Every finding on record at Sam Swope Care Center

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a residents' right to formulate an advance directive were honored for one of four residents reviewed for advance directives out of 35 sampled residents (Resident (R) 85). R85 who was his own decision maker, requested and signed to be a full code status (life saving measures) upon admission to the facility; however, the facility inadvertently entered a Do Not Resuscitate (DNR) order which contradicted the resident's decision. Additionally, the facility allowed the resident's Power of Attorney (POA) to sign DNR documents instead of the resident signing his own code status forms. This failure placed the resident at risk for death in the event of a cardiac and/or respiratory failure. An Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in S483.10 F578: Request/Refuse/Discontinue; Formulate Advance Directives. The Administrator was notified on [DATE] at 3:57 PM of the Immediate Jeopardy. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] at 12:55 PM and was validated on [DATE] at 10:55 PM. The Administrator was notified the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D. The findings include: Review of the facility's policy titled, Advance Directives, revised ,d+[DATE], revealed Advance directives will be respected in accordance with state law and facility policy .3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative or resident representative in accordance with state and federal laws .7. In accordance with the State and Federal requirements, the legal representative may also have the right to refuse or forego treatment .a. Advance Directive-a written instruction, such as a living will or durable power of attorney for heath care, recognized by State law, relating to the provisions of health care when the individual is incapacitated .c. Durable Power of Attorney for Health Care (i.e., Medical Power of Attorney)-a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated .14. Nursing Services or designee will notify the Attending Physician as necessary of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of the facility's Physician orders Process, revised ,d+[DATE] revealed .5. Code status for residents will [be] based upon the completed code status form signed by the resident or the resident representative or legal representative. Physician order will be obtained. 6. The physician or extender that gives a verbal order will be required to electronically sign the order in accordance with the most update [sic] federal and state regulation . Review of R85's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet, tab revealed the resident was admitted to the facility [DATE] with diagnoses which included chest pain, asthma, hypercholesterolemia, hypertension, and coronary atherosclerosis of unspecified type of vessel, native or graft. Further review of R85's Face Sheet revealed the resident had a POA. Review of R85's Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R85's MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed R85 chose to be a Full Code. R85 signed the document himself. Review of R85's Physician Verbal Order, dated [DATE] revealed an order of Do Not Resuscitate [DNR]. The order was entered by Licensed Practical Nurse Unit Manager (LPNUM) 1. During an interview on [DATE] at 3:39 PM, R85 stated if he was found unresponsive, he would want staff to start cardiopulmonary resuscitation (CPR) on him. During a subsequent interview on [DATE] at 4:20 PM, R85 told a Registered Nurse Surveyor he had signed a paper saying he wanted to be a full code. When asked what a full code meant, R85 stated if his heart stopped, or he stopped breathing, he wanted chest compressions to be done. During an interview on [DATE] at 4:29 PM, LPNUM1 reviewed R85's code status in the EMR and stated R85 was a DNR, so no CPR would be done. During an interview on [DATE] at 4:30 PM, LPN1 was asked what he would do if he found R85 unresponsive. LPN1 checked his assignment sheet which documented R85 as a DNR. The LPN then checked R85's physician order in the EMR which also reflected the code status of DNR. LPN1 stated CPR would not be done on R85. Review of the facility's untitled and undated assignment sheet provided by LPN1 revealed the document had R85 listed as a DNR. During an interview on [DATE] at 4:56 PM, Social Worker (SW) 1 stated R85 was his own decision maker. When asked what R85's code status was, SW1 stated she thought he was a DNR. When asked who should have signed the DNR paperwork, SW1 stated R85 or the POA should have. During an interview on [DATE] at 6:42 PM, POA 85 stated he signed DNR papers back in [DATE] because he did not want his brother to just lay there, so he thought it would be best to sign the DNR paperwork. Continued interview revealed the POA did not recall having a telephone conversation with a nurse regarding a decision to make the resident a DNR or full code. The POA stated approximately two years ago R85 became severely ill and R85 was a DNR; however, he had not had a conversation since then with his brother regarding code status and he did not know R85 wanted to be a full code. The POA also stated R85 could make his own decisions, and the facility should follow his brothers wishes. During an interview on [DATE] at 5:01 PM, the Social Service Director (SSD) stated she was not really familiar with R85 as he was not on her case load. The SSD stated R85 had a BIMS of 14 so she would assume he could make his own decisions. The SSD confirmed R85 signed a Directives for Code Status, document on [DATE] choosing to have a full code status. The SSD also confirmed a DNR was signed by POA1 on [DATE]. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed POA85 chose for R85 to be a DNR. POA85 signed the document and not R85 who was his own decision maker. During an interview on [DATE] at 5:28 PM, the Director of Nursing (DON) stated residents who had decision making capacity would make their own code status decision. The DON confirmed R85 signed to be a full code on [DATE]. The DON also confirmed a physician's order dated [DATE] which ordered R85 to be a DNR. When asked why the resident's decision to be a full code status and the physician's order contradicted each other, the DON stated it appeared the physician's order entered on [DATE] which ordered the resident to be a DNR was entered in error. During an interview on [DATE] at 10:24 AM, LPNUM1 confirmed she was the nurse who entered the physician's order for R85 to be a DNR. LPNUM1 stated she reviewed R85's Directives for Code Status, document dated [DATE] and seen the resident selected to be a full code. The LPNUM also stated when she put the electronic order in the EMR, it was a drop-down box and she erroneously selected DNR instead of Full Code. Continued interview revealed on [DATE] she called R85's POA in the presence of R85 to go over the resident's baseline care plan. During this conversation, she discussed R85's code status of DNR with the POA and the R85 per the physician's order on [DATE]. LPNUM1 stated neither R85 nor POA85 questioned the code status. The LPNUM further stated she let the resident and the POA know that paperwork (DNR form and EMS form) needed to be signed and the POA stated he would sign the paperwork the next time he was at the facility. During an interview on [DATE] at 4:48 PM, the Executive Director stated it was his expectation residents' wishes regarding code status would have been honored.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for four of 35 sampled residents (Resident (R) 85, R90, R59, and R117). Upon admission to the facility, R85 chose his code status to be a full code; however, the resident's Care Plan contradicted his code status by having conflicting information when his care plan indicated he was a full code and had a do not resuscitate (DNR) code status. This placed the resident at risk for death in the event of cardiac and/or respiratory failure episode. An Immediate Jeopardy was identified at on [DATE] and was determined to exist on [DATE] at S483.21(b)(1) F656-Develop/Implement Comprehensive Care Plan. The Administrator was notified on [DATE] at 3:57 PM of the Immediate Jeopardy. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] at 12:55 PM and was validated on [DATE] at 10:55 PM. The Administrator was notified the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D. Findings include: Review of the facility's policy dated ,d+[DATE] revised on ,d+[DATE], titled Care-Plans Comprehensive revealed The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the Policy interpretation and implementation revealed The interdisciplinary Team, in coordination with the resident, his/her resident representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS [Minimum Data Set] . Each resident's comprehensive care plan will include services that are to be furnished to maintain the resident's highest practical physical, mental, psychosocial wellbeing, including advance directive code status . Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plans . Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . the interdisciplinary Team is responsible for the review and revision of care plans after each assessment, including comprehensive and quarterly assessments. 1. Review of R85's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet, tab revealed the resident was admitted to the facility [DATE] with diagnoses which included chest pain, asthma, hypercholesterolemia, hypertension, and coronary atherosclerosis of unspecified type of vessel, native or graft. Further review of R85's Face Sheet revealed the resident had a Power of Attorney (POA). Review of R85's Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on [DATE] at 3:39 PM, R85 stated if he was found unresponsive, he would want staff to start cardiopulmonary resuscitation (CPR) on him. During a subsequent interview on [DATE] at 4:20 PM, R85 told a Registered Nurse Surveyor he had signed a paper saying he wanted to be a full code. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed R85 chose to be a Full Code. R85 signed the document himself. Review of R85's Physician Verbal Order, dated [DATE] revealed an order of Do Not Resuscitate [DNR]. The order was entered by Licensed Practical Nurse Unit Manager (LPNUM) 1. Review of R85's Comprehensive Care Plan, created and effective on [DATE] and last evaluated (updated) on [DATE], located in the resident's EMR under the Care Plan tab revealed a problem of . [R85's Name] advance directive: Full Code. The Care Plan had a goal of [R85's Name] wishes will be respected and honored. Interventions included .EMS DNR IN PLACE . which contradicted the residents wishes to be a full code and indicated EMS would not perform CPR in the event of a cardiac and/or respiratory event. During an interview on [DATE] at 10:24 AM, LPNUM1 confirmed she was the one who completed the code status section of R85's initial comprehensive care plan which reflected full code. The LPNUM stated she forgot that the resident had wanted to be a full code and when she went over the baseline care plan, she was looking at the ribbon of the EMR which indicated DNR based on the physician's order she entered on [DATE]. The LPNUM also confirmed the care plan indicated the resident was a full code; however, the care plan included DNR . as an intervention which contradicted each other. During an interview on [DATE] at 2:49 PM, the [NAME] President of Risk Management (VP) 1 confirmed the resident's care plan had a problem which indicated the resident was a full code but had an intervention which indicated the resident was a DNR. VP1 stated it was her expectation residents' care plans would have been reflective of person centered care which included residents' code status wishes. During an interview on [DATE] at 4:48 PM, the Executive Director stated it was his expectation resident's code status wishes be honored and followed. The Executive Director also stated it was his expectation care plans would be accurate and reflected the resident's preferences and care needs. (Cross Reference F578) 2. Review of the Face Sheet located in the EMR under the Profile tab revealed R117 was admitted to the facility on [DATE] with diagnoses of neoplasm (cancer) of the prostrate, injury of ureter, obstructive uropathy, and acute kidney failure. Review of R117's admission MDS located in the EMR under the MDS tab with an ARD of [DATE] revealed R117 had a BIMS of 15 out of 15 which indicated the resident was cognitively intact. Review of the MDS revealed R117 had an indwelling foley catheter. Review of R117's admission comprehensive Care Plan dated [DATE] located in the EMR under the Care Plan tab revealed a problem was not addressed for the use of the foley catheter. Review of R117's physician orders located in the EMR under the Orders tab with a date of ,d+[DATE] revealed an order for an 18 French (FR) with a 10 cubic centimeter (cc) balloon. The physician order further revealed R117 was to have catheter care done twice daily and urine output was to be documented. During an observation of R117 on [DATE] at 11:16 AM revealed the resident was lying in bed and had a foley catheter bag attached to the bedside. During an interview with R117 on [DATE] at 11:16 AM revealed he had prostate cancer and used the foley. During an interview on [DATE] at 1:12 PM with the MDS Coordinator (MDSC) confirmed she did not see a care plan in place for the foley catheter use and there should be. The MDSC further revealed the foley catheter should have an individual problem with individual interventions. The MDSC revealed the physician orders should have been on the Care Plan. The MDSC further revealed the Care Plan was utilized to provide staff with the knowledge of what needs to be done for the residents. The MDSC revealed she updated the care plans; however, the nurses should update the care plans too. The MDSC revealed the care plan was also carried over to the resident summary which went into the kiosk so that the Certified Nursing Assistants (CNAs) could see what care needed to be done. During an interview on [DATE] at 4:39 PM with the Director of Nursing (DON) revealed a foley catheter use should be care planned. The DON further revealed the staff would use the care plan as a guide for care of R117. During an interview on [DATE] at 5:18 PM with the Executive Director revealed the care plan should be updated according to the resident's needs. 3. Review of R90's quarterly MDS with an ARD of [DATE], located in the MDS tab of the EMR, revealed an admitted [DATE]. R90 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R90's cognition was intact. R90's vision was severely impaired, received dialysis and chronic renal failure. Review of R90's Care Plan with an effective date of [DATE] to present, located in the EMR under the Care Plan tab, revealed R90 has the potential for complications related to hemodialysis for diagnosis of chronic renal failure and a goal Resident will remain free from complications related to renal dialysis, goal date [DATE]. An intervention included Monitor access area for redness or pain or signs of infection and report to MD [physician]. Review of R90's [DATE] Treatment Administration Record (TAR) located in the EMR under the Order tab revealed: Dialysis: Dialysis: Assess Access Site () Two Times Daily starting [DATE], order date: [DATE], Discontinued ([DATE]), Notes: Monitor Tunnel Catheter twice daily right chest, Dialysis: Check for Thrill, Bruit, and Assess Site () Two Times Daily starting [DATE], order date: [DATE], Deleted-entry error, Notes: right chest tunnel cath. Order ID: 977651 has not been assigned administration times in the Date Range Specified, and Scheduled 3 times weekly Three Times Weekly starting [DATE], order date: [DATE], Notes: days of dialysis Monday, Wednesday, Friday at 6:30 AM . Review of R90's Dialysis Communication forms, dated [DATE], [DATE], and [DATE] located in the EMR under the Provider tab revealed no monitoring of R90's right chest tunnel catheter. Review of R90's notes, dated [DATE] to [DATE], located in the EMR under the Note tab revealed no documentation of R90's right chest tunnel catheter. During an interview on [DATE] at 9:46 AM, the Director of Nursing (DON) was asked where the implementation of R90's Care Plan related to the documentation for the monitoring of R90's right chest tunnel catheter was located. The DON reviewed the TAR in the EMR and stated she could not find a treatment order specifically for monitoring the catheter, just a general order for infection. The DON then pointed to a treatment order that had been discontinued for monitoring the Tunnel Catheter. The DON stated the treatment order had inadvertently been discontinued. The DON stated R90's access site had changed several times from her arm to her chest and confirmed the order must not have been reinstated. During an interview on [DATE] at 11:09 AM, Registered Nurse (RN)2 was asked if he checked R90's chest catheter after dialysis. RN2 stated, No, he only checked to ensure the port was covered because the dialysis center would check for bruit/thrill before they covered it. At 11:25 AM, the RN stated the old order was discontinued because R90's port sites changed from the arm to the chest. During an interview on [DATE] at 2:06 PM, the Executive Director was asked if he was aware of R90's access catheter for dialysis was not being implemented per the Care Plan. The Executive Director stated he was not aware. The Executive Director stated his expectation would be for staff to follow protocols, physician orders, and the Care Plan. During an observation and interview on [DATE] at 6:53 PM, R90 was asked if the nurse checked her access site on her right chest after dialysis. R90 stated, No, the nurse just checked her blood sugar. R90 then pointed to the bandaged area over her access site. 4. Review of R59's significant change MDS with an ARD date of [DATE], located in the MDS tab of the EMR, revealed an admitted [DATE]. R59 had a BIMS score of 15 out of 15 indicating R59's cognition was intact. The MDS indicated the resident received an anticoagulant (blood thinner), and had diagnoses of coronary artery disease, atrial fibrillation, and deep venous thrombosis. Review of R59's physician Orders located in the EMR under the Order tab, revealed warfarin 4 mg [milligram] tablet Every Day, dated [DATE] and warfarin 1 mg tablet Every Evening, dated [DATE]. The medication notes on the orders included side effects that should be monitored any signs of serious bleeding, including nosebleeds that happen often or don't stop, unusual pain/swelling/discomfort, unusual/easy bruising, prolonged bleeding from cuts or gums unusually heavy/prolonged menstrual flow, pink/dark urine, coughing up blood, vomit that is bloody or looks like coffee grounds, severe headache, dizziness/fainting, unusual tiredness/weakness, bloody/black/tarry stools, chest pain, shortness of breath, difficulty swallowing. Review of R59's Care Plan with an effective date of [DATE] to present, located in the EMR under the Care Plan tab, revealed no evidence of a Care Plan for the ordered warfarin Review of R59's [DATE] TAR located in the EMR under the Order tab revealed no evidence of monitoring for bleeding and other side effects. Review of R59's Notes dated [DATE] to [DATE], located in the EMR under the Note tab revealed no documentation of monitoring for warfarin potential side effects. During an interview on [DATE] at 7:31 AM, Licensed Practical Nurse (LPN)2 confirmed there was no care plan developed for R59's ordered warfarin or monitoring being completed except for laboratory tests. LPN2 stated her expectation would be for the warfarin to be care planned. LPN2 confirmed it was important to have a care plan for the use of an anticoagulant to ensure the resident was monitored for bleeding gums, stools, and when using the electric razor. During an interview on [DATE] at 4:38 PM, the DON stated she was not aware R59 did not have a Care Plan for the ordered warfarin, however; she stated the resident should have had one developed. During an interview on [DATE] at 2:09 PM, the Executive Director stated he was not aware of R59's anticoagulant not being care planned or that the resident was not monitored for bleeding, however, his expectation would be to care plan the medication, follow the care plan, monitor the medication for side effects, and follow the physician order and any protocols.

Based on observation, record review, interview, and review of the facility's policy, the facility failed to ensure all supplies in the medication room and crash carts were not expired for three out of the six medication rooms and three out of the six crash carts. This had the potential for the facility to use expired medications and supplies that could potentially not be effective. The findings include: Review of the facility's policy dated 05/2023, titled Crash Cart Stocking Protocol revealed the Director of Nursing or Nursing leadership provided Central supply a list of supplies needed for crash cart . Crash Carts are stocked by Central Supply and are covered until opened and used . Nursing staff verify daily crash has not been opened and if the crash cart is open the entire crash cart is re-stocked by Central Supply. Review of the facility's policy dated 09/2013 and revised on 04/2022, titled Medication Room Storage of Medications Policy revealed it is the policy of this facility that drugs are to be stored in a secure and orderly manner under proper temperature. During an observation and interview on 08/14/2024 at 1:47 PM with Licensed Practical Nurse (LPN)3, on the [NAME] unit medication room, revealed a tuberculin purified serum was not dated when it was opened and should be removed as it could have been opened past the 30 days. Observation further revealed five ifob test kits for occult stool had an expiration date of 06/30/2024. LPN3 stated since the test kits were outdated the assessment would not be accurate and could give false readings. LPN3 further stated the crash cart was checked each night by nursing and central supply has a check list that showed what the supplies should be. LPN3 stated central supply kept a log of when they checked the crash cart. Observation of the crash cart revealed connection tubing for the suction machine had an expiration date of 04/01/2023. LPN3 stated nursing should have been checking for expiration dates of the supplies on the crash cart. During an observation and interview on 08/14/2024 at 2:28 PM with LPN4, on the [NAME] unit medication room, revealed five athgrip tube securements (to hold IV catheters in place) had an expiration date of 07/31/2024. Observation further revealed four snap secure three way and temperature sensing foley securement device had an expiration date of 03/31/2024 and was expired. LPN4 stated they might not work as good as it should since it was expired, and she would not use them. Observation further revealed eleven packets of Immunological fecal occult blood (ifob) test kit for occult stool had an expiration date of 06/30/2024. LPN4 stated that since the test were expired it could give false readings. LPN4 revealed the crash cart was checked every night by nursing. Observation further revealed a suction tubing nonconductive connecting tube had an expiration date of 04/01/2023. Observation revealed two containers of sterile water had an expiration date of 05/25/2024. During an interview on 08/14/2024 at 2:30 PM with LPN4 revealed the crash cart was checked once a week by central supply or the nurse leader. LPN4 revealed she had not checked this crash cart, but she looked to make sure the blue tag and a suctioning machine were on the crash cart. LPN4 revealed the blue tag meant the crash cart was locked and everything that had been used was replaced. Interview with LPN4 further revealed the sterile water was used to suction the resident and sterile water should not be used if outdated. During an observation on 08/14/2024 at 3:00 PM with LPN2, on the [NAME] House hall, revealed a cath grip tube securement device was expired with an expiration date of 07/31/2024. Observation and interview with LPN2 further revealed a hydrocolloid medium device ( to secure a catheter) was expired with a date of 12/31/2023. During an observation on 08/14/2024 at 3:15 PM further revealed the crash cart log showed it had been checked every night. Observation and interview with LPN2 revealed a suction kit was expired with a date of 08/01/2020, a nonconductive connecting tubing was expired with a date of 08/06/2023, and a portex nasopharyngeal airway tube was expired with a date of 11/2015. During an interview on 08/14/2024 at 3:15 PM with LPN2 she stated the nurses should make sure the cart was locked, a suction machine was available, and there was oxygen on the cart. LPN2 stated central supply should have checked there were supplies in the crash cart. LPN2 revealed nobody wanted to use something that was expired because it may malfunction and that could hurt the resident who needed it. During an interview on 08/16/2024 at 7:59 AM with Central Supply Worker stated they stocked the crash cart only if it had been opened. The Central Supply worker revealed they checked that the blue tag was still on the cart and that was all they checked. She stated they did not check inside the crash cart and had never thought about checking for expiration dates. During an interview on 08/16/2024 at 8:08 AM with the Director of Nursing (DON) she stated central supply stocked and audited the crash carts weekly. The nurses verified the tag had been sealed and not broken. Central supply had a supply list, and they should make sure all items were stocked and not expired. The DON revealed the crash cart should be opened weekly and checked for expired supplies and that all supplies were available. The DON revealed she did not know why there were expired supplies on the crash cart. The DON revealed if a supply was expired it may not function properly. During an interview on 08/16/2024 at 6:05 PM the Administrator confirmed the crash carts and medication rooms should be checked and audited for supplies that were not expired.

Based on interview, record review, and review of the facility's policy, the facility failed to report an allegation of abuse within two hours of the allegation for one of seven residents reviewed for abuse (Resident (R) 88) out of 35 sampled residents. On 06/28/2024 R88 reported an allegation of sexual abuse to the facility; however, the facility failed to report the allegation to the State Survey Agency (SSA) within the required two-hour time frame. R88 reported the allegation to the facility staff on 07/04/2024 at approximately 9:00 AM; however, the Administrator did not report the allegation to the SSA until 12:41 PM, which was outside of the required two-hour reporting timeframe. This failure placed the investigation of the allegation made by the resident at risk of being compromised. (Cross reference F610 and F842) The findings include: Review of the facility's policy titled, Abuse and Neglect Policy and Procedure, dated 10/2022 revealed The purpose of this policy is to attempt to prevent any type of abuse to residents through pre-employment and pre-admission screening, training of new staff and ongoing training for all staff, identification, investigation, protection, prevention, and reporting of abuse .Sexual Abuse .non-consensual sexual contact of any type with a resident .7. Training on reporting abuse .Reporting: 1. In accordance with the state and federal regulation all suspicions of abuse .will be reported. Reports will be made by the Administrator, or designee. Notification to the Department for Community Based Services, Office of Inspector General .will occur as indicated by the most current regulation of the community .c. Initial allegations involving .sexual abuse .are reported immediately, but not later than 2 hours after the allegation is made . 1. Review of the facility's investigation revealed on 07/04/2024 Resident [R88 was] admitted to the facility on [DATE] and stated that she was raped by a white woman on 06/27/2024 while at the hospital. She could not remember the name. During the interview with the DON [Director of Nursing], resident's cognition was alert and confused. Her current BIMS [Brief Interview for Mental Status Score] is a 7 [seven] [severely cognitively impaired]. [The] Resident did not exhibit any distress during the interview .DON when speaking to the resident's husband, he stated she was raped when she was [AGE] years old and fixated on the situation. The resident later stated it was a black woman. The resident alleged it happened prior to admission at the hospital. Other residents were interviewed, and body checks were completed on residents who were not cognitively intact. The facility reported timely. Unsubstantiated. The investigation revealed the facility documented the date and time the facility became aware of incident was 07/04/2024 at 11:15 AM and documented the Administrator was notified of the allegation on 07/04/2024 at 11:30 AM. Review of an email, dated 07/04/2024 at 12:41 PM, provided by the Administrator, revealed the subject line of the email was [R88's Name] initial report. The email was sent to the SSA. Review of R88's entire medical record revealed no documented evidence of the allegation made by R88. R88's medical record also lacked any documented evidence of immediate assessments made by nursing staff on R88 related to the allegation of sexual abuse. Review of R88's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disorder, and generalized anxiety disorder (GAD). Review of R88's admission Minimum Data Set (MDS), with and assessment reference date (ARD) of 06/06/2024 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. Review of R88's Physical Therapy Treatment Encounter Note(s), electronically signed and dated 07/04/2024 at 12:07 PM, located in the resident's EMR under the Therapy tap revealed .During session, pt [R88] reported an incident that happened last Thursday evening. Social Services was called, and incident was reported to social worker . The note was electronically signed by Physical Therapy Assistant (PTA) 1. During an interview on 08/16/2024 at 2:50 PM, PTA1 stated at approximately 9:00 AM on 07/04/2024, R88 reported her bottom was sore and she had been raped by two black women. The PTA stated she immediately notified Social Worker (SW) 1. During an interview on 08/16/2024 at 3:05 PM, SW1 stated on 07/04/2024 between 9:00 AM and 9:15 AM she received a telephone call from PTA1 who reported R88 made an allegation of being raped. The SW stated when she received the call, she was almost to the facility and as soon as she arrived at the facility she went and interviewed R88. SW1 stated R88 reported the allegation occurred on Thursday. The SW stated she then asked the resident was it the current Thursday (07/04/2024) while she was at the facility or the prior Thursday when she was at the hospital; however, R88 was not able to tell her which Thursday the rape allegation occurred. When asked if she documented the interview with R88, SW1 stated she wrote it down on a scrap piece of paper; however, she threw the paper away and did not document the interview in the resident's medical record. Continued interview revealed she reported the allegation to the DON on 07/04/2024 at approximately 9:30 AM. During an interview on 08/16/2024 at 4:11 PM, the DON stated she was in the morning clinical meeting on 07/04/2024 when SW1 came and reported to her R88 was alleging she had been raped. The DON stated she immediately left the meeting and went and interviewed R88. When asked what R88 told her in her interview, the DON stated it was what was documented in her (DON) statement which was part of the facility's investigation. Continued interview revealed when asked what time the SW reported the allegation to her and what time she interviewed R88, the DON stated the clinical meeting started at 10:00 AM and ended at approximately 11:00 AM, so it was reported to her between 10:00 AM and 11:00 AM but could not give the exact time. The DON also stated she did not document the time she interviewed R88 about the allegations. During an interview on 08/16/2024 at 4:26 PM, the Administrator stated abuse allegations were to be reported to the SSA within two hours once the allegation was made. The Administrator stated the allegation was reported to him on 07/04/2024 at 11:30 AM. When asked what time the facility's staff became aware of the allegation, the Administrator stated, I don't have that in here [in his investigation]. When asked if he could definitively say the allegation was reported to the SSA timely, the Administrator stated, on my part yes. When the Administrator was informed the allegation was made by R88 to facility staff on 07/04/2024 at approximately 9:00 AM, the Administrator stated he was not aware there was an issue with the timeliness of the reported allegation.

