/27/2022 at 3:34 PM; Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM, and the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed Resident #1 was placed on one-to-one supervision after the elopement and remained on one-to-one supervision until the resident was discharged . 2. A review of the progress notes for Resident #1 dated 04/18/2022 at 8:45 PM revealed LPN #1 had assessed Resident #1 with no concerns identified. Interview with LPN #1, on 04/28/2022 at 11:34 AM, revealed the LPN a had assessed Resident #1, on 04/18/2022 after the resident was returned to the facility. 3. A review of the progress notes for Resident #1, dated 04/18/2022, revealed the resident ' s Physician and family were notified of the elopement on 04/18/2022. Interview with LPN #1, on 04/28/2022 at 11:34 AM, revealed the LPN had notified Resident #1's family and physician of the elopement. 4. A review of the facility quality assurance meeting minutes revealed the facility Emergency and Disaster Plan for missing residents were reviewed in the quality assurance meeting on 04/19/2022, 04/20/2022, and 04/21/2022. Interview with the Administrator, on 05/12/2022 at 10:54 AM, revealed the facility disaster plan for missing residents was reviewed in the daily Quality Assurance meetings conducted on 04/19/2022, 04/20/2022, and 04/21/2022. 5. A review of the facility's daily staffing schedule for 04/18/2022 revealed no concerns with the facility staffing at the time of the elopement on 04/18/2022. A review of the working schedule for April 2022 revealed no staffing concerns. Interviews with staff who worked on 04/18/2022 to include SRNA #1 on 04/27/2022 at 3:34 PM; SRNA #3 on 05/03/2022 at 1:22 PM; SRNA #9 on 5/11/2022 at 2:18 PM; SRNA #12 on 05/11/2022 at 2:37 PM; LPN #1 on 04/28/2022 at 11:34 AM; LPN #3 on 05/02/2022 at 3:56 PM; and RN #2 on 05/12/2022 at 8:32 AM revealed no concerns with adequate facility staffing Interview with the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed daily staffing schedules to include monitoring during breaks and lunch were reviewed daily, Monday through Friday, in clinical meetings and on Saturday and Sunday by the on-call manager. She stated the schedules were revised as needed based on the needs of the facility. 6. A review of the medical record for Residents #6, #7, #8, and #9 who were assessed to wander elopement risk by the facility, revealed the resident ' s thirty (30) minute checks were completed. The residents were listed in the facility's elopement binder located at the nurse ' s station. A review of the plan of care for Residents #6, #7, #8, and #9 revealed the resident ' s plans of care had been reviewed/updated on 04/19/2022 and was completed by the Social Services Director, Director of Nursing, and Signature Care Consultant. Interviews with the facility social worker on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; and the Signature Care Consultant on 05/12/2022 at 10:38 AM, revealed they had completed wander risk assessments on all residents on 04/19/2022 and reviewed/revised the resident ' s plan of care and were monitored daily to ensure the residents thirty (30) minute checks were being completed. 7. Medical record reviews conducted for Residents #6, #7, #8, and #9 revealed elopement risk evaluations were completed by the facility on 04/19/2022 and the resident's care plans were updated. Continued review revealed the residents were on thirty (30) minute visual elopement checks. During this review, all residents who were identified as an elopement risk were validated to have thirty (30) minute visual elopement checks in place, and none of the identified residents were identified to need increased supervision with no concerns identified. Interviews with the facility social worker on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; and the Care Consultant on 05/12/2022 at 10:38 AM, revealed they had completed wander risk assessments on all residents on 04/19/2022 and had reviewed/revised the resident ' s plan of care and were monitored daily to ensure the residents thirty (30) minute checks were being completed. 8. A review of a census audit sheet dated 04/19/2022 revealed one-hundred percent (100%) of residents were reviewed to have elopement risk assessments, up-to-date personalized care plans, and Point of Care SRNA Care plans. Continued review revealed the elopement books were updated. Record reviews conducted for Residents #6, #7, #8, and #9 revealed no concerns with wander risk assessments, the plans of care, or any need for increased supervision. 9. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM; and Maintenance staff on 04/28/2022 at 11:50 AM; revealed on 04/18/2022, after the incident, all doors and alarms were checked and found to be in working order. Interview with Maintenance Supervisor, on 05/12/2022 at 9:15 AM, revealed on 04/19/2022 when it was determined Resident #1 exited through a window all facility windows were checked and fitted/resecured with specialty wood screws to prevent the windows from opening more than four inches and that maintenance was checking the windows daily for any concerns. Observations of the facility windows, on 05/12/2022 at 9:00 AM, with the Maintenance Supervisor revealed all windows had been fitted with bracket devices and specialty wood screws to prevent the windows from opening more than four (4) inches. 10. A review of inservice documentation revealed the facility's consultant educated the Administrator, Staff Development Coordinator, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Minimum Data Set nurse on 04/18/2022 and 04/19/2022 on the following: Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, behavior management of residents at risk for elopement and wandering and Comprehensive Care Plan Policy related to elopement. Interview with the facility's consultant, on 05/12/2022 at 10:38 AM, revealed she had in service the administrative staff on the facility elopement/wandering policy from 04/18/2022 through 04/19/2022 Interview with the facility's social worker, on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; the Unit Manager on 05/12/2022 at 9:08 AM; Staff Development Coordinator on 05/12/2022 at 8:55 AM, and the Administrator on 05/12/2022 at10:54 AM, revealed they had been in service on the facility elopement/wandering policy by the facility's consultant. 11. A review of the facility's in-service documentation revealed re-education with staff started on 04/19/2022 and was completed by 04/20/2022 for all staff who were working on Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement by the Staff Development Coordinator, Unit Manager, and Director of Nursing for all staff and nurses. Review of the post-test revealed the test was completed by staff to ensure they retained the information. A review of the post-test completed by staff revealed the post-test had been conducted and no concerns were identified. Interviews with the Unit Manager on 05/12/2022 at 9:08 AM; the Staff Development Coordinator on 05/12/2022; and the Director of Nursing on 05/12/2022 at 10:19 AM; revealed they had conducted in-services for all working staff starting on 04/19/2022 and was ongoing for staff who had been off work. Further interviews revealed the inservice was conducted when staff returned to the facility before they worked their unit. Interviews revealed staff were in-service on The Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement. Interviews on 05/12/2022 with State Registered Nuse Aide (SRNA) #9 at 2:18 PM; SRNA #10 at 1:55 PM; SRNA #11 at 2:05 PM; SRNA #12 at 2:37 PM; SRNA #13 at 2:48 PM; LPN #6 at 8:24 AM; LPN #3 at 8:38 AM, and RN #2 at 8:32 AM revealed they were in service on the Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident and Comprehensive Care Plan Policy related to elopement and following the plan of care for a wandering/exit seeking resident. No concerns were identified. 12. A review of the facility's elopement drill documentation revealed elopement drills were conducted on 04/19/2022, and 04/20/2022, then continued daily starting on 04/21/2022 to 04/25/2022 by the Social Services Director and/or the Maintenance Supervisor. A review of the elopement drill documentation conducted on 05/11/2022 and 05/12/2022 revealed they were being conducted three (3) times weekly on different shifts and were ongoing according to the facility plan. Interview with the facility's Social Worker on 05/12/2022 at 8:45 AM, and the Maintenance Supervisor who was the Plant Operations Director on 05/12/2022 at 9:15 AM revealed elopement drills had been conducted daily from 04/19/2022 and were currently being conducted three (3) times weekly on different shifts. 13. A review of the facility's documentation of the daily review of progress notes revealed Resident's Progress notes were reviewed daily from 04/19/2022 to 05/10/2022 for wandering\elopement concerns. No concerns were identified with the residents. A review of progress notes for Residents #6, #7, #8, and #9 from 04/21/2022 to 05/10/2022 revealed no concerns with wandering/elopement behaviors. Interviews with the Unit Manager on 05/12/2022 at 9:08 AM; and the Director of Nursing on 05/12/2022 at 10:19 AM, revealed resident progress notes were reviewed daily in the morning meeting and on weekends by the manager on duty. 14. A review of staff Inservice documentation revealed staff education was initiated on 04/18/2022 regarding following the comprehensive care plan and State Registered Nurse Aide (SRNA) Point of Care policy in the event a resident expresses or displays exit seeking or wandering risk behaviors. Re-education was initiated by the Director of Nursing with staff on 04/18/2022 regarding immediate reporting of any identified behaviors related to exit seeking and wandering. One-to-one education regarding following the care plan interventions, and reporting residents who display or express exit seeking and wandering behaviors, was reviewed with the State Registered Nurse Aide (SRNA) #1 upon returning to work completed by the Administrator, Director of Nursing, and the facility's Care Consultant. Interview with SRNA #1, on 04/27/2022 at 3:34 PM, revealed she had received in-service training and education on following the resident ' s plan of care if the resident was displaying exit-seeking behaviors or making statements of wanting to leave and to report behaviors immediately to the nurse on 04/18/2022. Interviews on 05/12/2022 with SRNA #9 at 2:18 PM; SRNA #10 at 1:55 PM; SRNA #11 at 2:05 PM; SRNA #12 at 2:37 PM; SRNA #13 at 2:48 PM; Licensed Practical Nurse (LPN) #6 at 8:24 AM; LPN #3 at 8:38 AM; and Registered Nurse (RN) #2 at 8:32 AM, revealed they were in service on the Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident and Comprehensive Care Plan Policy related to elopement and following the plan of care for a wandering/exit seeking resident on 04/18/2022. 15. A review of the Quality Assurance Meeting notes, dated 04/19/2022 revealed the facility proposed education and action plan was reviewed with the Medical Director, Administrator, Director of Nursing, and the facility's Care C [TRUNCATED]

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to supervise one (1) of nine (9) sampled residents (Resident #1) to prevent accidents. The facility identified Resident #1 was at risk for elopement due to dementia and developed a plan of care for elopement to monitor and provide supervision to the resident. Interviews with staff revealed on the evening of 04/18/2022, Resident #1 was wandering the facility and attempted to exit the building by pushing on doors. The staff heard the resident making statements of wanting to go home. On 04/18/2022, at approximately 8:24 PM, Resident #1 entered an empty resident's room, within the facility, and exited the window without the staff's knowledge traveling approximately two-tenths (0.2) of a mile from the facility and was found beside a major highway by a police officer. The facility's failure to ensure residents were provided supervision and free from accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/04/2022 and was determined to exist on 04/18/2022 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 05/04/2022. An acceptable removal plan was received on 05/10/2022, which alleged removal of the Immediate Jeopardy on 04/21/2022. The State Survey Agency (SSA) validated removal of the IJ, on 04/21/2022, as alleged, the facility corrected the deficient practice prior to the start of the abbreviated survey initiated on 04/26/2022. The findings include: Review of the facility's policy titled, Elopement/Wandering, dated 05/30/2018, and Care of a Wandering Resident, dated 06/26/2018, revealed any resident displaying significant wandering behavior would be assessed for elopement/wandering risk. Further review of the policy revealed the facility would provide safety within the facility, to reduce the risk from exit-seeking behaviors, and increase supervision as deemed necessary to prevent elopement. Review of Resident #1's medical record revealed the facility admitted the resident on 04/05/2022 with diagnoses of Dementia, Altered Mental Status, Type II Diabetes Mellitus and Generalized Weakness. Review of the resident's Admission Minimum Data Set (MDS) Assessment, dated 04/10/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident was cognitively impaired. Further review revealed Resident #1 required staff supervision, oversight, and encouragement or cueing for ambulation in his/her room and on the unit, with no mobility devices. Continued review of Resident #1's MDS revealed wandering behavior was not exhibited by the resident at the time of the assessment. Further review of the medical record revealed the resident was discharged home with family on 04/19/2022 because the resident did not want to stay at the facility. A review of an elopement risk assessment, dated 04/05/2022, revealed the resident exhibited statements of leaving or questioning the need to stay at the facility. Further review of the assessment revealed the resident was assessed to display behaviors that would indicate an attempt to leave, and that elopement would be forthcoming. According to the assessment, the resident was determined to be at risk for exit seeking/elopement. Review of Resident #1's Comprehensive Care Plan, dated 04/05/2022, revealed the facility identified the resident was at risk for wandering/elopement because the resident ambulates independently and wanders at times, has impaired cognition, and would make statements he/she wanted to go home. The following interventions were developed to keep the resident safe within the environment: staff were to assess the needs of the resident, complete elopement observations with changes, increase involvement in activities, monitor behavior for recent changes, monitor the resident's statements of leaving, exiting, or pushing on exit doors, and conduct visual checks of the resident every thirty minutes. A review of the nurse's notes, dated 04/18/2022 at 8:45 PM, revealed the facility had received a call from 911 dispatch that Resident #1 had been found walking near the middle school. According to the note, the resident was brought back to the facility by a police officer. Further review of the note revealed the resident was found to be in no distress with a pleasant demeanor. Further review revealed the resident was dressed in long pants shirt jacket socks shoes, and a cowboy hat. A skin assessment was conducted, and no issues were identified. The resident was placed on one-to-one (1:1) supervision. Observation of the facility's video camera footage, dated 04/18/2022, revealed Resident #1 was observed on 4/18/2022 at 8:23 PM ambulating by Licensed Practical Nurse (LPN) #1 in the hallway. At 8:24 PM the resident was observed to enter room [ROOM NUMBER], an unoccupied room when the nurse had her back turned to the resident. Further review of the footage revealed Resident #1 exited the window of the room at 8:28 PM on 04/18/2022 and was observed to ambulate in the direction of the highway in front of the facility before going out of view of the camera. An interview with the Police Officer, on 04/27/2022 at 2:50 AM, revealed the Police Officer was on duty on 04/18/2022 and received a call from dispatch that an elderly man was observed walking on the highway near the school. According to the officer, he arrived on the scene at 8:36 PM and found Resident #1 near the road at the entrance to the school and returned the resident to the facility. A review of National Weather Service Data for Prestonsburg KY, on 04/18/2022 at 8:00 PM, revealed the weather was cloudy, and the temperature was forty (40) degrees Fahrenheit. Observation, on 04/27/2022 at 12:45 PM, revealed the location of the area near the school where the police officer located Resident #1 was two tenths (0.2) of a mile from the facility on a major highway and within approximately three hundred (300) yards of a river. Interview with State Registered Nurse Aide (SRNA) #1, on 04/27/2022 at 3:34 PM, revealed on the night of 04/18/2022 at approximately 8:00 PM, the SRNA was on lunch break in the facility dining area and Resident #1 entered the dining area and was pushing on the exit doors attempting to open the doors. Additional interview with SRNA #1 revealed the resident asked her, how he/she could go home. Further interview revealed the resident left the dining room area and went back to the unit. According to the SRNA she did not see the resident again until the resident was brought back to the facility by a police officer at approximately 8:50 PM on 04/18/2022. SRNA further stated she should have alerted the nurse when the resident made statements of wanting to go home. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM, revealed the LPN was assigned to care for Resident #1 and was monitoring the resident ' s elopement/exit seeking behavior by conducting visual checks of the resident every thirty (30) minutes and had visually checked the resident at 8:10 PM when the resident was ambulating in the hallway. Further interview with LPN #1 revealed she was not aware the resident had eloped from the facility until contacted by the 911 dispatcher at 8:45 PM on 04/18/2022. According to LPN #1, she was not aware Resident #1 had been pushing on doors in the dining room or had made statements to SRNA #1, he/she wanted to go home. LPN #1 stated if she had been made aware the resident was exit seeking by pushing on doors or making statements of wanting to go home she would have monitored the resident more frequently or increased the resident's supervision. Interview with the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed she was notified Resident #1 had eloped from the facility by LPN #1, on 04/18/2022, immediately after the incident occurred and she contacted the Interim Administrator to inform him of the elopement. Per interview, the DON revealed she directed staff to initiate one-to-one (1:1) supervision of the resident. She further stated she asked staff to assess the resident for any injuries and for staff to implement the missing person policy by completing a headcount, to ensure accountability of all residents. Interview with the Interim Administrator, on 05/11/2022 at 12:30 PM, revealed he had been at the facility filling in while the Administrator was on maternity leave. According to the Interim Administrator, he was contacted by the Director of Nursing (DON) about the elopement, and he contacted maintenance to come to the facility to check all the facility exit doors to ensure the doors were locked and were functioning. According to the Interim Administrator, at the time of Resident #1's elopement, he thought the resident would have exited through a door. He stated all the required notifications were made. Further interview revealed the next day while conducting the investigation with the Administrator, it was discovered, when reviewing the facility's video camera footage Resident #1 exited the building through a window in a vacant room. Interview with the Administrator, on 05/12/2022 at 10:54 AM, revealed she was made aware of the elopement by the Interim Administrator after she had returned from maternity leave on 04/19/2022. Per the interview, she stated the resident was on continued one-to-one (1:1) supervision, had no injuries, and was in no distress. She further stated that all the residents were accounted for, all the required notifications were made, and an investigation of the incident had been initiated when it was determined the resident had eloped from the facility premises through a window. The Administrator stated that all the windows were checked, and the facility implemented a removal plan to secure the windows with uncommon screws that were not easily removed. Continued interview revealed all the residents were assessed for wandering behaviors and their care plans were reviewed and revised. The elopement books were updated and additional thirty (30) minute checks, including the thirty (30) minute checks the residents already received, were conducted by the nurse aides. She further revealed training for all staff on the facility policy for elopement/wandering residents was initiated and the facility plan was being monitored through quality assurance. The facility implemented the following actions to remove the Immediate Jeopardy as follows: 1. Resident #1 was placed on one-to-one supervision immediately upon being brought back into the facility on [DATE]. Resident # 1 remained on one-to-one supervision from the time of his/her return to the facility on [DATE] until Resident # 1's planned discharge to home with family on 04/19/2022. 2. Resident #1 received a head-to-toe assessment by a Licensed Practical Nurse (LPN), on 04/18/2022, with no new concerns identified. 3. The resident ' s Physician and family were notified of the elopement on 04/18/2022. 4. The Facility reviewed the Emergency and Disaster Plan for missing residents on 04/19/2022, 04/20/2022, and 04/21/2022 during the Quality Assurance meeting. 5. On 04/18/2022, the Director of Nursing (DON) reviewed staffing and schedules to include monitoring during breaks and lunch. The staffing and schedules were reviewed by the Director of Nursing, Administrator, and Assistant Director of Nursing daily, Monday through Friday, in clinical meetings and revised as needed based on the needs of the facility, or any newly identified resident needs. The staffing and the Schedule were reviewed on Saturday and Sunday by one of the following Nurse Manger's on Call: the Director of Nursing, the Assistant Director of Nursing, the RN Unit Manager, or the Staff Development Coordinator and reviewed with the Administrator as needed. 6. On 04/19/2022, thirteen (13) residents that had already been identified to be an elopement risk were reviewed for any new wandering, statements, or signs of exit seeking behavior and validation ensuring thirty (30) minute visual elopement checks were in place, elopement binder up to date, elopement assessment and care plan were up to date. This was completed by the Social Services Director, Director of Nursing, and Signature Care Consultant. 7. Elopement risk evaluation was completed on one-hundred percent (100%) of residents on 04/19/2022 by the Staff Development Coordinator, Restorative Nurse, Minimum Data Set Nurses, Unit Manager, Administrator, and Care Consultant. One additional resident was identified to be at risk for elopement and was placed into the elopement binder. The resident's care plan was updated and he/she was placed on thirty (30) minute visual elopement checks. During this review, all residents who were identified as an elopement risk were validated to have thirty (30) minute visual elopement checks in place, and none of the identified residents were identified to need increased supervision. 8. The facility completed an audit to review and revise current residents' care plans who were at risk for exit seeking/elopement. The State Registered Nurse Aides (SRNA) point of care plans, based on the latest elopement risk evaluations were completed by Staff Development Coordinator, Restorative Nurse, Minimum Data Set Nurses, Unit Manager, Administrator, and the Care Consultant. This was completed on 04/19/2022. A census audit sheet was used to ensure and verify one-hundred percent (100%) of residents' care plans were reviewed to have elopement risk assessments, up-to-date personalized care plans, and Point of Care SRNA Care plans. If the resident was previously or newly identified as an elopement or wandering risk, they were verified to have personalized elopement care plans in place, reviewed for any new or increased behaviors, the need for increased supervision was reviewed, and all elopement books were up to date with any newly identified concern. 9. On 04/18/2022 Licensed Practical Nurse and Maintenance checked all doors and alarms. All doors and door alarms were in working order. On 04/19/2022 security camera footage was reviewed, and it was identified Resident #1 climbed out of an unoccupied resident room window on the first floor at the approximate time of 8:24 PM. Upon inspection of the room the window was closed; however, the window screen, a hairbrush, and the device that prevented the window from being raised (greater than a few inches) were found on the ground outside of the room. There were sixty-two (62) resident windows in the facility and on 04/19/2022, the Assistant Plant Ops checked all sixty-two (62) resident's room windows to ensure the brackets that prevented the windows from being raised more than a few inches were in place and re-secured. On 04/20/2022, the Assistant Plant Ops, Plant Ops Director, and Regional Plant Ops Director further re-secured the brackets in all sixty-two (62) resident's room windows with tamper-proof specialty wood screws; a type of screw that has a non-traditional type of screw head that would require a specialty screwdriver to unscrew these screws. The Administrator reviewed the past thirty (30) day window checks completed by Plant Ops on 04/19/2022 and found no concerns. All facility resident room windows would be checked Monday-Friday by the facility's maintenance and the same checks would be done on Saturday and Sunday by the facility's Manager on Duty. 10. The Care Consultant educated the Administrator, Staff Development Coordinator, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Minimum Data Set nurse on 04/18/2022 and 04/19/2022 on the following Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, behavior management of residents at risk for elopement and wandering and Comprehensive Care Plan Policy related to elopement. 11. Re-education started on 04/19/2022 and was completed by 04/20/2022 on Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement by the Staff Development Coordinator, Unit Manager, Assistant Director of Nursing and Director of Nursing for all staff and nurses for comprehensive care plans and what to include, behavior management of residents at risk for elopement and wandering. Post-tests were completed with staff during education to ensure that knowledge of the policies was retained. All stakeholders working on 04/19/2022 were educated on that day and all stakeholders were educated from then on before they worked. As of 04/20/2022, eighty-five (85) out of one-hundred and thirty-five (135) stakeholders had been educated. Stakeholders who have not received the re-education by the start of shift 04/21/2022 would be expected to complete the education before the next shift they work by the Staff Development Coordinator, Assistant Director of Nursing, and Director of Nursing. This education would include orientation for all new staff. 12. Elopement drills were completed on 04/19/2022 and 04/20/2022, and reviewed during Quality Assurance meetings on 04/19/2022, and 04/20/2022. Moving forward, on 04/21/2022, elopement drills were conducted daily for five (5) days starting on 04/21/2022 through 04/25/2022. Elopement drills were completed by Social Services Director or Plant Operations. Following the elopement drills for five (5) days then elopement drills would be conducted three (3) times a week on different shifts for thirty (30) days and two (2) times a week for the next thirty (30) days and one (1) time a week for the next thirty (30) days. Any issues identified would be immediately corrected, re-education provided, up to and including disciplinary action as deemed necessary by the Director of Nursing and Administrator. 13. All residents ' progress notes were reviewed daily during the clinical meeting for monitoring of any exit seeking behavior by the interdisciplinary team starting on 04/19/2022 by (the Director of Nursing, Unit Manager, and Assistant Director of Nursing) for seven (7) days a week for thirty (30) days, Monday through Friday during the clinical whiteboard meeting and on Saturday and Sunday the progress notes would be reviewed by the Director of Nursing and/or Administrator. Then for five (5) days a week for the next thirty (30) days and then for three (3) days a week for the next thirty (30) days. Any resident identified as an elopement risk would have an elopement assessment completed and if determined to be at risk, would have personalized intervention(s) put into place, appropriate care plans updated, and the elopement binders updated. All resident windows would have monitoring seven (7) days per week, Monday-Friday by facility maintenance and Saturday and Sunday by the facility Manager on Duty. 14. Staff education was initiated on 04/18/2022 regarding following the comprehensive care plan and SRNA Point of Care policy in the event a resident expresses or displays exit seeking or wandering risk behaviors. Re-education was initiated by the Director of Nursing with staff on 04/18/2022 regarding immediate reporting of any identified behaviors related to exit seeking and wandering. One-to-one education regarding following the care plan interventions, and reporting residents who display or express exit seeking and wandering behaviors, were reviewed with State Registered Nurse Aide (SRNA) #1 upon returning to work completed by the Administrator, Director of Nursing, and the Care Consultant. 15. Quality Assurance Meeting was conducted on 04/19/2022 reviewing all proposed education and action plans with the Medical Director, Administrator, Director of Nursing, and Care Consultant. On 04/20/2022, the Quality Assurance committee meeting consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Care Consultant, Staff Development Coordinator, and Social Service Director was held to review all added interventions and the plan moving forward. It was determined that the Assistant Director of Nursing, Staff Development Coordinator, or Director of Nursing would educate all stakeholders who had not yet worked and would be serviced before they worked on 04/21/2022 forward. 16. Quality Assurance would review elopement drills, staff education, and daily clinical meeting audits for completion and accuracy as outlined in this plan. Quality Assurance committee reviewed elopement drills from 04/19/2022 and 04/20/2022 on 04/21/2022. The committee determined to continue moving forward with the plan. The Quality Assurance Committee met weekly for the first thirty (30) days, two (2) times a month for the next thirty (30) days, and monthly thereafter. Any further action would be as determined by the Quality Assurance committee as needed. 17. Regional oversight was in place daily for this plan since 04/19/2022. The Regional oversight occurred on-site or by phone from the Care Consultant, the Regional [NAME] President, or a member of the Regional Team. This would continue until immediate jeopardy was abated. The State Survey Agency validated the removal of Immediate Jeopardy as follows: 1. A review of the closed medical record for Resident #1 revealed the resident was placed on one-to-one supervision immediately upon being brought back into the facility on [DATE] and remained on one-to-one supervision until the resident's planned discharge home on 04/19/2022. Interviews with State Registered Nurse Aide (SRNA) #1, on 04/27/2022 at 3:34 PM; Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM, and the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed Resident #1 was placed on one-to-one supervision after the elopement and remained on one-to-one supervision until the resident was discharged . 2. A review of the progress notes for Resident #1 dated 04/18/2022 at 8:45 PM revealed LPN #1 had assessed Resident #1 with no concerns identified. Interview with LPN #1, on 04/28/2022 at 11:34 AM, revealed the LPN a had assessed Resident #1, on 04/18/2022 after the resident was returned to the facility. 3. A review of the progress notes for Resident #1, dated 04/18/2022, revealed the resident ' s Physician and family were notified of the elopement on 04/18/2022. Interview with LPN #1, on 04/28/2022 at 11:34 AM, revealed the LPN had notified Resident #1's family and physician of the elopement. 4. A review of the facility quality assurance meeting minutes revealed the facility Emergency and Disaster Plan for missing residents were reviewed in the quality assurance meeting on 04/19/2022, 04/20/2022, and 04/21/2022. Interview with the Administrator, on 05/12/2022 at 10:54 AM, revealed the facility disaster plan for missing residents was reviewed in the daily Quality Assurance meetings conducted on 04/19/2022, 04/20/2022, and 04/21/2022. 5. A review of the facility's daily staffing schedule for 04/18/2022 revealed no concerns with the facility staffing at the time of the elopement on 04/18/2022. A review of the working schedule for April 2022 revealed no staffing concerns. Interviews with staff who worked on 04/18/2022 to include SRNA #1 on 04/27/2022 at 3:34 PM; SRNA #3 on 05/03/2022 at 1:22 PM; SRNA #9 on 5/11/2022 at 2:18 PM; SRNA #12 on 05/11/2022 at 2:37 PM; LPN #1 on 04/28/2022 at 11:34 AM; LPN #3 on 05/02/2022 at 3:56 PM; and RN #2 on 05/12/2022 at 8:32 AM revealed no concerns with adequate facility staffing Interview with the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed daily staffing schedules to include monitoring during breaks and lunch were reviewed daily, Monday through Friday, in clinical meetings and on Saturday and Sunday by the on-call manager. She stated the schedules were revised as needed based on the needs of the facility. 6. A review of the medical record for Residents #6, #7, #8, and #9 who were assessed to wander elopement risk by the facility, revealed the resident ' s thirty (30) minute checks were completed. The residents were listed in the facility's elopement binder located at the nurse ' s station. A review of the plan of care for Residents #6, #7, #8, and #9 revealed the resident ' s plans of care had been reviewed/updated on 04/19/2022 and was completed by the Social Services Director, Director of Nursing, and Signature Care Consultant. Interviews with the facility social worker on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; and the Signature Care Consultant on 05/12/2022 at 10:38 AM, revealed they had completed wander risk assessments on all residents on 04/19/2022 and reviewed/revised the resident ' s plan of care and were monitored daily to ensure the residents thirty (30) minute checks were being completed. 7. Medical record reviews conducted for Residents #6, #7, #8, and #9 revealed elopement risk evaluations were completed by the facility on 04/19/2022 and the resident's care plans were updated. Continued review revealed the residents were on thirty (30) minute visual elopement checks. During this review, all residents who were identified as an elopement risk were validated to have thirty (30) minute visual elopement checks in place, and none of the identified residents were identified to need increased supervision with no concerns identified. Interviews with the facility social worker on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; and the Care Consultant on 05/12/2022 at 10:38 AM, revealed they had completed wander risk assessments on all residents on 04/19/2022 and had reviewed/revised the resident ' s plan of care and were monitored daily to ensure the residents thirty (30) minute checks were being completed. 8. A review of a census audit sheet dated 04/19/2022 revealed one-hundred percent (100%) of residents were reviewed to have elopement risk assessments, up-to-date personalized care plans, and Point of Care SRNA Care plans. Continued review revealed the elopement books were updated. Record reviews conducted for Residents #6, #7, #8, and #9 revealed no concerns with wander risk assessments, the plans of care, or any need for increased supervision. 9. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/2022 at 11:34 AM; and Maintenance staff on 04/28/2022 at 11:50 AM; revealed on 04/18/2022, after the incident, all doors and alarms were checked and found to be in working order. Interview with Maintenance Supervisor, on 05/12/2022 at 9:15 AM, revealed on 04/19/2022 when it was determined Resident #1 exited through a window all facility windows were checked and fitted/resecured with specialty wood screws to prevent the windows from opening more than four inches and that maintenance was checking the windows daily for any concerns. Observations of the facility windows, on 05/12/2022 at 9:00 AM, with the Maintenance Supervisor revealed all windows had been fitted with bracket devices and specialty wood screws to prevent the windows from opening more than four (4) inches. 10. A review of inservice documentation revealed the facility's consultant educated the Administrator, Staff Development Coordinator, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Minimum Data Set nurse on 04/18/2022 and 04/19/2022 on the following: Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, behavior management of residents at risk for elopement and wandering and Comprehensive Care Plan Policy related to elopement. Interview with the facility's consultant, on 05/12/2022 at 10:38 AM, revealed she had in service the administrative staff on the facility elopement/wandering policy from 04/18/2022 through 04/19/2022 Interview with the facility's social worker, on 05/12/2022 at 8:45 AM; The Director of Nursing on 05/12/2022 at 10:19 AM; the Unit Manager on 05/12/2022 at 9:08 AM; Staff Development Coordinator on 05/12/2022 at 8:55 AM, and the Administrator on 05/12/2022 at10:54 AM, revealed they had been in service on the facility elopement/wandering policy by the facility's consultant. 11. A review of the facility's in-service documentation revealed re-education with staff started on 04/19/2022 and was completed by 04/20/2022 for all staff who were working on Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement by the Staff Development Coordinator, Unit Manager, and Director of Nursing for all staff and nurses. Review of the post-test revealed the test was completed by staff to ensure they retained the information. A review of the post-test completed by staff revealed the post-test had been conducted and no concerns were identified. Interviews with the Unit Manager on 05/12/2022 at 9:08 AM; the Staff Development Coordinator on 05/12/2022; and the Director of Nursing on 05/12/2022 at 10:19 AM; revealed they had conducted in-services for all working staff starting on 04/19/2022 and was ongoing for staff who had been off work. Further interviews revealed the inservice was conducted when staff returned to the facility before they worked their unit. Interviews revealed staff were in-service on The Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident, and Comprehensive Care Plan Policy related to elopement. Interviews on 05/12/2022 with State Registered Nuse Aide (SRNA) #9 at 2:18 PM; SRNA #10 at 1:55 PM; SRNA #11 at 2:05 PM; SRNA #12 at 2:37 PM; SRNA #13 at 2:48 PM; LPN #6 at 8:24 AM; LPN #3 at 8:38 AM, and RN #2 at 8:32 AM revealed they were in service on the Elopement/Wandering Policy, Missing Resident Policy, Care of a Wandering Resident and Comprehensive Care Plan Policy related to elopement and following the plan of care for a wandering/exit seeking resident. No concerns were identified. 12. A review of the facility's elopement drill documentation revealed elopement drills were conducted on 04/19/2022, and 04/20/2022, then continued daily starting on 04/21/2022 to 04/25/2022 by the Social Services Director and/or the Maintenance Supervisor. A review of the elopement drill documentation conducted on 05/11/2022 and 05/12/2022 revealed they were being conducted three (3) times weekly on different shifts and were ongoing according to the facility plan. Interview with the facility's Social Worker on 05/12/2022 at 8:45 AM, and the Maintenance Supervisor who was the Plant Operations Director on 05/12/2022 at 9:15 AM revealed elopement drills had been conducted daily from 04/19/2022 and were currently being conducted three (3) times weekly on different shifts. 13. A review of the facility's documentation of the daily review of progress notes revealed Resident's Progress notes were reviewed daily from 04/19/2022 to 05/10/2022 for wandering\elopement concerns. No concerns were identified with the residents. A review of progress notes for Residents #6, #7, #8, and #9 from 04/21/2022 to 05/10/2022 revealed no concerns with wandering/elopement behaviors. Interviews with the Unit Manager on 05/12/2022 at 9:08 AM; and the Director of Nursing on 05/12/2022 at 10:19 AM, revealed resident progress notes were reviewed daily in the morning meeting and on weekends by the manager on duty. 14. A review of staff Inservice documentation revealed staff education was initiated on 04/18/2022 regarding following the comprehensive care plan and State Registered Nurse Aide (SRNA) Point of Care policy in the event a resident expresses or displays exit seeking or wandering risk behaviors. Re-education was initiated by the Director of Nursing with staff on 04/18/2022 regarding immediate reporting of any identified behaviors related to exit seeking and wandering. One-to-one education regarding following the care plan interventions, and reporting residents who display or express exit seeking and wandering behaviors, was reviewed with the State Registered Nurse Aide (SRNA) #1 upon returning to work completed by the Administrator, Director of Nursing, and the faci [TRUNCATED]

Based on the interview, record review, and a review of the facility policy, it was determined the facility failed to provide foods that accommodated the resident's allergies, intolerances, and preferences for one (1) of nine (9) sampled residents (Resident #4). On 12/10/2021, the facility documented that Resident #4 had a known allergy to shrimp; however, on 12/24/2021, the facility served the resident shrimp during his/her lunch meal service. The findings include: A review of the facility policy for food allergies titled, Therapeutic Diets, with a revision date of September 2017, revealed the resident's diets were ordered by the physician to provide food that a resident was able to eat. Continued review revealed a licensed nurse would complete and sign the diet requisition to include the full diet order and food allergies with specific food requests. Closed Record Review of Resident #4 revealed the facility admitted the resident on 12/01/2021 with diagnoses that included Acute Respiratory Disease Cognitive-Communication Deficit, Dysphagia, and Dementia. Review of the resident's Admission Minimum Data Set (MDS) Assessment, dated 12/08/2021, revealed Resident #4 was assessed to have a brief interview for mental status (BIMS) score of three (3), indicating the resident was severely impaired in cognition. Further review of the assessment revealed that the resident was assessed to require the limited assistance of one (1) person to eat. A review of the resident's admission dietary assessment dated [DATE] revealed the resident had no food allergies or intolerances. A review of Resident #4's admission physicians orders, dated 12/01/2021, revealed the resident had no known drug or food allergies and was ordered to have a regular dysphagia advanced diet. Review of Resident #4's Progress Notes, dated 12/10/2021, revealed the resident's family informed the facility the resident had a shellfish allergy. The resident's allergies were updated to include shellfish, at that time. Continued record review revealed staff gave the resident ' s family member a tray to serve the resident his/her lunch. Continued review revealed the resident was assisted by the family member and served Resident #4 the food containing shrimp (a type of shellfish), on 12/24/2021. Further record review revealed the resident's family and his/her physician were notified. Continued review of the record revealed the resident was monitored with no distress noted. Interview with the Dietary Manager, on 05/02/2022 at 3:15 PM, revealed in December of 2021, shrimp was on the planned menu and could have been served by accident to the resident. According to the Dietary Manager, she was not able to check the resident ' s old tray card to see if the allergy was listed because the resident was no longer at the facility. Further interview revealed that if the resident had an allergy listed, then the resident would most likely not be served food that he/she was allergic to, but she added, a mistake could happen, and the resident could have been accidentally served shrimp. She further revealed it was up to staff on the floor with the resident to notice the resident's allergies and obtain a different tray. Interview with Licensed Practical Nurse (LPN) #3, on 05/02/2022 at 3:56 PM, revealed she was working when the shrimp was served to Resident #4 and the resident's family fed the shrimp to the resident. The LPN stated the resident consumed all the shrimp. She stated the Nurse Practitioner was contacted and the family was aware. She further revealed the resident was monitored and had no effects from consuming the shrimp. Interview with Advanced Registered Nurse Practitioner (ARNP), on 05/03/2022, revealed she was contacted by the facility and made aware of Resident #4 consuming shrimp with a shellfish allergy. The ARNP stated she ordered the resident to be monitored for any reaction. Per the interview, she stated the resident did not react to consuming the shrimp. Interview with the Director of Nursing (DON), on 05/12/2022 at 10:19 AM, revealed the DON was aware that Resident #4 had consumed the shrimp but was not able to determine who had delivered the tray to the resident. Further interview revealed staff was required to check the resident's tray with the tray card to ensure the resident was served the correct diet. The DON stated that if a resident was served food, they were allergic to, they could potentially have a reaction to the food. Interview with the Administrator, on 05/12/2022 at 10:54 AM, revealed she was not aware Resident #4 was served shrimp. The Administrator stated she expected that staff would check the residents' trays to ensure they were being served the correct diet. The Administrator stated that if a resident was served food they were allergic to could potentially have a negative reaction and/or harm the resident.