Based on interview, record review, and review of the facility's policy, the facility failed to thoroughly investigate allegations of abuse for two of seven residents reviewed for abuse (Resident (R) 88 and R103) out of 35 sampled residents. R88 made an allegation of abuse on 07/04/2024 at approximately 9:00 AM. A facility staff member reported R103 was a victim of verbal abuse. (Cross Reference F842) The findings include: Review of the facility's policy titled, Abuse and Neglect Policy and Procedure, 10/2022 and provided by the facility revealed The purpose of this policy is to attempt to prevent any type of abuse to residents through investigation, protection, prevention .of abuse .Identification of Abuse: .2. The Administrator, or designee, will initiate an in-house investigation into any allegations and make appropriate determination related to the reporting of events to the .Office of Inspector General [State Survey Agency (SSA)] .Investigation: 1. The Administrator will be responsible for ensuring the facility's compliance with all applicable provisions .4. Information related to a report of abuse, will be obtained from persons with knowledge of the reported incident . 1. Review of R88's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disorder, and generalized anxiety disorder (GAD). During an interview on 08/16/2024 at 2:50 PM, Physical Therapy Assistant (PTA) 1 stated at approximately 9:00 AM on 07/04/2024, R88 reported her bottom was sore and she had been raped by two black women. The PTA stated she immediately notified Social Worker (SW) 1. During an interview on 08/16/2024 at 3:05 PM, SW1 stated on 07/04/2024 at approximately 9:00 AM, PTA1 called her and reported to her R88 made an allegation of sexual abuse. SW1 stated she was on her way to the facility at that time and arrived approximately five minutes later. SW1 also stated she immediately went and interviewed R88 who alleged she was raped. Continued interview revealed the SW finished interviewing R88 and then immediately reported this to the Director of Nursing (DON). Review of the facility's 5 Day Follow up/Final Report, of their internal investigation revealed no documented evidence SW1 was interviewed related to her interview with R88. Additionally, there was no documented evidence in the resident's medical record the resident was assessed by nursing staff. During an interview on 08/16/2024 at 4:26 PM with the Administrator, when asked if he interviewed SW1 or obtained a statement from SW1 since she was the first person to interview R88 after she made the allegation to PTA1 and if it could have been pertinent to his investigation since the resident could not tell the SW which Thursday the sexual abuse allegedly occurred, the Administrator stated he got what the resident was alleging through other interviews. When asked if it would have been important to know what the resident reported to SW1 during the social worker's interview including what time it was reported to her by PTA1, the Administrator stated, my role is once I am notified, I start the investigation [the Administrator avoided the specific question asked]. (Cross Reference F609 and F842) 2. Review of R103's undated Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. Review of R103's quarterly Minimum Data Set (MDS),with an assessment reference date of 04/29/2023 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Review of the facility's 5 Day Follow up/Final Report, dated 08/21/2023 revealed on 08/17/2023 Licensed Practical Nurse (LPN) 4 reported CNA [Certified Nurse Aide] 8 and CNA9 were cursing in the dining room with resident [R103's Name] present .Staff interviews with no new findings, resident interviews no new findings, skin assessments with no new issues. After a thorough investigation, we are unable to substantiate the allegation of abuse . Review of a document titled, Verbal Statement from [LPN4's Name], dated 08/17/2023 with no interview time documented located in the facility's investigation revealed [R103's Name] asked me [LPN4] for some butter. I found the butter in the fridge and told the CNA [CNA8's Name], here was some butter. [R103's Name] became upset and began cursing. [CNA8's Name] then silently mouthed the word 'B***h' and then said some other things which I didn't hear. The other CNA, [CNA9's Name] jumps up, and her and resident were exchanging words. [CNA9] then said to [R103's Name] to get the [expletive] out of her face and back up,' he raised his cane and I [LPN4] got in between the resident and staff member to separate the situation. Review of a document titled, Verbal Statement via phone [CNA8's Name], dated 08/17/2023 with no interview time documented located in the facility's investigation provided by the facility revealed [R103's Name was asking for butter for his shrimp. I looked in the refrigerator and didn't see any. The nurse came over and found some butter. [R103's Name] started calling me a fu****g liar and I really didn't see the butter. He also told me I need to wear glasses, and I said I don't wear glasses and then I walked away. I did not curse [R103's Name]. Review of a document titled, Verbal Statement via phone [CNA9's Name], dated 08/17/2023 with no interview time documented located in the facility's investigation provided by the facility revealed [R103's Name] was upset and came at me. I kept telling him to 'back up,' he was calling me a 'fu****g liar' and was talking to [CNA8's Name] that way. He said he was going to hit me with his cane and the nurse came over and got him away. I never cussed him at all. I would never curse any residents Review of CNA9's document titled, Employee Counseling, dated 08/21/2023, located in the employee's personnel file provided by the facility revealed CNA9 was discharged (terminated) from her employment for .Unprofessional behavior in the workplace that is considered by management to be unacceptable . Review of CNA9's Payroll Activity/Change Form, dated 08/24/2023 and located in the CNA's employee personnel file provided by the facility revealed the CNA was terminated for Misconduct/Policy Violation and was not eligible for re-hire. It was documented that the last day CNA9 worked was 08/17/2023. During an interview on 08/16/2024 at 4:41 PM, when asked if he reviewed the facility's video surveillance which was located in the dining room where the alleged allegation occurred, the Administrator stated he did not recall if he reviewed it; however, if he had reviewed it, he would not have included it in his investigation if it was not pertinent. When asked would it had been helpful to review the video footage to validate or invalidate the event that was alleged, the Administrator stated sure. The Administrator also stated CNA9 was terminated for cussing in the dining room [during the alleged allegation] as it was unprofessional even though it was not towards a resident.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a resident from wandering into other resident rooms for one (Resident (R) 68) of one sampled resident reviewed for wandering out of a total sample of 35. The findings include: Review of the facility policy titled Wander/Elopement Precautions Policy, updated 03/22, revealed It is the policy of the facility to provide the least restrictive environment for residents, while doing so attempt to implement inventions for those residents who are identified at risk of wandering /elopement to maintain safety. The policy did not address the intrusion of the privacy of others. Review of R68's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/22/2024, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R68 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating R68's cognition was severely impaired. Behaviors of wandering was marked behavior not exhibited. The question does the wandering significantly intrude on the privacy of activities of others? was left blank. The question how does resident's current behavior status, care rejection, or wandering compare to prior assessment? was answered Worse. R68 had a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, insomnia, and malnutrition. Review of R68's Care Plan with an effective date of 11/01/2022 to present, located in the EMR under the Care Plan tab revealed R68 has behavioral symptoms directed toward others: aggressive towards staff and refusing care, wandering into resident's rooms, taking items off nurse's cart, taking items out of other resident rooms, and laying in other resident's beds. The goal included R68 will have decreased behaviors within the next 30 days, goal date 09/27/2024. Review of R68's Progress Note dated 03/29/2024, located in the EMR under the Note tab revealed Resident noted to be entering other residents' rooms and sitting on their beds. When this nurse and the caregivers attempted to redirect resident, res [resident] noted to be resistant and inappropriate towards staff. This nurse educated on the importance of resident privacy and not entering their rooms and also educated on the importance of appropriate behavior towards staff, but education ineffective due to resident being confused and kept entering rooms. Review of R68's Progress Note dated 05/01/2024, located in the EMR under the Note tab revealed Res continues to wander the hallways, whispering to herself and entering other resident's rooms and laying down in their beds. This nurse has attempted to redirect her several times and re orient her but all attempts ineffective because her agitation has increased, and she has spent all morning walking incessantly and entering resident's room Review of R68's Progress Note dated 05/03/24, located in the EMR under the Note tab revealed Res observed to keep wandering the hallways and whispering to herself. Three residents reached out to this nurse and complained because res entered to the three resident's rooms and laid down in their beds. This nurse has attempted to redirect her several times and re orient her but all attempts were ineffective. Res keeps spending all morning walking incessantly and entering resident's room. Review of R68's Behavior Note dated 06/08/2024, located in the EMR under the Note tab revealed Resident has continued to wander around the unit this shift. She has wandered into other Residents' rooms several times and other Residents have become very distressed and agitated, Nursing staff continues to redirect and distract with very little success . Review of R68's Behavior Notes dated 06/09/2024, located in the EMR under the Note tab revealed the Resident was observed to have taken a stick of deodorant from another Resident's room and was attempting to eat it. This Nurse was able to get deodorant away from R68 before she ate more than one bite . Resident was observed by Caregiver trying to pry an electrical outlet covering away from the wall, R68 was redirected but then began to remove the plated glass cover from the fire extinguisher cabinet less than an hour later. She was redirected again. Due to Resident's poor cognition, she is unable to understand these safety risks. Review of R68's Behavior Note dated 06/10/2024, located in the EMR under the Note tab revealed res found lying in another resident's bed sleeping. Res would not get out of bed for 2 hours despite staff's attempts . once in her own room and bed, res got back up out of bed and was wandering around her room and trying to come in the bathroom where this nurse and another res was at. During an observation on 08/13/2024 at 12:10 PM, R68 was observed walking down the hall pulling down the mesh stop sign attached across the doorway of room [ROOM NUMBER]. During an observation on 08/14/2024 at 5:35 PM, R68 was observed to stop at R37's room and the gate on the entry way prevented R68 from entering. R37 stated at this time this is why I have a gate. R37 told R68 to leave. R68 then turned into R68 suitemate's room. R68 was observed to pick up items in room [ROOM NUMBER]. During an observation on 08/14/2024 at 5:40 PM, R68 was observed walking in rooms [ROOM NUMBERS], which had a mesh stop sign across the entryway. R68 was observed bending down walking under the mesh stop sign. R68 then walked back into room [ROOM NUMBER] where another resident sat in her wheelchair. R68 picked up a tissue box from room [ROOM NUMBER] and left the room with the box. During an observation on 08/14/2024 at 5:42 PM, the unit was observed with mesh stop signs or a gate on the entry ways to rooms 265, 268, 269, 270, 271, 273, 276, and 278. During an observation on 08/16/2024 at 6:53 PM, R90 was in her room listening to music. R68 was observed at R90's doorway. R90 complained of R68 wandering into her room and how she found R68 in her bed one day. R90 stated she made her way to the hall and hollered down the hall to get R68 out of my room. R90 stated R68 would then return to her room after the nurse walked her out. R90 stated she has lost items like tissue paper, wipes, and condiments because R68 takes them. R90 stated she is blind and R68 will place things in a different spot than when she had it. R90 stated due to her sight she needs things to stay in the place where she knows they will be. During an interview on 08/15/2024 at 3:12 PM, Certified Nurse Aide (CNA)1 stated R68 did wander into other resident rooms, but R68 means no harm. CNA1 stated they occupy R68 with tasks, toys, a special apron to use with things on it for her to play with. CNA1 stated R68 needs a lot of redirections. CNA1 stated she understands R68's wandering into other resident's rooms was uncomfortable for the affected residents and some residents have mesh stop signs in the effect to keep R68 out of their rooms. During an interview on 08/16/2024 at 7:10 PM, CNA5 confirmed R68 wandered a lot in and out of other resident rooms and they redirect her or take her to her room, but it doesn't last long. During an interview on 08/14/2024 at 5:43 PM, Registered Nurse (RN)1 stated she was familiar with R68's behaviors of wandering into other resident rooms, but she wasn't aware of R68 walking under the mesh stop signs. RN1 stated F68 was redirected and offered diverting choices, but none of the interventions were effective. RN1 stated R68 wandered up and down both halls on the unit. During an interview on 08/15/2024 at 9:53 AM, the Director of Nursing (DON) was asked if she was aware of R68 wandered into other resident rooms. DON stated, Yes she was aware, but she thought the Fidget apron helped. DON states they tried to come up with activities to keep R68 occupied, such as redirecting her, and psychiatry had worked with her as well. The DON was informed of residents complaining of R68 wandering into their rooms, taking the mesh stop signs down, going under the mesh stop sign, and even getting in their bed. The DON acknowledged this was a problem. During a follow up interview on 08/16/2024 at 4:43 PM, the DON said her expectations for R68 was to redirect her, use diversion activities, snacks, fidget apron, and hydration. During an interview on 08/16/2024 at 2:09 PM, the Executive Director stated he was aware of R68 wandering into other resident rooms and their complaints. The Executive Director stated they were currently working on a resolution but in the meantime his expectation would be for staff to keep her occupied and redirect her out of other resident's space.

Based on observation, interview, record review, and facility policy review, the facility failed to monitor the tunnel catheter post dialysis for complications for one (Resident (R) 90) of one sampled resident reviewed for dialysis out of a sample of 35 residents. The deficient practice could lead to potential complications that could impact the quality of R90's hemodialysis. The findings include: Review of the facility's policy titled Instructions for Care of the Dialysis Catheter, dated 02/2023, revealed 3. Nursing will observe for signs of infection. Review of R90's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R90 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R90's cognition was intact, and vision is severely impaired. R90 received dialysis and had chronic renal failure. Review of R90's Care Plan with an effective date of 03/29/2023 to present, located in the EMR under the Care Plan tab, revealed R90 has the potential for complications related to hemodialysis for diagnosis of chronic renal failure and a goal Resident will remain free from complications related to renal dialysis, goal date 10/02/2024. An intervention included Monitor access area for redness or pain or signs of infection and report to MD [physician]. Review of R90's August 2024 treatment administration record (TAR), located in the EMR under the Order tab revealed: Dialysis: Dialysis: Assess Access Site () Two Times Daily starting 03/30/2023, order date: 03/30/2023, Discontinued (09/18/2023), Notes: Monitor Tunnel Catheter twice daily right chest, Dialysis: Check for Thrill, Bruit, and Assess Site () Two Times Daily starting 03/30/2023, order date: 03/30/2023, Deleted-entry error, Notes: right chest tunnel cath. Order ID: 977651 has not been assigned administration times in the Date Range Specified, and Scheduled 3 times weekly Three Times Weekly starting 05/29/2023, order date: 05/29/2023, Notes: days of dialysis Monday, Wednesday, Friday at 0630 . Review of R90's Dialysis Communication forms, dated 08/14/2024, 08/12/2024, and 08/09/2024 located in the EMR under the Provider tab revealed no monitoring of R90's right chest tunnel catheter. Review of R90's Notes dated 08/01/2024 to 08/13/2024, located in the EMR under the Note tab revealed no documentation of monitoring of R90's right chest tunnel catheter. During an interview on 08/15/2024 at 6:13 PM, Licensed Practical Nurse (LPN)2 confirmed R90's treatment order for monitoring of the access catheter was discontinued. LPN2 thought it was because of so many changes of the site. During an interview on 08/16/2024 at 11:09 AM, Registered Nurse (RN)2 was asked if he checked R90's chest catheter after dialysis. RN2 stated, No, he only checked to ensure the port was covered because the dialysis center would check for bruit/thrill before they covered it. RN2 stated the old order was discontinued because R90's port sites changed from the arm to the chest. During an interview on 08/15/2024 at 9:46 AM, the Director of Nursing (DON) was asked where R90's dialysis access catheter was monitored per the Care Plan. The DON reviewed the Treatment Administration Record (TAR) in the EMR and stated she could not find a treatment order specifically monitoring the catheter, just a general one for infection. The DON stated the treatment order had inadvertently been discontinued because R90's access site had changed several times from her arm to her chest and confirmed the order must not have been reinstated. During an interview on 08/16/2024 at 2:06 PM, the Executive Director stated his expectation would be for staff to follow protocols, physician orders, and the care plan related to R90's tunnel catheter.

Based on observation, interview, and record review, the facility failed to monitor for side effects of an anticoagulant (blood thinner) for one (Resident (R)59) of five residents reviewed for unnecessary drugs out of a total sample of 35 residents. The deficient practice could potentially result in unnoticed bleeding. The findings include: A policy for warfarin and/or anticoagulant medications was requested. The Director of Nursing (DON) and the [NAME] President of Risk Management stated they did not have a policy for coumadin/warfarin or for anticoagulant medications. Review of R59's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/21/2024, located in the MDS tab of the Electronic Medical Record (EMR), revealed an admitted [DATE]. R59 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R59's cognition was intact, received an anticoagulant, and diagnoses of coronary artery disease, atrial fibrillation, and deep venous thrombosis. Review of R59's physician Orders located in the EMR under the Order tab, revealed warfarin 4 mg [milligram] tablet Every 1 Day, dated 07/17/2024 and warfarin 1 mg tablet Every Evening, dated 08/05/2024. The medication notes on the orders included side effects that should be monitored any signs of serious bleeding, including nosebleeds that happen often or do not stop, unusual pain/swelling/discomfort, unusual/easy bruising, prolonged bleeding from cuts or gums unusually heavy/prolonged menstrual flow, pink/dark urine, coughing up blood, vomit that is bloody or looks like coffee grounds, severe headache, dizziness/fainting, unusual tiredness/weakness, bloody/black/tarry stools, chest pain, shortness of breath, difficulty swallowing. Review of R59's August 2024 Treatment Administration Record (TAR) located in the EMR under the Order tab revealed no documentation of monitoring for bleeding or other side effects for the use of the anticoagulant. Review of R59's Notes dated 06/15/2024 to 08/15/2024, located in the EMR under the Note tab revealed no documentation of monitoring warfarin side effects. During an interview on 08/16/2024 at 4:38 PM, the Director of Nursing (DON) said her expectation was for the resident to be monitored for bleeding and other side effects. During a follow up interview on 08/16/2024 at 8:45 PM, the DON confirmed there was no documentation for monitoring for bleeding nor were bleeding precautions in effect. During an interview on 08/16/2024 at 2:09 PM, the Executive Director stated he was not aware of R59's anticoagulant not being monitored for bleeding, but his expectation would be to monitor the medication for side effects, and follow the physician's orders and any protocols.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' medical records were complete, accurately documented, contained a record of residents' assessments, and staff documentation of medical and non-medical status including the care and services provided across all disciplines for one of seven residents reviewed for abuse (Resident (R) 88 out of 35 sampled residents). The findings include: Review of the facility policy, Resident Medical Record Process, dated 03/2024 revealed It is the policy of this facility that appropriate medical records be maintained/released for each resident in accordance with State and Federal regulation [483.70(i), 483.70(i)(2)(iv)] .Process . a. A medical record is maintained for each resident at this facility electronically. b. Medical record contains medical data that is reflective of the resident health care and care needs . 1. Review of R88's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab revealed the facility admitted the resident on 05/30/2024. Review of the facility's FRI dated 07/04/2024 revealed R88 made an allegation of sexual abuse (rape) to facility staff. Review of R88's entire medical record, including progress notes, nursing assessments, social service notes, etc., revealed no documented evidence of any information regarding R88 reporting the allegation of sexual abuse to the facility. During an interview on 08/16/2024 at 3:05 PM, Social Worker (SW) 1 stated she documented her interview with R88 on 07/04/2024 on a scrap piece of paper; however, after she verbally reported the allegation and interview with R88 to the Director of Nursing (DON), she threw away the scrap piece of paper. Continued interview with SW1 revealed it was the facility's practice not to document in any resident's medical record anything that could possibly be a reportable incident to the SSA unless the Administrator or the DON gave the ok to do so. When asked who told her this was the facility's process, SW1 stated she was given this direction by the Social Services Director (SSD). During an interview on 08/16/2024 at 3:19 PM, the SSD stated if any staff member, which included social service staff members, were told of any type of reportable incident, they (staff) were told to take the information to the Administrator or DON and not to document the concern in the resident's medical record. When asked why did SW1 not document her interview with the resident regarding the allegation of abuse in the resident's medical record, the SSD stated SW1 followed the practice of the facility. During an interview on 08/16/2024 at 4:26 PM, the Administrator stated it was his expectation residents' medical records be complete and accurate.

Based on interview, record review, review of the facility's camera footage, and review of the facility's policy, it was determined the facility failed to develop a Comprehensive Care Plan (CCP) to ensure one (1) of seventy-six (76) sampled residents (Resident #1) was provided adequate supervision to prevent elopement from the facility on [DATE]. Staff found Resident #1, outside, at the back of the facility on [DATE] at 10:26 PM, approximately five-hundred fifty-eight (558) feet from his/her room. The resident was found on the sidewalk face down and unresponsive behind the facility. Resident #1 was taken to a local Emergency Department (ED) by Emergency Medical Services (EMS). Resident #1 expired, on [DATE] at 11:23 PM. Resident #1's Elopement Risk Assessment, completed on admission, revealed the resident was too weak to have the ability to exit the facility and was not identified as an elopement risk. Resident #1's care plan did not identify any interventions needed to prevent elopement, such as increased supervision because he/she was not identified as an elopement risk. However, per the Director of Nursing's (DON) interview on [DATE] at 12:54 PM, the resident's status changed, and he/she became more mobile and should have been reassessed, and the resident's care plan should have been developed with new interventions added. The facility's failure to ensure each resident had a comprehensive care plan developed to direct staff to provide adequate supervision to prevent accidents and hazards through elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.21 Comprehensive Care Plans (F-656) Develop and Implement Comprehensive Care Plan at a Scope and Severity (S/S) of a J. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging the Immediate Jeopardy's removal and substantial compliance, on [DATE]. The State Survey Agency validated the IJ Removal Plan, prior to exit on [DATE], and determined the facility had implemented corrective actions and was in substantial compliance on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, last reviewed ,d+[DATE], revealed the facility must develop and implement a comprehensive person-centered care plan for each resident, to meet the resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Per the policy, assessments were ongoing and care plans were to be revised as changes and conditions of the resident changed. Review of Resident #1's medical record revealed the facility admitted the resident, on [DATE], for Rehabilitation Services related to increased weakness, increased confusion, and a high number of falls. The resident's diagnoses included [NAME] Encephalopathy, Vascular Dementia without Behaviors, Unspecified Convulsions, Insomnia, and Alcohol Dependence with Withdrawal. Review of the Brief Interview for Mental Status (BIMS) assessment, completed on [DATE], revealed the resident scored nine (9) of fifteen (15), which indicated moderate cognitive impairment. Review of Resident #1's CCP, dated [DATE], revealed the resident had an altered mental thought process, was at risk for self-care deficits, and at risk for injury related to his/her Dementia diagnosis. The goal set for the resident revealed he/she would be monitored for safety. Interventions, for this problem, included to facilitate the use of assistive devices for ambulation as appropriate, assess risk of elopement and initiate appropriate interventions, provide assistive devices per therapy evaluation to steady gait for ambulation. The interventions listed were to provide only the amount of assistance/supervision that was needed and to report any changes in Activities of Daily Living (ADL) self performance to the nurse. The facility was to provide the adaptive/safety equipment: walker and/or wheelchair. Record review revealed the facility care planned Resident #1 for psychotropic drug use. Staff was to observe the resident for signs and symptoms related to hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, and decline in appetite. Review of the Elopement Risk Assessment, completed for Resident #1, on [DATE] by Registered Nurse (RN) #13, revealed upon admission the resident was weak and unable to get out of bed. She documented the resident as not having the ability to leave the facility with or without assistance devices. Therefore, Resident #1 was not assessed to be an elopement risk. Since the resident was not determined to be an elopement risk, there was no care plan developed for additional supervision for the resident. Review of camera footage, with the Administrator, on [DATE] at 2:15 PM, revealed on [DATE] at 8:31 PM, the resident was seen walking in the hallway by his/her room, room [ROOM NUMBER]. The resident walked from the far end of the hallway toward the common area. The resident disappeared from the camera at 8:34 PM toward the common area. At 8:40 PM, the resident reappeared on camera back in the hallway, again, the resident could be seen with his/her walker. Resident #1 would move his/her walker up one (1) step, would look down and would move his/her left foot up and slightly around the walker before he/she moved the other foot up. The resident had a very slow gait. Continued observation of the camera footage revealed from 9:00 PM to 9:55 PM, no staff was present in the hallway. Additional review of the camera footage, with the Administrator on [DATE] at 12:30 PM, revealed on [DATE] at 9:47 PM, Resident #1 pushed through the fire doors setting off an alarm and walked through the Dialysis Unit lobby; at 9:48 PM, entered the elevator on the second floor; at 9:49 PM, exited the elevator into the first floor lobby; and at 9:51 PM, was outside of the facility. After exiting to the outside, the resident disappeared from the camera. Interview, with Resident #1's Son, on [DATE] at 2:40 PM, revealed the resident was sent back to the facility, on [DATE], because he/she had many falls at home and increased confusion. He stated his parent required assistance to get safely to the restroom. Further interview revealed the resident got around pretty well with his/her walker, but he/she had to be very deliberate about his/her walking. He stated the resident was weak and needed supervision. Continued interview revealed the Resident's Son stated the resident's memory was really bad. He also stated he would not expect his parent to be walking around outside of the facility. Interview, with Certified Nursing Assistant (CNA) #16, on [DATE] at 6:54 PM and CNA #17 on [DATE] at 9:00 PM, revealed it was very important to follow the care plan to know how to properly care for the resident. They stated if the care plan was not followed, the resident and/or staff could be hurt in the process. They stated the care plan was created to ensure residents got the best care possible. Interview, with Registered Nurse (RN) #9, on [DATE] at 5:19 PM; RN #10 on [DATE] at 5:56 PM; and RN #13 on [DATE] at 8:51 PM, revealed the CCP was to be followed to ensure the resident received the best possible care. They stated any changes to the resident's condition would require the CCP to be reviewed and revised if the interventions in place were not working. They stated, if staff did not follow the CCP when caring for the resident, the resident could be hurt. Interview with the Director of Nursing (DON) on [DATE] at 12:54 PM, revealed the resident was not care planned for elopement risk because he/she was assessed as not being able to leave the facility on his/her own with or without an assistance device. She stated the only part of the care plan which addressed monitoring for safety was because of the resident's Dementia. She stated Elopement interventions would only have been placed on the care plan if Resident #1 had been identified as a risk. She stated once the resident's status changed where he/she became more mobile, he should have been reassessed and the care plan should have been developed more with new interventions. Additional interview with the DON, on [DATE] at 3:14 PM, revealed if a resident was able to ambulate with a walker, wheelchair, or a cane, the resident would be ambulatory. Therefore, she stated, that resident would have the ability to physically leave the facility on his/her own with or without assistive devices. She also stated if staff noticed a change in Resident #1, so he/she could ambulate, the Elopement Risk Assessment should have been redone. However, she stated she would not have made Resident #1 an elopement risk because he/she never exhibited any exit seeking behaviors. Interview with the Administrator on [DATE] at 2:00 PM, revealed the Comprehensive Care Plans (CCP) were initially created by the Minimum Data Set (MDS) Coordinator, but they were reviewed by the entire team which included leadership from each department. He said it was each department's responsibility to ensure their section was developed completely. He stated, when the care plan was being developed, input from the resident and his/her family should be involved. Continued interview revealed it was important for staff to follow the resident's care plan because when they were developed well, they were a road map to the resident's care. Also, he stated, by following the care plan, the facility would ensure each resident had the ability to maintain his/her highest practicable physical, mental and psychosocial well-being. The Administrator stated the care plan needed to be reviewed frequently to ensure the interventions still worked for the resident. However, he stated the staff did everything they should have done for this case. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan, on [DATE], that alleged removal of the IJ, on [DATE]. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) educated the Unit Managers, Staff Development Coordinator, and the Night Shift Supervisor on updating and developing the resident's care plan to be reflective of the resident's care needs; to update the resident's care plans based on the resident's change of condition; and, the Elopement Precautions Policy which included a revised Elopement Assessment. The Elopement Precautions Policy included how often to assess residents, to ensure the care plan was reflective of individualized interventions to minimize risk for elopement, where to place a wandering device (a bracelet or anklet placed on the resident and a door device that would alarm if the resident crossed the threshold used to prevent elopement) placed on their person, maintaining a list of residents at risk, and when to check the wandering devices. The deficient practice that was cited with Resident #1 was the facility's failure to complete an updated Elopement Risk Assessment when his/her functional ability improved to allow him/her to physically use a device to independently leave the facility. 2. On [DATE], all residents were reassessed by the Unit Managers and the DON to ensure that any resident identified as an elopement risk was on a secured unit and a wandering device had been placed on the resident and was intact. 3. On [DATE], the DON reviewed the elopement binders to ensure anyone who identified as an elopement risk, had a picture, a face sheet, and a listing of residents included in the binders. 4. On [DATE], the DON created a Functional/Needs Change assessment tool to be completed when a change in a resident's condition was identified. If the tool identified a change that affected the resident's elopement risk, a newly created Elopement Risk Assessment would be completed by the licensed nurse, and these were reviewed in the Clinical Meeting by the Nurse Managers. 5. On [DATE], the Unit Managers and Minimum Data Set (MDS) Nurse reviewed and updated all residents' care plans ensuring interventions were reflective of the residents' care needs, and provided adequate supervision and monitoring to prevent elopement. 6. By [DATE], all licensed nurses were educated by the Staff Development Coordinator and the Night Shift Supervisor. The staff verbalized understanding on: updating/developing the resident's care plan to be reflective of the resident's care needs; to update/develop the resident's care plan based on his/her change in condition; and, the Elopement Precautions Policy, which included a revised Elopement Assessment. 7. By [DATE], the Staff Development Coordinator and the Night Shift Supervisor completed all education for all clinical staff including licensed nurses, Social Services, Activities, and the Registered Dietician. These staff members verbalized understanding of the education provided. This education included the implementation of a new Functional/Needs Change tool to identify residents with changed needs or a functional change. 8. The Quality Assurance Performance Improvement (QAPI) Committee, which included: Medical Directors, Administrator, DON, Staff Development Coordinator, Human Resource Director, Business Office Manager, Dietary, Activities, Housekeeping, Minimum Data Set Nurse, Director of Community Relations, Maintenance Director, Senior Vice-President (SR VP) of Risk Management/Corporate Representative, and Infection Preventionist. The QAPI Committee met on [DATE], and discussed the Comprehensive Care Plan implementation, updating and assessment processes, and the performance improvement plan. The current audit tools were agreed upon by QAPI members to be used to capture data needed to determine compliance. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Record review revealed the Current List of Residents at risk for elopement, the revised Elopement Assessment, and the revised Elopement Policy. Interview, with the DON, on [DATE] at 11:23 AM, revealed she educated the Unit Managers, the Staff Development Coordinator (SDC) and the Night Shift Supervisor on updating the residents' care plans. She stated she stressed that the care plans needed to be specific to the resident, especially his/her function. She stated she educated them on the Elopement Precautions Policy and the revised Elopement Assessment. The education was provided in the Nursing Conference room before [DATE]. Interview, with Licensed Practical Nurses (LPN) #9 and #10, and the Unit Managers, on [DATE] at 6:44 PM, revealed they were taught to update the care plan for anyone they identified as an elopement risk. Further, they stated they were educated on the Elopement Precautions Policy and the revised Elopement Assessment. The education, they said, included assessment of the resident, specifically for elopement prevention and placement of the wander guard (wandering device). Interview, with the Night Shift Supervisor, on [DATE] at 7:35 AM, revealed she was educated by the DON on updating the resident's care plan. Further, the updates needed to be specific to the resident's needs. She stated she was also educated that any changes needed to be put in the care plan. Further interview revealed the education included the Elopement Precautions Policy and the revised Elopement Assessment. She stated the policy included assessing and documenting any changes in the resident. Further, she said she was to keep a list of residents who were at risk of elopement. Interview with the SDC, on [DATE] at 11:27 AM, revealed she was educated on updating the resident's care plan, the Elopement Precautions Policy which included the revised Elopement Assessment, assessing residents for risk of elopement and wandering devices. She stated the education was provided in the Nursing Conference room prior to [DATE]. 2. Interview with the Unit Managers, LPN #9 and LPN #10, on [DATE] at 6:49 PM, revealed all residents were re-assessed using the new tools created and care plans were updated as needed. LPN #10 stated updates discovered some residents who were identified as elopement risks. They stated their care plans were revised, and they were moved to a locked unit as needed. Continued interview revealed they assisted with the assessment of all the residents for risk of elopement. LPN #9 assessed the residents in the [NAME] and [NAME] house. LPN #10 assessed the residents in the [NAME] and [NAME] Houses. They stated staff checked wander guards for each resident, per shift, and as needed and assured the device was in place. Interview, with the DON, on [DATE] at 11:34 AM, revealed all the residents had been reassessed and their care plans were updated, as needed. Interview and review of two (2) care plans with the DON revealed care plans had been updated as needed following the current process in place. Observations on [DATE] at 1:30 PM of residents that resided on the [NAME] House and [NAME] House Units, with Unit Manager #9, verified wander guards were in place for eight (8) residents, with one (1) resident asleep so verification could not be done. However, Unit Manager #9 stated this resident's wander guard was in place. The list for elopement risk residents was located in the Elopement Risk binder. 3. Review of the Elopement Binder on [DATE] revealed a total of fourteen (14) residents were identified as elopement risks. Further review revealed the binder had face sheets, pictures, and listing of the elopement risk residents. Interview, with Unit Manager/LPN #9 and Unit Manager/LPN #10, on [DATE] at 6:49 PM, revealed an elopement binder was in place on each unit, and each staff member knew the location of the binder. Interview, with the DON, on [DATE] at 11:37 AM, revealed she put most of the elopement binders together. She stated the elopement binder included a face sheet and picture of each resident at risk for elopement. Further, she stated she reviewed the binder often. 4. Review of the new Functional/Needs Change tool revealed it had a section under Alarms for Elopement Risk/Wanderguard. Interview, with LPN #7, #8, #11, #18, RN #1, and RN #8 on [DATE] at 6:15 PM, revealed they were taught to use the Functional/Needs Change tool. They stated the teaching included how to assess the resident and use the tool to identify if the resident was at risk for elopement. Further, they stated, any resident who was found to be at risk for elopement was identified in the morning clinical meetings. Interview, with LPN #12 on [DATE] at 6:38 PM, revealed he was taught by the SDC on the unit on how to use the Functional/Needs Change tool. He stated he was taught how to assess and document any changes in the resident's condition. Interview, with LPNs #26, #27, #55, and RN #18 on [DATE] at 7:37 PM, revealed they received education about the Functional/Needs Change tool which included identifying changes in a resident that could increase the risk of elopement. They stated the education was provided on the unit by the Night Shift Supervisor last month. They stated the education included assessment of the resident and how to use the tool. Continued interview revealed the Night Shift Supervisor asked questions after the training to assess the staff's understanding of the tool. Interview, with LPN #2, RN #2, and RN #4, on [DATE] at 10:02 AM, revealed they received education about the Functional/Needs Change tool. They stated the education was about noticing changes in a resident. They stated the SDC educated them on the unit and showed the tool when she talked about it. Further, they reported they answered questions after the education. Interview, with LPNs #9 and #10 and the Unit Managers on [DATE] at 6:50 PM, revealed they were taught by the DON in the Nurse's Conference room to use the Functional/Needs Change tool. They stated they were taught how to assess the residents and if they saw a change what to do, using different examples. They stated the examples were changes in activities of daily living, cognitive changes, and other changes. They stated, if a resident had a change in function, this would be discussed in the morning clinical meetings. Interview, with the DON on [DATE] at 11:34 AM, revealed the new Functional/ Needs Change tool to identify changes in residents' condition was now being used for identification of possible behaviors that might trigger residents as elopement risks. She stated she obtained the Functional/Needs Change tool from the Vision software. The DON stated she reviewed different tools, and this was the most appropriate for the facility. She stated any change in a resident's condition would be discussed in the morning clinical meetings. 5. Review of the identified Elopement Risk Residents' Care Plans were reviewed and had the interventions put in to address elopement risk. Interview with LPN #9 and LPN #10, Unit Managers on [DATE] at 6:52 PM, revealed they were part of the process of reviewing and updating the care plans. They stated they specifically looked for elopement risks. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 11:44 AM, revealed she reviewed the residents' care plans. Further, she stated the care plans were updated as needed. She stated she especially focused on making sure the care plans were specific to each resident's functional ability and risk for elopement. Continued interview revealed she attended the morning clinical meetings, and the reviewed care plans were discussed in the morning clinical meetings. 6. Review of the sign-in sheets for training on updating/developing the resident's care plan to be reflective of the resident's care needs; to update/develop the resident's care plan based on his/her change in condition; and the Elopement Precautions Policy, which included a revised Elopement Assessment revealed training begun on [DATE] and was completed on [DATE]. Interview, with LPNs #7, #8, #11, and #18, on [DATE] at 6:16 PM, revealed they were taught to update the resident's care plan if there were any changes in the resident. Further, they stated they were taught on the Elopement Precautions Policy and the revised Elopement Assessment. They stated the training specifically talked about changes in a resident that might result in elopement. They stated the training was provided by the Night Shift Supervisor on the unit, sometime in [DATE]. Interview, with LPN #12 on [DATE] at 6:40 PM, revealed he was taught by the SDC to update the care plan if a resident had a change in condition. He stated he was also taught about the Elopement Precautions Policy. He stated the training was provided on the unit. He stated the training was provided last month, and the SDC asked questions after the training to assure they understood the training. Interview, with LPNs #26, #27, #55 and RN #18, on [DATE] at 7:45 PM, revealed they were taught to update the care plan for any change in a resident. Further, they stated the education included the Elopement Policy and the elopement assessment tool. They stated the training also included assessing and documenting changes in a resident on the elopement assessment tool. They stated the training was provided by the Night Shift Supervisor on the unit last month. They stated she asked them questions after the training. Interview, with LPN #2, RN #2, and, RN #4 on [DATE] at 10:05 AM, revealed they were educated by the SDC on updating the resident's care plan if there was a change in the function of a resident. They stated they were taught to revise the care plan if the resident's function worsened or improved. Continued interview revealed the care plan was to be specific to any elopement risk. Further, they stated the SDC provided education on the Elopement Precautions Policy which included a revised Elopement Assessment. They stated the SDC came to the unit and provided them with a handout. Further interview revealed she answered questions after the training to validate they understood what was taught. They stated the training occurred last month. Interview, with the Night Shift Supervisor on [DATE] at 7:43 AM, revealed she educated the night staff on the importance of updating the resident's care plan if there were any changes in a resident. She stated she also educated the staff on the Elopement Policy and the revised Elopement Assessment. Further, she stated she stressed the importance of identifying any resident at risk for elopement. She stated she verified that the staff understood the education by having them verbally repeat the education. Also, she stated she went to the units to provide the education last month. Interview, with the SDC on [DATE] at 11:27 AM, revealed she educated all staff. She stated she went to the units and educated the staff on updating the resident's care plan for any change in the resident's condition. She stated she stressed the importance of noticing a change in the resident's function. Further, she said she educated staff on the Elopement Precautions Policy which included a revised Elopement Assessment. Also, she stated she asked the staff members questions after the education to assure they understood the education. Further, she stated she stressed the importance of identifying any resident at risk of elopement. 7. Review of the sign-in sheets for training on the implementation of a new Functional/Needs Change tool to identify residents with changed needs or a functional change revealed training was completed on [DATE]. Interview, with CNAs #3, #9, #23, #44, #48 and #49, on [DATE] at 5:30 PM, revealed they were educated on the new Functional/Needs Change tool. They stated education was provided by the SDC on the unit last month. They stated the SDC talked about the tool and showed them the tool. They stated the tool was about noticing any changes in a resident, such as behaviors, change in mental status, and changes in ambulation. Further, they stated if there were any changes in a resident, this was to be documented on the resident's care plan. Interview with CNAs #4, #7, #41, #43, #45, #47 and #50, on [DATE] at 6:00 PM, revealed they received training on the new Functional/Needs Change tool. They stated they were taught by the SDC on the unit. Further interview revealed one (1) of the CNA's was not present on the day of the training, and she went to the SDC's office for the training. Interview, with LPNs #7, #8, #11, #18, RN #1, and RN #8, on [DATE] at 6:18 PM, revealed they were educated on the new Functional/Needs Change tool. They stated the education was done by the Night Shift Supervisor on the unit. Continued interview revealed the Night Shift Supervisor talked about the tool and showed them the tool. They stated the tool included significant changes, especially related to elopement. Further, they stated they were taught to document any changes on the resident's care plan. Interview, with LPNs #26, #27, #55 and RN #18, on [DATE] at 7:50 PM, revealed they had received training on using the Functional/Needs Change tool. They stated the education was provided by the Night Shift Supervisor. They stated she came to the unit and taught them to identify any change in a resident that could increase their risk for elopement. Continued interview revealed they were also taught on the Elopement Policy and the revised assessment tool. They stated they were taught to update the care plan if a resident had any change. Interview, with the night shift CNAs #51, #52, #53 and #54 on [DATE] at 7:27 PM, revealed the Night Shift Supervisor taught them about the new Functional/Needs Change tool last month. They stated the Night Shift Supervisor came to the unit and showed them a copy of the tool and explained the tool. They stated they were instructed to tell the nurse if a resident had any change in condition. Continued interview revealed changes could be an unsteady gait, an improvement in ambulation, or behavior changes, such as crying. Further, they stated they gave feedback that showed they understood the training. Interview, with LPN #2, RN #2, and RN #4 on [DATE] at 10:06 AM, revealed they received education last month by the SDC on assessing residents for any change in function. They stated the training focused on the Functional/Needs Change tool. They stated the SDC came to the unit with a cart. Continued interview revealed the cart had educational materials on how to identify a change in a resident's function. Further, they stated the education included changing the resident's care plan for any change in function, even if the change was an improvement. Interview, with the Social Services Director and Activities Director on [DATE] at 10:37 AM, revealed they were educated by the SDC to identify a functional change or mental change in a resident and to notify the resident's nurse if they noticed a change. Interview, with the Registered Dietitian on [DATE] at 10:55 AM, revealed she received education by the SDC on identifying any change in a resident. The change was to be reported to the nurse. Interview, with the Night Shift Supervisor on [DATE] at 7:35 AM, revealed she taught the night shift staff on implementing the Functional/Needs Change tool. She stated she educated the staff to identify any change in a resident's function. She stated the education included updating the care plan if a resident had a change in condition. Further interview revealed the education was provided last month prior to [DATE]. Interview, with the SDC, on [DATE] at 11:27 AM, revealed she educated all staff including the Social Services Staff, the Registered Dietitian and the dietary staff, including the Activities Director and activities staff. She stated the education included the new Functional/Needs Change tool. Continued interview revealed the staff members were taught to notify the resident's nurse if they noticed a change in a resident. She stated licensed nurses were educated on updating the care plan if a resident had a change in function or any risk of wandering. The SDC stated she asked questions after the training to assure they understood the education. 8. Review of the sign-in sheet for the [DATE] QAPI Committee meeting revealed members in attendance were Medical Directors #1 and #2, the Administrator, Director of Nursing, Staff Development Coordinator, Human Resource Director, Business Office Manager, Dietary, Activities, Housekeeping, Minimum Data Set (MDS) Nurse, Director of Community Relations, Maintenance Director, Senior Vice-President (SR VP) of Risk Management/Corporate Representative, and Infection Preventionist. Interview, with the Director of Community Relations, Infection Preventionist, Business Office Manager, Environmental Services, Central Supply, Life Enrichment, Senior [NAME] President of Risk Management, Human Resource Director, MDS Coordinator, DON, Administrator, Social Worker, Dietary Manager, and Maintenance Director, members of the QAPI Committee, on [DATE] at 10:23 AM, revealed they had attended the [DATE] QAPI meeting and discussed the need for the residents' environment to be supervised to prevent accidents, specifically elopement. They stated they agreed on the audit tools to use to evaluate the processes. Further, they stated they reviewed the new Functional/Needs Change tool and the revised Elopement Assessment. The committee members stated they all agreed the new policy and new tools to help identify possible elopement risks would be very beneficial for staff to easily identify risks. Interview, wi [TRUNCATED]