Based on interview, record review, and the facility policy review, it was determined the facility failed to ensure one (1) of one (1) sampled residents (Resident #1) was protected from abuse. On 05/01/2021 at approximately 4:00 PM to 5:00 PM, State Registered Nurse Aide (SRNA) #2 struck Resident #1 in the chest when the resident grabbed her hair. The findings include: Review of the facility policy titled Abuse, Neglect and Misappropriation of Property, reviewed and revised on 05/08/2019, revealed the facility provided information for the prevention of allegations of abuse and neglect to residents. The procedures for the prevention of abuse was to include an evaluation of each resident upon admission and periodically thereafter to identify potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns and the plan of care to address identified vulnerabilities. Furthermore, the policy revealed during orientation all new employees will be trained on abuse. Review of the facility policy titled Resident Rights, reviewed and revised on 08/16/2018, revealed all residents have the right to be treated with respect and dignity. Furthermore, these rights will be promoted and protected by the facility. When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. Review of the facility investigation dated 05/07/2021 revealed while State Registered Nurse Aide (SRNA) #1 and #2 was providing care for Resident #1 on 05/01/2021, Resident #1 forcefully grabbed hold of SRNA #2's hair with both hands and started to pull. SRNA #2 brought her head close to Resident #1 chest to provide relief from her hair being pulled; however, Resident #1 brought his/her knees toward the SRNA #2 to strike her. At this time, SRNA #2 panicked and touched/pushed on Resident #1's chest. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Dementia, [CONDITION(S)], Convulsions and Other Depressive Episodes. Review of the resident's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed a BIMS score of zero (0) indicating severely impaired cognition. Further review revealed the resident exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) four (4) to six (6) days, but less than daily during the seven (7) day observation period. In addition the resident exhibited rejection of care one (1) to three (3) days during the seven (7) day observation period. Attempts to interview Resident #1 were unsuccessful due to the resident's cognitively impaired mental status. Interview with SRNA #1, on 07/01/2021 at 1:26 PM, revealed she worked on 05/01/2021 from approximately 3:00 PM. She revealed on 05/01/2021 at approximately 4:00 PM to 4:30 PM, SRNA #2 and herself entered Resident #1 room to provide care when Resident #1 grabbed the tips of SRNA #2 hair. She revealed the SRNA #2 became upset and began cussing. She stated she tried to assist SRNA #2 to remove her hair from the resident's hands; however, was unsuccessful and the resident kept pulling her hair tighter. She stated SRNA #2 then drew her fist back and punch him/her in the chest. She stated SRNA #2 hair remained in the residents hands, she informed SRNA #2, she couldn't hit residents. She revealed SRNA #2 stated I don't f***ing care, then proceeded to cuss at her. She stated she hollered for nurse; however, nobody heard her so she left the room and notified LPN #2. She stated LPN #2 immediately went to the room. Interview with SRNA #2, on 07/01/2021 at 2:08 PM, revealed around 4:00 PM to 5:00 PM on 05/01/2021, SRNA #1 and herself entered Resident #1 room. She revealed the resident had what appeared to be a hospital bracelet on his/her arm. She bent over slightly to identify what kind of bracelet the resident had on when the resident grabbed her hair. She stated she tried to calm the resident down and remove her hair; however, he/she would not calm down or let go of her hair. The SRNA stated she asked SRNA #1 to help her; however, the SRNA would not help. Per the SRNA, she started to get p*ssed and was stern with Resident#1, telling the resident to let go of her hair. Further interview revealed the resident was pulling her hair tighter, actively trying to pull her in the bed and attempting to knee her in the head. She stated she panicked and thumped the resident in the chest with her hand. She stated she only hit the resident because she was trying to keep herself from falling in the bed with Resident #1. She revealed she had no intention to hit Resident #1; however, she panicked and was trying to keep herself from falling. She stated she did tell SRNA #1 she needed to f***ing help me, however, she did not. She stated SRNA #1 then exited the room leaving her alone with Resident #1 at which time she jerked her hair out of his/her hands, leaving chunks of her hair in the residents hands and on the floor. She stated she was then removed from resident care, interviewed related to the incident and escorted out of the facility. She revealed she was later terminated from the facility. Interview with Licensed Practical Nurse (LPN) #2, on 07/01/2021 at 12:32 PM, revealed SRNA #1 notified her on 05/07/2021 at approximately 5:00 PM stating SRNA #2 had struck Resident #1. She further revealed she immediately went to the resident room when SRNA #2 met her at the door. She revealed SRNA #2 was then removed from resident care area. She revealed SRNA #2 admitted she had hit Resident #1 related to the resident having her by her hair and trying to get loose of his/her grip. She further stated SRNA #2 stated without thinking she thumped him/her in the chest. The LPN stated she then notified the Director of Nursing (DON) and escorted SRNA #2 out of the facility. She revealed she completed a skin assessment which did not identify any apparent injury for Resident #1. Interview with DON, on 07/01/2021 at 5:20 PM, revealed she was notified of the incident at approximately 5:00 PM to 5:30 PM on 05/01/2021. The DON stated Resident #1 had grabbed SRNA #2 hair and SRNA #2 had hit the resident. She stated the facility implemented an investigation and did not identify any other concerns with SRNA #2. Interview with Administrator, on 07/01/2021 at 4:30 PM, revealed she was notified by LPN #2 on 05/01/2021 at approximately 5:00 PM of the incident. The Administrator stated she, along with LPN #2, and the DON, interviewed SRNA #2 and the the SRNA #2 stated in the heat of the moment, she hit Resident #1 in chest. The SRNA stated in the interview, she hit him/her because the resident had her hair and was pulling her down to his/her chest while trying to kick her. Per the Administrator, the facility initiated an investigation immediately and SRNA #2 was escorted to the time clock and suspended. Continued interviewed revealed during the course of the investigation no other allegations of abuse was identified regarding SRNA #2. She stated based on the investigation the allegation of abuse was unsubstantiated by the facility due to Resident #1 not being harmed with no physical or psychological injury. She stated the facility terminated SRNA #2.

Based on observation, interview, and record review, it was determined that food served to residents during the noon meal on 09/08/2020 was not palatable. Interviews with unsampled residents (Residents A, B, and C) and a palatability test revealed the food was not seasoned and tasted bland. The findings include: Interview with the Assistant Dietary Manager (DM) on 09/08/2020 at 12:52 PM, revealed the facility did not have a policy related to food palatability. During the initial tour conducted on 09/08/2020 beginning at 12:25 PM, three (3) unsampled residents (Resident A, Resident B, and Resident C) stated that the food served at the facility did not have enough seasoning and tasted bland. A palatability test was conducted on 09/08/2020 at 12:49 PM for the noon meal. The meal consisted of salmon patties, mashed potatoes, and green beans. The regular consistency salmon patties, mashed potatoes, and green beans tasted bland and unseasoned. Interview with the Assistant DM on 09/08/2020 at 12:52 PM, revealed the DM was on vacation. The Assistant DM stated the facility had changed the way meals were prepared and received the meals already prepared and frozen in a box. The Assistant DM stated the packages had directions for how to reheat the food. The Assistant DM stated the facility did not add any additional seasonings to the food.

Based on observation, interview, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance, it was determined that the facility failed to prevent the possible spread of COVID-19. On 09/09/2020, one (1) State Registered Nurse Aide (SRNA) was observed wearing a face mask with the mask positioned below the nose. The findings include: A review of COVID-19 Long-Term Care Facility Guidance from CMS dated 04/02/2020 and review of the facility's policy, Novel Coronavirus (COVID-19), with a revision date of 08/18/2020, revealed all staff should wear a face mask while they are in the facility. According to CDC guidance for Using PPE, updated on 06/09/2020, when applying a face mask, the nose piece (if the mask has one), should be fitted to the nose with both hands and should be extended under (the) chin. The guidance stated both the mouth and nose should be protected. The guidance also stated that face masks should not be pulled below the chin. Observation on 09/09/2020 at 10:20 AM revealed SRNA #1 was in the hallway going into resident room [ROOM NUMBER]. The SRNA was observed to be wearing a face mask that was not covering her nose. One (1) resident was observed in the resident room. Interview with SRNA #1 on 09/09/2020 at 10:25 AM, revealed she had been trained on how to properly don a face mask and was required to wear her face mask while at work. The SRNA stated her mask kept falling down. An interview with the Director of Nursing (DON) on 09/10/2020 at 12:38 PM revealed all staff were required to wear a face mask at all times when in the building to help prevent the spread of the Coronavirus. She stated CMS's guidance was initiated on 04/03/2020 and all staff were trained. According to the DON, she made rounds to monitor to ensure staff were following the policy and she was providing on-the-spot education if needed. The DON stated she had not identified any concerns with staff not appropriately donning face masks or wearing them inappropriately.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure two (2) of three (3) sampled residents (Residents #1 and #3) received services that met professional standards of quality care and treatment to treat pressure ulcers to promote healing and prevent infection. On 06/13/18, the facility identified that Resident #1 had an unstageable pressure ulcer to the sacrum (tailbone). On 06/19/18, the resident's Physician wrote an order to cleanse the wound with Wound Cleanser, instead of normal saline, and to increase dressing changes from every three (3) days to every two (2) days. However, the facility failed to follow the Physician orders [REDACTED].#1's pressure ulcer with normal saline every three (3) days. Further, on 10/31/18 the resident's provider changed the treatment to the resident's pressure ulcer again; however, the facility failed to implement the new treatment. Resident #3 had a Stage II pressure ulcer to his/her sacrum upon readmission to the facility on [DATE] with a treatment order to cleanse the area with wound cleanser, pat the area dry, and apply a comfort foam dressing every day and as needed. However, review of Resident #3's Treatment Record (TAR) revealed the facility failed to have documented evidence that the treatment was provided on fourteen (14) days from 01/07/19 through 02/24/19. The findings include: Review of the facility's policy, Charting and Documentation, dated 06/01/15 revealed services provided to the resident would be documented in the resident's medical record. Documentation of procedures and treatments would include care-specific details and would include at a minimum: the date and time the procedure/treatment was provided and the name and title of the individual that provided care. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident on 06/27/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE], revealed the resident had no pressure ulcers, but was at risk for developing pressure ulcers. Further review revealed the resident required extensive assistance with activities of daily living (ADLs) including bed mobility, transfers, dressing, toilet use, and hygiene. Further review revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was not cognitively impaired. Review of Resident #1's comprehensive care plan dated 04/15/18, revealed the facility identified that the resident was at risk of developing skin breakdown. The facility developed interventions that included reporting changes in skin status, such as new areas, to the Physician/APRN; and turning and repositioning the resident every two (2) hours. Review of Resident #1's Pressure Ulcer Record dated 06/13/18 revealed the resident developed a facility-acquired unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar, which is necrotic or dead tissue) to his/her sacrum measuring 2.8 cm in length by 2.8 cm in width and zero depth. Review of a physician's orders [REDACTED]. Further review of Resident #1's physician's orders [REDACTED]. In addition, the Physician ordered dressing changes to the area to be increased from every three (3) days to every two (2) days and as needed and to ensure the dressing was dry and intact daily. Review of Resident #1's Treatment Administration Record (TAR) dated 06/19/18 revealed the facility changed the resident's TAR to reflect the order for dressing changes every two (2) days; however, there was no documented evidence that the order for cleansing the wound was changed to Wound Cleanser. According to the TAR, staff continued to cleanse the resident's pressure ulcer with normal saline (not the Physician-ordered wound cleanser). In addition, review of a Progress Note dated 10/31/18 for Resident #1 revealed the APRN documented that the resident's pressure ulcer had improved and was responsive to treatment. However, the APRN documented that the treatment for [REDACTED]. However, a review of Resident #1's physician's orders [REDACTED]. to reflect the order change. Continued review of Resident #1's (MONTH) and (MONTH) 2019 TAR revealed no documentation that the staff identified that the [MEDICATION NAME] treatment ordered by the resident's primary care provider on 10/31/18 was not being provided every shift. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 10/01/04 and readmitted the resident on 12/21/18 with [DIAGNOSES REDACTED]. Review of Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of five (5), indicating the resident was severely cognitively impaired. Further review of the assessment revealed the resident required extensive assistance of two (2) staff persons for bed mobility. Review of Resident #3's comprehensive care plan dated 12/21/18, revealed the facility identified that the resident had a Stage II pressure ulcer to his/her sacrum and developed interventions to provide wound care as ordered by the Physician, and to observe for effectiveness and response to treatment as ordered. Review of a Pressure Ulcer Record dated 12/21/18 for Resident #3 revealed the facility readmitted the resident from the hospital with a Stage II pressure ulcer to his/her sacrum measuring 0.5 cm in length, 0.5 cm in width, and 0.1 cm in depth. Review of a physician's orders [REDACTED].