Based on observation, interview, record review, review of the facility's investigation, review of the facility's camera footage, https://www.wunderground.com and review of the facility's policies, it was determined the facility failed to ensure a safe environment and failed to ensure each resident received adequate supervision and monitoring to prevent an elopement from the facility for one (1) of seventy-six (76) sampled residents (Resident #1). Resident #1 eloped from the facility, on [DATE] at 9:50 PM, and was not found by staff until 10:24 PM. When found, the resident was unresponsive, face down, with blood coming from his/her head. The resident expired at the hospital on [DATE] at 11:23 PM. On admission to the facility, on [DATE], the facility assessed Resident #1 to lack the ability to exit the facility on his/her own with or without the use of assistive devices. The facility did not assess the resident as an elopement risk. However, on [DATE] at 9:47 PM, the resident was observed on the facility's camera footage as he/she entered the lobby of the facility's second floor Dialysis Unit, boarded the elevator, and traveled to the first floor. The resident exited the elevator into the first floor lobby, walked through two (2) sliding glass doors, and exited the building at 9:50 PM. Interview with the Administrator revealed the cameras in the facility were motion activated. Once the resident stepped outside, the camera no longer picked up his/her movement and stopped recording. At approximately 10:24 PM, Certified Nursing Assistant (CNA) #8 observed an unknown person face down, bleeding and nonresponsive, on the sidewalk at the back of the facility. CNA #8 got Registered Nurse (RN) #3, who assessed the person and determined the person did not have a pulse or respirations. RN #3 began Cardiopulmonary Resuscitation (CPR) on him/her. More staff arrived on the scene, and it was not until approximately 10:36 PM when RN #11 identified the person as Resident #1, who resided at the facility. Emergency Medical Services (EMS) were called and arrived on the scene at approximately 10:36 PM. Resident #1 was taken to the hospital and was pronounced deceased at 11:23 PM. The facility's failure to ensure each resident had adequate supervision to prevent accidents and hazards has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.25 Quality of Care (F689) Free of Accident Hazards/Supervision/Devices at a Scope and Severity (S/S) of a J. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging the Immediate Jeopardy's removal and substantial compliance, on [DATE]. The State Survey Agency validated the IJ Removal Plan, prior to exit on [DATE], and determined the facility implemented corrective actions and was in substantial compliance on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Accidents and Supervision Prevention, last revised ,d+[DATE], revealed the facility would utilize an Interdisciplinary Team (IDT) to identify solutions to keep all residents safe; would identify additional resources to address safety concerns, and demonstrate a commitment to safety at all levels within the organization. The facility was to provide a process that would identify hazards and risks to include supervision, evaluations and analysis of the hazards and risks. Per the policy, implementation of interventions was to include adequate supervision and monitoring. The policy also stated the facility would provide comprehensive assessments for each resident upon admission, quarterly, and with any change in the resident's condition. Per the policy, the Administrator and Quality Assurance (QA) team would conduct environmental rounds to ensure the environment would remain free from hazards. The policy stated QA was to identify issues, develop and implement a plan of action to make corrections, and put interventions in place to reduce potential for accidents and hazards. Review of the facility's policy titled, Elopement, last reviewed ,d+[DATE], revealed residents were to be assessed upon admission, readmission, quarterly, with a significant change, and as needed to determine a resident's elopement risk. Per the policy, if the resident was determined to be at risk, the elopement form would be printed and placed in the elopement binder. The policy stated the Medical Director would be informed, and the resident would be moved to a secured unit or have a wander guard device (a system used to prevent elopement that had a bracelet or anklet on the resident and a door device that would alarm if the resident crossed the threshold) placed on their person. The resident's care plan would be updated, and he/she would be monitored. Per the policy, if an elopement occurred, staff was to immediately contact security, the Director of Nursing (DON), and the Administrator and start a full facility search. Review of the facility's Investigation and Five Day Follow-Up Report, dated [DATE], revealed the facility provided the following explanation for Resident #1 leaving the facility on [DATE]: (Resident #1) was admitted to [NAME] House on [DATE] for short term rehab services and had a prior stay from [DATE]-[DATE] and this room was directly across from the current room he/she was residing at the end of the hall. The unit is a short term rehab unit and is only for those individuals who do not need a more secure environment. (Resident #1) did not require a special type of supervision based on his/her assessments and interactions with staff. (Resident #1) had purpose with his/her day-to-day engagements like going to ride the exercise bike, and use of the public restroom. It appeared (Resident #1) had left the unit to go outside for a walk on the premises properly dressed in a safe area of the campus which was a sidewalk. (Resident #1's) actions were self-initiated and driven as an alert and oriented resident, and staff responded appropriately and followed proper plan of care for this resident during his/her entire stay. Review of Resident #1's closed record review revealed the facility admitted the resident, on [DATE], for Rehabilitation Services related to increased weakness, increased confusion, and a high number of falls while at home. The resident's diagnoses included [NAME] Encephalopathy, Vascular Dementia without Behaviors, Unspecified Convulsions, Insomnia, and Alcohol Dependence with Withdrawal. Review of Resident #1's Quarterly Risk Assessment completed by RN (Registered Nurse) #13 on [DATE], revealed the facility assessed Resident #1 to be at high risk for falls with a total score of twenty-two (22), in which a ten (10) or higher was determined to be high risk. Continued review revealed the facility assessed the resident as having behaviors present; moderately impaired vision; independent and incontinent; ambulated with problems and with the use of a device; and gait was unsteady, slow, and lurching. RN #13 also noted the resident was not steady on his/her feet and only stabilized with physical assistance. The resident received a score of twenty-two (22) and anything above ten (10) made the resident high risk for falls. Review of the facility's developed Elopement Risk Assessment, dated [DATE] revealed because the resident was assessed not to be able to exit the facility on his/her own, with/without assistive devices the elopement assessment ended. Interview with the Director of Nursing (DON), on [DATE] at 12:54 PM, revealed the resident should have been reassessed once he/she was up and walking again. Interview, with RN #13, on [DATE] at 8:51 PM, revealed when she completed Resident #1's assessment, he/she was unable to sit up in the bed and was very weak. She stated that was why she marked the resident as unable to leave the facility on his/her own. Interview with the DON, on [DATE] at 12:54 PM, revealed even if the resident had been reassessed when he/she was up and walking, she would not have identified him/her as an elopement risk because the resident did not show any exit seeking behaviors. However, based on the Elopement Risk Assessment, the resident should have been identified as an elopement risk with a score of two (2); one (1) point for being newly admitted to the facility (less than three (3) days); and one (1) point for exhibiting periods of confusion. Review of the Hospital Discharge Summary, dated [DATE], revealed the hospital treated Resident #1, from [DATE] to [DATE], for multiple falls and worsening confusion with underlying dementia. Review of the Geriatrics History and Physical, completed by the Primary Care Physician (PCP), dated [DATE], revealed the PCP assessed Resident #1 with decreased mobility, used a wheelchair, required assistance, and had previous falls. The resident was also noted with weakness, seizure disorder, mild memory loss, and unsteady gait. Review of the Five (5) Day Admission Minimum Data Set (MDS) Assessment, dated [DATE], but created on [DATE], revealed Resident #1 required supervision-oversight; and encouragement and/or cueing for dressing, eating, toileting and personal hygiene as well as bed mobility, transfers, walking in the room, and walking in the corridor and locomotion on the unit. The MDS assessment revealed the resident completed locomotion off the unit one (1) or two (2) times only, during the assessment. Resident #1 was also assessed to walk ten (10) feet and walk fifty (50) feet with two (2) turns with touch assistance/supervision provided. Review of the facility's camera footage (from [DATE]) with the Administrator, on [DATE] at 12:30 PM, revealed on [DATE] at 9:47 PM, Resident #1 appeared on the camera as he/she entered the lobby on the second floor Dialysis Unit. At 9:48:52 PM, the resident got on the elevator and closed the door. At 9:49:38 PM, the resident got off the elevator on the first floor. At 9:50:21 PM, Resident #1 exited the first set of electronic sliding glass doors and entered a byway. At 9:50:46 PM, the resident exited the second electronic sliding door to the outside. The resident disappeared off camera. Per the Administrator, the cameras in the facility were motion activated, and once the resident stepped outside, the camera no longer picked up his/her movement and stopped recording. The time on the camera skipped forward to 10:20 PM. A different camera showed, on [DATE] at 10:25:23 PM, which revealed a staff member entered the [NAME] House running for help. At 10:26:07 PM, that same staff member (an aide) and two (2) other aides ran and exited the building. Another staff member could be seen walking in the hall slowly, heading toward the door. That staff member exited the building at 10:26:28 PM. Another camera angle to the outside revealed emergency lights, and the fire truck arrived at 10:36:18 PM. Per the footage, movement could be seen in the upper right hand corner of the screen, but nothing was identifiable except the fire truck's arrival. The resident was outside of the facility for thirty-five (35) minutes before being discovered. Review of a weather report from https://www.wunderground.com, for [DATE] revealed at the facility at 8:56 PM it was thirty-six (36) degrees Fahrenheit (F) but felt like twenty-four (24) degrees F with south winds blowing at five (5) miles per hour (mph) with cloudy skies. At 9:56 PM, it was thirty-five (35) degrees F, but felt like twenty-four (24) degrees F with southeast winds blowing at five (5) mph and with cloudy skies. Review of the facility's camera footage (all from [DATE]) with the Administrator, on [DATE] at 2:15 PM, revealed at 7:10 PM, LPN #6 took the medication cart to the end of the hall toward room [ROOM NUMBER], Resident #1's room. At 7:24 PM, Resident #1 was seen in the hallway by room [ROOM NUMBER]. At 7:50 PM, the resident was seen in the hall and then disappeared. At 8:01 PM, LPN #6 was seen at the end of the hall near room [ROOM NUMBER]. At 8:19 PM, LPN #6 went into a room at the end of the hall. There was no activity in the hall again until 8:31 PM, when LPN #6 was seen at the end of the hall across from room [ROOM NUMBER]. Also, at 8:31 PM, the resident was seen in the hallway next to LPN #6. Resident #1 had the walker and moved up the hall toward the common area. At 8:34 PM, the resident disappeared out of the view of the camera into the common area. At 8:40 PM, LPN #6 was seen in the hallway and moving up toward the common area with the medication cart. At 8:44 PM, Resident #1 entered the hallway from the common area and headed toward the end of the hall where his/her room was. At 8:52 PM, the resident disappeared off the camera as he/she walked back to the room. The Administrator explained since the cameras were motion censored, it stopped recording because of the resident's slow movement and neutral colored clothes. From 9:00 PM until 10:00 PM, no staff was seen in the hallway, neither up toward the common area or at the end of the hall near room [ROOM NUMBER]. The fire door was noted to be thirteen (13) feet from the resident's room door. The camera footage skipped from 9:35 PM to 9:55 PM, after the resident had exited the building. Observation, on [DATE] at 8:50 AM, with the Administrator, revealed the path Resident #1 took when he/she left the building on [DATE] at 9:47 PM. Resident #1 was expected to be in his/her room, on the second floor, before pushing through the egress doors at the end of the [NAME] Hall. This door was noted to require a badge to open or it could be bypassed by pushing the fire lock for fifteen (15) seconds until the door released. Once through that door, there was a hallway to the left which led to a lobby in the upstairs Dialysis Unit. Per the observation, the Dialysis Unit had a large glass door which had a push button intercom. The lobby also had an elevator that was unlocked without any restrictions. The State Survey Agency (SSA) Surveyor and the Administrator entered the elevator and traveled down to the first floor. Exiting the elevator, there was another lobby, toward the right that had two (2) sliding glass doors. Those doors were locked from the outside only. Continued observation on [DATE] at 8:50 AM, with the Administrator, revealed based on where Resident #1 was found, he/she took a right out of the sliding glass doors and walked down the sidewalk almost making it to the flag pole at the back of the building. At the beginning of this sidewalk there was a wheelchair access dip. Walking down the sidewalk, there was an area that split because a road, which ran through it. This was a surface change from a regular sidewalk surface to a black road surface. Observation, on [DATE] at 1:00 PM, with the Maintenance Director, revealed he used a rolling counter to count out the distance Resident #1 traveled from his/her room to where the resident was found on [DATE]. From the resident's room to the first fire door was thirteen (13) feet; from that door to the elevator was fifty-nine (59) feet; from the elevator on the first floor to outside was fifty-four (54) feet; and to the spot on the sidewalk where the resident was found was four hundred and thirty-two (432) feet to the back side of the facility. Resident #1 was found unresponsive with no respirations or pulse, thirty-five (35) minutes after he/she exited the facility. Additional review of the camera footage, from [DATE], with the Administrator on [DATE] at 11:20 AM, revealed on [DATE] at 8:40 PM, LPN #6 left the hallway. At 9:33 PM, a visitor was seen exiting a door towards the front of the hall by the common area, to the right. At 10:09 PM, a staff member came out of the second door on the right of the hallway. The Administrator did not identify the staff member but said it was either CNA #16 or #17. At 10:13 PM, the visitor returned to the same room she had exited. At 10:17 PM, an Aide walked up the hall to the Nurses' Station. Per the interview with LPN #14, this was when CNA #17 notified the nurse she could not locate Resident #1. The facility confirmed the fire door alarm was on from 9:46:54 PM until 10:28:40 PM; however, camera footage did not show staff interact with the door at any time during this period. Review of the facility's Badge Transaction Report revealed the egress door which led out to the dialysis lobby was pushed open, causing the door fire alarm to sound on [DATE] at 9:46:54 PM; and the door closed at 9:47:16 PM. The report revealed the door was opened with LPN #6's badge at 10:28:40 PM. Continued review of the camera footage (all from [DATE]) with the Administrator on [DATE] at 11:20 AM, revealed LPN #6 took the same path Resident #1 had taken on [DATE] at 10:28:40 PM; however once outside, she did not locate the resident and returned to the unit. Review of the Emergency Medical Services (EMS) Incident Report #E22123538, dated [DATE], revealed dispatch was called at 10:28:11 PM, and EMS arrived on scene at 10:37:00 PM. The call came in as unknown problem and person down. The report stated CPR (cardiopulmonary resuscitation) had been and was performed. Further review revealed the clinical impression of the first responder was cardiac arrest and secondary impression was respiratory arrest. Per the report, the protocol used was for cardiac arrest. The person was noted to have bleeding to the face and was unconscious. The report stated at 10:40 PM, the person was still unresponsive, no blood pressure was observed and pulse was zero (0). The stats were noted as the same at 10:43 PM, 10:52 PM, and 11:00 PM. Per the report, before the person was taken away in the ambulance it was determined he/she was Resident #1, who could not be located within the [NAME] House at the same time. Review of Emergency Department Encounter Report ([NAME]), dated [DATE] at 11:24 PM, revealed Resident #1 arrived to the hospital in full cardiac arrest. It was noted the resident was found outside of the facility unresponsive. The total amount of time down was unknown and the report revealed a bystander performed CPR upon finding the resident. Per the [NAME], it was thought the resident might have been in fine ventricular fibrillation, and he/she was given five (5) rounds of intravenous (IV) Epinephrine (given to stimulate the heart to beat), IV Amiodarone (given as an antiarrhythmic during cardiac arrest), as well as being defibrillated numerous times. The report also revealed the resident had multiple facial abrasions with blood present. Per the [NAME], ACLS protocol was continued; however, on [DATE] at 11:23 PM, the resident was pronounced deceased . Interview with the Chief Information Officer (CIO) on [DATE] at 1:50 PM, revealed he was responsible for monitoring the badging system, reports, and camera footage. He stated the door at the end of the [NAME] Hall required a badge to silence the alarm, once it was triggered. He stated, based on the report provided, the alarm was not silenced until 10:28:40 PM by LPN #6. The CIO stated when the staff member badged out at 10:28:40 PM, that would have been the time the alarm on the door was silenced, and staff went out to look for the resident. He verified that the alarm sounded from 9:46 PM to 10:28 PM. Interview, with Resident #1's Son, on [DATE] at 2:40 PM, revealed the facility contacted the resident's spouse via telephone at approximately 12:30 AM to inform him/her the resident had been taken to the hospital. He stated he was called by his sister at 1:09 AM and she told him their father/mother was dead. The resident's son explained it was the hospital that told the family the resident was found outside, and EMS tried to get his/her heart started on the sidewalk and on the way to the hospital. He explained the resident was not in a wheelchair when he/she arrived at the facility. Further interview revealed the resident was put in a room all the way at the end of the hall. The resident's son explained the resident's walking was very deliberate because he/she had had many falls. He stated the resident used a double cane, which he described as two (2) canes held together by a bar. He stated the resident got around okay, but just could not move without thought. Continued interview revealed the resident's memory was bad. He stated the resident had been in the hospital because of falls, and he would not expect his father/mother to be out walking around, outside the facility. The Resident's son stated, the resident was not even supposed to go to the restroom alone. Interview, with Certified Nurse Aide (CNA) #8 on [DATE] at 4:18 PM, revealed she went on break at the back parking lot of the facility and was gone for only five (5) minutes. CNA #8 stated on her way back into the facility she saw a person down on the sidewalk. She stated she called out to him/her and asked, Are you okay?, but the person did not respond. CNA #8 stated she did not see the person when she started her break. Further interview revealed she ran to the second floor, to the unit where she worked, to get help. She stated she returned with RN #3, but they did not recognize the person as a resident. Review of the camera footage showed CNA #8 running to get help and three (3) staff members going back outside with her, on [DATE] from 10:25 PM to 10:26 PM. Interview, with CNA#16 on [DATE] at 6:54 PM, revealed she worked the night of [DATE]. She stated CNA #17 informed her she could not locate Resident #1 and they both started to search for him/her. CNA #16 stated Resident #1 was ambulatory and could have been in any room, so they searched the entire floor. She said she thought it was about that time she heard the Code Blue (a code given when someone needed cardiopulmonary resuscitation (CPR)). CNA #16 stated she continued to look for the resident but did not locate him/her. She stated she did not hear an alarm sounding during this time. Interview, with CNA #17 on [DATE] at 9:00 PM, revealed she provided care for Resident #1 on [DATE]. She stated she took the resident a snack and a drink between 7:00 PM and 7:30 PM. CNA #17 stated she went back to check on the resident around 8:00 PM. She stated she guessed it was about 9:00 PM or 9:30 PM when she noticed the resident was not in his/her room. She stated she went and found the other Aide, and they started to look for the resident. Continued interview revealed she did not hear any alarm coming from the hallway door next to the resident's room. She also stated she had never heard an alarm on that door. CNA #17 reported she thought the last time she saw the resident he/she was seated in his/her wheelchair, but she could not recall what clothes the resident was wearing. Additionally, she stated she only had cared for the resident one (1) other time. CNA #17 stated she thought resident dressed himself/herself for bed, so she did not assist him/her on [DATE]. Interview, with Certified Medication Technician (CMT) #1 on [DATE] at 8:25 PM, revealed on [DATE], CNA #8 came in the facility yelling for help. She stated when someone called for help, one had to move quickly. She stated staff followed CNA #8 outside, saw a person down, and the nurse with them told her to get more help. She stated she went back into the facility and got additional staff. CMT #1 stated she did not know the identity of the person who was down. She said it was hard to tell who was a resident and who just walked through the neighborhood. CMT #1 stated it was not until more staff started to show up that it was determined it was Resident #1. Interview, with LPN #14 on [DATE] at 6:32 PM, revealed CNA #17 informed her she could not locate Resident #1 and asked her to pass it on to LPN #6 upon her return. LPN #14 stated CNA #17 and the other Aides on duty started to look for the resident. She stated they searched all the common areas, looked in other rooms, covered the entire floor, but they did not locate the resident. LPN #14 stated she did not hear an alarm sounding during the search. She stated LPN #6 called the code for a missing person, and then it seemed right after that a Code Blue was called for an unresponsive person outside. LPN #14 stated she did not put the two (2) together and thought the facility just had a very busy night. Further interview revealed the process for the missing person was to call a Code Green, state the resident's name, and ask the resident to return to his/her hall. She stated this was done three (3) times, which notified other staff to report to that floor to help look for the resident. She stated the person who called the Code Green was responsible to notify management. Interview, with LPN #6 on [DATE] at 8:55 AM, revealed once CNA #17 informed her Resident #1 could not be located, all staff present on the floor started to look for the resident. She stated they checked where the exercise bike was located, the activity room, and the dining room. LPN #6 stated it was the facility's protocol to check the entire floor before calling a code for a missing person. She said to call the missing person alert, staff was to call the resident's name over the loud speaker, three (3) times, and ask the resident to return to his/her house. LPN #6 stated when she was near Resident #1's room, she could hear the alarm going off, which she identified as a soft hum. She stated she only heard it when she stood directly next to the door. The LPN stated that door required a badge to get in and out. She stated she badged out, took the elevator to the first floor, and went outside to look for the resident. Continued interview revealed she did not see the resident so she returned upstairs. LPN #6 stated once she got back to the floor, she heard a Code Blue being called, and it was about that time she announced the missing resident code, Code Green. She stated she talked with the Director of Nursing (DON), and they realized the Code Blue person and the missing person was the same person. Interview, with LPN #5 on [DATE] at 6:30 PM, revealed she was the nurse in charge on [DATE]. She stated she was charting on [NAME] House, another unit within the facility, when CNA #35 ran in and informed her of the incident happening at the back of the facility and that RN #3 needed help. She stated she initially ran out of the facility to determine what was going on, and once she arrived on the scene, RN #3 was doing CPR on a person he told her was not responsive. LPN #5 stated she ran into the facility to grab the crash cart and the Ambu bag. She stated they used the Ambu bag on the person. LPN #5 stated there was a lot going on at the time, and it was hard to keep track or time and/or people. She stated she did not render CPR, but another staff member switched off with RN #3. The LPN stated she did not recognize the person as a resident. LPN #5 stated EMS arrived on the scene and took over doing CPR. She stated RN #11 was on the scene too, and she recognized the person as Resident #1. LPN #5 stated she informed the DON of the situation. Interview, with Unit Manager (UM) #1 on [DATE] at 4:25 PM, revealed if staff was aware a resident was missing, management should be notified immediately of the situation and not wait until the floor was searched. She stated that would be best for resident safety so staff could find the resident quickly. Continued interview revealed the quicker staff knew about the situation, the quicker the response. The UM state the announcement (Code Green) should be made over the intercom so other staff was made aware of the situation and could help in the search. Interview with RN #3, on [DATE] at 4:24 PM, revealed on [DATE] he was on his floor charting when one of the Aides came running in and screaming for help. He stated he responded to the request. RN #3 stated he exited the facility to the back and found an unresponsive person, lying face down with blood coming from the head. He stated he rolled the person over and checked for a pulse and for breathing and found none, so he started to perform CPR. Continued interview revealed additional staff started to arrive on the scene, and they discussed if anybody knew the person and if he/she was a resident. He stated nobody recognized the person. RN #3 stated the facility grounds had a high number of people from around the community who walked in the area, and there was no way for him to know if the person was a resident or not. Prior to EMS arrival, he stated, staff determined the person was Resident #1. He stated EMS arrived on the scene, took over CPR, and transported the resident to the hospital. Interview, with RN #9 on [DATE] at 5:19 PM, revealed she was familiar with Resident #1, and he/she was not exactly independent. She stated the resident had a gastrostomy tube (G tube, an opening in the stomach with a tube inserted to receive liquid nutrition) during his/her prior visit and was in the facility for a stroke. She stated the resident ambulated with the use of a walker and was generally pretty steady on his/her feet. RN #9 stated it was not uncommon for a resident to be missing from their room. She stated many times therapy had taken the resident off the floor. Continued interview revealed if it was determined to truly be a missing resident, all staff would search the floor, and an announcement would be made over the intercom for the person to return to their house. She stated, if the resident still was not located, management and security would be notified. The RN stated the resident's family would be contacted and the police, if necessary, until the resident was found. RN #9 reported Resident #1 regularly went outside with his/her spouse to sit in the courtyard, but she did not know the resident to go out on his/her own. She stated it was not normal for any resident to be outside at 10:20 PM. She explained, even if family took a resident to the courtyard, she liked for them to take a wheelchair just for backup. Continued interview, with RN #9 on [DATE] at 5:19 PM, revealed she had heard the alarm on the fire door go off several times. She stated it was usually therapy students who would forget to badge out. RN #9 stated the only way to shut the alarm off, once it had been activated, was to use the badge to stop it. She stated the alarm, prior to the new louder alarm, could not be heard on the back hall. Interview with the Maintenance Director on [DATE] at 9:50 AM, revealed he put in the louder fire alarms on the doors on [DATE], after the [DATE] incident. Interview with RN #10 on [DATE] at 5:56 PM, revealed she was an agency staff member and had worked in the facility since [DATE]. She stated she was not aware there was a code for a missing person. Interview, with RN #11 on [DATE] at 7:04 PM, revealed on [DATE] she heard a Code Blue come across the intercom and then shortly after heard LPN #6 announce for Resident #1 to return to his/her room. She stated when she arrived at the location of the Code Blue, EMS was already present and doing CPR. She stated Resident #1 had a different kind of a walker, and she recognized it on the ground. She stated it took her a few minutes to actually see the resident, but when she saw his/her face, she recognized the person to be Resident #1. Continued interview with RN #11 on [DATE] at 7:04 PM, revealed she recalled the alarm on the [NAME] House door sounding one (1) time. She stated she could not recall what caused it to sound. The RN stated the alarm was not very loud, and staff members did not hear it going off until they were present in that hall. She said the alarm had to be turned off with the use of her badge. RN #11 stated she thought the alarm might have been louder on the outside of the door on the Dialysis side. Interview with RN #13 on [DATE] at 8:51 PM, revea [TRUNCATED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure they established, maintained, and implemented written policies and procedures in accordance with federal and state laws to ensure residents' advanced directives, Do Not Resuscitate were maintained as required and honored as requested, for two (2) out of seventy-six (76) sampled residents (Resident #1 and Resident #54). 1. On [DATE] at 10:26 PM, a Certified Nursing Assistant (CNA), who returned to the facility from break found an unidentified and unresponsive person at the back of the facility's grounds. She immediately ran into the facility to the second floor, yelling for help. At that time, three (3) other staff members joined her outside along with the Registered Nurse (RN) on duty, RN #3. RN #3 assessed the person and found him/her to be unresponsive, with no pulse and no respirations. He reported he turned the person over and initiated Cardiopulmonary Resuscitation (CPR). The staff, who were present at the time, did not recognize the person and were unable to determine if he/she was a resident of the facility. The facility was large and the property had an extensive walking population from the surrounding community. Approximately ten (10) minutes later, other staff started to gather around the incident and RN #11 noticed the person that had been found down was Resident #1. Once the person was identified as a resident of the facility, RN #11 entered the facility to determine the resident's Code Status and found him/her to be a Do Not Resuscitate (DNR). She gathered the facility DNR form but was unable to find an original copy of the required Kentucky Emergency Medical Services (EMS) form. RN #11 returned to the location of Resident #1 by which time EMS was on the scene and had taken over CPR. Because the facility did not have the appropriate form, CPR could not be stopped and the resident was transferred to the hospital, lights and sirens, while CPR was continued. The resident was pronounced deceased at the hospital at 11:26 PM. 2. Review of Resident #54's clinical records, on [DATE] revealed a Progress Note which stated the family had not completed the required Kentucky form to ensure the resident would not be resuscitated in the event an ambulance was called and the resident was unresponsive. Review of the Progress Note revealed the family would not return until after the holidays and would not be able to complete the form until then. The Emergency Medical Services (EMS) DNR instructions required the form to be an original and could not be a photocopy. There was no documented evidence the required form was in Resident #54's medical record upon admission on [DATE]. The findings include: Interview with the [NAME] President of Risk Management, on [DATE] at 1:00 PM, revealed the facility did not have a policy or procedure related to the requirement to have the specialized form on hand for the EMS to withhold life saving measures. Review of the facility's policy, titled Advance Directive last reviewed ,d+[DATE], revealed advance directives would be respected in accordance with State law and the facility's policy. The facility would provide written information concerning the right to refuse care such as a Do Not Resuscitate (DNR). Review of the standardized Emergency Medical Service (EMS) DNR Order instructions revealed it was developed and approved by the Kentucky Board of Medical Licensure. Further review revealed the original, completed EMS DNR Order or the EMS DNR Bracelet must be readily available to EMS personnel for the EMS DNR Order to be honored. 1. Record review revealed the facility admitted Resident #1, on [DATE], for Rehabilitation Services related to increased weakness, increased confusion, and a high number of falls while at home. Resident #1's diagnoses included [NAME] Encephalopathy, Vascular Dementia without behaviors, Unspecified Convulsions, Insomnia, and Alcohol Dependence with Withdrawal. Review of Resident #1's Brief Interview Mental Status (BIMS) assessment, completed on [DATE], revealed the facility assessed the resident with a score of nine (9) out of fifteen (15) which indicated the resident had moderate cognitive impairment. Interview, with Resident #1's son, on [DATE] at 2:40 PM, revealed he was the resident's Medical Power of Attorney (POA). He stated he was not present at admission and the facility sent all of the required forms to be filled out electronically. Continued interview revealed all the forms provided were sent back electronically. He stated the papers included a Do Not Resuscitate (DNR) form from the facility. Resident #1's son stated his family member was a DNR. Resident #1's son also explained he had not been provided information regarding the Kentucky state law, in which a person, who was as a DNR must complete a separate form for an Emergency Medical Services (EMS) DNR for the EMS to honor the wishes for the person not to be resuscitated. He stated this information was never discussed with him. Interview, with Certified Nursing Assistant (CNA) #8 on [DATE] at 4:54 PM, revealed she had been out back of the facility in her car for a break on [DATE] around 10:25 PM, for about five (5) minutes. She stated when she went to return to the facility she observed a person down, unresponsive on the sidewalk with blood coming from his/her head. CNA #8 stated she yelled out to the person several times and asked if he/she was okay and there was no response. She stated she ran inside to the second floor and got help. Three (3) staff members ran back with her to the person's location and one included Registered Nurse (RN) #3. The CNA stated once they were on sight, RN #3, assessed the resident and found him/her to be unresponsive. CNA #8 stated RN #3, rolled the person over and started CPR. Emergency Medical Services (EMS) were called and arrived on scene about ten (10) minutes later and took over CPR. It was about this time when staff gathered around and RN #11 identified the resident as Resident #1. Interview, with RN #3, on [DATE] at 8:39 AM, revealed he was working on [NAME] House when CNA #8 came running in stating she needed help. He and two (2) other staff went outside with CNA #8 to find out what was going on. RN #3 stated there was a person down, who was not breathing. Further interview revealed he did not recognize the person and neither did any of the other staff who were present at that time. He stated he checked the person for a pulse and did not find one, he said it was his duty as a nurse to start CPR on the person and he did. RN #3 stated it was very common for people from the surrounding neighborhood to walk leisurely throughout the facility's campus and that made it complicated to know if the person was a resident or a community member. Continued interview revealed when EMS arrived on site, they took over the CPR. About the same time, staff had determined the person was in fact a resident of the facility. RN #3 stated RN #11 returned to the facility to check the resident's Code Status and returned with a copy of the facility's DNR and a medication list. EMS was made aware the resident wished to be a DNR; however, they were not able to honor this because the facility did not have the required EMS DNR form on hand. EMS transported the resident to the hospital while they continued CPR. Interview with RN #11, on [DATE] at 7:04 PM, revealed she responded outside to a Code Blue. She also heard the announcement for a missing resident. When she arrived to the scene, CPR was already being done on the person. At first she did not know who the person was, but she saw the cane on the ground that looked like the cane Resident #1 used. She eventually was able to see the person's face and confirmed it was Resident #1. She went in to get the resident's code information and when she returned EMS was on site performing CPR. Further interview revealed the facility had a standard DNR form on file. However, RN #11 did not locate an EMS DNR form in Resident #1's file. Continued interview revealed as there was no EMS DNR form found, EMS continued CPR on the resident. RN #11 stated EMS transported the resident to the Emergency Department (ED) and continued the CPR. Once at the ED, CPR was continued until the resident was pronounced deceased at 11:26 PM. Interview with RN #11, on [DATE] at 7:04 PM, revealed she also did Admissions for new residents. She stated it was the nurses' responsibility to make sure the DNR forms were completed. She stated it was also her responsibility to determine the right person who needed to fill out that form. She stated the oncoming nurse, the UM or the DON were to follow up and make sure the form was completed timely. The RN stated it was important the nursing chain knew if the paper was not moving through the process quickly and could help move it along. RN #11 stated any action taken should be documented in the Progress Notes. She stated if she left a shift and returned the next day and the form still had not been completed, she would have to reach out to management. Continued interview revealed it had been a problem getting families to bring back the original form filled out. She stated if the resident wanted to be a DNR, the facility needed to make sure they got the form completed properly. Interview, with Unit Manager #1, on [DATE] at 4:25 PM, revealed she admitted Resident #1, and it was her responsibility to ensure the family completed the EMS DNR form. She stated she had called the family twice to inform them if the form was not completed, the resident would be a full code in the event of an emergency which required EMS/CPR. However, this was not documented in the EMR. She stated she went over the Admission Audit sheet used to ensure the medical record was accurate and complete. The UM stated the resident's spouse was present at Admission and he/she requested that the resident's son, who was the Medical Power of Attorney (POA), be contacted to complete the form. She explained some times the forms would be left at the desk and another nurse would make sure it got filled out. She stated the Nurse Leaders were responsible to ensure the forms were completed. The UM stated the Director of Nursing (DON) was her supervisor and she usually checked the forms behind her. However, the forms stayed with her until every item was completed on it, then it would be sent to the DON. The Unit Manager stated she left at least two (2) voice messages for the son, but she never got a call back. She stated she did not note this in the medical record. Interview with the DON on [DATE] at 12:54 PM, revealed the facility did not have a policy or procedure to ensure staff knew the expectation for ensuring the resident or Resident's Representative (RR) signed an original EMS DNR form to have in the event the resident was transported by the ambulance. The DON stated the nurse who admitted the resident was responsible to ensure this task was completed. She stated the day after admission, the Unit Manager (UM) completed an audit of the Electronic Medical Record (EMR) to ensure every item was accounted for in the record. The DON stated the audit sheet would not be forwarded to her until every item was accounted for. She stated it was up to the UM to continue to attempt to contact the family until the form was obtained. She stated she was not aware Resident #1's son had not completed the EMS form and he had been been informed about it. The DON stated the UM should have documented this in the notes. Interview, with the Administrator on [DATE] at 2:00 PM, revealed the DON did reeducation with staff on Advanced Directives and EMS DNR forms. It was determined staff had reached out to Resident #1's family/responsible party to have the form completed. The Administrator stated, in this situation he did not think anything could have been done differently. He stated CPR had already been started on an unknown person, but then the person was identified as a resident. The Administrator stated he was not aware the family reported they had not been informed of the need to have the required EMS DNR form completed. 2. The facility admitted , Resident #54 to the facility on [DATE], with diagnoses of Vascular Dementia, Altered Mental Status and Hypertension. Review of the Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #54, Electronic Medical Record (EMR) revealed the resident or resident representative had identified him/her as a DNR Code Status. However, there was no documentation of the EMS DNR form. On [DATE], the facility documented the Resident Representative was out of town and would not be back until after the holiday to complete the form. Further review revealed Kentucky state law required the issuer to have an original document on file and EMS could not accept a photocopy. This would result in the resident being a full code if he/she became unresponsive and EMS was called. During interview, on [DATE] at 4:00 PM, the [NAME] President of Risk Management was informed Resident #54 did not have an EMS DNR in the clinical record and was asked to produce the document. Continued interview revealed the form was in the resident's file over in the Personal Care Home, where the resident was transferred from on [DATE]. However, the required form was not in Resident #54's current record at the facility.

Based on observation, interview and record review, and review of facility's policies, it was determined the facility failed to protect residents from abuse for three (3) of seventy-one (71) sampled residents, Resident #3, Resident #4, and Resident #53 from abuse. Review of the Facility Self-Report form dated 2/16/2021 for Resident #3 revealed Certified Nursing Assistant (CNA) #11 had held up middle finger in presence of Resident #3, which was verified with cameras, and suspension was immediate for CNA#11 . Review of the Facility Self-Report form dated 01/30/2022 for Resident #4 and Resident #53 revealed resident to resident altercation over a chair, staff was present and immediately separated. The findings include: Review of Facility Policy titled Abuse and Neglect Policy and Procedure, revision dates of 5/17, 12/18, and 10/22, revealed purpose was to attempt to prevent any type of abuse to residents through pre-employment and pre-admission, screening, training of new staff and ongoing training for all staff, identification, investigation, protection, prevention and reporting abuse. Policy is to include all forms of abuse and definitions included Abuse -as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse- includes the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. Sexual Abuse-non-consensual sexual contact of any type with a resident. Willful- means individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse- means hitting, slapping, pinching and kicking. Mental Abuse- means the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Continued review of facility policy titled Abuse and Neglect Policy and Procedure revealed Resident to Resident Abuse would be viewed as a potential situation of abuse and each situation will be evaluated per observation, identifying behaviors and provide care plan interventions and updated as needed. Further review of Abuse and Neglect Policy and Procedure revealed prevention would include signs of burn out would be monitored for all employees through various areas such as schedules, overtime, acuity of group assignments and employees would be offered free Employee Assistance support through outside source to attempt to reduce any signs of burnout or life stressors. Review of Facility Policy titled Residents' Rights for Residents in Long Term Care Communities, no date or revision date given, revealed under Section numbered six (6) included, All Residents shall be free from mental and physical abuse. Review of the job description titled Certified Nursing Assistant/Caregiver, no date or revision date given revealed under responsibilities inclusion of promptness, courteous and respectful to residents and co-workers. 1. Facility admitted Resident #3 on 03/20/2020 with diagnoses of metabolic encephalopathy, panic disorder, depressive disorder and hypertension. Review of the Minimum Data Set (MDS) Assessment, dated 12/09/2022, revealed a Brief Interview of Mental Status (BIMS) score of eleven (11) out fifteen (15) indicating intact cognition. Review of Resident Summary, dated 02/16/2021, revealed Behavioral Interventions included encourage caregivers to participate in activities to promote positive interactions, monitor need for psychiatric services and provide if agreed by Resident #3 or responsible party and ordered by physician. Additional interventions included gently remind Resident #3 that screaming, and cursing was not appropriate and respond in a calm voice, and remove Resident #3 from area if verbally abusive to others. Review of Resident #3's care plan, dated 02/17/2021, revealed interventions for behavioral alterations to include offering positive re-enforcement, approach in calm manner and report and record any mood changes. Review of personnel records for Certified Nursing Assistant (CNA) #11, revealed a hire date of 11/04/2019, and an Abuse Registry check, dated May 2021, revealed no findings. Further review of the personnel record revealed a signed acknowledgement of Abuse and Neglect Policy and Procedure, dated 11/04/2019. Review of the facility's telephone interview, with CNA #11, dated 02/17/2022, revealed (he/she) called me a stupid bitch for the third time, so yes I flipped (him/her) off. This interview was related to the 02/16/2022 incident. Review of Resident #3 interview statement, dated 02/16/2021 at 4:40 PM, revealed Resident #3 had asked CNA #11 to clean up soda spilled in his/her room and when she refused I called her a bitch too. Interview, on 11/29/2022 at 2:40 PM, with Resident #3, revealed he/she had resided in the facility for nine (9) years and was treated well. Continued interview revealed no staff member had ever been mean, hit him/her or called him/her names or yelled at him/her. Continued interview revealed no staff member had ever treated him/her rough while providing care and the call light was always answered timely and they help me when I need it, everybody is real good here. Further review of the facility's investigation, dated 02/19/2021, for the incident reported to have occurred on 02/16/2021, revealed no specific time was given, cameras were viewed by the previous Administrator and CNA #11. Further review revealed CNA #11 was visually seen holding her middle finger up to Resident #3. The facility suspended CNA #11 immediately. Later that same day CNA #11 resigned per text. An interview was attempted with CNA #11, but the State Agency was unable to contact CNA #11, due to no phone service. Interview, with Licensed Practical Nurse (LPN) #4, on 11/29/2022 at 2:45 PM, revealed she had worked at the facility for about a year and vaguely remembered the incident between CNA #11 and Resident #3. She stated she heard Resident #3 yelling at CNA #11 and calling her a lazy bitch. She stated at that time CNA #11 turned and yelled, but she could not say what was said. Continued interview revealed CNA #11 gave Resident #3 the finger then walked off the floor. LPN #4 stated the incident was reported, but she could not remember to whom, probably a manager. She stated CNA #11 had never had behaviors before but, nobody liked her. In addition, she stated Resident #3 had never exhibited that behavior before. Interview, with the Director of Nursing (DON), on 12/06/2022 at 10:20 AM, revealed she had worked as the DON since May of 2021. She stated her job duties included oversight of the clinical operations of the facility. The DON stated her expectations of staff were to recognize abuse, assure safety of the residents and report immediately. She stated the facility's abuse process included interviewing residents with a BIMS' score of eight (8) and higher and performing skin assessment on residents with a BIMS score of less than eight. The DON stated additional expectations of staff included to report any declines and to notify the physician. Interview, with the former Social Worker (SW), on 12/07/2022 at 10:50 AM, revealed the staff member was sent home immediately. The SW stated she did not have any other information to add. 2. Record review revealed the facility admitted Resident #4, on 07/03/2021, with diagnoses of metabolic encephalopathy, mild cognitive impairment and essential hypertension. Further review revealed Resident #4 was discharged from the facility on 03/29/2022. Review of the Minimum Data Set (MDS) Assessment, dated 12/20/2021, revealed the facility assessed Resident #4 to have a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) which indicated intact cognition. Review of the Physician's Orders, dated 01/29/2022, revealed an order for behavior monitoring, as needed, to start 01/30/2022 and activity as tolerated. In addition, there was an order, dated 06/28/2021, for Psychology/Psychiatric Professional consult. Review of Resident #4's care plan, dated 01/20/2022, revealed a problem list that included mild cognitive impairment fluctuation throughout the day. Interventions included safety measures as indicated. Continued review of Resident #4's Care Plan, revealed to encourage the resident to use the activity board. Record review revealed the facility admitted Resident #53, on 11/12/2021, with diagnoses of orthopedic after care, dementia with behavioral disturbance and hypertension. The facility discharged Resident #53 on 02/21/2022. Review of the Minimum Data Set (MDS) Assessment, dated 02/11/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated impaired cognition. Review of Resident #53's Care Plan, dated 11/12/2021, with a goal date of 05/11/2022, revealed a problem list for physical behavioral symptoms directed at others: inappropriate touching of staff, physically aggressive toward other residents (Hitting). Interventions put in place included sitting with staff during mealtime and activities, 1:1 activities during times of stress and aggregation and psych consult referral/follow-up as needed, dated 01/30/2022 and 01/31/2022. Review of the Psychiatric Periodic Evaluation, dated 02/02/2022 revealed the chief complaint/nature of presenting problem was physical aggression, inappropriate behaviors, poor impulse control, and advanced dementia with history of poor impulse control. Continued review of the evaluation revealed recommendations to monitor changes in mood or behaviors and increase medications. Review of Physician's Orders, dated 12/22/2021, revealed an order for Psychology/Psychiatric Professional. Continued review of the Physician's Orders, dated 11/12/2021, revealed an order for Aricept 10 mg (milligrams) tablet one time daily for dementia with behavioral disturbance (medication given to treat mild to moderate dementia). Additional review revealed an order, dated 12/17/2021, for Divalproex 125 mg capsule sprinkles two times daily for dementia with behavioral disturbance, (medication given for bipolar disorder). Review of the facility's investigation report, dated 02/03/2022, revealed Resident #4 and Resident #53 got into an altercation over a chair. Continued review revealed Resident #53 hit Resident #4 in the face in the dining room. There were no injuries to either resident; staff and other residents were interviewed with no new findings. The report revealed Resident #4 did not recall the incident and psychiatric services were provided to Resident #53 with interventions placed for each resident. Interview, with CNA #25, on 12/09/2022 at 1:40 PM, revealed she had worked at the facility for [AGE] years as a nurse aide and her tasks/job duties included helping residents with meals, ADLs and pretty much everything they needed. Continued interview revealed CNA #25 had training on abuse, neglect and misappropriation and had no concerns for any resident being mistreated in any way. CNA #25 stated if she did see any abuse, she would report it to a manager. When interviewed about the altercation between Resident #4 and Resident #53 in the dining room, she stated she was assisting another resident to eat and had her back turned, but heard some type of commotion. The CNA stated she turned and saw Resident #53 hit Resident #4 in the face, but it did not cause any injury. CNA #25 stated Resident #53 had finished his/her meal and walked into the dining room. She stated she immediately separated the residents and Resident #53 went on walking down the hallway to his/her room as if nothing happened. CNA #25 stated she reported the incident to the nurse, who was in office, after making sure Resident #4 was ok. She stated Resident #53 was confused and she felt that was the reason he/she struck another resident. CNA #25 stated it appeared Resident #25 never understood what had happened, almost as if it never happened. The CNA stated the incident happened toward the end of the meal and she was the only one in the dining room. She stated the other residents had finished their meal. Interview, with CNA #39, on 12/21/2022 at 10:30 AM, revealed when 1:1 supervision was needed, the resident would have a sitter, but while in the common area, staff would keep residents in line of sight. Interview, with CNA #41, on 12/21/2022 at 11:30 AM, revealed 1:1 supervision was usually not performed by staff. Interview, with the Director of Nursing (DON), on 12/12/2022 at 12:40 PM, revealed after the altercation between Resident #4 and Resident #53 in the dining room, the residents were separated immediately per staff interviews. The DON stated there were no injuries to either resident or the other residents that were assessed on the unit. Continued interview revealed the process to protect residents during meal time was to sit with the residents during dining. The DON stated Resident #4 was encouraged to use a activity board and for Resident #53 to engage in 1:1 activities. Interview with the Administrator, during review of the facility's Internal Investigations, on 12/21/2022 at 10:15 AM, revealed the facility's policy and procedures were followed for reporting and investigating each complaint received. Continued interview on 12/21/2021 at 10:30 AM revealed he was a member of the Quality Assurance Committee and had attended the November meeting. The Administrator stated revisions and plans were discussed in the meeting and agreed upon by members.

43694 Based on observation, interview, record review, and facility policy review, it was determined the facility failed to protect two (2) of seventy-five (75) sampled residents (Resident #40 and Resident #610 from misappropriation of property. Record review revealed it was reported on 09/28/2022, that Resident #61 had personal checks stolen from his/her room, date unknown. Review of the facility's investigation revealed a copy of the stolen check, number 212, dated 09/24/2022, and made out to Certified Nursing Assistant (CNA) #38. The amount was $316.12. Observations, on 11/29/2022, revealed Resident #61 had a locked drawer that was at the top drawer of the night stand. Resident #61 reported the lock did not lock every time and would sometimes just turn and turn. Observation revealed there was no safe in Resident #61's room at this time. Resident #40 stated he/she had $58 go missing from his/her room in February 2022 and $20 in March 2022. The resident reported the locked drawer provided by the facility to secure his/her valuables, could not be secured to prevent theft. The resident reported the lock would just spin and spin and even if it stayed in place, it did not prevent the drawer from being opened. The resident stated many staff went in and out of his/her room every day. Resident #40 reported money went missing February 11, 2022, after an agency personal sitter left his/her presence. The resident reported his/her concerns to management. Observation, of Resident #40's nightstand/locked drawer, on 12/16/2022 at 9:00 AM, revealed the resident and sitter showed the State Survey Surveyor how the key went into the lock and how the lock spun all the way around. The locking device was loose and when the drawer was closed the lock did not secure the drawer. The drawer was loose, the locking mechanism could be seen and wiggled loose to open the drawer. The findings include: Review of the facility's policy, Abuse and Neglect Policy and Procedure last reviewed 10/2022, revealed the facility would attempt to prevent any type of abuse through pre-employment and pre-admission screening, training of new staff and ongoing training of all staff, identification, investigation, protection, prevention and reporting of abuse. Misappropriation of property was the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. All allegations of abuse would be reported, investigated and reported to appropriate state agencies, as required. Review of the facility's, Information Guide, revealed each resident and/or Resident Representative, signed on admission, that the residents could temporarily store small valuables in a safe located in the Business Office. The facility also provided short-term stay residents an in-room safe with instructions for setting a unique combination for each lock. The facility asked that residents to store items elsewhere if they did not fit on the shelves provided. Review of the facility's, Resident Fund and Security Acknowledgement form, revised 03/2021, which the facility recently implemented, revealed each resident, upon admission was given the opportunity to place valuables temporarily in the safe in the Business Office until other arrangements could be made for safekeeping. Additionally, the form noted residents in short-term rehabilitation could choose or decline to use the in-room safe for their valuables. It was noted at the bottom of the form I understand the above options were available for my convenience and that I am responsible for using the options available to secure my valuables. I understand (the facility) is not responsible for my personal valuables. 1. Record review revealed the facility admitted Resident #61 on 02/07/2022. Admitting diagnoses included Vertigo, Generalized Muscle Weakness, numerous circulatory issues, and Atrial Fibrillation. The facility assessed Resident #61 as having a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Interview, with Resident #61, on 12/02/2022, at 11:07 AM, revealed he/she noticed missing checks from his/her checkbook, which was kept in his/her locked drawer, sometime at the end of September. Further interview revealed he/she then checked his/her account balance and noticed a check he/she had not written. Continued interview revealed he/she then called the bank and was told about check #212 in the amount of $316.12. The check was dated 09/24/2022, made out to CNA #38, signed and cashed by CNA #38. Resident #61 stated the bank reimbursed the check amount of $316.12, and that account was closed. Resident #61 opened a new account. The resident stated the facility interviewed him/her and reimbursed him/her the cost of ordering checks for the new account. Additional interview, on 12/16/2022, revealed Maintenance had inspected the top drawer lock and said it was locking. Resident #61 stated that sometimes the lock worked but, often times it would not lock. He/she stated that there was no offer of a room safe until the State Survey Agency (SSA) Representative began investigating the incident. Review of the Resident Fund and Security Acknowledgement form, dated 02/07/2022 (admitted ) revealed Resident #61 had checked the boxes declining Resident Trust Account and utilizing the facility safe but did check the box that he/she wanted to use a room safe. Interview with the Director of Nursing (DON), on 12/05/2022 at 4:04 PM, revealed when a resident was admitted to the facility, they were offered a safe for their valuables. The safe would be installed by maintenance, usually in the closet. All staff had been educated on the process of talking to residents about keeping their valuables locked up or perhaps sending them home with family. Interview on 11/30/2022, at 3:24 PM, with the Administrator, revealed the facility discussed valuables with the residents on admission. He stated residents were offered a safe and only the resident would have the code. He stated he was not aware Resident #61 had requested a safe or that the lock did not always work on the resident's locked drawer. Interview with the Maintenance Director, on 12/07/2022 at 10:24 AM, revealed if a resident had valuables there was a locked drawer in the room they could use. If the resident requested a safe in the room a work order was placed, and he installed the safe the next day. If a resident wanted the valuables locked in a safe immediately, the facility had a safe in the Business Office residents could use to store small valuables. Review of the facility investigation, dated 09/30/2022, revealed CNA #38 was suspended pending the investigation results. Residents or Representatives that she may have taken care of, were interviewed without further concerns. Staff was interviewed and re-educated on Abuse and the reporting process (reviewed by this writer). Additionally, a report was made to the local Police Department. 2. The facility admitted Resident #40 on 12/28/2021 and he/she was discharged on [DATE]. Please check these dates, I though Resident #40 was in the facility at the time of the survey. The resident had diagnoses of diverticulitis, anxiety and gastrointestinal bleeding. The facility assessed the resident with a Brief Interview Mental Status (BIMS) of fourteen (14) out of fifteen (15) showing the resident was cognitively intact. Interview with Resident #40's Health Surrogate, on 12/14/2022 at 10:50 AM, revealed she tried to convince the resident he/she really had no need to keep money in the room, but the resident was someone who was used to always having money on himself/herself. Resident #40's Health Surrogate also stated the facility provided a locked drawer to keep money in; however, she felt it could very easily be broken into and it was not very secure. She also revealed the resident had a credit/debit card that the sitter used to purchase items for the resident. Interview with Resident #40, on 12/16/2022 at 9:00 AM, revealed his/her money continued to get stolen out of his/her room. The resident revealed the locked cabinet was not a secure place to keep his/her money. The resident explained the lock on the cabinet just spun around and around and did not keep the drawer locked. Review of facility five (5) day report dated 03/01/2022 revealed Resident #40 reported he/she had $20 missing from his/her room. Staff were interviewed and asked did you go into [NAME] House room [ROOM NUMBER] on 02/18/2022 through 02/21/2022, Did the resident tell you he/she was missing money?, Did you see any money in the resident's room?, Do you know what happened to the resident's missing money? These questions were all answered in a way that left the facility unable to substantiate the case. However, there was no documentation or evidence the facility checked the resident's locking cabinet to identify if it was in working order. The Administrator revealed on 12/16/2022 at 9:20 AM, overtime the mechanisms in which residents secured their valuables could fail. Police Report #80-22-01032 was filed. Review of facility five (5) day report dated 02/18/2022, revealed the resident reported $58 was missing from his/her room. The facility interview with Resident #40 revealed his/her private sitter did not return to care for him/her the day after the money went missing. The resident stated, He/She did not give anyone permission to take his/her money from his/her wallet or giving money to anyone since Friday. The resident stated the money that went missing was in his/her wallet located in the nightstand. The facility also talked to the resident Health Surrogate, who informed them she did leave the resident with $58 in his/her wallet and she had contacted the private sitter company and reported it was believed the sitter took the money. All of the residents on [NAME] House were questions as to any missing money or property and revealed they had not had money missing and any property they could not locate was recovered. All staff working in the area were asked if they were aware of a resident missing any money and each staff member stated No except the staff member Resident #40 reported to. All staff were asked if they were aware of anyone taking money from a resident and each staff member answered no. The Executive Director (ED) of the outside Sitter Agency sent an email on 12/19/2022 at 3:15 PM, and revealed a staff member from the facility (she did not know who) called and informed her there was a problem with Sitter #1 and complained on 02/13/2022, he had taken the resident's car without permission for an excessive amount of time. The ED revealed it was asked that Sitter #1 not return to provide care for Resident #40 anymore. The ED also revealed Sitter #1 had other complaints from different family members and different facilities, in which they no longer wanted Sitter #1 to provide care for their family member. Sitter #1 quit his job without notice. Interview with Personal Sitter #2 present in the room, on 12/16/2022 at 9:00 AM, revealed she had been sitting with Resident #40 for about a week and a half. She stated the lock on the drawer did not work, she would assist the resident in trying to lock it before they left the room. She stated when the key was in the lock it just spun and spun. She also revealed if the lock stayed in place the drawer could easily be opened. On 12/08/2022 at 3:31 PM, interview with the Director of Nursing (DON), revealed staff was educated, in new hire orientation, regarding abuse. It included the different types of abuse, reporting of abuse, and the immediate response. The staff was offered the types of abuse on their name tags. Her process for preventing abuse was constant education, she was always out talking to residents, following up on grievance and complaints. She stated she had no tolerance for abuse. Attempted interview with Social Worker #3, on 12/14/2022 at 10:22 AM and 12/15/2022 at 2:20 PM, voice message left each time without a call back. Interview with the previous Social Service Director (SSD) on 12/07/2022 at 10:52 AM, revealed she was not able to remember any incidents for her time at the facility. She was not willing to answer questions. Interview with the Administrator, on 12/15/2022 at 11:55 AM, revealed all staff during admission of new residents go over the importance of residents keeping their valuables locked up. He explained resident in long term care could use the Business Office safe for any amount of time even though documentation says it is temporary. He stated when a resident went out to the hospital staff would bring items such as Interactive Personal Application Device (IPAD) or phones and they would be placed in the safe until a family member or the resident picked it up. Additional interview with the Administrator, on 12/16/2022 at 9:20 AM, revealed the facility had taken the necessary action to prevent resident proper/valuables from being taken. He expressed that over time mechanisms could fail. However, he was looking into getting safes for each resident room, to better secure resident valuables. The Administrator reported nothing had been identified as a trend for misappropriation of property.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to implement the care plan for one (1) of forty-four (44) residents, Resident #62. Resident #62 had a urinary catheter with a care plan to keep the collection tube below the level of the resident's bladder; however, observation revealed the resident's urinary collection bag was on the bed with the resident at the same level of the bladder. The findings include: The facility did not provide a policy for care plans. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 4, pages 4-8 to 4-11, revealed the comprehensive care plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. In addition, under Section H: Bladder and Bowel, the facility was to consider all complications associated with the use of a catheter and implement interventions to minimize the associated complications. Review of the facility's policy, Catheter Care Procedures, undated, revealed the catheter was to be below the level of the bladder. Review of Resident #62's clinical record revealed the facility readmitted the resident on 04/25/19, with [DIAGNOSES REDACTED]. Further review revealed Resident #62 had an indwelling urinary catheter. Review of Resident #62's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a urinary catheter. Review of Resident #62's Care Plan, dated 11/21/18, revealed Resident #62 had a urinary catheter with the goal to prevent complications. Interventions included to keep the urine tube below the level of the bladder. Review of Resident #62's Certified Nursing Assistant (CNA) Care Summary Sheet, dated 05/16/19, revealed under toileting, the resident care included an indwelling catheter. Observation, on 05/17/19 at 8:38 AM, revealed Resident #62 in bed and the urinary catheter bag was on the bed near the resident's knee area and at the same level of the resident's bladder. Interview with CNA #3, on 05/17/19 at 8:40 AM, revealed the catheter bag was to be below the level of the resident to allow urine to drain. She stated if the urine was not allowed to drain, the resident could develop issues because the urine would settle in the resident's bladder. However, she stated when daily care was provided she placed the bag on the bed. Interview with CNA #6, on 05/17/19 at 8:40 AM, revealed it was important to position the urinary collection bag below the resident's bladder at all times to allow the urine to drain. She stated CNAs were expected to follow the care plan to prevent resident harm. Interview with Licensed Practical Nurse (LPN) #7, on 05/17/19 at 9:49, revealed all staff was to follow the care plans at all times for the residents' well-being, and if not, the resident could become ill or their condition could worsen. Interview with the Walter House Nurse Leader, on 05/17/19 at 10:15 AM, revealed care plans identified resident issues and interventions were put in place to care for the resident. She stated resident care plans guided the staff's care for the resident. The Nurse Leader further stated if the staff did not follow the care plan, the resident could be harmed. She stated all staff was to review care plans daily. She further stated care plan education was part of orientation and annual required modules. Per interview, she conducted morning rounds to observe for proper care, and had not identified issues with residents not being provided the appropriate care for catheters and drainage bags. Interview with Staff Development, on 05/17/19 at 2:27 PM, revealed staff received education for resident care plans upon hire, annually, and as needed. She stated care plans were the guide for resident care needs and were to be followed by all staff. She further stated when a resident's care plan was not followed, the resident could decline and become ill. Interview with the CNA Care Coordinator, on 05/17/19 at 3:20 PM, revealed CNA Care Summaries were generated from the comprehensive care plan but did not list in detail the care for urinary catheters. She stated it was a standard of care to keep the urinary bag below the bladder and not on the bed with the resident. She further stated she completed frequent audit rounds for proper care and position of resident urinary catheter bags without identified concerns. Interview with the Infection Preventionist, on 05/17/19 at 3:20 PM, revealed if care plans were not followed, the resident could present with a negative outcome. She stated all staff had access to resident care plans or care summaries and staff was expected to be knowledgeable about the care plans and follow the care plans. Interview with the MDS Coordinator, on 05/17/19 at 4:03 PM, revealed care plans contained individualized interventions and were the model of how to care for the resident. She stated staff was to follow the care plans at all times and if not, the resident might suffer a negative outcome, such as an infection. She further stated she had not identified issues with care plans not being followed. Interview with the Assistant Director of Nursing (ADON), on 05/17/19 at 3:47 PM, revealed care plans were tools to be used to know how to care for a resident. She stated all medical staff was to use and follow resident care plans at all times. She further stated if staff did not follow the care plans, it could lead to a poor result, such as an infection. She stated the facility did not identify issues with care plans not being followed. Interview with the Director of Nursing (DON), on 05/17/19 at 2:27 PM, revealed the Infection Preventionist audited urinary catheters monthly and had not identified issues with care plans not followed. He stated all medical staff was responsible to follow care plans to prevent issues for the residents. The DON revealed staff was to keep urinary collection bags in the correct place and position at all times or it could cause a urinary tract infection. Interview with the Administrator, on 05/17/19 at 1:09 PM, revealed the facility did not identify through the Quality Assurance (QA), or with random reviews, issues with the implementation of care plans for residents with urinary catheters.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment was free from accident hazards on one (1) of six (6) neighborhoods, the(NAME)neighborhood. Observation revealed a laundry dryer available for resident use had a sharp, protruding plastic piece sticking out where the door handle should be. The findings include: Review of the facility's policy, Accident Supervision and Prevention, revised (MONTH) 2011, revealed the facility would identify environmental hazards for residents using quality assurance activities, environmental rounds, MDS/RAPS data, medial history, and physical exam. Observation of the(NAME)neighborhood, on 05/16/19 at 9:38 AM, revealed a front loading washer and dryer in a clean laundry room in the B Hall. The dryer did not have a handle and there was a broken sharp and protruding plastic piece sticking out where the door handle should be. Interview with Certified Nursing Assistant (CNA) #3, on 05/16/19 at 10:01 AM, revealed some residents on the(NAME)neighborhood did their own laundry. She stated the dryer door with the sharp plastic protruding piece had been that way for a couple of weeks. The CNA revealed the sharp piece could be a safety hazard for the residents, as they could get cut or get a skin tear when they used the dryer. If there was broken equipment, she stated staff notified the nurse so they could put in a work order. Interview with the Environmental Director, on 05/16/19 at 9:44 AM, revealed she was not sure how long the dryer door handle had been broken. She stated it was the nurse leader's responsibility to report it so maintenance could repair it. She stated residents used the washer and dryer to launder their clothes and the dryer was not safe for their use, as they could injure their hand. Interview with Registered Nurse (RN) #3, on 05/16/19 at 9:52 AM, revealed she was the team leader and was not aware of the broken dryer door handle in the laundry room. She stated typically, whoever finds broken equipment would let their nurse or supervisor know, and they would put in a ticket via the computer or let the Environmental Director know. The RN denied the broken handle was a safety hazard for the residents; however, she stated she was going to immediately cover the sharp protruding piece on the dryer. Review of the facility's Work Order Summary List, dated 04/15/19 to 05/15/19, revealed no work order for the broken dryer handle. Interview with the Vice President (VP)/Facilities Management (Head of Maintenance), on 05/16/19 at 10:12 AM, revealed he had not received a work order for the broken dryer door. He stated it looked like the handle was busted completely off, and two brackets remained and the bracket in the mid door area was broken almost completely off. The VP stated any time equipment was found broken, any staff could submit a work order through the computer, and it went to him via email notification and then was delegated to one of his staff to resolve. He relied on staff to report any equipment issues or safety concerns and he personally did life safety rounds bi-weekly. Interview with the Director of Nursing (DON), on 05/17/19 at 4:37 PM, revealed he did not know if the faulty dryer door had been reported. The DON stated it was hard to determine exactly what the risk would be to a resident because when he went to observe the dryer, the facility had repaired it.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide one (1) of forty-four (44) residents, Resident #62, with services to prevent complications related to an indwelling urinary catheter. Observations revealed Resident #62's urinary collection bag touched the floor and was on the bed at the level of the resident's bladder. The findings include: Review of the facility's policy, Urinary-Catheterization (Indwelling/Intermittent, revised (MONTH) (YEAR), revealed the catheter drainage bag was to have a dignity cover and was to be at an appropriate level to reduce the risk of back flow of the urine. The objective for utilizing correct techniques and standards of practice were to prevent a Urinary Tract Infection [MEDICAL CONDITION]. Review of the facility's policy, Catheter Care Procedures, undated, revealed the catheter was to be below the level of the bladder. Review of the facility's Lippincott Manual, revised (MONTH) (YEAR), revealed the urine drainage bag was to be placed below the resident's bladder to prevent urine stasis, which increased the risk of a UTI. Review of the facility's audit tool, Catheter Audit, revealed the facility audited for catheter care, which included proper size and diagnosis, if the catheter bag appeared clean, dry, and intact, and if the resident showed signs and symptoms of adverse reactions. However, the audit did not monitor position of the catheter collection bag. Review of Resident #62's clinical record revealed the facility readmitted the resident on 04/25/19, with the [DIAGNOSES REDACTED]. Further review revealed the resident had an indwelling urinary catheter. Observation, on 05/14/19 at 2:42 PM, revealed Resident #62 was in bed and had a urinary catheter. The urinary collection bag laid on the floor. Observation, on 05/15/19 at 9:04 AM, revealed Resident #62 was in bed and the urinary collection bag was in contact with the rug on the floor. Observation, on 05/16/19 at 9:17 AM, revealed Resident #62's urinary collection bag was in contact with the rug. Observation, on 05/17/19 at 8:38 AM, revealed Resident #62 was flat in bed and the urinary collection bag was positioned on the bed at the resident's knee area, at the level of the resident's bladder. Certified Nursing Assistant (CNA) #3 and #6 completed peri-care and skin care, and then Licensed Practical Nurse (LPN) #7 performed wound care. The urinary collection bag remained on the bed with the resident. Registered Nurse (RN) #4 and the Marsh Home Nurse Leader were present to assist with positioning needs and the urinary collection bag. Interview, on 05/17/19 at 8:40 AM, with CNA #3 revealed the resident's urinary collection bag should be positioned to allow urine to drain in order to prevent issues related to the urine settling in the resident's bladder. Interview with RN #4, on 05/17/19 at 9:41, revealed the urinary collection bag was to be on the side of the bed and not touching the floor. She stated the contact of the floor could cause contact with bacteria and result in an infection to the resident. RN #4 revealed the urinary collection bag should be below the resident's bladder to drain urine, or the urine could become stagnant in the bladder and cause infection. She stated all staff received education on positioning of the urinary collection bag and infection control. Interview with LPN #7, on 05/17/19 at 9:47 AM, revealed the urinary collection bag was to be below the waist, on the side of the bed, and was not to be on the bed at the same level of the bladder. She stated when urinary collection bags were at the same level of the bladder; the urine would not drain and could cause an infection. She further stated the urinary collection bag was to be off the floor at all times because the facility did not know what was on the carpet and was a pathway for infection. LPN #7 stated Resident #62 developed a bladder infection every other month and the facility did not identify the source of the reason the resident was getting infections. Per interview, staff received education on positioning of urinary collection bags and staff was to properly position the urinary collection bag to prevent infections. Interview with Resident #62's Nurse Practitioner (NP), on 05/17/19 at 2:39 PM, revealed she previously treated the resident in (MONTH) 2019 and (MONTH) of 2019 for a UTI. She stated the facility reported decreased meal intake and decreased alertness which were the first symptoms of a UTI for Resident #62 therefore she ordered a urinalysis. Review of Resident #62's Urinalysis Laboratory Results, dated 05/14/19, revealed the resident's urine contained 3+ blood with normal to be negative for the presence of blood in the urine. Leukocytes were noted as 3+ and the normal lab value was to have none in the urine. White Blood Cells (WBC) were found at a level of 21-50 and normal findings were to be below the level of 6. Further review revealed bacteria was present in the urine and the normal was to have an absent level of bacteria. The result findings revealed a culture of the urine was indicated for infection; however, the culture results were not available at the time of the survey. Interview with RN #5, on 05/17/19 at 10:20 PM, revealed the urinary collection bag was to be positioned below the resident's bladder at all times to prevent infection. She stated everyone was responsible to ensure the position of the urinary collection bag was correct at all times. She further stated the urinary collection bag should never be in contact with the floor surfaces or residents could get sick due to an infection. Interview with Staff Development, on 05/17/9 at 2:27 PM, revealed urinary collection bags were to be kept at a level to allow drainage and staff was to follow the standard of care for urinary collection bags, which was below the bladder and off the floor. She stated if the standards were not followed, it could be an infection control issue, which could cause the resident to get a bladder infection. She stated staff and the Infection Preventionist (IP) conducted monthly walking rounds to ensure urinary collection bags were off the floor and properly positioned and no concerns were identified. She further stated all staff was required to complete education for UTI prevention, catheter care, and complete a skills check off for competency. Interview with the IP, on 05/17/19 at 3:20 PM, revealed the facility used the Lippincott Nursing Care Manual for standard of care. She stated the standard was for the urinary collection bag to be below the bladder and on the bed frame, which was below the bladder. She stated she made walking rounds to ensure the catheter bags were not on the floor to prevent contamination. She stated her audits for infection control revealed no issues with urinary collection bags on the floor. Interview with the Assistant Director of Nursing (ADON), on 05/17/19 at 3:47 PM, revealed the urinary collection bag was to be at the bedside, below the bladder, and the bag was not to be on the floor. She stated staff was required to complete annual modules on catheter care and infection control as well as a skill check off. The ADON stated all staff was required to ensure the urinary collection bags were off the floor and positioned properly. She further stated the facility did not identify issues during daily walking rounds regarding urinary collection bags on the floor or on the bed. According to the ADON, residents could become sick with a bladder infection and it did not take much for elder residents to become sick enough to be hospitalized . Interview with the Director of Nursing (DON), on 05/17/19 at 2:27 PM, revealed monthly audits were completed for residents with urinary catheters for proper positioning, care, and services. He stated he thought the urinary collection bags were not to be touching the floor, and when urinary collection bags were on the bed with the resident, the urine could flow back into the bladder and cause an infection. According to the DON, all staff was to ensure proper positioning of urinary collection bags at all times. He stated the facility had not identified issues with urinary collection bag positioning or infection control issues. Interview with the Administrator, on 05/17/19 at 1:09 PM, revealed the facility did not identify through the Quality Assurance (QA) or with random reviews, any issues with positioning of urinary collection bags.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare and distribute food under sanitary conditions. Observations revealed two (2) male dietary cooks in the kitchen wearing beard restraints; however, their mustaches were not covered. In addition, dietary staff failed to obtain food temperatures for two (2) of ten (10) food items prior to serving the residents and three (3) of the ten (10) food items were served at the incorrect temperature in one (1) of six (6) houses, the Campbell House. The findings include: 1. Review of the facility's policy, Hair Restraints, dated March 2014, revealed employees would use hair restraints (such as hair nets and beard nets) that were effective in keeping their hair in control when on duty. Observation of the kitchen, on 01/05/17 at 11:30 AM, revealed a male chef in the kitchen obtaining temperatures of prepared food. He was wearing a hair/beard restraint over his beard, but his mustache was not covered by the restraint. Observation of the kitchen, on 01/06/17 at 10:40 AM, revealed a male Dietary Cook (DC) in the food preparation area of the grill wearing a hair/beard restraint over his beard. The restraint was not covering his mustache. Observation of the kitchen, on 01/06/17 at 10:48 AM, revealed the DC standing at the stove stirring food while wearing a hair/beard restraint; however, the restraint was not covering his mustache. Interview with the DC, on 01/06/17 at 2:00 PM, revealed staff wore a hair/beard restraint in the kitchen and whenever handling food. The DC stated the hair/beard restraint should cover all facial hair including a mustache. He stated a hair/beard restraint prevented hair from falling into the residents' food and possibly contaminating the food and making the residents ill. Interview with the Dietary Manager (DM), on 01/06/17 at 1:48 PM, revealed the facility's policy required staff members to wear hair restraints in the kitchen. The DM stated hair restraints must cover all hair. The DM stated the facility trained staff on the hair restraint policy in orientation and periodically. The DM added hair restraints prevented hair and bacteria from entering residents' and guests' food. The DM revealed she monitored dietary staff using hair restraints monthly and she had not discovered any issue with hair restraint usage. Interview with the Administrator, on 01/06/17 at 2:25 PM, revealed staff wore hair/beard restraints per facility policy to cover hair on the head or face. The Administrator stated the proper use of hair/beard restraints prevented hair from falling into the residents' food. 2. Review of the facility's policy, Meal Service at Preferable Temperatures, dated May 2015, revealed Dietary would ensure all food items sent from the kitchen were plated at the proper holding temperature. Review of the facility's form, Tray line Temperature Monitoring Form, not dated, revealed the bottom of the form listed the point of service food temperature ranges. At the point of service, the temperature of hot foods should be one hundred thirty-five (135) degrees Fahrenheit (F) or above, and cold foods should be thirty-two (32) to forty-one (41) degrees (F). Observation of the Campbell House lunch meal, on 01/05/17 at 12:00 PM, revealed ten (10) food items on the tray line for dietary staff to serve to the residents. Dietary Aid (DA) #1 obtained the food item temperatures; however, she did not obtain the temperature for the Pureed Chicken and Cheese Cake. The Pureed Corn and Sweet Potato Fries temperatures were one hundred twenty-nine (129) degrees (F) (a temperature below the point of service for hot foods). The Macaroni Salad's temperature was forty-six (46) degrees (F) (a temperature above the point of service for cold foods.) Dietary staff served the Pureed Chicken, Cheese Cake, Pureed Corn, and Sweet Potato Fries, to the residents. Continued observation of the Campbell House lunch meal, on 01/05/17 at 12:20 PM, revealed staff served the Macaroni Salad to three (3) residents. When the surveyor brought the temperature of the salad to the attention of the Assistant Dietary Manager (ADM), the ADM put the salad in the refrigerator. At 12:30 PM, the ADM removed the Macaroni Salad from the refrigerator, obtained the temperature of the salad at forty-eight point three (48.3) degrees (F) and then put the salad container in a container of ice. Interview with DA #1, on 01/05/17 at 12:10 PM, revealed she was aware she should have obtained the temperature of all foods items on the tray line. She stated she was nervous and she missed some of the items. DA #1 did not know what the food temperatures should be at the point of service. Interview with the ADM, on 01/05/17 at 12:30 PM, revealed dietary staff should not serve Macaroni Salad at a temperature of forty-six (46) degrees (F). The ADM stated it was acceptable for dietary staff to serve cold foods at a temperature below forty-four (44) degrees (F), but was uncertain what the facility's policy stated. Interview with the Dietary Manager (DM), on 01/05/16 at 2:30 PM, revealed dietary staff should obtain the temperature of all food items on the tray line. The DM stated dietary staff should serve Macaroni Salad at a temperature of thirty-two (32) to forty-five (45) degrees (F). She stated if dietary staff left the salad out long enough, it could get in the danger zone (temperature range in which food-borne bacteria can grow), but it was not left out that long. Interview with the Certified Dietician (CD), on 01/05/17 at 4:15 PM, revealed DA #1 should have obtained every food item's temperature that was on the tray line. Cold foods should be at forty-one (41) degrees (F) or less, but not frozen. Hot foods should be one hundred forty (140) Degrees or greater when leaving the kitchen. An egg or mayonnaise based food item could grow bacteria and make a resident ill if it was not kept at the proper temperature. She stated Macaroni Salad had a mayonnaise base; therefore, it could grow bacteria. The CD revealed dietary staff should obtain the temperatures of food at the point of service.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to maintain effective infection control practices for two (2) of twenty-four (24) sampled residents, (Residents #15 and #19). Certified Nursing Assistants (CNA's) #1 and #2 were observed entering a Contact Precautions room lifting bed linen, kneeling on the floor, opening and closing drawers, moving the resident's personal belongings around, and handling items on the resident's bedside table. The CNA #1 failed to apply Personal Protective Equipment (PPE) and CNA #2 applied gloves only. A family member was observed in a Contact Precautions room without PPE on who stated the facility failed to educate him/her of the safety precautions regarding a contact precaution room. The findings include: Review of the facility's policy regarding Contact Precautions, not dated, revealed the staff used contact precautions for residents known to have serious illnesses that were transmitted by direct resident contact or by contact with items in the resident's environment. Contact precaution were used by the facility for residents who had acquired Methicillin-Resistant Staphylococcus Aureus (MRSA), a multi-drug resistant organism, to prevent the spread of the bacteria. Review of the Centers for Disease Control (CDC) Guideline regarding Precautions to Prevent the Spread of MRSA in Healthcare Settings, not dated, revealed Contact Precautions required gloves and gowns to be worn upon entry into a room of a patient/resident who was known to have MRSA. Review of the facility's Community Immunity pamphlet, not dated, described the different types of hospital acquired infections and how to avoid them. This pamphlet was given to each family/resident as part of the admission process, but it did not provide individualized education regarding infection or recommended PPE for a specific resident and family. 1. Review of Resident #15's clinical record revealed the facility admitted the resident on 09/23/15 with [DIAGNOSES REDACTED]. Review of Resident #15's Discharge Summary, dated 10/31/15, revealed on 10/23/15, Resident #15 was transferred to the hospital's emergency room Department due to pus coming from an open wound on the resident's RAKA which contained [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) growth and cellulitis and admitted . On 10/31/15, Resident #15 was discharged from the hospital and readmitted to the nursing facility with a Wound VAC (Vacuum Assisted Closure) applied to the RAKA site. Review of Resident #15's Physician order [REDACTED]. Review of Resident #15's Care Plan, dated 10/09/15, revealed nursing staff were to follow contact isolation precautions to prevent cross-contamination to visitors and employees. Review of Resident #15's Resident Summary (CNA Assignment Sheet), dated 10/31/15, revealed the CNAs were to follow contact isolation precautions for Resident #15 related to the right leg surgical wound with a Wound VAC. Observation, on 11/03/15 at 3:17 PM, revealed two (2) CNA's entered Resident #15,s room then proceeded to lift bed linen and pillows on the bed, kneeled on the floor looking under the bed and a chair, touched the resident's personal belongings and clothes, opened and closed drawers, touched items on the resident's bedside table, and walked in and out of the resident's bathroom. CNA #2, who entered the room first, had gloves on, and CNA #1 was not wearing any PPE. Interview with CNA #1, on 11/03/15 at 3:34 PM, revealed she had entered into Resident #15's room to look for the resident's cell phone and she had touched items in Resident #15's room attempting to locate the cell phone. CNA #1 stated she knew the resident was in isolation because of the cart that was outside the room, but since she didn't touch Resident #15, she wasn't required to wear PPE. CNA #1 also stated she had been trained by the facility's Staffing Coordinator to put on PPE before entering a resident's room who was in isolation to prevent the spread of infection to other residents and staff. Interview with CNA #2, on 11/03/15 at 4:05 PM, revealed she didn't put a gown on before she entered Resident#15's room because there wasn't any in the drawer and she would just quickly look for the resident's cell phone and leave the room. CNA #2 stated she thought it would be all right not to put the gown on because she had not given the resident personal care. CNA #2 also stated she was trained on Contact Precaution when she was employed in an assisted living facility. CNA #2 stated the purpose of PPE was to protect staff and residents from getting germs. Interview with the Unit Manager, on 11/04/15 at 11:56 AM, revealed staff was required to put PPE on before entering into an isolation room to prevent the spread of infection. The Unit Manager stated all staff had received orientation and in-services on infection precautions and protocols by the Staffing Coordinator and via computer. The Unit Manager also stated PPE gowns were located in the clean utility room on the unit and there was no excuse for staff not to put it on before entering a contact precaution room. Interview with Licensed Practical Nurse (LPN) #4, on 11/04/15 at 4:28 PM, revealed she had often provided care to Resident #15 and she knew that Resident #15 had VRE that was located in the resident's wound according to the infectious disease doctor. LPN #4 stated Resident #15 was placed in isolation and all staff was required to wear PPE before going into the resident's room to prevent transferring the infection to other residents because it would cause more residents to become ill. 2. Review of Resident #19's Clinical Record revealed the facility admitted the resident on 10/13/15 with [DIAGNOSES REDACTED]. Review of Resident #19's Physician order [REDACTED].#1 had an order that placed the resident in contact isolation on 10/13/15. Review of Resident #19's Care Plan, dated 10/21/15, revealed nursing staff were to follow contact isolation precautions for Resident #19 to prevent cross-contamination to visitors and employees. Observation, on 11/04/15 at 4:15 PM, revealed a stop sign outside Resident #19's door, instructing individuals to see the Nurse before entering and a PPE cart was to the right of the door. A gentleman was in Resident #19's room without any PPE on his person at the time. Interview with LPN #8, on 11/04/15 at 4:20 PM, revealed he had not educated Resident #19's family about the use of PPE and he was not sure if anyone else had either. Interview with LPN #3, on 11/05/15 at 9:15 AM, revealed the nursing staff educated the family and residents regarding the disease process related to infection and PPE. They do not demonstrate application of PPE, unless the family has requested it. She was not sure if Resident #19's family had been educated and she stated the education was not documented. She also stated when the wound was contained staff had difficulty getting the family to don PPE. Interview with Resident #19's family member, on 11/05/15 at 10:30 AM, revealed he/she was in Resident #19's room on 11/04/15 without PPE. He/she stated they had not received any education about MRSA or PPE from the facility. He/She did not think it was necessary. Interview with LPN #6, on 11/05/15 at 11:15 AM, revealed she was an agency staff and had worked for the facility for (two) 2 days. She stated the report sheet showed Resident #19 had MRSA and PPE was ordered. She stated she had infection control training within the last few months. Interview with LPN #7, on 11/05/15 at 11:20 AM, revealed he had worked for the facility for one and one half (1½) years and had been Resident #19's primary nurse on day shift. He stated Resident #19 had been on precautions since his/her admission. He stated he was trained on infection control with an online module and didactic methods. He did not educate the family regarding PPE or infection control stating he thought it was done on admission. Interview with Nurse Leader #1, on 11/05/15 at 11:30 AM, revealed the stop signs on the door had specific directions on the back describing the type of precautions and what PPE the staff was specifically to use. This helped CNAs to remain knowledgeable about the appropriate PPE. Families were educated on admission or if an infection developed following admission, but it was not documented. All families were given a Community Immunity pamphlet, as well. Interview with the Director of Nursing (DON), on 11/05/15 at 1:32 PM, revealed it was facility's policy for staff to put on PPE before entering into a contact precaution room for the protection of staff and other residents in the facility. The DON stated after the physician orders [REDACTED]. The DON also stated nursing staff was trained by the Staff Development Coordinator annually and they were in-serviced throughout the year on the on-line computer system. The DON stated she expected all staff to wear PPE as stated on the back of the sign outside the contact precaution rooms, before they entered the room. The DON further stated leadership staff had a track and trend system in place on infection control and they discussed the findings in their monthly meetings. Interview with the Administrator, on 11/05/15 at 1:32 PM, revealed staff was to put on PPE before entering an isolation room to protect residents, staff, and family members from acquiring the infection of the resident. The Administrator stated staff was trained during the orientation process of newly hired employees, staff had been in-serviced annually, staff were updated during the flu season and they had received additional training as needed on infection control and PPE. The Administrator stated the Nurse Managers and the Infection Control Nurse monitored staff and the residents that have been placed in isolation to ensure proper isolation protocols were in place and were adhered to by the staff, residents, and visitors. The Administrator also stated staff should not have entered an isolation room without PPE.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure glucometers were in safe operating condition by performing daily quality control tests on four (4) of twelve (12) glucometers on Walters House and Chandler House. The findings include: Review of the facility's policy regarding Blood Glucose Monitoring, revised June 2015, revealed quality control procedures were to be performed daily. Review of the Nightly Duties for nurses, not dated, revealed glucometer logs were to be completed nightly. Review of the Blood Glucose Monitoring System Daily Quality Control logs for Walters House, dated October 2015, revealed glucometer number one (#1) had only been tested twenty-two (22) out of thirty-one (31) days. Glucometer number two (#2) had only been tested twenty (20) out of thirty-one (31) days. Glucometers number one (#1) and number two (#2) had only been tested on e (1) of three (3) days for the month of November 2015. Review of the Blood Glucose Monitoring System Daily Quality Control logs for Chandler House, dated October 2015, revealed glucometer number one (#1) and number two (#2) had only been tested twenty (20) out of thirty-one (31) days. Glucometers number one (#1) and number two (#2) had only been tested on e (1) of three (3) days for the month of November 2015. Interview with Licensed Practical Nurse (LPN) #4, on 11/04/15 at 11:50 AM, revealed night shift nurses were responsible for completing daily quality control checks on glucometers and were to document results on the log. LPN #4 stated the purpose of the quality control test was to ensure glucometers were functioning properly. Interview with the Unit Manager of Chandler House, on 11/04/15 at 12:00 PM, revealed the blanks on the Blood Glucose Quality Control log meant quality control tests were not completed daily as directed by facility policy. The Chandler House Unit Manager stated if quality control tests were not completed the glucometer could give a false reading and a resident could receive the wrong dose of insulin. Interview, on 11/04/15 at 3:50 PM, with the Unit Manager of Walters House, revealed quality control tests were to be performed daily on the night shift. The Walters House Unit Manager stated the blanks on the Blood Glucose Quality Control log meant quality control tests were not done. In addition, the Walters House Unit Manager stated it was a standard of practice that all care provided, including quality control testing, be documented. Interview with the Director of Nursing (DON), on 11/05/15 at 8:45 AM, revealed facility policy directed nurses to complete quality control testing daily. The DON stated night shift nurses were instructed during new hire orientation on their responsibility to complete nightly glucometer testing. She stated the blanks on the Blood Glucose Quality Control log meant quality control tests were not completed on those days. The DON stated the glucometers were equipped with the option for a Quality Control (QC) lock mode, which did not allow a blood glucose test to be performed unless a control test had been performed in the past twenty-four (24) hours. However the lock mode was not set in all of the glucometers. The DON stated she did not monitor the logs for glucometer testing.