#3's sacrum with wound cleanser, pat the area dry, and apply a comfort foam dressing daily and as needed. However, review of Resident #3's Treatment Record (TAR) dated 01/07/19, 01/16/19, 01/17/19, 01/22/19, 02/05/19, 02/06/19, 02/09/19, 02/10/19, 02/14/19, 02/19/19, 02/20/19, 02/22/19, 02/23/19, and 02/24/19 revealed no documented evidence that the facility provided the treatment to the pressure ulcer to the resident's sacrum. Interview with the Wound Care Nurse on 03/05/19 at 4:16 PM revealed she reviewed the resident's treatment order in the computer prior to administering treatments and did not necessarily review the resident's care plan. Interview with Licensed Practical Nurse (LPN) #1 on 03/06/19 at 12:30 PM revealed she provided treatment to Residents #1 and #3's pressure ulcers as directed by the residents' Treatment Administration Record (TAR). The LPN stated she did not know why Resident #1's treatment did not get changed on the TAR on 06/16/18, when the order to clean the wound was changed from normal saline to wound cleanser or why the resident's order for [MEDICATION NAME] was not implemented on 10/31/18 as ordered by the physician. In addition, the LPN stated she had always provided treatments to the residents as ordered and did not know why Resident #3's TAR contained blanks indicating the treatment had not been provided. Interview with the Wound Care Nurse on 03/05/19 at 4:16 PM revealed she measured residents' pressure ulcers every Wednesday and assisted nurses with providing daily treatments. She stated staff were required to document in the resident's electronic medical record (TAR) when a treatment was provided. Further interview with the Wound Care Nurse revealed she recalled APRN #1 ordering [MEDICATION NAME] to treat Resident #1's pressure ulcer, but did not know why the order was not written or implemented or why the treatment had not been changed for the resident's wound to be cleaned with wound cleanser on 06/19/18. Interview with Physician #1 on 03/06/19 at 2:20 PM revealed if a medication or a treatment was ordered, he expected the facility to follow the order. Interview with the Director of Nursing (DON) on 03/07/19 at 3:23 PM revealed Physician orders [REDACTED]. She stated she was not sure why the order for [MEDICATION NAME] was not written and implemented or why the treatment change from normal saline to wound cleanser was also not implemented for Resident #1. Further interview with the DON revealed she had not identified any concerns with physician orders [REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care for one (1) of twenty-two (22) sampled residents (Resident #2). A review of the comprehensive plan of care for Resident #2 revealed catheter care would be provided per the facility's protocol. A review of the facility's policy for indwelling urinary catheters revealed staff was required to secure the catheter after performing catheter care and allow slack in the catheter so movement did not create tension (to prevent trauma). However, observation of catheter care for Resident #2 revealed the indwelling catheter was not secured to the resident (to prevent trauma). The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, with a revision date of October 2010, revealed care plans identified needs of the resident through each discipline's assessment process, and specified which disciplines would carry out the interventions. Interview conducted with the Director of Nursing (DON) on 06/15/17, at 7:10 PM revealed the facility did not have a policy related to State Registered Nurse Aide (SRNA) care plans. A review of the facility's policy titled Catheterization Care, undated, revealed staff was required to secure the catheter after performing catheter care and allow slack in the catheter so movement did not create tension. However, the policy did not address what staff was to use to secure the catheter with (to prevent trauma). A review of the medical record revealed the facility admitted Resident #2 on 02/02/16, with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 05/30/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident had severely impaired cognition and was not interviewable. The MDS further revealed the resident had an indwelling urinary catheter. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's comprehensive plan of care dated 03/01/17, revealed an intervention for nursing staff to provide indwelling urinary catheter care per facility policy. Review of the State Registered Nurse Aide (SRNA) care plan developed for Resident #2, dated June 2017, revealed a catheter strap was to be used to secure Resident #2's urinary catheter. Observation on 06/14/17 at 1:30 PM revealed SRNA #3 was providing catheter care for Resident #2. Observation revealed the resident's catheter was not secured prior to providing catheter care. After performing catheter care, the SRNA was observed to drape the catheter over the resident's right leg and apply a brief, but did not secure the catheter with a catheter strap prior to leaving the resident's bedside. Interview conducted with SRNA #3 on 06/14/17 at 2:15 PM, revealed she was required to check residents' care plans every shift and any time she had a question regarding the resident's care. SRNA #3 stated she was aware Resident #2 had a care plan intervention for a catheter strap and she should not have left the resident without securing Resident #2's indwelling urinary catheter to the resident's thigh. Interview conducted with Registered Nurse (RN) #1 on 06/15/17 at 4:45 PM, revealed she was responsible for the care of Resident #2. The RN stated she made rounds at least every two hours to ensure residents were being provided care and treatment as directed by their care plans. The RN stated the SRNAs were required to use catheter straps to secure catheter tubing (to prevent trauma), but had not identified that staff was not using the catheter straps as required. Interview conducted with the DON on 06/15/17 at 7:10 PM, revealed she made rounds throughout the facility several times a day to ensure residents were being provided the care and treatment as directed by the residents' care plans. The DON stated staff was required to secure an indwelling urinary catheter to the resident's thigh with a catheter strap to prevent trauma. The DON stated she had not identified any concerns with staff not properly securing indwelling urinary catheters to prevent trauma or not following residents' care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #2) received indwelling urinary catheter treatment and services to prevent trauma. A review of the facility's policy for indwelling urinary catheters and a review of Resident #2's care plan revealed staff was required to secure the resident's catheter and allow slack in the catheter so movement did not create tension and cause trauma. However, observation of catheter care revealed Resident #2's indwelling catheter was not secured. The findings include: A review of the facility's policy titled Catheterization Care, undated, revealed staff was required to secure the catheter after performing catheter care and allow slack in the catheter so movement does not create tension. However, the policy does not reveal what staff was to use to secure the catheter with (to prevent trauma). A review of the medical record revealed the facility admitted Resident #2 on 02/02/16, with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 05/30/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident had severely impaired cognition and was not interviewable, and the resident had an indwelling urinary catheter. Review of Resident #2's comprehensive plan of care dated 03/01/17, revealed an intervention for nursing staff to provide indwelling urinary catheter care per facility policy. Review of Resident #2's State Registered Nurse Aide (SRNA) care plan, dated June 2017, revealed a catheter strap was to be used to secure Resident #2's urinary catheter. However, observation of catheter care on 06/14/17 at 1:30 PM, revealed the resident's catheter was not secured prior to catheter care, and SRNA #3 provided catheter care for Resident #2 and draped the catheter over the resident's right leg and applied a brief, but did not secure the catheter with a catheter strap prior to leaving the resident's bedside. Interview conducted with SRNA #3 on 06/14/17 at 2:15 PM, revealed she was aware that Resident #2's indwelling urinary catheter was required to be secured to the resident's thigh, but was unsure why she did not secure the catheter. Interview conducted with Registered Nurse (RN) #1 on 06/15/17 at 4:45 PM, revealed she was responsible for the care of Resident #2. RN #2 stated catheter straps were required to secure the catheter tubing to prevent trauma, but she had identified that staff was not using the catheter straps as required. Interview conducted with the DON on 06/15/17 at 7:10 PM, revealed staff was required to secure an indwelling urinary catheter to the resident's thigh with a catheter strap to prevent trauma, but she had not identified any concerns with staff not properly securing indwelling urinary catheters.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to appropriately check gastrostomy tube placement prior to medication administration for one (1) of twenty-two (22) sampled residents (Resident #16). Observation of Resident #16 on 06/15/17 during medication administration revealed staff failed to check placement of the resident's gastrostomy tube prior to administering medication. The findings include: Review of the facility's policy, Enteral Tubes, dated May 2016, revealed gastrostomy tube placement would be verified before medication administration by inserting a small amount of air into the tube with a syringe and listening to the stomach with a stethoscope for gurgling sounds. Review of Resident #16's medical record revealed the facility admitted the resident on 09/20/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed the facility assessed Resident #16 to have a gastrostomy tube feeding. Review of the physician orders [REDACTED]. Observation of gastrostomy medication administration on 06/16/17 at 8:28 AM revealed Registered Nurse (RN) #2 administered [MEDICATION NAME] 2.5 mg (medication to treat high blood pressure) to Resident #16, but failed to check for gastrostomy tube placement before administering the medication. Interview with RN #2 on 06/15/17 at 5:13 PM, revealed she should have checked gastrostomy tube placement before administering medication through Resident #16's gastrostomy tube. RN #2 further revealed she had been taught to check for placement before medication administration, but was nervous and forgot to check placement. Interview with RN #1, the Second Floor Unit Coordinator, on 06/16/17 at 5:20 PM, revealed any staff administering medications through a gastrostomy tube should always check to ensure the gastrostomy tube is in the right place before administering medications by inserting air into the tube with a syringe and listening with a stethoscope for gurgling sounds. RN #1 further revealed nurses were required to do a skills check-off annually during their evaluation and education was provided if needed. RN #1 revealed she had not identified any concerns with gastrostomy tube placement not being checked before gastrostomy medication administration. Interview with the Director of Nursing (DON) on 06/15/17 at 7:11 PM, revealed staff administering medications through a gastrostomy tube was required to check for placement per the Enteral Tube Policy before medication administration. The DON further revealed she routinely monitored medication administration by checking staff competency and randomly making rounds. The DON also revealed trainings and in-services were provided for staff annually or as needed. The DON stated she had not identified any concerns with placement not being checked prior to gastrostomy medication administration.

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure all drugs used in the facility were labeled in accordance with currently accepted professional principles. During observation of medication storage conducted on 06/15/17, Inhalers for Residents B, C, and F and nasal sprays for Residents D and E were observed to be opened and not dated in a medication cart on the North Hall on the First Floor of the facility. The findings include: Review of the facility Storage of Medication Policy, dated May 2016, revealed medications and biologicals would be stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. However, the policy did not address labeling and dating multi-use containers of medications when the containers were opened. Interview conducted with the DON on 06/15/17, at 7:00 PM, revealed staff was required to label and date all multi-use containers of medication with the date opened, and their initials, upon opening the medication containers. Observations conducted of the First floor, North Hall medication cart on 06/15/17, at 6:15 PM, revealed the following medications had been administered and not dated when opened: Pulmicort Flexhaler for Resident B, Anoro Ellipta Inhaler for Resident B, Spiriva Inhaler for Resident C, Fluticasone Nasal Spray for Resident D, Fluticasone Nasal Spray for Resident E, and ProAir HFA Inhaler for Resident F. Interview with Licensed Practical Nurse (LPN) #1 on 06/15/17, at 6:30 PM revealed she was not sure what the facility's policy was related to dating the inhalers and nasal sprays after opening. However, the LPN stated she did try to remember to date the medications when she opened them. Interview conducted with the DON on 06/15/17, at 7:00 PM, revealed she checked the medication carts at least monthly to ensure the medications were being dated when opened as required. The DON stated the pharmacist also checked the medication carts monthly and she was not aware of any problems with medications not being dated when opened.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain infection control practices to prevent the spread of infections. The facility failed to ensure lemon pie served on resident food trays on 06/13/17 was served in a sanitary manner. In addition, observation of medication administration on 06/14/17, revealed facility staff touched Resident #13's ten (10) medications with their bare hands prior to administering the medications to the resident. The findings include: 1. Review of the Tray Line Setup and Service policy (dated 06/01/14) revealed when delivering food to resident rooms, all food items must be covered unless the food tray was transported in an enclosed cart and the food tray was taken directly to the resident from the location of the enclosed cart. Observation of the noon meal service on the South Hall on the First Floor revealed the first enclosed cart arrived at 12:43 PM on 06/13/17. Further observation revealed three (3) State Registered Nurse Aides (SRNA) were observed to carry three (3) trays with the lemon pie uncovered approximately thirty-two (32) feet away from the enclosed cart. The second enclosed cart arrived on the North Hall on the First Floor at 1:00 PM on 06/13/17. Observation revealed one (1) SRNA carried one (1) tray with the lemon pie uncovered away from the enclosed cart approximately three-fourths the length of the hallway to the front of the nurses' station. Interview with CNA #4 at 10:00 AM on 06/15/17 revealed staff was supposed to deliver food trays within two (2) doors from the food cart. CNA #4 stated they just got in a hurry and did not realize the lemon pie was uncovered. Interview with the Dietary Manager at 9:25 AM on 06/15/17 revealed staff was supposed to take the enclosed cart down the hallway and only serve trays in the location of the cart. The Dietary Manager stated staff was not supposed to carry food trays away from the enclosed cart unless the food was covered. 2. Review of the facility Handwashing/Hand Hygiene policy (revision date August 2012) revealed handwashing procedure or hand hygiene with an alcohol-based hand rub should be performed before preparing or handling medications. However, the policy did not address staff not touching medications with bare hands. Interview conducted with the DON on 06/15/17, at 7:00 PM, revealed staff was not to touch a resident's medication with their bare hands. A medication observation pass was conducted with facility staff (LPN #1) on 06/14/17, at 8:50 AM. The LPN was observed to remove ten (10) medications from their individual blister packets. LPN #1 was observed to push each medication through the plastic into her bare hand before placing it into the plastic medication cup. After handling the ten (10) individual medications, the medications were administered by mouth to Resident #13. Interview with LPN #1 on 06/14/17, at 9:00 AM, revealed the LPN confirmed she handled each medication with her bare hands prior to placing the medicines into the plastic medicine cup. The LPN stated she should not have touched the medications with her bare hands prior to administering the medications to the resident. Further interview with the DON on 06/15/17, at 7:00 PM, revealed she and the Assistant DON conducted daily rounds to observe staff to ensure handwashing and infection control procedures were being followed. The DON stated competency skill checks which included medication administration were also conducted annually with each nurse. The DON further stated no problems had been identified regarding handwashing during medication pass.