Based on interviews, closed record review, and review of the facility's care plan policy, it was determined the facility failed to ensure an interim care plan was developed that was sufficient in meeting the resident's identified needs (risk for falls) for one (1) of seven (7) sampled residents (Resident #1). The facility admitted Resident #1 on 05/29/14 with a [DIAGNOSES REDACTED]. Upon admission, the facility assessed the resident to be at risk for falls and the physician ordered a bed/chair alarm at all times. Review of the patient transfer form, from the acute hospital revealed the resident was forgetful, did not use the call light for communication, needed falls' protocol with alarms, and required the assist of two (2) for transfers. However, the interim care plan did not include these risk factors, or the physician ordered alarm device. On 06/13/14, Resident #1 was placed on the commode and left unattended by a Certified Nurse Aide (CNA). Resident #1 fell from the commode and sustained a [MEDICAL CONDITION] to the left femoral neck. The resident required surgical intervention to repair the fracture. The findings include: Review of the facility's care plan policy, revised April 2014, revealed the policy included initial admission care plans. The policy stated the facility would implement care planning procedures in accordance with acceptable standards of practice. The initial admission care plan would be initiated upon admission and revised until the comprehensive care plans were completed. The Admission Nurse would complete the initial care plan based on the admission assessment information. The Nurse Leaders would review orders, clinical issues, and update the care plan as indicated with new or discontinued treatments and changes of conditions. Care plan interventions were incorporated into the CNA assignment sheets as indicated to ensure implementation of interventions. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 05/29/14 with [DIAGNOSES REDACTED]. During the admission process, the facility conducted a fall assessment of Resident #1 that identified a fall risk. Review of the Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 06/05/14, revealed the facility assessed the resident to be totally dependent on staff for bed mobility, transfers, dressing, and toilet use with support of two (2) person physical assist. The balance test revealed the resident was not steady and needed staff assistance for stabilization for moving from a seated to standing position, and surface to surface transfer. Range of Motion (ROM) was impaired on the left side. A Brief Interview for Mental Status (BIMS) was performed with a score of eight (8) out of fifteen (15) obtained with the resident not being able to recall with cues, three (3) of three (3) words minutes after having them repeated. Review of the Care Area Assessment (CAA) summary revealed falls triggered and the facility documented a new care plan was started. Review of the Falls Care Plan, initiated on 05/29/14, revealed the resident was at risk for falls with a goal that the resident would not sustain a fall with injury by utilizing fall precautions through the next review on 08/29/14. Care plan approaches were to use the fall risk screen to identify risk factors, observe medications for side effects and report to physician, call light within reach, provide adaptive devices (walker, wheelchair), and remind the resident to lock the brakes on the bed/chair, Etc, before transferring. Referrals to Speech, Physical, and Occupational Therapy were included. The care plan was a standardized, check all that applies paper form. Further review revealed there were no specific approaches from the fall risk screen, nor did the care plan include the bed/chair alarm ordered by the physician upon admission. In addition, the initial care plan had not been revised to include therapy evaluations. The interventions for the call light to be within reach and remind the resident to lock the wheelchair brakes were not specific to this resident. Upon admission, the facility was knowledgeable that the resident did not utilize the call light system in the hospital and could not transfer without assistance of two (2) persons. Continued record review revealed an Interdisciplinary Care Plan meeting was held on 06/09/14 with Nursing, Dietary, Therapy, Social Worker, MDS Coordinator and Resident #1's spouse in attendance. The purpose of the meeting was to discuss the plan of care, goals, and concerns for Resident #1. However, there was no evidence the Falls Care Plan had been revised to reflect the resident's current functional status. Review of Speech Therapy Notes revealed an evaluation and treatment was initiated on 05/30/14. The Speech Therapist assessed the resident's cognition as moderate impairment and he/she was at risk for injury due to lack of orientation and judgment/reasoning. The Therapist documented the resident had difficulty with memory. Interview with the Speech Therapist, on 07/16/14 at 9:42 AM, revealed the resident had difficulty following directions and remembering. She stated she had to provide frequent cues and reminders. Review of the Occupational Therapy (OT) Notes revealed an evaluation and treatment was initiated on 05/30/14. The Therapist assessed the resident to require maximum assistance of two (2) persons to achieve balance on the commode and, to complete toileting tasks. Review of the Physical Therapist Notes, dated 06/12/14, revealed an evaluation and treatment was initiated on 05/30/14. On 06/12/14, a postural assessment scale for stroke patients was conducted. The test revealed the resident could stand with the strong support of two (2) people and could sit for more than ten (10) seconds without support. The test noted the resident could not sit for five (5) minutes without support. The Note stated if the resident was discharged at that time, the resident would be at increased risk of falling and functional decline. Interview with the Physical Therapist, on 07/16/14 at 9:57 AM, revealed she had been working with the resident on bed mobility, transfers and ambulation. She stated the resident's sitting balance was poor and he/she could not maintain for five (5) minutes without support. The resident's standing was very poor and he/she could not stand without support. Review of the closed clinical record revealed, on 06/13/14 at 10:35 AM, an entry by LPN #1, stated Resident #1 was found on the bathroom floor by the resident's daughter. The resident was found laying on his/her left side and complained of left hip pain. Further record review revealed a portable x-ray was ordered for the left hip that revealed a fractured femoral head. The resident was transferred to an acute hospital and required surgery to repair the left [MEDICAL CONDITION]. Interview with Certified Nurse Aide (CNA) #1, on 07/16/14 at 9:05 AM, revealed she was familiar with the resident's care needs. She stated on the day of the fall, she had taken Resident #1 into the bathroom to give the resident a sponge bath. She transferred the resident from the wheelchair to the commode (by herself) because that was normally where she bathed the resident. CNA #1 stated she had removed the resident's clothing, completed the sponge bath, and started to dress the resident (pants and underwear were pulled up to the resident's knees) when she received a message on her electronic device (device to alert staff when residents ring for assistance) that the emergency call light was activated from a resident's bathroom, directly across the hall. She stated the electronic device had been going off for some time and she was concerned about the resident across the hall. She stated she felt Resident #1 was safe to leave alone. CNA #1 instructed the resident to remain on the commode and told him/her that she would be right back. CNA #1 left Resident #1 alone in the bathroom. In addition, she failed to tell the daughter (who was in the resident's room) she was leaving the resident alone. CNA #1 stated she went across the hall and found the other resident brushing his/her teeth. She deactivated the light and returned to Resident #1's room. However, before she could reach the resident's room, she saw the resident's daughter running toward the bathroom and heard her say the resident was falling. When the aide entered Resident #1's bathroom, the resident was laying on the floor, on his/her left side. She notified the nurse and she came to assess the resident. CNA #1 stated she would know the resident's safety and care needs, because that information should be on the CNA's assignment sheet. However, CNA #1 stated she did not recall anything on the resident's sheet and she was unaware of the resident's fall risk, functional mobility status, and safety precautions. She stated she would not have left the resident alone if she had known about the resident's fall risk. When asked if the resident had an alarm attached, she said she knew nothing about an alarm and to her knowledge the resident had not utilized an alarm in the bed or chair. Request to review the assignment sheet for 06/13/14 was unsuccessful. The facility had deleted the resident from the current computer program and they did not keep a hard copy with that information. Interview with the daughter, on 07/16/14 at 12:15 PM, revealed she was in the resident's room (not the bathroom) when the fall occurred. She stated a nurse aide had transferred the resident into a wheelchair and taken him/her to the bathroom for a bath. She stated she was on the phone when she heard a yell and a crash sound in the bathroom. She jumped up and saw the resident laying on the bathroom floor. The wheelchair was unlocked and pushed to the middle of the bathroom floor. She noticed the left toilet rail had not been placed down as usual. She indicated she did not know when the aide had left the resident alone and stated the resident should never be left alone. She stated she did not recall any alarms being used in the bed or the chair. Interview with the Assistant Director of Nursing (ADON), in the presence of the new Director of Nursing, on 07/15/14 at 8:40 AM, revealed the root cause analysis of the fall was CNA #1 left the resident alone and did not inform the daughter she was leaving. He stated it was not a common practice to leave a resident on the commode alone. He continued, stating that Resident #1 was not stable enough to be left alone. He stated instructions or communication provided to CNA #1 in regards to Resident #1's care needs and safety interventions would have been on the CNA's assignment sheet. However, the ADON could not provide a copy of the assignment sheet for the day of the fall (06/13/14) and did not know what the resident's needs were at that time. Another interview with the ADON, on 07/16/14 at 11:40 AM, revealed communication between Therapy and Nursing occurred during the weekly utilization meetings. He stated residents under skilled care were discussed regarding the residents' care needs, goals, and functional mobility. He stated he would then update the CNA's assignment sheet with that information. He could not recall if Resident #1's assignment sheet included therapy's evaluation of the resident's functional mobility (including balance). He stated he would have considered what the resident was doing in therapy and compared that with nursing's goals. The ADON revealed he was unaware Resident #1 utilized a bed/chair alarm. He confirmed he had not revised the care plan until after the resident's fall. Interview with the Director of Nursing, on 07/16/14 at 12:49 AM, revealed she had asked several nurse aides about the alarm for the bed/chair and there was some confusion about if the resident ever utilized the alarm. She revealed she was not working at the facility when Resident #1 fell and had just recently reviewed the fall investigation. She stated the alarm use was not included in the root cause analysis. Interview, on 06/16/14 at 1:15 PM, with Registered Nurse (RN #1) who completed the admission paperwork for Resident #1, revealed the resident's admission was late in the day and she recalled the paperwork from the acute hospital ordered fall protocols. She stated that would mean bed/chair alarms and the facility utilized the pressure sensor type. She did put that order on the admission medication/treatment orders and verified with the resident's physician. She validated she initiated the Initial Care Plan for falls. Interview with the two (2) MDS Coordinators, on 07/16/14 at 4:31 PM, revealed neither developed or revised the fall's care plan for Resident #1. They both stated the falls care plan was not specific to this resident's functional status. Normally, they would complete the fall assessment then develop interventions addressing the identified risks. MDS Coordinator #1 stated since the resident was status [REDACTED]. She stated she would have spoken with Therapy and developed specific interventions to ensure the resident's safety. She indicated the bed/chair alarm and level of assistance required should have been on the interim care plan.

Based on interviews, closed record review, and review of the facility's Fall Policy, it was determined the facility failed to ensure one (1) of seven (7) sampled residents (Resident #1) received adequate supervision and assistive devices to prevent accidents while receiving daily care assistance. The facility admitted Resident #1 on 05/29/14 with [DIAGNOSES REDACTED]. Upon admission the facility assessed the resident to be at risk for falls. The physician ordered a bed/chair alarm at all times. On 06/13/14, Resident #1 was placed on the commode without the alarm and was left unattended by a Certified Nurse Aide (CNA). Resident #1 fell from the commode and sustained a hip fracture to the left femoral neck. The resident required surgical intervention to repair the fracture. The findings include: Review of the facility's Fall Policy, revised April 2014, revealed a fall risk assessment would be conducted upon admission, re-admission, quarterly, with significant changes, and post fall incidents. The objectives of the fall assessment would be to identify residents at high risk for falls and identify resident-specific fall prevention interventions for at risk residents. Co-morbidities for falls identified in the policy included stroke (CVA). Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 05/29/14, with [DIAGNOSES REDACTED]. Review of the patient transfer form from the acute hospital, dated 05/29/14, revealed the resident was forgetful, did not use a call light for communication, needed fall protocols with alarms, and required assist of two (2) for transfers. Review of the admission orders [REDACTED]. Review of the History and Physical revealed the resident had fallen at home with the CVA. During the admission process, the facility conducted a fall assessment for Resident #1 that revealed a score of fourteen (14) with fifteen (15) or greater representing high risk. However, further review revealed the facility did not assess the resident's gait/balance status, and instead documented the resident was unable to participate in the test. Review of the admission assessment, with an Assessment Reference Date (ARD) of 06/05/14, revealed the facility assessed the resident as totally dependent on staff for bed mobility, transfers, dressing, and toilet use with the support of a two (2) person physical assist. The balance test revealed the resident was not steady and needed staff assistance for stabilization for moving from seated to standing position, and surface to surface transfers. Range of motion (ROM) was impaired on the left side. A Brief Interview for Mental Status (BIMS) was performed with a score of eight (8) out of fifteen (15) obtained with the resident not being able to recall with cues, three (3) of three (3) words minutes after having them repeated. Review of the Care Area Assessment (CAA) summary revealed falls triggered and the facility documented a new care plan was started. Review of the CAA worksheet for falls revealed the facility identified the resident as being at risk for falls related to a history of falls, CVA with left [DIAGNOSES REDACTED], and a cognition impairment. Review of the Falls' Care Plan, initiated on 05/29/14, revealed the resident was at risk for falls with a goal that the resident would not sustain a fall with injury by utilizing fall precautions through the next review on 08/29/14. Care plan approaches were to use the fall risk screen to identify risk factors, observe medications for side effects and report to the physician, call light within reach, provide adaptive devices (walker, wheelchair), and remind the resident to lock brakes on the bed, chair, etc., before transferring. Referrals to Speech, Physical, and Occupational therapy were included. The care plan was a standardized, check all that applies paper form. Further review revealed there were no specific approaches from the fall risk screen, nor did the care plan include the bed/chair alarm that was ordered by the physician upon admission. (Refer to F-281) Review of the Speech Therapy Notes revealed an evaluation and treatment was initiated on 05/30/14. The Speech Therapist assessed the resident to have cognition with moderate impairment and was at risk for injury due to lack of orientation and judgment/reasoning. The goal for the resident to have functional problem solving and safety awareness for daily living tasks was not met. The Therapist documented the resident had difficulty with memory. Interview with the Speech Therapist, on 07/16/14 at 9:42 AM, revealed she was working with Resident #1 on safe swallowing techniques and orientation. She indicated the resident had difficulty following directions and remembering. She stated she had to provide frequent cues and reminders. Review of the Occupational Therapy (OT) Notes revealed an evaluation and treatment was initiated on 05/30/14. The Therapist assessed the resident to require a maximum assistance of two (2) persons to achieve balance on the commode and complete toileting tasks. Review of the Discharge Summary, dated 06/20/14, revealed the resident did not meet the goal of being able to achieve balance on the commode utilizing an arm sling and toilet rails with the minimum assistance of one (1) and moderate-maximum assistance for toilet transfers. The resident was identified as being at high risk for falls. The OT was not available for interview during the survey. Review of the Physical Therapist Notes revealed an evaluation and treatment was initiated on 05/30/14. On 06/12/14, the Therapist documented the resident was able to safely complete stand-pivot-sit transfers from bed to wheelchair with maximum assistance. A postural assessment scale for stroke patients was conducted on 06/12/14 with a score of 15/36 obtained. This test revealed the resident could stand with strong support of two (2) people and could sit for more than 10 seconds without support. Further review revealed the Note stated if the resident was discharged at that time, the he/she would be at increased risk of falling and functional decline. Review of the Discharge Summary Note, completed on 06/16/14, revealed the resident did not meet any goals and could not stand without support and required maximum assistance with bed mobility and transfers. Interview with the Physical Therapist, on 07/16/14 at 9:57 AM, revealed she had been working with the resident on bed mobility, transfers and ambulation. She stated the resident's sitting balance was poor and could not be maintained for five (5) minutes without support. The resident's standing was very poor and he/she could not stand without support. Review of the closed clinical record revealed documentation by a Clinical Coordinator, on 06/13/14 at 9:56 AM, that stated she was called to Resident #1's room regarding the resident's fall. Review of the Note revealed she had spoken with the daughter regarding the fall. During a physical assessment, the resident complaining of mild pain during range of motion to the left hip. She suggested to LPN #1 to notify the Nurse Practitioner (ARNP) and request a left hip x-ray. Continued review of the closed clinical record revealed an entry by LPN #1, on 06/13/14 at 10:35 AM, category of accident/incident, which revealed Resident #1 was found on the bathroom floor by the resident's daughter. The resident was laying on the left side and he/she said they had hit his/her head and left side during the fall. The resident was moved from the floor and placed in a wheelchair then into bed. The resident complained of hip pain. A portable x-ray of the left hip was ordered. Review of the clinical record revealed no documentation regarding the time of the fall, and what actions were taken at that time. (Refer to F-514) Review of a late entry documented, on 06/15/14 at 5:56 PM, by LPN #1, who had documented the fall under the category of accident/incident, report revealed the resident was on the commode and the nurse aide left to answer a call light. The daughter, who was in the resident's room, heard the resident hit the bathroom floor. The daughter requested an x-ray be obtained to rule out injury. The nurse documented she called the ARNP and obtained an order to get a portable x-ray of the left hip. The x-ray was obtained with findings of a left femur neck fracture. Further review revealed the resident's physician was called and orders were received to send the resident to the emergency room . The nurse documented the nurse aide was educated for future references to never leave the resident in the bathroom alone because the resident did not always remember that he/she could not walk or stand alone. Interview with Certified Nurse Aide (CNA) #1, on 07/16/14 at 9:05 AM, revealed she had worked with Resident #1 before and was familiar with the resident's care needs. She stated on the day of the fall, she had taken Resident #1 into the bathroom to give him/her a sponge bath. She transferred the resident from the wheelchair to the commode (by herself) because that was normally where she bathed the resident. She removed the resident's clothing, completed the sponge bath, and had started to dress the resident (pants and underwear was to the resident's knees) when she received a message on her electronic device that the emergency call light was activated from a resident's bathroom, directly across the hall. She stated the electronic device had been going off for some time and she was concerned about the resident across the hall. She stated she felt Resident #1 was safe to leave alone. CNA #1 instructed the resident to remain on the commode and told the resident she would be right back. As she was leaving the bathroom, she saw the resident's daughter in the resident's room, but did not tell her she was leaving the resident. Further interview revealed the family stayed with the resident all the time and would come into the bathroom at times. CNA #1 stated she went across the hall and found the other resident brushing his/her teeth. She deactivated the light and returned to Resident #1's room. However, before she could reach the resident's room, she saw the resident's daughter running toward the bathroom and heard her say the resident was falling. When the aide entered Resident #1's bathroom, the resident was laying on the floor, on his/her left side, to the left of the commode. CNA #1 stated she had failed to put the left toilet rail down. She stated she would normally have placed the toilet rail down so the resident would have something to hold onto for safety. She notified the nurse and she came to assess the resident. Continued interview with CNA #1 revealed she was unaware of the resident's fall risk, functional mobility status, and safety precautions. She stated she would not have left the resident alone if she had known about the resident's fall risk. When asked if the resident had an alarm attached, she said she knew nothing about an alarm and to her knowledge the resident had not utilized an alarm in the bed or chair. Request to review the assignment sheet for 06/13/14 was unsuccessful. The facility had deleted the resident from the current computer program because the resident no longer lived there and they did not keep a hard copy with that information. Interview with the Daughter, on 07/16/14 at 12:15 PM, revealed she was in the resident's room (not the bathroom) when the fall occurred. She stated a nurse aide had transferred the resident into a wheelchair and took the resident to the bathroom for a bath. She stated the resident recently had a CVA and had left sided weakness and was at the nursing facility to receive therapy with the goal of returning home. She stated the resident would often lean forward and to the left side since the stroke and he/she should not have been left alone. Further interview revealed the family had been staying around the clock and would even go into the bathroom with the resident if that ensured the resident's safety. She said she told staff many times if they needed her assistance, to just let her know. The Daughter stated she was on the phone when she heard a yell and a crash sound in the bathroom. She jumped up and saw the resident laying on the bathroom floor. The wheelchair was unlocked and pushed to the middle of the bathroom floor. She noticed the left toilet rail was up and it had usually been placed down. She indicated she did not know when the aide had left the resident because the resident was never supposed to be left alone. She said she would have stayed with the resident if the aide had told her she needed to leave. Further interview revealed she did not recall any alarms used in the bed or chair. She revealed she had observed staff transferring the resident from the bed to the wheelchair and did not recall an alarm sounding. She said the only thing used was the pendant around the resident's neck that was used as a call light. She stated the resident required surgery to repair the hip fracture and had a decline in the functional mobility since the fall. Interview with the Assistant Director of Nursing (ADON), in the presence of the new Director of Nursing, on 07/16/14 at 8:40 AM, revealed he conducted part of the fall investigation and had went to Resident #1's room after the fall. The ADON revealed the root cause analysis of the fall was CNA #1 left the resident alone and did not inform the daughter she was leaving. He stated it was not a common practice to leave a resident on the commode alone and continued to state Resident #1 was not stable enough to be left alone. He indicated the CNA was worried about the resident across the hall and thought Resident #1 would be okay to leave. When asked what instructions or communication had been provided to CNA #1 in regard to Resident #1's care needs, he stated that information would have been on the CNA's assignment sheet. However, the ADON could not provide a copy of the assignment sheet for the day of the fall (06/13/14) and did not know what the resident's needs were at that time. He did not keep a hard copy for the fall investigation. The ADON stated other administrative staff reviewed the fall investigation and confirmed the root cause. He stated CNA #1 was instructed not to leave the resident alone, the care plan and the CNA assignment sheet were all updated after the fall. The facility did not provide access to the fall investigation. The ADON revealed the nurse who assessed the resident and cared for Resident #1 on the day of the fall, 06/13/14, no longer worked at the facility and did not return their calls for further information. The surveyor attempted to contact this nurse three (3) times via telephone with no success. The nurse did not return the requested call. Another interview with the ADON, on 07/16/14 at 11:40 AM, after he provided a late entry note from the computer, dated 06/15/14 at 5:56 PM, revealed he had requested the nurse to document more information about Resident #1's fall. When he reviewed the incident report he identified the nurse had left out pertinent information and requested the late entry. He also revealed communication between Therapy and Nursing occurred during the weekly utilization meetings. He stated residents under skilled care were discussed regarding the residents' care needs, goals, and functional mobility. He stated he would then update the CNA's assignment sheet with that information. He could not recall if Resident #1's assignment sheet included a therapy evaluation of the resident's functional mobility (including balance). He stated he would have considered what the resident was doing in therapy and compared that with nursing's goals. The ADON revealed he was unaware Resident #1 utilized a bed/chair alarm. He said, it was not included in the facility's fall investigation. Interview with the Director of Nursing, on 07/16/14 at 12:49 AM, revealed she had asked several nurse aides about the alarm for the bed/chair and there was some confusion if the resident ever utilized the alarm. She revealed she was not working at the facility when Resident #1 fell and had just recently reviewed the fall investigation. She stated the alarm use was not included in the root cause analysis. Interview, on 06/16/14 at 1:15 PM, with Registered Nurse (RN #1) who completed the admission paperwork for Resident #1, revealed she recalled the paperwork from the acute hospital had ordered fall protocols. She stated that would mean bed/chair alarm and the facility utilized the pressure sensor type. She put that order on the admission medication/treatment orders and verified with the resident's physician. She could not recall, but she thought she went to central supply to obtain a sensor alarm, but she did not put it on Resident #1's bed. She stated nurses were supposed to check for those devices, but did not recall if the resident utilized an alarm. She revealed she was not working the day of Resident #1's fall.