Based on observation, interview, and record review it was determined the facility failed to ensure dietary choices that were significant to the resident were honored for one (1) of one (1) sampled resident (Resident #1). Resident #1's family had requested that the resident be provided two (2) servings of milk on the tray at each meal. The resident was observed to receive only one (1) serving of milk at the lunch and supper meals on 02/06/17. The findings include: A review of the facility policy titled Menu Planning Criteria, with a revision date of 10/01/14, revealed daily menus should contain standard levels of nutrients and dairy products including milk. Milk was to be at least two (2) or more servings per day. According to the facility procedure, milk was available at all three (3) meals and any time upon request. All residents who take meals in their rooms have milk provided to them on their tray during meal pass. Resident #1 was admitted by the facility on 09/08/15 with [DIAGNOSES REDACTED]. A review of the most recent comprehensive minimum data set (MDS) assessment completed for Resident #1 dated 12/05/16 revealed the resident was assessed to require the extensive assistance of one (1) staff member for eating. A review of physician orders revealed the resident was ordered a regular diet with thin liquids. A review of the plan of care developed for Resident #1 revealed the resident was care planned to be fed by staff. A review of the meal card for Resident #1 revealed no evidence the resident was to have two (2) servings of milk provided on the meal tray. Observation of Resident #1 conducted on 02/06/17 at 1:00 PM during the lunch meal service revealed the resident was sitting in the room with a family member assisting the resident to eat and only one (1) serving of milk was observed on the resident's tray. Observation of Resident #1 during the supper meal on 02/06/17 at 5:55 PM revealed the resident was delivered a meal tray to the room by staff. The tray was observed to have only one (1) serving of milk on the tray. Interview conducted with State Registered Nurse Aide (SRNA) #1 on 02/06/16 at 6:00 PM revealed Resident #1 was served one (1) serving of milk on the tray and the SRNA was not aware the resident's family had requested that the resident have two (2) servings of milk at each meal. An interview with Family Member (FM) #1 on 02/07/17 at 9:15 AM revealed the family member had requested that Resident #1 be provided two (2) servings of milk at each meal but could not recall when. FM #1 further stated this had been discussed with the kitchen staff also. An interview with the Dietary Manager on 02/07/17 at 10:45 AM revealed FM #1 had requested that Resident #1 have two (2) servings of milk on the tray at each meal a few months ago. The Dietary Manager thought the nursing staff was aware of the request to give the resident two (2) servings of milk when serving meals. According to the Dietary Manager, she forgot to add the request to the resident's tray card.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide care in accordance with the comprehensive plan of care for one (1) of five (5) sampled residents (Resident #1). On 01/04/17, staff observed Resident #1 smoking in his/her room. Resident #1 denied he/she had been smoking; however, a search of the resident's room revealed the resident had a lighter and a pack of cigarettes under a cap in the windowsill. Interviews with Administrative staff revealed that only the staff working at the time of the incident was made aware that the resident had been smoking in his/her room. The resident's care plan was updated with new interventions related to the incident. Interviews with facility staff revealed they were not aware that the resident had been observed smoking in his/her room; that smoking materials had been found in the resident's room; or, that an intervention had been implemented to search for contraband, as needed. On 01/08/17, at approximately 10:45 AM, a fire was discovered in the room of Resident #1. The facility sprinkler system was activated and the fire department responded and the blaze was subsequently extinguished. Review of the State Fire Marshal Report revealed Resident #1 smoking in the room was the likely cause of the fire. Three (3) facility residents had to be transported to the hospital for evaluation related to smoke inhalation, and one (1) resident was transferred to the hospital for a toe injury that occurred during the evacuation. Eleven (11) facility staff was transferred to the emergency room for treatment related to smoke inhalation. The facility's failure to ensure that staff followed resident care plans in accordance with the written plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/12/17 and determined to exist on 12/16/16 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F323) and 42 CFR 483.75 Administration (F490). Substandard Quality of Care was also identified at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/12/17. An acceptable Allegation of Compliance was received on 01/24/17, which alleged removal of the Immediate Jeopardy on 01/21/17. The State Survey Agency determined the Immediate Jeopardy was removed on 01/21/17, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Care Plans- Comprehensive, reviewed 06/01/15, revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes. Further review of the policy revealed care plans were revised as information about the resident and the resident's condition change. Review of the facility's policy titled, Smoking Resident, date reviewed 06/01/15, revealed it was not the intent of the facility to prohibit or restrict smoking privileges but to provide safety for residents, visitors and employees. Further review of the policy revealed the smoking regulations shall be explained to the residents and family upon admission to the facility and provided to the resident, visitors and employees. Continued review of the policy revealed smoking would be allowed in the designated smoking area only. The policy stated all residents who smoke would be supervised by designated facility staff and No Smoking signs shall be prominently displayed throughout the facility where smoking was prohibited. Further review of the policy revealed all smoking materials (lighters, matches, and cigarettes) were to be deposited and kept in a designated area for single use distribution only, and the facility would be responsible for lighting residents' smoking material. The policy stated staff would keep smoking materials for residents that smoke, until smoking times would be designated, per facility policy. The policy stated smoking would not be permitted in any areas with oxygen related devices. Review of the facility's policy titled, Contraband Discovery, reviewed 04/19/16, revealed staff would conduct inspections and searches of residents' rooms under circumstances where there was reasonable suspicion that the resident may be concealing contraband (smoking materials). Further review of the policy revealed the purpose of the policy was to identify resident's that were non-compliant with the use of tobacco products, as per the facility smoking policy. Continued review of the policy revealed it was the responsibility of the staff members to monitor and enforce inspection policies in order to maintain a safe, secure environment for residents, visitors, families, and employees. Further review of the Contraband Discovery policy revealed a search of the resident and/or resident's room may be conducted if the staff has a reasonable suspicion that the resident has contraband and the responsible parties and the resident would be notified of the search and the results of the search. The policy stated the resident's clothing and personal items would be thoroughly inspected including the clothing worn by the resident. Continued review of the policy revealed residents who were found to be noncompliant with the smoking policy or discovery of contraband would be subjected to administrative actions which may include the following: reassessment of the resident's care plan or the initiation of a Behavior Management Plan between the resident and the facility and discharge from the facility when the violations meet the threshold of state and federal regulations of involuntary discharge (violations were a danger to the resident and others). Record review revealed the facility readmitted Resident #1 on 09/09/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 12/06/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12). The facility assessed the resident to be moderately cognitively impaired. Further review of Resident #1's MDS assessment revealed the facility assessed the resident to require supervision for transfers and ambulation. Review of Resident #1's Social Services Progress Notes, dated 01/04/17, revealed a staff member reported to administrative staff that she had observed Resident #1 smoking in his/her room. Continued review of the Note revealed the Social Services Director (SSD) and the Administrator immediately went to Resident #1's room to discuss the concern. The resident denied he/she had been smoking in the room. Further review of the Note revealed Resident #1's room was then searched and smoking contraband was found under the resident's cap on the windowsill. The Note stated the contraband was removed from the Resident #1's room and the resident was educated on the facility's smoking policy. Review of Resident #1's care plan Potential for Smoking Related Complications, updated on 01/04/17, stated the resident will attempt to hide cigarettes and lighters in the resident's room. Further review of the care plan revealed interventions were added to the care plan which included: contraband searches, as needed; and, educated Resident #1 on the facility's smoking and contraband policy. Review of Resident #1's Nursing Assistant Record, dated December 2016 and January 2017, revealed the record did not include that the resident was a smoker, or the interventions that the resident required increased monitoring for non-compliance with the facility's smoking policy. Further review revealed the record did not alert the staff of the intervention of contraband searches as needed, related to the resident's non-compliance with the smoking policy. Interviews on 01/11/17 with State Registered Nurse Aide (SRNA) #1 at 3:05 PM, SRNA #2 at 3:14 PM, SRNA #3 at 3:21 PM, SRNA #4 at 3:31 PM, SRNA #5 at 3:40 PM, Registered Nurse (RN) #1 at 2:54 PM, RN #2 at 3:43 PM and RN #3 at 4:01 PM revealed the staff had not been made aware Resident #1 had been observed by a facility staff member smoking in his/her room or that cigarettes and a lighter had been found in the resident's room. Interview on 01/11/17 at 5:30 PM with the Administrator revealed a staff member reported to the SSD, on 01/04/17, that she had observed Resident #1 smoking with his hand outside of the window in his/her room. The interview further revealed the SSD immediately reported the incident to the Administrator. The SSD and the Administrator immediately went to the resident's room to speak with Resident #1; the resident denied he/she had been smoking in his/her room. The Administrator denied that she smelled cigarette smoke; however, a contraband search was done and smoking materials were found under the resident's cap on the windowsill. The smoking material was removed from the resident's room. The interview further revealed that Resident #1 was educated on the facility's smoking and contraband policy. Continued interview revealed the staff working at the time of the incident were made aware of the incident and that it was everyone's responsibility to take cigarettes and lighters when found on a resident. She stated the care plan was updated related to the incident, and a new intervention of as needed contraband searches was added. However, the Administrator stated the facility did not take action to ensure all facility employees were made aware of the concern that Resident #1 was possibly smoking in the room or implement specific interventions for staff to follow if they suspected or observed the Resident #1 smoking in the room. The Administrator stated she believed updating the resident's care plan would be sufficient, and that the staff notified at the time of the incident would pass it along in report. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) At approximately 10:45 AM on 01/08/17, a smoke alarm sounded on the second floor North Unit. All facility staff immediately reacted and assured the residents' safety. The facility sprinklers detonated and put the fire out. The fire department responded, along with the State Fire Marshal and the Kentucky State Police Arson Investigator. There was cigarette evidence found in Resident #1's room, and the resident was placed on one to one supervision. 2) All residents were medically and psychosocially assessed for any signs and symptoms of potential injury by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), Staff Development Coordinator (SDC), or Regional Nurse Consultant (RNC) on 01/08/17. There were no concerns identified. 3) Twenty-two (22) residents were displaced due to the fire. The twenty-two residents were assessed for any signs/symptoms of smoke inhalation and any psychosocial concerns by the Charge Nurse every shift for 48 hours. The Social Services Director (SSD)/Chaplain visited the residents daily and provided any psychosocial/spiritual support needed. This started on 01/08/17 and was completed on 01/10/17 with no issues or concerns noted. 4) Residents that smoke were assessed utilizing a Smoking Evaluation, by the RNC, DON, ADON, UM or SDC on 01/08/17. Eight (8) residents were identified as smokers from the completed smoking evaluation. The smoking evaluation included assessing residents for cognitive patterns, communication/hearing/vision deficits and physical ability, to ensure the residents were safe to smoke and the level of supervision which was required. 5) The Vice President of Operations (VPO), the SSD, and the Resident Council President met with all the residents who smoke on 01/09/17. The smoking policy and the contraband policy was explained and reviewed in detail. All residents that smoke were present and each resident was asked to sign an understanding of the policy and that they agreed to abide by the smoking policy. Based on the acknowledgments, it was determined that each of the residents was at a low risk to not follow policy. 6) On 1/8/17, the facility placed Resident #1 on five (5) minute checks and were to watch the resident closely. During contraband checks on the evening of 01/08/17, Resident #1 was found to have cigarette paraphilia. The resident was then placed on one to one supervision on 01/09/17 to ensure he/she was compliant with the smoking and contraband policy. The facility initiated Resident #1's safe emergent discharge planning. Resident #1 remained on one to one until he/she was discharged from the facility. The facility defined one to one supervision as: staff member would be close to resident at all times, 24 hours per day; the staff member would visualize the resident at all times, 24 hours per day; and, the staff member would be present with the resident even when visitors are visiting with resident. 7) Resident #1 was assessed for behaviors on 01/10/17 by the Regional Behavioral Health Specialist, the resident's care plan was updated to encourage the resident to smoke in designated areas, monitor for compliance of the facility smoking policy, educate the resident on the smoking policy as needed, and conduct contraband searches as needed. 8) All resident rooms were searched for contraband by the RNC, DON, ADON, Unit Managers or SDC on 01/08/17, with one area of concern noted. Facility identified Resident D had cigarettes. Facility staff removed the cigarettes and placed them in a secure location. 9) Environmental rounds were completed in all resident rooms by the RNC and the DON on 01/08/17. Each room was assessed for smoke smell and/or ashes in the room or bathroom, no concerns were identified. 10) The care plans of all residents that smoke were reviewed by the RNC, DON, ADON, Unit Managers, or SDC on 01/09/17, to ensure the care plans were updated to reflect current care needs of the residents. Each resident care plans were updated with the following interventions: Observing for signs of noncompliance with the smoking policy, smell for smoke when in the room, observing for ashes in the room or bathroom, and observe for contraband within eyesight. 11) Chart reviews were completed for residents that smoke. The charts were reviewed for any changes in behaviors or indications of noncompliance with the smoking policy for the past thirty (30) days. These reviews were conducted by the DON, Nursing Supervisors, UM, SDC, or RNC on 01/08/17, no issues were identified. 12) Facility staff completed smoking assessments on all residents on 01/08/17. The facility had eight (8) residents that smoke. Of the eight (8) residents that smoke, the facility identified two (2) additional residents that were considered at higher risk to be noncompliant. Identification was based on residents that leave the facility with family often, residents that family visits frequently, resident that had access to obtaining contraband through home visits. Interviews with the two residents revealed each had, or in the past had, contraband in their rooms. The following action was taken related to the two (2) identified residents: A) Facility SRNAs observed for any signs of noncompliance with the smoking policy during their two (2) hour rounds on each shift. Staff will smell for smoke, look for ashes in the resident's room/bathroom, and observe for smoking contraband. This started on 01/09/17 and will continue for two (2) weeks. Additional documentation was initiated on 01/20/17, utilizing the Smoking Noncompliance Audit Log. The log identifies specific times for the SRNA's to conduct the checks. The checks will be conducted at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. The findings of the audits and rounds will be presented to the Quality Assurance Committee weekly to determine if any changes were needed. B) Charge Nurses monitored compliance with SRNA rounds two (2) times per shift during their medication pass. They also monitored for any noncompliance with the smoking policy by smelling for smoke and looking for ashes or any contraband left out in eyesight. This started on 01/09/17 and continued for two (2) weeks. Additional documentation was initiated on 01/20/17 for high risk residents utilizing the Smoking Noncompliance Audit Log. The log directs nurses to observe for smoke, ashes, or contraband at specific times: 1:00 AM, 3:00 AM, 5:00 AM, 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, 9:00 PM, and 11:00 PM. The findings of the audits and rounds were presented to the QA Committee to determine any needed changes. C) Unit Managers or Nursing Supervisors checked compliance with SRNA and Charge Nurse rounding tools for noncompliance with the smoking policy daily. The UM reported the findings of the audit to the DON/ADON daily during the clinical white board meeting starting on 01/10/17. D) Staff conducted weekly meetings with the residents identified to be at higher risk with noncompliance of the smoking policy. This was conducted by the Administrator, DON, or SSD to reinforce understanding of the smoking and contraband policies and why it was important to be compliant with said policies. 13) The Administrator, DON, ADON, Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on 01/08/17 regarding appropriately updating the residents' care plan to reflect residents' current care needs along with supervision needs, and following care plan interventions to ensure resident safety and meet resident needs and identifying and reporting to the Charge Nurse, SSD, DON, Administrator, MD and POA. The education provided included what exactly constituted an incident, such as smelling smoke or seeing ashes in a resident room, who to report that to, and when it needed to be reported. All training was performed face to face in order to facilitate discussion and questions on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided. A post-test had to be completed that consisted of questions from all the above education provided, administered and 100% score obtained. If a manager did not score 100% on post-test, the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. All post-tests were completed and graded for 100% score on 01/08/17 by the Regional Nurse Consultant or VP of Clinical Operations. All post-tests were reviewed for compliance by the Regional Nurse Consultant by 01/09/17. 14) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records were educated on accidents and incidents, care plans, smoking, contraband, aspects of care, quality of care/safety and supervision, resident rights, QAPI and administrative/professional standards policies and procedures, they were then assigned to re-educate the staff which started on 01/08/17. 15) On 01/10/17, the SDC notified the remaining twenty-six (26) employees that they would be taken off the schedule and could not work until education was completed. Certified letters were sent out to seven (7) as needed (PRN) staff, staff on vacation, or Family Medical Leave Act (FMLA) staff that could not be contacted. No employee will be allowed to work until education is provided. A post-test was administered to validate knowledge and retention of provided education, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered, and 100% score obtained. 16) On 01/20/17 the smoking policy was revised to include Supervision and monitoring residents who smokes and whose comprehensive assessment and plan of care indicates a need for supervision and high risk residents who are not compliant with the smoking policy because of the smell of smoke, cigarette ashes found in room/around resident or the recovery of contraband. An incident report detailing a violation of smoking policy will result in a care plan update, increased monitoring of resident including one to one supervision if needed, and increased contraband searches until it is determined through the interdisciplinary team QA process that the resident is safe, or a safe discharge is scheduled. 17) Beginning on 1/20/17, staff was provided with education/training on the policy revision, high risk rounds for noncompliance with smoking policy and smoking noncompliance audit log by the DON, ADON, Nursing Supervisors, SDC or Regional Nurse Consultant. Staff not working was notified that they could not work until they received their education/training on the above with signs posted on the time clock to prevent staff from clocking in prior to receiving education/training. The above education/training will be included during orientation for any new hires. 18) On 1/20/17, the DON, ADON, Nursing supervisors, SDC or Regional Nurse Consultant trained staff that if there is suspicion of smoking, the Charge Nurse, with another staff member will immediately go to the room in question, remove any contraband, and report immediately to the DON, Social Services Director, and/or Administrator. The DON, Social Services Director, and/or Administrator will immediately go to that room, following the contraband policy and search the room. If these staff members were not in the building, the Charge Nurse, along with another staff member, will search the room. If it is determined the resident was smoking or has contraband, the accident/incident policy and smoking policy will be implemented and policy will be reviewed with the resident, and the family will be notified. If warranted, the resident will be placed on one to one (1:1)supervision. Staff was also trained on what constituted contraband and when searches for contraband could be conducted. 19) The Administrator, DON, Nursing Supervisions, Minimum Data Set (MDS) Coordinator, ESD, Staffing Coordinator, SDC, Director of Dining Services, Business Office Manager, SSD, Central Supply, Chaplain, Marketing/Admissions, or Medical Records were on site daily, starting 01/08/17, to perform walking environmental rounds in which all rooms and common areas were visited by the Department Head. Environmental rounds include: identifying the smell of smoke, ashes or contraband in eyesight. Contraband searches were conducted of residents and residents' rooms who smoke, with the consent of the residents. The environmental rounds and contraband searches were completed daily for one week, then completed three (3) times a week for one week; then completed one time per week for two (2) weeks. Results of the walking environmental rounds were reported to the QA committee weekly to determine the further need of continued education or revision of plan. Based on evaluation, the QA committee determined at what frequency the environmental rounds needed to continue. Concerns identified were corrected immediately and reported to the Administrator. 20) Beginning on 01/08/17, a nurse from the regional team or corporate office was onsite in the facility and remained in contact with the facility daily for two (2) weeks, either onsite or by phone to review ongoing post-test, environmental rounds and contraband searches, then weekly for one month. The nurse(s) from the regional team or home office assisted with rounding, validation of compliance with smoking policy and providing oversight and consultation. 21) Beginning on 01/09/17, RNC, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, Medical Records, SDC, ESD or HR were administering questionnaires to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. The questionnaires include where residents can smoke; where would you find resident specific interventions for safe smoking to ensure resident care needs are met; what should you do when you see a resident with contraband or think a resident has contraband, is responsible for providing the resident with a safe accident free environment; where residents can keep their cigarettes and lighters; when are smoking evaluations completed on residents; and does a resident have the right to keep cigarettes and lighter on them or in their room. 22) On 01/20/17, an additional questionnaire was initiated by the facility that included have you smelled smoke in the facility since the fire on 01/08/17, have you seen any resident with contraband, do you know how many and who the residents are that smoke, do you know the residents who are high risk for being noncompliant with smoking policy. 23) Results of the staff questionnaires will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. Based on evaluation, the QA committee will determine at what frequency the staff questionnaire needs to continue. 24) Beginning on 01/09/17, the facility DON, ADON, SSD, or Nursing Supervisor questioned residents who were interviewable five (5) per week for two (2) weeks. The interviews consisted of if they have seen any resident with smoking contraband or if they had seen any resident smoke in their rooms. Results of the resident questionnaires will be reported to the QA committee weekly to determine the further need of continued education. Based on evaluation, the QA committee will determine at what frequency the staff questionnaire needed to continue. 25) Beginning on 01/08/17, the facility held a QA meeting weekly until the immediacy was removed, then for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. A QA meeting was held on 01/08/17, and an action plan was formulated and implemented at that time. On 01/10/17, the facility held a second QA meeting to review the current plan in place for any needed revisions, compliance, and/or further education. Based upon evaluation, the QA Committee determined at what frequency any ongoing audits needed to continue. The Administrator had the oversight to ensure an effective plan was in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QAs meetings were by the VPO or a member of the regional staff daily until removal of immediacy then weekly for four (4) weeks, then monthly. 26) On 01/10/17, facility staff mailed the Smoking Policy to all family members to ensure they had an understanding of the facility's policy as it related to smoking. ***The State Survey Agency validated the corrective actions taken by the facility as follows: 1) Review of the facility's investigation revealed the city fire department, the State Fire Marshall and the Kentucky State Police Arson Investigator were involved in investigating the possible cause of the fire. Further review of the facility's investigation revealed Resident #1, other residents, and facility staff were interviewed about the fire and possible cause. Interviews on 01/25/17 with the DON at 2:01 PM and the VPO (Acting Administrator) at 3:33 PM revealed Resident #1 was immediately placed on increased supervision after the fire. The interviews further revealed Resident #1, all interviewable residents, and all facility staff were interviewed about contraband and possible causes of the fire. 2) Review of the facility's documentation revealed all of the residents were assessed physically and psychosocially on 01/08/17 by facility staff. Interviews on 01/24/17 with the Regional Nurse Consultant (RNC) at 2:30 PM and UM (Unit Manager) #1 at 3:54 PM and, on 01/25/17 with Staff Development Coordinator (SDC) at 1:22 PM, Unit Manager (UM) #2 at 1:42 PM, Assistant Director of Nursing (ADON) at 1:49 PM and the Director of Nursing (DON) at 2:04 PM revealed all the residents were assessed on 01/08/17 for physical and psychosocial problems related to the fire. 3) Review of the Progress Notes, dated 01/08/17 through 01/10/17, revealed all of the residents that were displaced due to the fire, were assessed for any signs/symptoms of smoke inhalation and any psychosocial concerns by the Charge Nurse every shift for 48 hours. Interviews on 01/25/17 with Licensed Practical Nurse (LPN) #1 at 12:06 PM, LPN #2 at 12:29 PM, Registered Nurse (RN) #1 at 11:47 PM, and RN #2 at 11:53 PM revealed the START residents that had been displaced due to the fire were assessed each day for 48 hours to ensure there were no physical concerns related to smoke inhalation and no psychological concerns. Further review of the facility Progress Notes, dated 01/08/17 through 01/10/17, revealed the SSD/Chaplain visited the residents daily to provide any psychosocial/spiritual support needed. Interview on 01/25/17 at 1:19 PM with the Chaplain revealed himself or the SSD checked on the residents that had been displaced by the fire daily to offer support and to ensure all their psychosocial and spiritual needs were being met. 4) Review of facility documentation revealed Smoking Evaluations, dated 01/08/17, were completed for all facility residents that smoke by the RNC, DON, ADON, UM or SDC. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed Smoking Evaluations were completed for all residents that smoke to determine safety and supervision needs. 5) Review of facility documentation, dated 01/09/17, revealed a meeting was held with all facility residents that smoke to discuss the smoking and the contraband policy in detail and to ensure all the residents knowledge, agreement to follow the policies and understanding of the policies. Interview on 01/25/17 at 3:33 PM with the VPO revealed a meeting was conducted on 01/09/17 with the facility residents that smoke to discuss the smoking policy and the contraband policy and all residents verbalized understanding of the policies and their agreement to follow the policies. 6) Review of Resident #1's Safety Check Log, dated 01/08/17, revealed the resident was on line of site every five (5) minutes. Further review of Resident #1's Safety Check Log, dated 01/09/17 through 01/20/17, revealed the resident was on 1:1 supervision, which was documented every five (5) minutes by facility staff. Interviews on 01/24/17 with State Registered Nurse Aide (SRNA) #7 at 3:08 PM, SRNA #2 at 3:12 PM, SRNA #8 at 3:17 PM, SRNA #9 at 3:22 PM, SRNA #10 at 3:25 PM, SRNA #11 at 3:32 PM, SRNA #12 at 3:39 PM, SRNA #13 at 3:43 PM, SRNA #14 at 3:46 PM, SRNA #15 at 3:48 PM, SRNA #16 at 3:59 PM, SRNA #16 at 3:59 PM, SRNA #17 at 4:03 PM, SRNA #3 at 4:07 PM and SRNA #18 at 4:12 PM and on 01/25/17 with Hospitality Aide #1 at 1:26; LPN #1 at 12:06 PM and LPN #2 at 12:29 PM and with RN #1 at 11:47 AM and RN #2 at 11:53 AM revealed Resident #1 was placed on increased supervision after the fire on the evening of 01/08/17. The facility staff revealed Resident #1 was placed on 1:1 supervision and the staff documented on the resident every five (5)

Based on observation, interview, record review, review of the facility's policy and review of its investigations, it was determined the facility failed to provide supervision to prevent accidents for one (5) of five (5) sampled residents (Residents #1, #2, #3, #4 and #5). Although Resident #1 sustained no injuries as a result of the fire, four (4) residents were transferred to the hospital for an evaluation (Resident #2, Resident #3, Resident #4 and Resident #5). Residents #2 and Resident #3 were admitted to the hospital for treatment of [REDACTED]. Resident #2 was admitted back to the facility on [DATE] and Resident #3 was admitted back to the facility on [DATE]. Resident # 4 was admitted to the hospital on [DATE] for treatment of [REDACTED]. Resident #5 was transferred to the hospital on [DATE] and treated for [REDACTED]. Interviews with facility staff and review of the facility's investigation revealed on 12/16/16, Resident #1 was suspected of smoking in his/her room by facility staff. Further interviews and review of the investigation revealed on 01/04/17, Resident #1 was observed smoking in his/her room by a facility staff member. Smoking materials were found in the resident's room. Resident #1's care plan was updated to include contraband searches as needed. However, facility staff was not made aware the resident had been observed smoking in his/her room or that smoking materials had been found his/her room. On 01/08/17, there was a fire in room 207 (Resident #1's room) and the suspected origin of the fire was Resident #1 smoking in that room. As a result of the fire three (3) residents were transported to the hospital for evaluation related to smoke inhalation, and one (1) resident was transferred to the hospital after he/she sustained a laceration to the toe which occurred during the evacuation. The facility's failure to ensure that the residents' environment remained as free from accident hazards as possible; and, failure to ensure Resident #1 received 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 01/12/17 and determined to exist on 12/16/16 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F323) and 42 CFR 483.75 Administration (F490). Substandard Quality of Care was also identified at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/12/17. An acceptable Allegation of Compliance was received on 01/24/17, which alleged removal of the Immediate Jeopardy on 01/21/17. The State Survey Agency determined the Immediate Jeopardy was removed on 01/21/17, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F282); 42 CFR 483.25 Quality of Care (F323); and, 42 CFR 483.75 Administration (F490), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Resident Handbook, revised November 2013, revealed smoking was allowed only in designated smoking areas and at designated times. Review of the facility's policy titled Smoking Resident, date reviewed 06/01/15, revealed it was not the intent of the facility to prohibit or restrict smoking privileges but to provide safety for residents, visitors and employees. Further review of the policy revealed all smoking materials (lighters, matches, and cigarettes) were to be deposited and kept in a designated area until designated smoking times,when staff would be required to assist residents. which would be designated per facility policy. Review of the facility's policy titled, Contraband Discovery, reviewed 04/19/16, revealed inspections and searches would be conducted of the resident and their belongings if it was suspected that the resident was not following the facility's policy and procedures related to smoking in order to maintain a safe, secure environment for residents, visitors, families, and employees. Record review revealed the facility readmitted the resident on 09/09/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment, dated 12/06/16, revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which revealed the facility assessed the resident to be moderately cognitively impaired. Further review of Resident #1's MDS assessment revealed the facility assessed the resident to require supervision for transfers and ambulation. Review of Resident #1's Room Change Notification, dated 12/01/16, revealed the resident requested to have a bed by the window and was moved from room 208-1 to room 207-2. Review of Resident #1's Safe Smoking Evaluation, dated 12/14/16, revealed the resident was assessed to be a safe smoker with constant supervision needed while smoking. Review of the facility's final investigation, dated 01/11/17, revealed on 01/08/17 at approximately 10:45 AM, the second floor north smoke alarm sounded and a fire was observed in room 207 (Resident #1's room). The investigation stated the State Fire Marshall reported to Administrative staff that the cause of the fire could not be determined but the suspected origin was Resident #1 smoking in the room. Further review of the investigation revealed Resident #1 was interviewed and initially denied smoking in his/her room or having anything to do with the fire. However, when presented with findings by the Fire Marshall, Resident #1 stated that he/she had not smoked in his/her room since 01/04/17. Resident #1 was questioned several times by the Fire Marshall and the facility's Administrative Staff and strongly denied smoking in his/her room or having anything to do with the fire. Further review of the investigation revealed Resident #1 had obtained smoking materials when his/her family member took him/her out of the facility. Continued review of the investigation revealed video footage which showed Resident #1 exiting his/her room and smoke emanating from his/her room approximately seven (7) minutes later. The investigation stated four (4) residents were sent to the emergency room for evaluation; three (3) for possible smoke inhalation; and, one (1) for a toe injury. Eleven (11) staff members were sent to the emergency room for possible smoke inhalation. The investigation revealed that all interviewable residents and staff were interviewed about knowledge of how the fire started and/or knowledge of any contraband smoking materials. The facility searched the entire building and all resident rooms were searched for smoking materials. The conclusion of the investigation revealed the facility could not substantiate that the fire was started by Resident #1 smoking in his/her room. However, due to the findings in the State Fire Marshall investigation report the facility had placed the resident on one to one supervision with an immediate but safe discharge plan in place. Review of the report received from the City Fire Department, dated 01/08/17, revealed when the firefighters arrived at the facility they were informed by staff that a resident was trapped in room 207 and was screaming they were burning alive. The report stated the facility's staff was unable to evacuate room 207 because of the smoke and heat from the fire. Further review revealed the firefighters entered and located the fire in room 207. Review of the Emergency Response Investigation Report, dated 01/08/17, revealed upon arrival to the scene the fire had been extinguished and personnel were active in checking on the conditions of residents. They went to the area of the fire and attempted to determine the cause, origin, and intent of the fire. The investigators were able to determine the area and origin of the fire; however, the exact ignition source could not be determined and there was no sign of anything that could have enhanced the fire. Further review of the investigation revealed Resident #1 was interviewed about the possibility of him/her smoking in room 207. The resident denied he/she had been smoking in the area. Continued review of the investigation revealed Resident #1 was presented with the cigarette evidence in the area of the fire; however, the resident continued to deny he/she had smoked in the area. Further review of the Emergency Response Investigation Report revealed staff had suspicion that Resident #1 had smoked in the area. The Investigation stated Resident #1 stated he/she kept his/her smoking materials in his/her pocket. Smoking materials found in the area of the fire included a lighter, cigarettes and disposed butts. Review of the investigation revealed video footage which showed Resident #1 had been in his/her room seven (7) minutes prior to the activation of the fire alarm. Review of the facility's final investigation, dated 01/11/17, revealed on 12/16/16 a staff member voiced concern of possibly smelling smoke in Resident #1's room. The investigation stated the DON and Administrator immediately investigated the concern. They questioned Resident #1 and searched his/her room and nothing was found. Interviews on 01/11/17 at 5:30 PM with the DON and the Administrator revealed on 12/16/16, staff reported that they could smell smoke in Resident #1's room. The DON and the Administrator stated they immediately went to the resident's room and could not smell smoke. A room search was conducted, but it did not reveal the resident had smoking materials in his/her room. Continued interview revealed Resident #1 was educated on the facility's smoking and contraband policy. Further interview revealed an incident report was not completed related to this incident. Review of Resident #1's Social Services Progress Notes, dated 01/04/17, revealed Certified Medication Aide (CMA) #1 reported to administrative staff that she observed Resident #1 smoking in his/her room. Further review of the Note revealed the Social Services Director (SSD) and the Administrator immediately went to Resident #1's room to discuss the concern with the resident. The resident denied he/she had been smoking in the room. Continued review of the Note revealed Resident #1's room was then searched and a pack of cigarettes and a lighter were found under the resident's cap on the windowsill. The Note stated the contraband was removed from Resident #1's room and the resident was educated on the facility's smoking policy. Review of Resident #1's care plan for Potential for Smoking Related Complications, revealed it was updated on 01/04/17, related to the concern that the resident will attempt to hide cigarettes and lighters in the resident's room. Further review of the care plan revealed interventions were added to the care plan which included, contraband searches, as needed and educated Resident #1 on the smoking and contraband policy. However, review of Resident #1's Nursing Assistant Record, dated December 2016 and January 2017, revealed the record did not include information that the resident was a smoker, or include interventions that the resident required increased monitoring for non-compliance with the smoking policy. Further review revealed the record did not alert the staff of the intervention of contraband searches, as needed related to non-compliance of the smoking policy. Review of the facility's final investigation, dated 01/11/17, revealed on 01/04/17, a staff member visualized Resident #1 at his/her room window smoking. The Administrator was immediately notified. Further review of the investigation revealed the Administrator immediately went to the resident's room and confiscated one (1) pack of cigarettes and one (1) lighter. Continued review of the investigation revealed the Administrator informed the resident that smoking was not allowed in his/her room and if it occurred again the resident would be immediately discharged . Resident #1 acknowledged understanding. Interview on 01/11/17 at 4:44 PM with CMA #1 revealed, on 01/04/17, the CMA had walked out into the facility parking lot and was walking back into the facility and heard someone yell her name. CMA #1 stated she looked up into Resident #1's window and the resident had his/her arm out of the window with a cigarette in his/her hand. Continued interview revealed CMA #1 immediately reported what she had observed to the SSD. Interview on 01/11/17 at 1:57 PM, with the SSD revealed, on 01/04/17, CMA #1 reported that she had observed Resident #1 smoking, with the cigarette in his/her hand out of the resident's room window. The interview further revealed the SSD immediately informed the Administrator. They went to speak to Resident #1 in his/her room, the resident denied he/she had been smoking in the room and the Administrative staff did not smell smoke. Continued interview revealed the Administrative staff searched Resident #1's room and found cigarettes and a lighter under the resident's cap on the windowsill. The SSD stated the contraband was removed from the resident's room and the resident was educated on the facility's smoking and contraband policy. The interview further revealed Resident #1's care plan was updated with interventions that included: contraband searches could be done, as needed if the staff had suspicions the resident was smoking. The facility failed to notify all the staff, only the staff working at the time of the incident were notified. The SSD stated that an incident report was not completed as a result of the incident, and she was not aware of any staff or other residents being interviewed. Interview on 01/11/17 at 5:30 PM with the Administrator revealed CMA #1 reported to the SSD, on 01/04/17, that she had observed Resident #1 smoking outside of the window in his/her room. The interview further revealed the SSD immediately reported the incident to the Administrator. The SSD and the Administrator immediately went to the resident's room to speak with Resident #1; the resident denied he/she had been smoking in his/her room. The Administrator stated she did not smell cigarette smoke; however, a contraband search was done and cigarettes and a lighter were found under the resident's cap in the windowsill. The cigarettes and lighter were removed from the resident's room. The interview further revealed Resident #1 was educated on the facility's smoking and contraband policy. The Administrator stated the staff working at the time of the incident was made aware of the incident and that it was everyone's