Based on interview, record review and review of nursing standards of practice and the facility's policy, it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality related to physician orders. Interview and record review revealed licensed staff were not ensuring physician orders were reviewed and validated for accuracy for six (6) of thirty-eight (38) sampled residents. (Resident #1, #3, #16, #29, #31 and #35) and one (1) of the eight (8) unsampled residents (Unsampled Resident H). On [DATE] the facility admitted Resident #1 with an order for [REDACTED]. The admitting Licensed Practical Nurse (LPN) #3 altered the physician's order by adding to the directions to administer the antibiotic "after HD on HD", (after [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days). This order was never verified with the resident's physician; the [MEDICAL TREATMENT] center was not aware of the antibiotic therapy; and, the facility staff failed to transcribe the order to the Medication Administration Record to ensure medication administration occurred. Record review revealed no documented evidence Resident #1 received the antibiotic on [DATE] through [DATE], twenty-four (24) of the twenty-eight (28) days as ordered by the physician. On [DATE], the resident developed a mental status change and was transferred to the hospital and admitted with an impression of Toxic Metabolic [MEDICAL CONDITION] secondary to gram-positive cocci [MEDICAL CONDITION] with Bacteremia, likely a recurrence of underlying [MEDICAL CONDITION]. The resident did not return to the facility, but was transferred to another local Long Term Care facility and expired on [DATE]. In addition, the Assistant Director of Nursing (ADON), wrote an order for [REDACTED]. LPN #8 transcribed an order, for [MEDICATION NAME] 500 milligrams (mg) every day for ten (10) days from the emergency room information for Resident #16, without verifying the order with the resident's physician. The ADON wrote a physician's order on the physician order sheet for [MEDICATION NAME] 20 mg for Resident #29 without an order from the physician and did not have the physician sign the order. LPN #2 transcribed a duplicated medication order for [MEDICATION NAME] 40 mg that caused a double dose of the medication to be given three times to Resident #31 before it was identified and there was no evidence the physician had been notified of the duplicated error. LPN #14 failed to accurately transcribe a physician's order for Resident #35 onto the EMAR for Vitamin B-12. The physician's order should have read Vitamin B-12 1000 microgram (mcg) orally to be given every day. However, it was written as Vitamin B-12 250 mcg orally every day. A clarification order was not obtained until [DATE], thirty-four (34) days after the medication was entered incorrectly into the EMAR computer system. Unsampled Resident H had an order for [REDACTED]. The facility's failure to have an effective system in place to ensure services provided met professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] and the Immediate Jeopardy was determined to be removed on [DATE] as alleged, prior to exit. The scope and severity was lowered to a "E" while the facility continues to implement and monitor quality assurance measures. The findings include: A review of the Kentucky Board of Nursing, Advisory Opinion Statement, (AOS) #14 Patient Care Orders, revised ,[DATE], #5 revealed a nurse was obligated to not change an order of a physician/provider without the physician/provider's order to do so. Review of the Scope of Practice Determination Guidelines, revised ,[DATE] revealed Licensed Practical Nurses would practice the administration of medication or treatment as authorized by a physician, physician assistant, dentist, or advanced practice registered nurse and as further authorized or limited by the board which is consistent with the National Federation of Licensed Practical Nurses or with standards of practice established by nationally accepted organizations of licensed practical nurses. Review of the facility's policy regarding Medication Orders, not dated, revealed medications are administered only upon the clear, complete and signed order of a person lawfully authorized to prescribe. Elements of the medication order include the name of the medication, strength of the medication, time or frequency of administration, route of administration, quantity or duration of therapy and [DIAGNOSES REDACTED]. 1. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Summary, dated [DATE], revealed Resident #1 was to receive [MEDICATION NAME] two (2) grams intravenously (IV) for twenty-eight (28) days. Further review of the Physician Orders, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 documented Resident #1 was to receive [MEDICATION NAME] two (2) grams intravenously daily after [MEDICAL TREATMENT] (HD) on HD days. LPN #3 then signed on the reviewed line that she had called the Physician to verify the orders. Interview with LPN #3, on [DATE] at 3:56 PM, revealed she transcribed the orders from the discharge summary onto the physician's order sheet. She stated she changed the order to read after [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days as this was the usual routine so the antibiotic did not get flushed from the system. LPN #3 further stated she did not verify the order because she did not want to call the physician at 2:00 AM. She further stated she did not transcribe the order onto the Medication Administration Record (MAR). Further interview with LPN #3 revealed she did sign the order to indicate it was verified with the physician even though she did not call the physician to receive verification of the orders she wrote. LPN #3 stated she should not have changed the order without a physician's order to do so. Interview with LPN #1, on [DATE] at 1:13 PM, revealed she could not remember working on Resident #1's admission. LPN #1 did not remember putting the orders into the computer and further did not remember working on the unit. Interview with LPN #4, on [DATE] at 11:50 AM, revealed she would not add to an order on the Physician Order Sheet, unless directed by a physician. LPN #4 stated it was not her scope of practice to add to the order that a physician had given her. She stated she would call and verify the order with the doctor and sign the physician's order statement (POS) indicating that the order had been verified. Interview with the House Leader LPN #2, on [DATE] at 12:19 PM, revealed she was not teaching the nursing staff to add (on HD after HD) to the orders. The House Leader stated it was above the nurses scope of practice to add to an order that the doctor did not give her. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 1:10 PM, revealed the orders were not accurate since the order had been changed without physician clarification. Interview with the Director of Nursing (DON), on [DATE] at 4:50 PM, revealed the facility had identified transcription of medications as a concern when the medication error was discovered for Resident #1 and was it was being investigated. She stated the nurses had to ensure the orders validated what was in the computer. Interview with Physician #1, on [DATE] at 1:35 PM, revealed he did not remember instructing the nurse to give Resident #1's antibiotic on [MEDICAL TREATMENT] days after the [MEDICAL TREATMENT] treatment. He further stated nurses should not add to the orders. 2. Review of the clinical record for Resident #31 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission physician order sheet (POS), dated [DATE], revealed Resident #31 had an order for [REDACTED]. Further review of Resident #31's physician orders revealed a telephone order, dated [DATE], to increase [MEDICATION NAME] to 40 milligrams daily and to add [MEDICATION NAME] 20 milligrams by mouth daily for three (3) days. Review of the Electronic Medication Administration Record (EMAR) revealed the [MEDICATION NAME] 40 milligram order was on the EMAR twice (a duplicated order) and the duplicated [MEDICATION NAME] 40 milligrams was documented as having been given twice on [DATE], [DATE], once on [DATE] and then twice on [DATE] for a total of 80 mg each day. Review of the notes attached to the EMAR revealed the Certified Medication Technician (CMT) administered the routine 40 mg dose of [MEDICATION NAME] and held the duplicated dose on [DATE] as the CMT assigned to administer those medications had recognized the duplicated order. However, continued review of the EMAR revealed the resident received another 80 mg dose on [DATE], even though the CMT had noted it was a duplicate order. Attempt to interview Resident #31's physician, on [DATE] at 10:50 AM, revealed she was on vacation and unavailable. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 11:00 AM, revealed she could not locate a medication error incident report for the three (3) doses of 80 mg of [MEDICATION NAME] Resident #31 received in the computerized nurses notes and she did not find any evidence the resident's physician was informed. Interview with CMT #15, on [DATE] at 11:30 AM, revealed she did recognize the duplicate order of [MEDICATION NAME] for Resident #31, but as a CMT, she was not authorized to correct the order in the EMAR or to complete a medication error incident report. She stated she did tell the nurse on duty on [DATE] when she recognized the error but she did not remember who the nurse was and she did not document what she did. Interview with LPN #2, on [DATE] at 3:40 PM, revealed she was the nurse who transcribed the duplicate order of [MEDICATION NAME] onto Resident #31's EMAR, but she did not realize it was a duplicate order at that time. She stated she should have discontinued the [DATE] order for [MEDICATION NAME] 40 milligrams when she entered the [DATE] order for [MEDICATION NAME] 40 milligrams. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 1:45 PM, revealed she recognized the duplicate order for [MEDICATION NAME] 40 milligrams for Resident #31 on [DATE] after the duplicate dose had been given and she completed a medication error report. She presented the report with no indication the physician was informed and no date of completion. She indicated she did not follow-up with the CMT or nurses involved, but passed that responsibility on to the nurse House Leader who no longer worked at the facility. 3. Record review revealed the facility admitted Resident #35, on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. However, review of the EMAR revealed the order was entered, on [DATE], by the facility as Vitamin B-12 250 mcg orally every day. The resident received the 250 mcg every day. A clarification order was not obtained until [DATE], thirty-four (34) days after the medication was entered incorrectly into the EMAR computer system. Interview with Licensed Practical Nurse (LPN) #14, on [DATE] at 3:40 PM, revealed she did remember completing the admission for Resident #35, but did not remember the resident's ordered Vitamin B-12 dosage. The LPN revealed no one had told her of an order entry error, or questioned the admission orders [REDACTED] Interview with Physician #2, on [DATE] at 3:16 PM, revealed the facility entering the wrong dosage was not a significant error that would have hurt the resident, but was definitely wrong and a transcription error. The physician revealed he was not notified by the facility of the error. Interview with ADON, on [DATE] at 3:05 PM, revealed Resident #35's medication error was discovered with the audits that were taking place in the building on [DATE] to [DATE]. The ADON revealed she did complete the clarification order. However, the ADON revealed she did not complete an incident report or complete an investigation as to why the error occurred. 4. Review of the clinical record for Resident #29 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. On admission the resident had a physician order for [REDACTED]. On [DATE] the physician ordered to increase [MEDICATION NAME] to 40 mg daily for five (5) days for [MEDICAL CONDITION]. On [DATE] the ADON clarified the order. The order was not signed by the physician from [DATE] to [DATE] (21 days). Interview with the ADON, on [DATE] at 2:20 PM, revealed she had written the order to be signed on the physician's next visit. Although the EMAR was correct and the resident received the appropriate amount of [MEDICATION NAME], there was no order signed by the physician. Interview with the DON, on [DATE] at 2:40 PM, revealed she did not know the ADON was writing orders without legal authorization to do so. She further revealed she was not aware the resident received additional [MEDICATION NAME] without a signed physician's order. 5. Review of the clinical record for Resident #3 revealed the facility admitted the resident on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. There was no frequency (how often the drug should be given) included in the admission order. Review of the Electronic Medication Administration Record (EMAR) revealed on [DATE] the order was placed in the electronic system to be given daily despite no physician's orders or an order clarifying the medication. Further review of the resident's medical record revealed [REDACTED]. The clarification order did not indicate which physician gave the order, or how the order was obtained. The order sheet was marked as being faxed to pharmacy. Telephone interview with Physician #5, on [DATE] at 10:10 AM, revealed he did not receive a phone call from the facility to verify the resident's order for [MEDICATION NAME], or any other order. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 10:39 AM, revealed she was not asked by any member of the facility staff to clarify any orders for the resident and did not write any orders for the resident the evening of [DATE]. Interview with the ADON, on [DATE] at 2:20 PM, revealed the clarification order was written by her. The ADON confirmed she did write the order without obtaining a physician's order, or from anyone legally authorized to do so. The ADON revealed she knew writing the order was outside her scope of practice, but wanted to ensure clarification was done. The ADON revealed she thought she could just get the doctor to sign the order for her when he came in the next day. 6. Record review for Resident #16, on [DATE], revealed there was an order for [REDACTED]. Review of Resident #16's Electronic Medication Administration Record (EMAR) revealed the order was transcribed onto the resident's EMAR and faxed to the pharmacy on [DATE]. Further review of Resident #16's EMAR revealed the medication was administered to the resident for two (2) days on [DATE] and [DATE], before the attending physician was notified and the order verified. Interview with LPN #8, on [DATE] at 12:02 PM, revealed she received Resident #16 (a current resident) from an emergency room (ER) visit at a local hospital on [DATE]. The ER physician (no name) wrote an order for [REDACTED]. physician. LPN #8 stated, she always writes the orders from the ER per the ER physician and she does not verify the order with the attending physician. However, review of the facility's policy revealed the nurse who received the order was to verify the order with the current attending physician before medications were administered. Interview with LPN #9, on [DATE] at 11:40 AM, revealed if she had received an order from a local hospital she would call the attending physician for approval of the orders. Interview with the Director of Nursing (DON), on [DATE] at 11:15 AM, revealed the nurse receiving the order from a local hospital should call the primary care physician to obtain approval for the medication ordered. There should have been a clarification order from the primary care physician for Resident #16. 7. Review of the closed record for Unsampled Resident H revealed the resident was ordered to receive [MEDICATION NAME] 3 milligrams (mg) at night (HS) on [DATE]. The [MEDICATION NAME] order was not placed onto the Medication Administration Record (MAR) until [DATE]. Therefore, Resident H did not receive his/her medication until four (4) days later. Review of the Medication Error Report revealed the error was discovered through a chart audit completed on [DATE] to [DATE]; however, an investigation was not completed as to what the root cause was for the medication not being transcribed onto the MAR. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 10:40 AM, revealed there was no documented investigation report for the medication error. The investigation report would document who reported the incident, whom was involved, notifications to the House Leader, ADON, Director of Nursing (DON) with date and time. In addition there was no follow-up provided with the medication error. Interview with the DON, on [DATE] at 10:01 AM, revealed she did not complete an investigation into Resident H's medication error. She stated she thought the House Leader would of completed one. The DON stated she did print out incident reports, but did not have one for Resident H. Review of the Acceptable Allegation of Compliance (AOC) on [DATE], revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review that verified care plan were updated,beginning [DATE] through [DATE]. 3. In-services were conducted from [DATE] through [DATE]. The in-services included topics of updating the care plan related to medication orders were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor for accurate processing of new orders and that care plans were updated accordingly. 5. The DON was responsible for assuring the daily review process of physician orders and care plan updates as discussed were audited and reported for weekly review by the Quality Assurance Committee. The State Survey Agency validated the AOC on [DATE] prior to exit as follows: 1. Record review revealed Resident #1 had been discharged on [DATE] and not scheduled to return. 2. Record review revealed chart audits were completed on [DATE] through [DATE] to ensure nursing care plans for residents were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders and medication administration records. Interview with the interim DON (Consultant), on [DATE] at 12:30 PM, revealed she had completed all chart audits from [DATE] to [DATE] by looking at physician orders and medication administration records. 3. Record review revealed an in-service was provided by ADON and Quality Consultant on [DATE] through [DATE], by review of the content of the in-service and review of the attendance logs for the in-service revealed all nursing staff attended the inservice. Interviews conducted on [DATE] with five (5) Licensed Practical Nurses: LPN #4 at 4:55 PM, LPN #2 at 6:05 PM, LPN #13 at 5:45 PM, LPN #14 at 6:33 PM, LPN #15 at 6:33 PM, two (2) Registered Nurses: RN #5 at 4:50 PM, and RN #4 at 5:57 PM, and three (3) Certified Medication Technicians (CMT)'s; CMT #1 at 11:22 AM, CMT #20 at 5:55 PM, and CMT #21 at 5:50 PM revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, and re-verification of orders in the EMAR system. Interview with LPN #3 at [DATE] at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on [DATE] at 6:33 PM, revealed she was also educated on checking for accuracy and making sure not to interpret the orders, but to write the orders exactly as the physician wrote them. 4. Record review revealed the Administrative staff conducted daily reviews of new admission and daily orders to monitor to ensure records were accurate. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily. Interview with the ADON, on [DATE] at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order sheet and then compared these documents to the computer to ensure items were correct and matched. Record review revealed the DON submitted all reviews to the Quality Assurance Committee. 5. Review of the care plan audit updates and weekly review information given to the QA committee revealed the documents were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), (Nursing, Activities, Social Services and Dietary), on [DATE] at 2:03 PM, revealed the interdisciplinary team met daily to review audits for updates and weekly review of all information obtained through out the week.

Based on interview, record review, and facility policy review it was determined the facility failed to be administered to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to have an effective system to ensure policy and procedures were implemented related to medication orders and failed to ensure licensed staff followed nursing standards of practice. On [DATE] the facility admitted Resident #1 with an order for [REDACTED].[REDACTED]'s order by adding to the directions to administer the antibiotic "after HD on HD", (after [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days). This order was never verified with the resident's physician and the [MEDICAL TREATMENT] center was not aware of the antibiotic therapy. Record review revealed no documented evidence Resident #1 received the antibiotic on [DATE] through [DATE] twenty-four (24) of the twenty-eight (28) days as ordered by the physician. On [DATE], the resident developed a mental status change and was transferred to the hospital and admitted with an impression of Toxic Metabolic [MEDICAL CONDITION] secondary to gram-positive cocci [MEDICAL CONDITION] with Bacteremia, likely a recurrence of underlying [MEDICAL CONDITION]. The resident did not return to the facility, but was transferred to another local Long Term Care facility and expired on [DATE]. Interview and record review revealed medication errors and/or transcription errors for eight (8) of thirty-eight (38) sampled residents (Residents #1, #3, #5, #6, #16, #29, #31, #35) and one (1) unsampled resident (Unsampled Resident H) during the standard/abbreviated survey. (Refer to F281, F333, F514 and F520) The facility's failure to be administered to maintain the highest practicable physical, mental and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] and the Immediate Jeopardy was determined to be removed on [DATE] as alleged, prior to exit. The scope and severity was lowered to a "E" while the facility continues to implement and monitor quality assurance measures. The findings include: A review of the Kentucky Board of Nursing, Advisory Opinion Statement, (AOS) #14 Patient Care Orders, revised ,[DATE], #5 revealed a nurse was obligated to not change an order of a physician/provider without the physician/provider's order to do so. Review of the Scope of Practice Determination Guidelines, revised ,[DATE] revealed Licensed Practical Nurses would practice the administration of medication or treatment as authorized by a physician, physician assistant, dentist, or advanced practice registered nurse and as further authorized or limited by the board which is consistent with the National Federation of Licensed Practical Nurses or with standards of practice established by nationally accepted organizations of licensed practical nurses. Review of the facility's policy regarding Medication Orders, not dated, revealed medications were administered only upon the clear, complete and signed order of a person lawfully authorized to prescribe. Elements of the medication order included the name of the medication, strength of the medication, time or frequency of administration, route of administration, quantity or duration of therapy and [DIAGNOSES REDACTED]. Interview with the Administrator, the Executive Director, and the Interim Director of Nursing, on [DATE] at 2:15 PM, revealed the Executive Director came to the facility on [DATE] and Administrator came to the facility on [DATE]. They stated they were aware of medication/transcription errors occurring in the facility and had addressed the problems with an audit process, but the errors continued to occur. The Executive Director stated it would not be acceptable for medication errors to continue at the rate they have been in order to maintain the highest well-being of it's residents and that the facility had not been administered in a manner to ensure the highest well-being of it's residents. Interview and record review revealed facility licensed staff was changing physician medication orders and/or implementing medication orders without notifying or verifying the medication order with the physician. Interview with Licensed Practical Nurse (LPN) #3 and the Assistant Director of Nursing (ADON) revealed they had not received any training in the physician order [REDACTED]. Further interview with LPN #3 and the ADON revealed they knew writing orders was outside their scope of practice, and orders should not have been altered and/or implemented without physician verification. Interview with LPN #8 revealed she always wrote the orders for readmissions and did not verify the order with the attending physician for approval. Interview with the ADON, on [DATE] at 2:20 PM, revealed she was also the Staff Development Coordinator and conducted training for facility staff. She stated in orientation new nurses were trained in medication administration and medication error policies. The ADON stated the first of June and [DATE] an in-service was held on the resident admission process and covered the policy on physician orders [REDACTED]. Interview with the Director of Nursing (DON), on [DATE] at 11:15 AM, revealed the nurse receiving the order from a local hospital should call the primary care physician to obtain approval for the medication ordered. Further interview with the Director of Nursing (DON), on [DATE] at 2:40 PM, revealed the facility was in the process of doing chart reviews and any discrepancies which were identified should have been clarified prior to [DATE]. Interview with the Administrator, the Executive Director, the Director of Nursing and the Interim Director of Nursing, on [DATE] at 2:00 PM, revealed the 'root cause' of multiple medication errors in the facility was a 'computer glitch'. However, they did not have a facility plan to address the computer glitch. Review of the Acceptable Allegation of Compliance (AOC) on [DATE], revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review that verified care plan were updated,beginning [DATE] through [DATE]. 3. In-services were conducted from [DATE] through [DATE]. The in-services included topics of updating the care plan related to medication orders were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor for accurate processing of new orders and that care plans were updated accordingly. 5. The DON was responsible for assuring the daily review process of physician orders [REDACTED]. The State Survey Agency validated the AOC on [DATE] prior to exit as follows: 1. Record review revealed Resident #1 had been discharged on [DATE] and not scheduled to return. 2. Record review revealed chart audits were completed on [DATE] through [DATE] to ensure nursing care plans for residents were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders [REDACTED]. 3. Record review revealed an in-service was provided by ADON and Quality Consultant on [DATE] through [DATE], by review of the content of the in-service and review of the attendance logs for the in-service revealed all nursing staff attended the inservice. Interviews conducted on [DATE] with five (5) Licensed Practical Nurses: LPN #4 at 4:55 PM, LPN #2 at 6:05 PM, LPN #13 at 5:45 PM, LPN #14 at 6:33 PM, LPN #15 at 6:33 PM, two (2) Registered Nurses: RN #5 at 4:50 PM, and RN #4 at 5:57 PM, and three (3) Certified Medication Technicians (CMT)'s; CMT #1 at 11:22 AM, CMT #20 at 5:55 PM, and CMT #21 at 5:50 PM revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, and re-verification of orders in the EMAR system. Interview with LPN #3 at [DATE] at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on [DATE] at 6:33 PM, revealed she was also educated on checking for accuracy and making sure not to interpret the orders, but to write the orders exactly as the physician wrote them. 4. Record review revealed the Administrative staff conducted daily reviews of new admission and daily orders to monitor to ensure records were accurate. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily. Interview with the ADON, on [DATE] at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order [REDACTED]. Record review revealed the DON submitted all reviews to the Quality Assurance Committee. 5. Review of the care plan audit updates and weekly review information given to the QA committee revealed the documents were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), (Nursing, Activities, Social Services and Dietary), on [DATE] at 2:03 PM, revealed the interdisciplinary team met daily to review audits for updates and weekly review of all information obtained through out the week.