responsibility to take cigarettes and lighters when found on a resident. Interviews on 01/11/17 with State Registered Nurse Aide (SRNA) #1 at 3:05 PM, SRNA #2 at 3:14 PM, SRNA #3 at 3:21 PM, SRNA #4 at 3:31 PM, SRNA #5 at 3:40 PM, Registered Nurse (RN) #1 at 2:54 PM, RN #2 at 3:43 PM and RN #3 at 4:01 PM revealed the staff had not been made aware Resident #1 had been seen by a staff member smoking in his/her room or that cigarettes and a lighter had been found in the resident's room. Review of Resident #1's Safety Check Log, dated 01/08/17, revealed five (5) minute checks were initiated at 11:00 PM. Review of Social Services Progress Notes, dated 01/08/17, revealed Resident #1 was placed on one on one (1:1) supervision. Review of Resident #1's Safety Check Log, dated 01/09/17 through 01/20/17, revealed the resident was on one to one (1:1) supervision. Interview on 01/11/17 at 12:33 PM; and, on 01/12/17 at 2:27 PM with Resident #1 revealed the resident had exited his/her room to go to the 11:00 AM smoke break and was in front of the nurses' station, Then I heard the fire alarm sound. Further interview revealed Resident #1 denied smoking in his/her room that day but had smoked in his/her room many times previously. The resident stated staff had told him/her to stop smoking in his/her room. The resident stated that when he/she did smoke, he/she used a cup with water to put the ashes and he/she put the cigarette butts in the cup in the windowsill. Further interview revealed the only time the facility staff had taken away his/her cigarettes and lighter was about a week ago, and the night of the fire. During continued interview, Resident #1 stated he/she had been taken outside to smoke on the night of the fire, and had cigarettes and a lighter in his/her hoodie (jacket) that had been there prior to the fire. Continued interview revealed Resident #1 did not have any problems getting cigarettes or a lighter because he/she went often with a family member. Resident #1 stated after the fire a staff member was constantly with him/her. Interview on 01/11/17 at 4:45 PM with Resident D revealed he/she had heard that Resident #1 smoked in his/her room. Resident D stated he/she had reported this to staff. Further interview revealed on the night of the fire, the Assistant Director of Nursing (ADON) had taken the resident and Resident #1 out to smoke and searched them when they came back into the facility. Resident D stated he/she informed the ADON that (Resident #1) had pulled a fast one over on her and had cigarettes hid on him/her. Interview on 01/11/17 at 3:05 PM with SRNA #1 revealed she heard the alarm sound and then someone yelled, It's a real fire in room 207. The SRNA stated she opened the big door to assist the staff on that end and all you could see was black smoke so she went down the North Hall and started to assist residents out of their rooms. Continued interview revealed residents were yelling for help. Interview on 01/11/17 at 3:14 PM with SRNA #2 revealed she was working the day of the fire and was at the nurses' station when the alarm went off. She stated someone yelled they saw smoke in room 207. SRNA #2 stated remembered seeing Resident #1 in the day area at that time. She stated she, opened room 207 and all you could see was thick black smoke and a housekeeper was behind me with a fire extinguisher because we were trying to get (Resident #2) out of the room, but I couldn't see because of the smoke. SRNA #2 stated she had smelled cigarette smoke in Resident #1's room before; however, she never reported it because, I could have just smelled a smoke smell from where the resident had been to the smoke room to smoke. Interview on 01/11/17 at 3:21 PM with SRNA #4 revealed she had been in room 207 about 10 to 20 minutes prior to the fire alarm sounding and Resident #1 had been in the room. She stated the alarm sounded and someone yelled, it's in room 207. SRNA #4 stated she went into the room and saw thick black smoke and flames behind Resident #1's bed. Continued interview revealed staff was attempting to get Resident #1's roommate (Resident #2) out of the room and staff was attempting to extinguish the fire with an extinguisher. SRNA #4 stated she worked with Resident #1 often and would suspect the resident was smoking in his/her room because of the smoke smell. She stated she reported this to the nurse on duty. Interview on 01/11/17 at 2:54 PM with RN #1, revealed she was working the day of the fire. She stated the smoke alarm sounded and the smoke was so dark and thick down the North Hall that it was hard to see. RN #1 stated she helped evacuate the residents to the South side of the hall until the staff could evacuate the residents from the second floor. Interview on 01/11/17 at 3:43 PM with RN #2 revealed the alarm sounded and the panel showed the fire was in room 207, so she immediately went to the room. RN #2 stated staff members that were in front of her entered the room and stated it was a real fire. Continued interview revealed RN #2 went room to room assisting residents out of their rooms. Interview on 01/11/17 at 4:01 PM with RN #3 revealed she heard the alarm sound and immediately went to the room. RN #3 stated she arrived at the room, the same time as Housekeeper #1 and a SRNA. They opened the door and observed the smoke and the flames toward the back of the room by the windows. Continued interview revealed Housekeeper #1 was attempting to extinguish the fire while RN #3 was attempting to get Resident #2 out of the room. She stated it was very hard to see because of the black smoke. RN #3 stated, she and the staff were able to get Resident #2 out of the room and proceeded to assisted more residents out of their rooms. Interview on 01/11/17 at 5:14 PM with the ADON revealed Resident #1 was placed on one on one (1:1) supervision after the fire. She stated she took Resident #1 to smoke outside on Sunday night (the night of the fire, after the fire). The ADON stated she checked the resident for contraband when they went back into the building, after the smoke, and didn't find anything. She stated Resident D reported to her that she had been snowed by Resident #1 and the resident (Resident #1) had contraband on him/her. Continued interview revealed the ADON reported to the DON what Resident D had reported. The ADON denied being aware at that time if Resident #1 had been found to have cigarettes or a lighter. Interview on 01/12/17 at 3:15 PM with the Regional Nurse Consultant revealed Resident #1 was placed on increased supervision after the fire. She stated the resident was placed on five (5) minute checks. When the resident was found with contraband, (the night of the fire) he/she was placed on one on one (1:1) supervision. Interview on 01/11/17 at 5:30 PM with the DON and the Administrator revealed Resident #1 was placed on one on one supervision after the fire so the resident could be closely monitored and supervised. The interview further revealed after the fire, Resident #1 had been searched by staff three (3) times and no contraband had been found. Continued interview revealed the ADON reported to administrative staff that Resident D reported that Resident #1 had snowed the ADON when she had searched the resident for contraband . She stated Resident #1 was searched again by the Regional Vice President and the DON and the resident was found to have cigarettes and a lighter in his/her hoodie sweatshirt. 2. Record review revealed the facility admitted Resident #2 on 12/20/16 with [DIAGNOSES REDACTED]. Review of Resident #2's MDS admission assessment, dated 12/27/16, revealed the resident's BIMS score was nine (9), which revealed the facility assessed the resident to be moderately cognitively impaired. Further review of the MDS assessment revealed the facility assessed the resident to need total assistance of two (2) staff members for transfers and total assistance of one (1) staff member for locomotion. Review of Resident #2's Nursing Notes, dated 01/08/17 at 7:46 PM revealed the resident was admitted to the hospital related to smoke inhalation. Review of Resident #2's hospital Patient Transfer Form, dated 01/11/17, revealed the resident was transferred back to the facility with [DIAGNOSES REDACTED]. Observation on 01/11/17 at 4:57 PM, revealed the resident in bed with his/her eyes closed with his/her face covered up. Interview on 01/12/17 at 2:37 PM with Resident #2 revealed the fire got about a foot away from him/her and there was fire all over that way (the resident pointed towards the window). Resident #2 stated when the staff got me out of my room they took me to the hospital because they thought I had smoke on my lungs but I'm ok now. 3. Review of Resident #3's medical record revealed the facility readmitted the resident on 01/10/17 with [DIAGNOSES REDACTED]. Review of Resident #3's MDS Significant Change assessment, dated 12/08/16, revealed the resident's BIMS score was ten (10), which revealed the facility assessed the resident to be moderately cognitively impaired. Further review of the MDS assessment revealed the resident was assessed to need extensive assistance of two (2) staff members for transfers. Review of Resident #3's Nurse's Notes, dated 01/08/17 at 7:50 PM, revealed the resident was admitted to the hospital related to smoke inhalation. Further review of the Nurse's Notes, dated 01/10/17 at 6:43 PM, revealed Resident #3 was admitted back to the facility. Review of Resident #3's hospital record, dated 01/08/17, revealed the resident was admitted to the hospital with [REDACTED]. Observation on 01/11/17 at 11:34 AM, revealed the resident in bed with oxygen per nasal canula. Interview on 01/11/17 at 11:34 AM with Resident #3 revealed he/she was in bed at the time of the fire. The resident stated he/she saw fire in the corner of his/her room by the his/her bed. The interview revealed Resident #3 tried to kick his/her shoe at the fire but he/she couldn't raise his/her leg. Resident #3 stated, . (he/she)started hollering for help and a guy and a couple of girls came to help me. The resident stated he/she was scared and, thought (they) would all burn up. Further interview revealed Resident #3 was taken to the hospital as he/she could not catch his/her breath. 4. Review of Resident #4's medical record revealed the facility readmitted the resident on 12/20/16 with [DIAGNOSES REDACTED]. Review of Resident #4's MDS Significant Change assessment, dated 10/20/16, revealed the resident's BIMS score was six (6) which revealed the facility assessed the resident to be severely cognitively impaired. Further review of the MDS assessment revealed the resident was assessed to need total assistance of two (2) staff members for transfers. Observation on 01/11/17 at 11:30 AM of Resident #4 revealed the resident was in bed on his/her back with oxygen per nasal cannula. Review of Resident #4's hospital record, dated 01/08/17, revealed the resident was diagnosed with [REDACTED]. However, review of Resident #4's Nurse's Notes, dated 01/08/17, revealed no documented evidence the resident was transferred out to the hospital. Review of the Notes, dated 01/09/17 at 2:33 AM, revealed Resident #4 had no adverse reactions noted from smoke inhalation and no psychological concerns noted. 5. Review of Resident #5's medical record revealed the facility readmitted the resident on 12/11/15 with [DIAGNOSES REDACTED]. Review of Resident #5's MDS Quarterly assessment, dated 11/21/16, revealed the resident's BIMS score was five (5), which revealed the facility assessed the resident to be severely cognitively impaired. Further review of the MDS assessment revealed the facility assessed the resident to need extensive assistance of two (2) staff members for transfers. Review of Resident #5's Nurse's Notes, dated 01/08/17, revealed no documented evidence the resident was transferred to the hospital for an evaluation. However, review of the Notes, dated 01/08/17 at 9:30 PM, revealed Resident #5 was back in the facility from the hospital with no new orders. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) At approximately 10:45 AM on 01/08/17, a smoke alarm sounded on the second floor North Unit. All facility staff immediately reacted and assured the residents' safety. The facility sprinklers detonated and put the fire out. The fire department responded, along with the State Fire Marshal and the Kentucky State Police Arson Investigator. There was cigarette evidence found in Resident #1's room, and the resident was placed on one to one supervision. 2) All residents were medically and psychosocially assessed for any signs and symptoms of potential injury by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), Staff Development Coordinator (SDC), or Regional Nurse Consultant (RNC) on 01/08/17. There were no concerns identified. 3) Twenty-two (22) residents were displaced due to the fire. The twenty-two residents were assessed for any signs/symptoms of smoke inhalation and any psychosocial concerns by the Charge Nurse every shift for 48 hours. The Social Services Director (SSD)/Chaplain visited the residents daily and provided any psychosocial/spiritual support needed. This started on 01/08/17 and was completed on 01/10/17 with no issues or concerns noted. 4) Residents that smoke were assessed utilizing a Smoking Evaluation, by the RNC, DON, ADON, UM or SDC on 01/08/17. Eight (8) residents were identified as smokers from the completed smoking evaluation. The smoking evaluation included assessing residents for cognitive patterns, communication/hearing/vision deficits and physical ability, to ensure the residents were safe to smoke and the level of supervision which was required. 5) The Vice President of Operations (VPO), the SSD, and the Resident Council President met with all the residents who smoke on 01/09/17. The smoking policy and the contraband policy was explained and reviewed in detail. All residents that smoke were present and each resident was asked to sign an understanding of the policy and that they agreed to abide by the smoking policy. Based on the acknowledgments, it was determined that each of the residents was at a low risk to not follow policy. 6) On 1/8/17, the facility placed Resident #1 on five (5) minute checks and were to watch the resident closely. During contraband checks on the evening of 01/08/17, Resident #1 was found to have cigarette paraphilia. The resident was then placed on one to one supervision on 01/09/17 to ensure he/she was compliant with the smoking and contraband policy. The facility initiated Resident #1's safe emergent discharge planning. Resident #1 remained on one to one until he/she was discharged from the facility. The facility defined one to one supervision as: staff member would be close to resident at all times, 24 hours per day; the staff member would visualize the resident at all times, 24 hours per day; and, the staff member would be present with the resident even when visitors are visiting with resident. 7) Resident #1 was assessed for behaviors on 01/10/17 by the Regional Behavioral Health Specialist, the resident's care plan was updated to encourage the resident to smoke in designated areas, monitor for compliance of the facility smoking policy, educate the resident on the smoking policy as needed, and conduct contraband searches as needed. 8) All resident rooms were searched for contraband by the RNC, DON, ADON, Unit Managers or SDC on 01/08/17, with one area of concern noted. Facility identified Resident D had cigarettes. Facility staff removed the cigarettes and placed them in a secure location. 9) Environmental rounds were completed in all resident rooms by the RNC and the DON on 01/08/17. Each room was assessed for smoke smell and/or ashes in the room or bathroom, no concerns were identified. 10) The care plans of all residents that smoke were reviewed by the RNC, DON, ADON, Unit Managers, or SDC on 01/09/17, to ensure the care plans were updated to reflect current care needs of the residents. Each resident care plans were updated with the following interventions: Observing for signs of noncompliance with the smoking policy, smell for smoke when in the room, observing for ashes in the room or bathroom, and observe for contraband within eyesight. 11) Chart reviews were completed for residents that smoke. The charts were reviewed for any changes in behaviors or indications of noncompliance with the smoking policy for the past thirty (30) days. These reviews were conducted by the DON, Nursing Supervi

Based on interview, review of the facility investigation, and review of the Administrator Job Description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of five (5) sampled residents (Resident #1). Interview with the Administrator and review of the facility's investigation revealed facility staff suspected Resident #1 was smoking in his/her room on 12/16/16. The resident's room was searched by the Administrator and the resident was educated on the smoking and contraband policy. No other interventions were put in place at this time. Resident #1 was also observed on 01/04/17, by staff, to be smoking, with the cigarette in his/her hand outside the window in his/her room. The Administrator searched the resident's room and smoking materials were found in his/her room. The facility's investigation revealed on 01/08/17, a fire originated in Resident #1's room and the suspected cause of the fire was Resident #1 smoking in his/her room. Interviews with facility staff revealed they were not aware there had been suspicions that Resident #1 had been smoking in his/her room, or that smoking materials had been found in the resident's room. The Administrator failed to ensure staff was aware the resident had been smoking in his/her room. The facility's failure to ensure it was administered in a manner that enabled residents to attain or maintain their highest practicable physical, mental and psychosocial well being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/12/17 and determined to exist on 12/16/16 at 42 CFR 483.20 Resident Assessment (F282); 42 CFR 483.25 Quality of Care (F323); and, 42 CFR 483.75 Administration (F490). Substandard Quality of Care was also identified at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/12/17. An acceptable Allegation of Compliance was received on 01/24/17, which alleged removal of the Immediate Jeopardy on 01/21/17. The State Survey Agency determined the Immediate Jeopardy was removed on 01/21/17, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490), while the facility monitors the effectiveness of systemic changes and quality assurance activities. Refer to F282 and F323. The findings include: Review of the facility's Administrator's Job Description, updated December 2011, revealed essential duties and responsibilities were to oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness, and appearance of the facility; morale of staff; and to ensure resident needs were being addressed. Further review of the job description revealed the Administrator verified the facility as maintained appropriately; that equipment and work areas were clean, safe, and orderly; and, any hazardous conditions were addressed. Review of the facility's final investigation, dated 01/11/17, revealed on 12/16/16 a staff member voiced a concern of smelling smoke in Resident #1's room. The Director of Nursing (DON) and Administrator immediately investigated the concern and searched the resident's room and nothing was found. Continued review of the investigation revealed on 01/04/17, a staff member visualized Resident #1 at his/her room window smoking; the Administrator was immediately notified. Review of the investigation revealed the Administrator immediately went to the resident's room and confiscated smoking materials and informed the resident that smoking was not allowed in his/her room and if it occurred again the resident would be immediately discharged . Even though staff reported the resident had been observed smoking in his/her room, and cigarettes and a lighter were found in the resident's room, the Administrator took no further action to ensure Resident #1 was monitored for smoking in his/her room; and failed to ensure the safety of other facility residents. Further review of the investigation revealed on 01/08/17, at approximately 10:45 AM the second floor North Hall smoke alarm sounded and a fire was observed to be in room [ROOM NUMBER] (Resident #1's room). Residents had to be transferred to the hospital related to smoke inhalation and others were displaced from their rooms. Interviews on 01/11/17 with State Registered Nurse Aide (SRNA) #1 at 3:05 PM, SRNA #2 at 3:14 PM, SRNA #3 at 3:21 PM, SRNA #4 at 3:31 PM, SRNA #5 at 3:40 PM, Registered Nurse (RN) #1 at 2:54 PM, RN #2 at 3:43 PM, and RN #3 at 4:01 PM revealed the staff had not been made aware Resident #1 had been seen by a facility staff member smoking in his/her room or that cigarettes and a lighter had been found in the resident's room. Interview on 01/11/17 at 5:30 PM with the Administrator revealed when Resident #1 was suspected of smoking and the smoking materials were found in his/her room the resident was educated about the smoking and contraband policy. Continued interview revealed the staff working at the time of the incident was made aware of the incident and that it was everyone's responsibility to take cigarettes and lighters when found on a resident. The Administrator stated Resident #1's care plan was also updated with the incident and that staff was to do contraband searches (cigarettes and lighters) as needed. However, interviews with staff, revealed they had not been informed that the resident had been smoking in his/her room, or that they were to conduct contraband searches. The Administrator stated she believed updating the resident's care plan would be sufficient, and that the staff notified at the time of the incident would pass it along in report. ***The facility implemented the following actions to remove the Immediate Jeopardy: 1) At approximately 10:45 AM on 01/08/17, a smoke alarm sounded on the second floor North Unit. All facility staff immediately reacted and assured the residents' safety. The facility sprinklers detonated and put the fire out. The fire department responded, along with the State Fire Marshal and the Kentucky State Police Arson Investigator. There was cigarette evidence found in Resident #1's room, and the resident was placed on one to one supervision. 2) All residents were medically and psychosocially assessed for any signs and symptoms of potential injury by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), Staff Development Coordinator (SDC), or Regional Nurse Consultant (RNC) on 01/08/17. There were no concerns identified. 3) Twenty-two (22) residents were displaced due to the fire. The twenty-two residents were assessed for any signs/symptoms of smoke inhalation and any psychosocial concerns by the Charge Nurse every shift for 48 hours. The Social Services Director (SSD)/Chaplain visited the residents daily and provided any psychosocial/spiritual support needed. This started on 01/08/17 and was completed on 01/10/17 with no issues or concerns noted. 4) Residents that smoke were assessed utilizing a Smoking Evaluation, by the RNC, DON, ADON, UM or SDC on 01/08/17. Eight (8) residents were identified as smokers from the completed smoking evaluation. The smoking evaluation included assessing residents for cognitive patterns, communication/hearing/vision deficits and physical ability, to ensure the residents were safe to smoke and the level of supervision which was required. 5) The Vice President of Operations (VPO), the SSD, and the Resident Council President met with all the residents who smoke on 01/09/17. The smoking policy and the contraband policy was explained and reviewed in detail. All residents that smoke were present and each resident was asked to sign an understanding of the policy and that they agreed to abide by the smoking policy. Based on the acknowledgments, it was determined that each of the residents was at a low risk to not follow policy. 6) On 1/8/17, the facility placed Resident #1 on five (5) minute checks and were to watch the resident closely. During contraband checks on the evening of 01/08/17, Resident #1 was found to have cigarette paraphilia. The resident was then placed on one to one supervision on 01/09/17 to ensure he/she was compliant with the smoking and contraband policy. The facility initiated Resident #1's safe emergent discharge planning. Resident #1 remained on one to one until he/she was discharged from the facility. The facility defined one to one supervision as: staff member would be close to resident at all times, 24 hours per day; the staff member would visualize the resident at all times, 24 hours per day; and, the staff member would be present with the resident even when visitors are visiting with resident. 7) Resident #1 was assessed for behaviors on 01/10/17 by the Regional Behavioral Health Specialist, the resident's care plan was updated to encourage the resident to smoke in designated areas, monitor for compliance of the facility smoking policy, educate the resident on the smoking policy as needed, and conduct contraband searches as needed. 8) All resident rooms were searched for contraband by the RNC, DON, ADON, Unit Managers or SDC on 01/08/17, with one area of concern noted. Facility identified Resident D had cigarettes. Facility staff removed the cigarettes and placed them in a secure location. 9) Environmental rounds were completed in all resident rooms by the RNC and the DON on 01/08/17. Each room was assessed for smoke smell and/or ashes in the room or bathroom, no concerns were identified. 10) The care plans of all residents that smoke were reviewed by the RNC, DON, ADON, Unit Managers, or SDC on 01/09/17, to ensure the care plans were updated to reflect current care needs of the residents. Each resident care plans were updated with the following interventions: Observing for signs of noncompliance with the smoking policy, smell for smoke when in the room, observing for ashes in the room or bathroom, and observe for contraband within eyesight. 11) Chart reviews were completed for residents that smoke. The charts were reviewed for any changes in behaviors or indications of noncompliance with the smoking policy for the past thirty (30) days. These reviews were conducted by the DON, Nursing Supervisors, UM, SDC, or RNC on 01/08/17, no issues were identified. 12) Facility staff completed smoking assessments on all residents on 01/08/17. The facility had eight (8) residents that smoke. Of the eight (8) residents that smoke, the facility identified two (2) additional residents that were considered at higher risk to be noncompliant. Identification was based on residents that leave the facility with family often, residents that family visits frequently, resident that had access to obtaining contraband through home visits. Interviews with the two residents revealed each had, or in the past had, contraband in their rooms. The following action was taken related to the two (2) identified residents: A) Facility SRNAs observed for any signs of noncompliance with the smoking policy during their two (2) hour rounds on each shift. Staff will smell for smoke, look for ashes in the resident's room/bathroom, and observe for smoking contraband. This started on 01/09/17 and will continue for two (2) weeks. Additional documentation was initiated on 01/20/17, utilizing the Smoking Noncompliance Audit Log. The log identifies specific times for the SRNA's to conduct the checks. The checks will be conducted at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. The findings of the audits and rounds will be presented to the Quality Assurance Committee weekly to determine if any changes were needed. B) Charge Nurses monitored compliance with SRNA rounds two (2) times per shift during their medication pass. They also monitored for any noncompliance with the smoking policy by smelling for smoke and looking for ashes or any contraband left out in eyesight. This started on 01/09/17 and continued for two (2) weeks. Additional documentation was initiated on 01/20/17 for high risk residents utilizing the Smoking Noncompliance Audit Log. The log directs nurses to observe for smoke, ashes, or contraband at specific times: 1:00 AM, 3:00 AM, 5:00 AM, 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, 9:00 PM, and 11:00 PM. The findings of the audits and rounds were presented to the QA Committee to determine any needed changes. C) Unit Managers or Nursing Supervisors checked compliance with SRNA and Charge Nurse rounding tools for noncompliance with the smoking policy daily. The UM reported the findings of the audit to the DON/ADON daily during the clinical white board meeting starting on 01/10/17. D) Staff conducted weekly meetings with the residents identified to be at higher risk with noncompliance of the smoking policy. This was conducted by the Administrator, DON, or SSD to reinforce understanding of the smoking and contraband policies and why it was important to be compliant with said policies. 13) The Administrator, DON, ADON, Unit Managers, Nursing Supervisor, MDS Coordinator, Staff Development Coordinator, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions Director, Rehab Services Manager, and Medical Records Staff were educated by the Regional Nurse Consultant on 01/08/17 regarding appropriately updating the residents' care plan to reflect residents' current care needs along with supervision needs, and following care plan interventions to ensure resident safety and meet resident needs and identifying and reporting to the Charge Nurse, SSD, DON, Administrator, MD and POA. The education provided included what exactly constituted an incident, such as smelling smoke or seeing ashes in a resident room, who to report that to, and when it needed to be reported. All training was performed face to face in order to facilitate discussion and questions on policies, procedures, and processes. Department Administrative Managers could not return to work until education was provided. A post-test had to be completed that consisted of questions from all the above education provided, administered and 100% score obtained. If a manager did not score 100% on post-test, the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. All post-tests were completed and graded for 100% score on 01/08/17 by the Regional Nurse Consultant or VP of Clinical Operations. All post-tests were reviewed for compliance by the Regional Nurse Consultant by 01/09/17. 14) Once the Administrator, DON, ADON, Unit Mangers, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, and Medical Records were educated on accidents and incidents, care plans, smoking, contraband, aspects of care, quality of care/safety and supervision, resident rights, QAPI and administrative/professional standards policies and procedures, they were then assigned to re-educate the staff which started on 01/08/17. 15) On 01/10/17, the SDC notified the remaining twenty-six (26) employees that they would be taken off the schedule and could not work until education was completed. Certified letters were sent out to seven (7) as needed (PRN) staff, staff on vacation, or Family Medical Leave Act (FMLA) staff that could not be contacted. No employee will be allowed to work until education is provided. A post-test was administered to validate knowledge and retention of provided education, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered, and 100% score obtained. 16) On 01/20/17 the smoking policy was revised to include Supervision and monitoring residents who smokes and whose comprehensive assessment and plan of care indicates a need for supervision and high risk residents who are not compliant with the smoking policy because of the smell of smoke, cigarette ashes found in room/around resident or the recovery of contraband. An incident report detailing a violation of smoking policy will result in a care plan update, increased monitoring of resident including one to one supervision if needed, and increased contraband searches until it is determined through the interdisciplinary team QA process that the resident is safe, or a safe discharge is scheduled. 17) Beginning on 1/20/17, staff was provided with education/training on the policy revision, high risk rounds for noncompliance with smoking policy and smoking noncompliance audit log by the DON, ADON, Nursing Supervisors, SDC or Regional Nurse Consultant. Staff not working was notified that they could not work until they received their education/training on the above with signs posted on the time clock to prevent staff from clocking in prior to receiving education/training. The above education/training will be included during orientation for any new hires. 18) On 1/20/17, the DON, ADON, Nursing supervisors, SDC or Regional Nurse Consultant trained staff that if there is suspicion of smoking, the Charge Nurse, with another staff member will immediately go to the room in question, remove any contraband, and report immediately to the DON, Social Services Director, and/or Administrator. The DON, Social Services Director, and/or Administrator will immediately go to that room, following the contraband policy and search the room. If these staff members were not in the building, the Charge Nurse, along with another staff member, will search the room. If it is determined the resident was smoking or has contraband, the accident/incident policy and smoking policy will be implemented and policy will be reviewed with the resident, and the family will be notified. If warranted, the resident will be placed on one to one (1:1)supervision. Staff was also trained on what constituted contraband and when searches for contraband could be conducted. 19) The Administrator, DON, Nursing Supervisions, Minimum Data Set (MDS) Coordinator, ESD, Staffing Coordinator, SDC, Director of Dining Services, Business Office Manager, SSD, Central Supply, Chaplain, Marketing/Admissions, or Medical Records were on site daily, starting 01/08/17, to perform walking environmental rounds in which all rooms and common areas were visited by the Department Head. Environmental rounds include: identifying the smell of smoke, ashes or contraband in eyesight. Contraband searches were conducted of residents and residents' rooms who smoke, with the consent of the residents. The environmental rounds and contraband searches were completed daily for one week, then completed three (3) times a week for one week; then completed one time per week for two (2) weeks. Results of the walking environmental rounds were reported to the QA committee weekly to determine the further need of continued education or revision of plan. Based on evaluation, the QA committee determined at what frequency the environmental rounds needed to continue. Concerns identified were corrected immediately and reported to the Administrator. 20) Beginning on 01/08/17, a nurse from the regional team or corporate office was onsite in the facility and remained in contact with the facility daily for two (2) weeks, either onsite or by phone to review ongoing post-test, environmental rounds and contraband searches, then weekly for one month. The nurse(s) from the regional team or home office assisted with rounding, validation of compliance with smoking policy and providing oversight and consultation. 21) Beginning on 01/09/17, RNC, DON, Nursing Supervisors, MDS Coordinator, SDC, Director of Dining Services, Business office manager, Social Services Director, Central Supply, Chaplain, Marketing/Admissions, RSM, Medical Records, SDC, ESD or HR were administering questionnaires to ten (10) different staff members on different shifts daily for one (1) week, then to five (5) different staff members on different shifts daily for one (1) week. The questionnaires include where residents can smoke; where would you find resident specific interventions for safe smoking to ensure resident care needs are met; what should you do when you see a resident with contraband or think a resident has contraband, is responsible for providing the resident with a safe accident free environment; where residents can keep their cigarettes and lighters; when are smoking evaluations completed on residents; and does a resident have the right to keep cigarettes and lighter on them or in their room. 22) On 01/20/17, an additional questionnaire was initiated by the facility that included have you smelled smoke in the facility since the fire on 01/08/17, have you seen any resident with contraband, do you know how many and who the residents are that smoke, do you know the residents who are high risk for being noncompliant with smoking policy. 23) Results of the staff questionnaires will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. Based on evaluation, the QA committee will determine at what frequency the staff questionnaire needs to continue. 24) Beginning on 01/09/17, the facility DON, ADON, SSD, or Nursing Supervisor questioned residents who were interviewable five (5) per week for two (2) weeks. The interviews consisted of if they have seen any resident with smoking contraband or if they had seen any resident smoke in their rooms. Results of the resident questionnaires will be reported to the QA committee weekly to determine the further need of continued education. Based on evaluation, the QA committee will determine at what frequency the staff questionnaire needed to continue. 25) Beginning on 01/08/17, the facility held a QA meeting weekly until the immediacy was removed, then for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. A QA meeting was held on 01/08/17, and an action plan was formulated and implemented at that time. On 01/10/17, the facility held a second QA meeting to review the current plan in place for any needed revisions, compliance, and/or further education. Based upon evaluation, the QA Committee determined at what frequency any ongoing audits needed to continue. The Administrator had the oversight to ensure an effective plan was in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QAs meetings were by the VPO or a member of the regional staff daily until removal of immediacy then weekly for four (4) weeks, then monthly. 26) On 01/10/17, facility staff mailed the Smoking Policy to all family members to ensure they had an understanding of the facility's policy as it related to smoking. ***The State Survey Agency validated the corrective actions taken by the facility as follows: 1) Review of the facility's investigation revealed the city fire department, the State Fire Marshall and the Kentucky State Police Arson Investigator were involved in investigating the possible cause of the fire. Further review of the facility's investigation revealed Resident #1, other residents, and facility staff were interviewed about the fire and possible cause. Interviews on 01/25/17 with the DON at 2:01 PM and the VPO (Acting Administrator) at 3:33 PM revealed Resident #1 was immediately placed on increased supervision after the fire. The interviews further revealed Resident #1, all interviewable residents, and all facility staff were interviewed about contraband and possible causes of the fire. 2) Review of the facility's documentation revealed all of the residents were assessed physically and psychosocially on 01/08/17 by facility staff. Interviews on 01/24/17 with the Regional Nurse Consultant (RNC) at 2:30 PM and UM (Unit Manager) #1 at 3:54 PM and, on 01/25/17 with Staff Development Coordinator (SDC) at 1:22 PM, Unit Manager (UM) #2 at 1:42 PM, Assistant Director of Nursing (ADON) at 1:49 PM and the Director of Nursing (DON) at 2:04 PM revealed all the residents were assessed on 01/08/17 for physical and psychosocial problems related to the fire. 3) Review of the Progress Notes, dated 01/08/17 through 01/10/17, revealed all of the residents that were displaced due to the fire, were assessed for any signs/symptoms of smoke inhalation and any psychosocial concerns by the Charge Nurse every shift for 48 hours. Interviews on 01/25/17 with Licensed Practical Nurse (LPN) #1 at 12:06 PM, LPN #2 at 12:29 PM, Registered Nurse (RN) #1 at 11:47 PM, and RN #2 at 11:53 PM revealed the START residents that had been displaced due to the fire were assessed each day for 48 hours to ensure there were no physical concerns related to smoke inhalation and no psychological concerns. Further review of the facility Progress Notes, dated 01/08/17 through 01/10/17, revealed the SSD/Chaplain visited the residents daily to provide any psychosocial/spiritual support needed. Interview on 01/25/17 at 1:19 PM with the Chaplain revealed himself or the SSD checked on the residents that had been displaced by the fire daily to offer support and to ensure all their psychosocial and spiritual needs were being met. 4) Review of facility documentation revealed Smoking Evaluations, dated 01/08/17, were completed for all facility residents that smoke by the RNC, DON, ADON, UM or SDC. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed Smoking Evaluations were completed for all residents that smoke to determine safety and supervision needs. 5) Review of facility documentation, dated 01/09/17, revealed a meeting was held with all facility residents that smoke to discuss the smoking and the contraband policy in detail and to ensure all the residents knowledge, agreement to follow the policies and understanding of the policies. Interview on 01/25/17 at 3:33 PM with the VPO revealed a meeting was conducted on 01/09/17 with the facility residents that smoke to discuss the smoking policy and the contraband policy and all residents verbalized understanding of the policies and their agreement to follow the policies. 6) Review of Resident #1's Safety Check Log, dated 01/08/17, revealed the resident was on line of site every five (5) minutes. Further review of Resident #1's Safety Check Log, dated 01/09/17 through 01/20/17, revealed the resident was on 1:1 supervision, which was documented every five (5) minutes by facility staff. Interviews on 01/24/17 with State Registered Nurse Aide (SRNA) #7 at 3:08 PM, SRNA #2 at 3:12 PM, SRNA #8 at 3:17 PM, SRNA #9 at 3:22 PM, SRNA #10 at 3:25 PM, SRNA #11 at 3:32 PM, SRNA #12 at 3:39 PM, SRNA #13 at 3:43 PM, SRNA #14 at 3:46 PM, SRNA #15 at 3:48 PM, SRNA #16 at 3:59 PM, SRNA #16 at 3:59 PM, SRNA #17 at 4:03 PM, SRNA #3 at 4:07 PM and SRNA #18 at 4:12 PM and on 01/25/17 with Hospitality Aide #1 at 1:26; LPN #1 at 12:06 PM and LPN #2 at 12:29 PM and with RN #1 at 11:47 AM and RN #2 at 11:53 AM revealed Resident #1 was placed on increased supervision after the fire on the evening of 01/08/17. The facility staff revealed Resident #1 was placed on 1:1 supervision and the staff documented on the resident every five (5) minutes. Further interviews with facility staff revealed the staff was aware of Resident #1's need for increased supervision related to the smoking policy and of the resident's updated care plan interventions. 7) Review of documentation revealed Resident #1 was assessed for behaviors on 01/10/17. Review of facility documentation of Resident #1's care plan, updated on 01/10/17, revealed the resident's care plan was updated to include interventions of: encourage resident to smoke in designated area, monitor for compliance of the facility smoking policy, educate resident on the smoking policy as needed and contraband searches as needed. 8) Review of facility documentation, dated 01/08/17, revealed facility staff checked all resident rooms for contraband and one area of concern was identified. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed all resident rooms were searched for contraband and only (1) area of concern was identified. The interviews revealed smoking materials were found in Resident D's room and were immediately removed and placed in a secure location. 9) Review of documentation of environmental rounds, dated 01/08/17, revealed rounds were conducted on all resident rooms to assess for the smell of smoke and/or ashes and no concerns were identified. Interview on 01/24/17 at 2:30 PM and on 01/25/17 at 2:04 PM with the DON confirmed environmental rounds were made on all resident rooms and no concerns were identified. 10) Review of facility documentation of care plans of the facility residents that smoke revealed all care plans were reviewed and updated on 01/09/17 with each resident's current care needs. Further review the care plans revealed the updated interventions were: observe for signs of noncompliance with smoking policy by smelling for smoke when in the room, observe for any ashes in the room or bathroom, and observe for contraband within eyesight. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed all facility residents that smoke care plans were reviewed and updated with current care needs and updated intervention related to noncompliance with the smoking policy. 11) Review of documentation revealed the medical record of all residents that smoke were reviewed for changes in behaviors and any indication of noncompliance with the smoking policy. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed all residents that smoke medical records were reviewed for changes in behaviors or indication that the smoking policy was not being followed and no concerns were identified. 12) Review of facility documentation revealed smoking evaluations were completed on all residents on 01/08/17. Further review of the documentation revealed the facility identified two (2) other residents at a higher risk to be noncompliant with the smoking policy. Interviews on 01/24/17 with the RNC at 2:30 PM and UM #1 at 3:54 PM and on 01/25/17 with SDC at 1:22 PM, UM #2 at 1:42 PM, ADON at 1:49 PM and the DON at 2:04 PM revealed all residents had a smoking evaluation completed to ensure all residents that smoke were identified. The interviews further revealed of the eight (8) smokers two (2) other smokers were identified to be at a high risk to be noncompliant with the smoking and contraband policy. Review of facility documentation, dated 01/09/17 through 01/19/17, revealed facility staff had been making rounds to ensure compliance with the smoking policy. Review of the facility documentation the Smoking Noncompliance Audit Log, dated 01/20/17 through 01/25/17, revealed facility staff had made rounds observing for noncompliance to the smoking policy every hour- the nurses made rounds on the odd hours and the SRNAs made rounds on the even hours. Interviews on 01/24/17 with SRNA #7 at 3:08 PM, SRNA #2 at 3:12 PM, SRNA #8 at 3:17 PM, SRNA #9 at 3:22 PM, SRNA #10 at 3:25 PM, SRNA #11 at 3:32 PM, SRNA #12 at 3:39 PM, SRNA #13 at 3