Based on interview, record review, and review of facility policy it was determined the facility failed to have an effective system to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for seven (7) of thirty-eight (38) sampled Residents #1, #3, #5, #16, #29, #31, #35) and one (1) unsampled resident records (Unsampled Resident H). On [DATE] the facility admitted Resident #1 with orders for the antibiotic [MEDICATION NAME] to be administered daily intravenously for twenty-eight (28) days due to an infection in the hip and elbow. The facility staff failed to administer the antibiotic daily for 28 days when the admitting Licensed Practical Nurse (LPN # 3) altered the physician's order by adding directions to administer the antibiotic at the [MEDICAL TREATMENT] center after treatment. This order was never clarified with the resident's physician and the [MEDICAL TREATMENT] center was not aware of the antibiotic therapy. Resident #1 did not receive the antibiotic for twenty-four (24) days (length of stay) of the ordered 28 days. On [DATE], the resident developed a mental status change and was transferred to the hospital and admitted with an impression of Toxic Metabolic [MEDICAL CONDITION] secondary to gram-positive cocci [MEDICAL CONDITION] with Bacteremia, likely a recurrence of underlying [MEDICAL CONDITION]. The resident did not return to the facility, but was transferred to another local Long Term Care facility and expired on [DATE]. In addition Residents #3, #5, #16, #29, #31, #35, and Unsampled Resident H had transcription errors related to medication orders. The facility's failure to have a system in place to ensure the accuracy of the medical record has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] and the Immediate Jeopardy was determined to be removed on [DATE] as alleged, prior to exit on [DATE]. 42 CFR 483.75 Administration (F514) scope and severity was lowered to a "E" while the facility continues to implement and monitor quality assurance measures. The findings include: Record review of the Health Information Management and Procedure Policy, revised ,[DATE], revealed medical records utilized in the facility consisted of both paper and electronic documentation. Electronically maintained medical records follow the same guidelines for completion, accuracy and privacy as those maintained on paper. The residents record is a legal, factual and objective recording of the residents condition, problems, plans of care and outcomes. 1. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Discharge Summary, dated [DATE], revealed Resident #1 was to receive [MEDICATION NAME] two (2) grams into the vein daily for twenty-eight (28) days. Review of Resident #1's POS, dated [DATE], revealed the [MEDICATION NAME] order was written to read: [MEDICATION NAME] 2g IV QD (after HD on HD days). Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 3:56 PM, revealed she initiated Resident #1's admission Physician Order Sheet (POS) and documented on the POS that Resident #1 was to receive [MEDICATION NAME] two (2) grams daily (QD), after [MEDICAL TREATMENT] (HD) on HD days. LPN #3 stated she should have not added to the order the (after HD on HD days), since she did not obtain an order for [REDACTED]. Interview with the Physician, on [DATE] at 1:35 PM, revealed he did not remember instructing LPN #3 to give the antibiotic medication on [MEDICAL TREATMENT] days and after the [MEDICAL TREATMENT] treatment. Interview with the House Leader, on [DATE] at 12:19 PM, revealed she was to conduct chart checks on her unit daily. However, the House Leader stated she did not complete a chart check of Resident #1's Physician orders. Interview with the ADON, on [DATE] at 1:10 PM, revealed when she initially looked at Resident #1's order all she could see was the HD and did not notice the QD (daily). 2. Review of the closed record for Unsampled Resident H revealed the resident was ordered to receive [MEDICATION NAME] 3 milligrams (mg) at night (HS) on [DATE]. The [MEDICATION NAME] order was not placed onto the Medication Administration Record (MAR) until [DATE]. Therefore, Resident H did not receive his/her medication until four (4) days later. Review of the Medication Error Report revealed the error was discovered through a chart audit on [DATE] to [DATE]; however, an investigation was not completed as to what the root cause was for the medication not being transcribed onto the MAR. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 10:40 AM, revealed there was no documented investigation report for the medication error. The investigation report would document who reported the incident, whom was involved, Notifications to the House Leader, ADON, Director of Nursing (DON) with date and time. Was their any property involved, the activity time and who the report was prepared by. In addition there was no follow up provided to see who followed up with the medication error. The ADON stated Resident H's record was not kept as accurate as it should of been. Interview with the DON, on [DATE] at 10:01 AM, revealed she did not complete an investigation into Resident H's medication error. She stated she thought the House Leader would of completed one. The DON stated she did print out incident reports, but did not have one for Resident H. 3. Review of the clinical record for Resident #31 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission physician order sheet (POS) dated [DATE] revealed Resident #31 had [MEDICATION NAME] (a drug used to remove extra fluid) 40 milligrams by mouth daily ordered. Further review of Resident #31's physician orders revealed a telephone order dated [DATE] to increase [MEDICATION NAME] to 40 milligrams daily and to add [MEDICATION NAME] 20 milligrams by mouth daily for three (3) days. Review of the Electronic Medication Administration Record (EMAR) revealed the [MEDICATION NAME] 40 milligram order was on the EMAR twice (a duplicated order) and the duplicated [MEDICATION NAME] 40 milligrams was documented as having been given twice on [DATE], [DATE] and [DATE]. Review of the notes attached to the EMAR revealed the [MEDICATION NAME] 40 milligram duplicated dose was not given on [DATE] as the Certified Medication Technician (CMT) assigned to administer those medications had recognized the duplicated order. However, the resident received a duplicate dose on [DATE]. Review of a medication error incident report presented for the [MEDICATION NAME] duplicated order for Resident #31 revealed no contact was made to the resident's physician, there was no date on the form as to when it was completed and there was no indication of any follow-up for the error. Review of Resident #31's laboratory values revealed no concerns of too much fluid loss. 4. Review of the medical record for Resident #16 revealed the resident returned from an emergency room (ER) visit on [DATE] at a local hospital with an order for [REDACTED]. The local hospital sent a prescription written and signed by the ER physician. The order was present on the Medication Administration Record and the medication was given as ordered. There was no verification of the order with the attending physician for the order or evidence in the nurse's notes that the attending physician was notified. Interview with LPN #8, on [DATE] at 12:05 PM, revealed she did not verify the order with the physician and she further stated, she never verifies orders with the physician. In addition, when LPN #8 wrote the order on the physician order for [REDACTED]. The order was written per the ER physician. The ER physician's name was printed on the prescription and the prescription was signed. Interview with the Pharmacist, on [DATE] at 2:55 PM, revealed it was not the pharmacy's responsibility to verify that the physician had approved the order(s) the pharmacy fills, all orders with valid prescription orders are filled and they do not check that the order has been approved by the attending physician. 5. Review of the clinical record for Resident #29 revealed the facility admitted the resident [DATE] with [DIAGNOSES REDACTED]. On admission the resident had a physician order for [REDACTED]. On [DATE] the physician ordered to increase [MEDICATION NAME] to 40 mg daily for five (5) days for [MEDICAL CONDITION]. A nurse wrote an order, on [DATE], for [MEDICATION NAME] 20 mg daily to begin on [DATE] without the designation of the physician who gave the clarification of the medication order. Additionally, the order was not signed by the physician. Review of the EMAR for [DATE] revealed [MEDICATION NAME] 20 mg daily, with a start date of [DATE], was documented as administered to Resident #29. The EMAR reflected administration daily, beginning [DATE]. The facility did not provide an incident report, medication error report, or investigation for Resident #29's [MEDICATION NAME] medication error. 6. Review of the medical record for Resident #3 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. A review of the admission orders [REDACTED]. There was no frequency (or how often the drug should be given) included in the admission order. Review of the Electronic Medication Administration Record (EMAR) revealed the order was placed in the electronic system to be given daily despite no physician's order clarifying the medication. Review of the pharmacy initial medical record review, dated [DATE], revealed a request to include a frequency and stop date/parameter for the [MEDICATION NAME]. Further review of the resident's medical record revealed [REDACTED]. Interview with House Leader #1, on [DATE] at 9:45 AM, revealed when entering an order into the EMAR system, all order components have to be complete; therefore, when the nurse entering the orders reached the frequency section, something had to be entered in order to continue in the EMAR system. Continued interview with the House Leader revealed she completed an audit of all new admissions on the Clinical Coordinator 24 Hour Chart Audit form and turn it into the Director of Nursing (DON). However, further interview with the House Leader, on [DATE] at 3:37 PM, revealed the facility could not locate Resident #3's audit and stated one was never completed. 7. Record review revealed the facility admitted Resident #35, on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. However, review of the EMAR revealed the order was entered, on [DATE], by the facility as Vitamin B-12 250 mcg orally every day. The resident received the 250 mcg every day. A clarification order was not obtained until [DATE], thirty-four (34) days after the medication was entered incorrectly into the EMAR computer system. Interview with Licensed Practical Nurse (LPN) #14, on [DATE] at 3:40 PM, revealed she did remember completing the admission for Resident #35, but did not remember the resident's ordered Vitamin B-12 dosage. The LPN revealed no one had told her of an order entry error, or questioned the admission orders [REDACTED] Interview with ADON, on [DATE] at 3:05 PM, revealed Resident #35's medication error was discovered with the audits that were taking place in the building on [DATE] to [DATE] but a clarification order was not obtained until [DATE]. 8. Review of the clinical record for Resident #5 revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. The POS on [DATE] revealed the resident was to receive [MEDICATION NAME] 200 mg every bedtime for Gout. Additionally, the POS for [DATE] through [DATE] revealed the [MEDICATION NAME] was not listed to be administered. Review of the physician orders revealed there was no discontinue (D/C) order for the [MEDICATION NAME] for Resident #5. Review of Resident #5's electronic record revealed a facility staff member entered [MEDICATION NAME] 200 mg to be given every bedtime into the electronic record to start the medication on [DATE] at 10:03 PM and stop the medication on [DATE] at 8:00 PM. The EMAR, beginning [DATE] and ending [DATE], revealed the resident did not receive the [MEDICATION NAME] medication until [DATE] when the medication was placed on the POS and EMAR. The EMARs for [DATE] through [DATE] did not have the [MEDICATION NAME] listed to be administered to the resident. On [DATE] at 1:18 PM, interview with Licensed Practical Nurse (LPN) #6 revealed if the medication was not listed on the EMAR then the medicine would not be administered to the resident. The LPN stated the nurse receiving the physician order was responsible to enter the orders into the EMAR and the Nurse Leader on the unit was responsible to verify the orders entered into the EMAR were correct. The LPN stated the nurse on the next shift should check the information if the House Leader was not available. Interview, on [DATE] at 1:55 PM and 2:40 PM, and on [DATE] at 9:48 AM, 12:20 PM, and 2:52 PM, with the Director of Nursing (DON) revealed Resident #5's [MEDICATION NAME] had not been D/C'd by the physician after the resident's readmission to the facility [DATE] and when it was stopped in the EMAR on [DATE]. She stated the House Leader was responsible to audit resident charts. The DON stated Resident #5 was on a long term care unit which was audited the previous evening; however, she could not recall if anyone audited the resident's chart. Interview, on [DATE] at 3:23 PM and [DATE] at 3:07 PM, with the Nurse Consultant, now the Interim Director of Nursing (DON) revealed neither a facility incident report nor a medication error report for Resident #5's [MEDICATION NAME] were completed. The Interim DON stated an incident report still had not been completed and should have been completed when the medication transcription error was discovered. The Interim DON stated the system had failed along the way. Interview, on [DATE] at 3:23 PM, with the Administrator revealed entering information into the electronic chart could have a data entry error. She stated the facility was learning how the computer can cause data entry errors. Interview with the Director of Nursing (DON), on [DATE] at 1:41 PM, revealed it was the DON's and the ADON's responsibility to ensure the chart checks were completed. The DON stated the House Leaders should be checking the orders daily. The DON stated the House Leaders should compare the discharge summary, POS and the computer system to ensure all are documented appropriately. The DON stated she had not completed random chart checks since before the medication error occurred. Review of the Acceptable Allegation of Compliance (AOC) on [DATE], revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review beginning [DATE] through [DATE] that included verification of care plan updates. 3. In-services were conducted from [DATE] through [DATE]. The in-services were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses and incorporated updating the care plan related to medication orders. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor that care plans were updated accordingly. 5. The DON was responsible for assuring the routine care plan updates and review process discussed were audited and reported for weekly review by the Quality Assurance Committee. The State Agency Validated the AOC on [DATE] prior to exit as follows: 1. The State Agency validated by review, Resident #1 had been discharged on [DATE] and not scheduled to return. 2. The State Agency validated by record review chart audits that were completed on [DATE] through [DATE] by reviewing records of the chart audits on [DATE]. Record review of thirty-eight (38) records revealed nursing care plans for Residents were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders and medication administration records. Interview with the interim DON (Consultant), on [DATE] at 12:30 PM, revealed she had completed all chart audits by looking at physician orders and medication administration records. 3. The State Agency validated an in-service was provided by ADON and Quality Consultant on [DATE] through [DATE], by review of the content of the in-service and review of the attendance logs for the in-service. Interviews conducted on [DATE] with five (5) Licensed Practical Nurses, two (2) Registered Nurses and three (3) Certified Medication Technicians (CMT)'s revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, re-verification of orders in the EMAR system. Interview with LPN #3 at [DATE] at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on [DATE] at 6:33 PM, revealed she had attended the in-service that was provided by the ADON and was instructed on ensuring the care plan was updated with accurate information. LPN #16 was also educated on checking for accuracy and making sure as to not interpret the orders, but to write the orders exactly as the physician wrote them. Interview with LPN #17, on [DATE] at 6:33 PM, revealed he was in-serviced by pharmacy on communication and pharmacy notification protocol. 4. The State Agency validated by record review, the Administrative staff were conducting daily reviews of new admission and daily orders to monitor daily orders and care plans to ensure records were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily and ensured the care plan was accurate to the medications that were provided. Interview with the ADON, on [DATE] at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order sheet and then compared to the computer to ensure items were correct and matched. The State Agency validated the DON submitted all reviews to the Quality Assurance Committee through record review. 5. The State Agency validated by review of the care plan audit updates and weekly review information given to the QA committee were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), on [DATE] at 2:03 PM, revealed the interdisciplinary team met daily to review audit updates and weekly to review all information learned through out the week.

Based on interview, record review and facility policy review, it was determined the facility's Quality Assurance Committee failed to identify quality deficiencies, develop a plan of action, and implement the plan of action to correct medication errors. Eight (8) of thirty-eight (38) sampled records (Residents #1, #3, #5, #6, #16, #29, #31, #35) and one (1) of eight (8) unsampled records (Unsampled Resident H) were identified to have a medication/transcription errors that the facility failed to thoroughly investigate or follow-up to ensure corrective actions to prevent further incidents. (Refer to F281, F333, F514 and F490) The facility's failure to have an effective system in place to ensure the Quality Assurance Program/Committee identified quality deficiencies, developed plans of action, and implemented the plans of action to correct medication/transcription errors was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/24/13 and determined to exist on 03/22/13. The facility provided an acceptable Allegation of Compliance on 08/02/13 and the Immediate Jeopardy was determined to be removed on 08/02/13 as alleged, prior to exit. The scope and severity was lowered to a "E" while the facility continues to implement and monitor quality assurance measures. The findings include: Review of the Facility Accident and Incidents: Report, Investigation, Follow-up and Disposition policy, effective 12/2007, revealed the facility defined an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome. Accidents/incidents defined in the policy included medication errors. Per the policy if an accident/incident occurred, the facility would strive to prevent such an occurrence from happening again. A thorough investigation and follow-up would be completed within five (5) working days. All occurrences would be reviewed by the Administrator, Director of Nursing (DON), Medical Director and Quality Assurance Committee. A final disposition of the accident/incident would be documented. Review of the Medication Error Policy and Procedure policy, reviewed 04/2008, revealed for all significant and non-significant medication errors, the facility would complete a Medication Error Report located in the facility's computer system. Record review revealed eight (8) of thirty-eight (38) sampled residents and one (1) unsampled resident were identified to have a medication/transcription error that was not investigated and no follow-up was completed. Interview with the House Leaders revealed they were responsible for conducting checks weekly on all of the residents in the homes they supervised. The House Leaders stated two weeks before the end of the month the residents' physician orders [REDACTED]. The physician signed the orders and the House Leaders checked the orders to make sure there were no discrepancies. However, the House Leaders stated when they had to work the floor and complete chart checks, they could not do the chart checks as effectively. Interview with the Assistant Director of Nursing (ADON), on 07/05/13 at 1:10 PM, revealed monthly change overs were completed by the House Leaders at the beginning of each month. The ADON was not sure of what was actually compared when the House Leaders completed the chart checks and stated she had not received training on how to complete a chart check. The ADON stated the House Leaders should be reviewing all the orders daily and the House Leader should ensure what was transcribed matched the computer. The ADON stated no one was auditing the Admission/Readmission check list (used by the facility to ensure all documents are available on admission and are completed and faxed to the MD and pharmacy) to ensure the check list was completed. Per interview she was not instructed to do random chart checks to ensure the House Leaders were doing what they were suppose to be doing and was not sure if she should be doing them. Interview with the DON, on 07/05/13 at 1:41 PM, revealed the House Leader was responsible to do chart checks at the end of each month. The DON stated she and the ADON were responsible to ensure the chart checks were completed monthly. The DON stated she did not think there was an actual procedure for the end of the month chart checks, but that the orders should be checked daily. The DON stated the House Leader should take the discharge summary and the physician order [REDACTED]. Further interview with the ADON, on 08/01/13 at 1:21 PM, revealed the nursing staff was not responsible to complete incident reports. Nurses were taught to inform the House Leader of a medication error and the House Leader was responsible to complete the incident report. The Director of Nursing (DON) was then responsible to print the incident reports, but she was unsure how often the reports were printed. Per interview, if a House Leader did not complete an incident report then they would not know if there was a medication error. The ADON stated she conducted the training's in the facility, but she had not trained the House Leaders in regards to their role in completing incident reports. The ADON stated if there was no incident report then there was no follow up either. The ADON stated she had not looked at the form before, nor had she been asked to complete the form or print the form for morning meetings. Interview with the DON, on 07/23/13 at 11:53 AM, revealed she printed incident reports in the morning prior to the morning meeting. The DON stated the incident reports were mostly about falls, not medication errors. Interview with the Interim DON, on 08/01/13 at 3:07 PM, revealed she was not aware of a Medication Error Report. The Interim DON stated someone had brought the form to her attention by reporting the form was documented on the facility policy. The Interim DON stated she was aware there was a problem with incident reports not being completed and reported. The Interim DON stated she was looking to change the policy on reporting medication errors. The Interim DON stated when she was first hired by the facility as a consultant, she came to look at systems and did not identify medication errors as one of the systems that needed to be fixed. Interview with the Medical Director, on 08/01/13 at 4:43 PM, revealed he had attended QA two (2) months ago and five days from the day of the survey exit. The Medical Director stated he attended QA quarterly and he was not aware of the many medication errors identified. Interview with the Administrator, on 08/02/13 at 2:03 PM, revealed the facility had a Quality Assurance (QA) committee that met monthly. The Administrator stated the QA committee should have known about the medication/transcription errors. It was important for these errors to be tracked and trended. The Administrator stated she did look at incident reports in the morning meetings; however, they pertained more to falls. There were no medication errors identified in those meetings. The Administrator stated she would expect the DON to report any concerns. Interview with the Executive Director, on 08/02/13 at 2:03 PM, revealed no medication errors were identified in QA. The Executive Director stated she was not aware of the facility's medication transcription error rate of 12% (based on errors found during record reviews). Review of the Acceptable Allegation of Compliance (AOC) on 08/02/13, revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review that verified care plan were updated,beginning 07/01/13 through 07/31/13. 3. In-services were conducted from 07/02/13 through 07/25/13. The in-services included topics of updating the care plan related to medication orders were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor for accurate processing of new orders and that care plans were updated accordingly. 5. The DON was responsible for assuring the daily review process of physician orders [REDACTED]. The State Survey Agency validated the AOC on 08/02/13 prior to exit as follows: 1. Record review revealed Resident #1 had been discharged on [DATE] and not scheduled to return. 2. Record review revealed chart audits were completed on 07/01/13 through 07/31/13 to ensure nursing care plans for residents were up to date. Interview with the DON, on 07/24/13 at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders [REDACTED]. 3. Record review revealed an in-service was provided by ADON and Quality Consultant on 07/02/13 through 07/25/13, by review of the content of the in-service and review of the attendance logs for the in-service revealed all nursing staff attended the inservice. Interviews conducted on 08/02/13 with five (5) Licensed Practical Nurses: LPN #4 at 4:55 PM, LPN #2 at 6:05 PM, LPN #13 at 5:45 PM, LPN #14 at 6:33 PM, LPN #15 at 6:33 PM, two (2) Registered Nurses: RN #5 at 4:50 PM, and RN #4 at 5:57 PM, and three (3) Certified Medication Technicians (CMT)'s; CMT #1 at 11:22 AM, CMT #20 at 5:55 PM, and CMT #21 at 5:50 PM revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, and re-verification of orders in the EMAR system. Interview with LPN #3 at 08/01/13 at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on 08/02/13 at 6:33 PM, revealed she was also educated on checking for accuracy and making sure not to interpret the orders, but to write the orders exactly as the physician wrote them. 4. Record review revealed the Administrative staff conducted daily reviews of new admission and daily orders to monitor to ensure records were accurate. Interview with the DON, on 07/24/13 at 12:21 PM, revealed she reviewed the admission and readmission's orders daily. Interview with the ADON, on 07/24/13 at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order [REDACTED]. Record review revealed the DON submitted all reviews to the Quality Assurance Committee. 5. Review of the care plan audit updates and weekly review information given to the QA committee revealed the documents were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), (Nursing, Activities, Social Services and Dietary), on 08/02/13 at 2:03 PM, revealed the interdisciplinary team met daily to review audits for updates and weekly review of all information obtained through out the week.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to have an effective system to ensure residents were free from significant medication errors for two (2) of thirty-eight (38) sampled residents (Residents #1 and #2). On [DATE] the facility admitted Resident #1 with an order for [REDACTED]. The admitting Licensed Practical Nurse (LPN) #3 altered the physician's orders [REDACTED]. This order was never verified with the resident's physician; the [MEDICAL TREATMENT] center was not aware of the antibiotic therapy; and, staff failed to transcribe the order to the Medication Administration Record to ensure medication administration occurred. Record review revealed no documented evidence Resident #1 received the antibiotic from [DATE] to [DATE], twenty-four (24) of the twenty-eight (28) days, as ordered by the physician. On [DATE], the resident developed a mental status change and was transferred to the hospital and admitted with an impression of Toxic Metabolic [MEDICAL CONDITION] secondary to gram-positive cocci [MEDICAL CONDITION] with Bacteremia, likely a recurrence of underlying [MEDICAL CONDITION]. The resident did not return to the facility, but was transferred to another local Long Term Care facility and expired on [DATE]. In addition, the facility readmitted Resident #5 with a [DIAGNOSES REDACTED]. The facility staff discontinued the [MEDICATION NAME] from the EMAR and it was not administered from January through [DATE]. The physician orders [REDACTED].#5. The facility's failure to have an effective system in place to ensure the residents were free of significant medication errors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] and the Immediate Jeopardy was determined to be removed on [DATE] as alleged, prior to exit. The scope and severity was lowered to a "D" while the facility continues to implement and monitor quality assurance measures. The findings include: Review of the facility's Medication Error Policy and Procedure, revised [DATE], revealed if an error occurred with any frequency, there was reason to classify the error as significant. Therefore if a resident's drug was omitted several times, the error would be classified as significant. The policy also revealed the facility would report immediately, significant and non-significant medication errors to the attending physician, responsible party and immediate supervisor. The facility would also develop and maintain processes for defining, identifying and reviewing these significant medication errors collaboratively with nursing, pharmacy and other appropriate staff. A review of the Kentucky Board of Nursing, Advisory Opinion Statement, (AOS) #14 Patient Care Orders, revised ,[DATE], #5 revealed a nurse was obligated to not change a physician's without the physician's direction to do so. Review of the Scope of Practice Determination Guidelines, revised ,[DATE] revealed Licensed Practical Nurses would administer medications or treatments as directed by a physician, physician assistant, dentist, or advanced practice registered nurse and as allowed or limited by the board which is consistent with the National Federation of Licensed Practical Nurses or with standards of practice established by nationally accepted organizations of licensed practical nurses. 1. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's BIMs score at a twelve (12) which revealed Resident #1 was interviewable. Review of the Discharge Summary, dated [DATE], revealed Resident #1 was to start [MEDICATION NAME] two (2) grams intravenously (IV) daily for twenty-eight (28) days. Review of Physician Orders, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 documented Resident #1 was to receive [MEDICATION NAME] 2 grams intravenous daily after [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days. However, the resident received [MEDICAL TREATMENT] three times a week and not daily. Further review revealed there was no signature to show who read and verified the order or who faxed the order to pharmacy. Review of the [DATE] and [DATE] Medication Administration Record revealed the [MEDICATION NAME] two (2) grams was not transcribed to be administered. Interview with LPN #3, on [DATE] at 3:56 PM, revealed she had seven (7) admissions that night and Resident #1 was her last admission of the night. She stated she did transcribe the orders from the discharge summary onto the physician order [REDACTED].#1 that the orders needed to be called to the physician, and transferred into the computer. LPN #3 stated she wrote the [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days in parenthesis and that no doctor gave her the order to do so. LPN #3 stated she wrote the order herself, so the oncoming nurse would know how to enter it in the computer. LPN #3 stated she probably should not have added to the order from the discharge summary, but typically a lot of the [MEDICAL TREATMENT] patients received their antibiotics in [MEDICAL TREATMENT] and wanted to make sure it was clarified in the computer. LPN #3 stated she did not normally document that the order was read and verified to the doctor. LPN #3 stated that the pharmacy normally received a copy of the discharge summary and the Physician order [REDACTED]. Interview with LPN #1, on [DATE] at 1:13 PM, revealed she could not remember working on Resident #1's admission. LPN #1 did not remember putting the orders into the computer and further did not remember working on the unit. However, interview with the Assistant Director of Nursing (ADON), on [DATE] at 12:45 PM, revealed the ADON called their Computer Department and was informed LPN #1 was the nurse who placed the order in the system and who would have called the physician for verification of the orders. Further review of the [MEDICAL TREATMENT] orders, dated [DATE], revealed no antibiotics were ordered for Resident #1. Review of the Nephrologist's orders, dated [DATE], revealed the antibiotic section stated "N/A". Review of the Physician order [REDACTED]. Review of an e-mail sent by the Pharmacy Staff to the ADON, on [DATE] at 4:47 PM, revealed the pharmacy only sent one (1) dose on [DATE] from the discharge summary. Interview with the Pharmacy Consultant, on [DATE] at 11:34 AM, revealed they had sent the one dose based on the discharge summary so the medications would be ready for the resident when they arrived to the facility. However, the antibiotic was never transcribed to the POS and no further doses were sent. The admission orders [REDACTED]. Therefore, pharmacy never sent any further doses. However review of the residents MAR revealed no evidence the resident received the dose issued to the facility on [DATE]. Review of the Medication Regimen Review, revealed a pharmacy review was completed on [DATE] by the Pharmacy Consultant; however, it did not identify the resident was currently on an antibiotic. Further interview with the Pharmacy Consultant, on [DATE] at 11:34 AM, revealed when she completed a pharmacy review she looked for drug interactions, gradual dose reductions, labs and what was necessary for the patient. The Pharmacy Consultant stated when she received a new patient she did not generally look at the discharge orders, because the Doctor may change the orders. The Pharmacy Consultant stated she looked at the new orders and the verified orders because a lot of medications may change. However, did not see the order for the antibiotic at [MEDICAL TREATMENT]. Interview with Resident #1's Physician, on [DATE] at 12:53 PM, revealed he was aware Resident #1 was to receive an antibiotic daily. He stated the facility did not formally notify him of the medication error per facility policy or call for the Quality Assurance team to meet to talk about the medication error. Per interview and record review, Resident #1 did not have any signs of fever, head pain or chills, which all were signs [MEDICAL CONDITION], and his/her white cell count was within normal range, so the Physician thought the resident was still receiving the antibiotic. Continued interview with Resident #1's Physician, on [DATE] at 1:35 PM, revealed he did not remember instructing the nurse to write the order to say after [MEDICAL TREATMENT] on [MEDICAL TREATMENT] days. He further stated he did not compare the POS with the discharge summary and assumed the resident was still recieving the antibiotic. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 2:00 PM, and review of the APRN's progress note dated [DATE], revealed she assessed Resident #1, on [DATE]. Resident #1 had complained of nausea and vomiting. Therapy had reported the resident was now a maximum assist and prior to this, Resident #1 was a minimal assist. The APRN stated Resident #1 was slow to respond, and she decided to send Resident #1 to the emergency room for evaluations and treatment of [REDACTED]. Interview with the Administrator (new to the facility for one month), on [DATE] at 10:41 AM, revealed she was not aware of the medication error for Resident #1. The Administrator stated she did see a write-up dated [DATE] regarding LPN #3 related to a physician's orders [REDACTED]. The Administrator stated she became aware of the concern when the State Survey Agency came into the building, and did not have any more investigative information to provide regarding the medication error. 2. Review of the clinical record for Resident #5 revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. Additionally, the POS for [DATE] through [DATE] revealed the [MEDICATION NAME] was not listed to be administered. Review of the physician orders [REDACTED].#5. Review of Resident #5's electronic record revealed a facility staff member entered [MEDICATION NAME] 200 mg to be given every bedtime into the electronic record to start the medication on [DATE] at 10:03 PM and stop the medication on [DATE] at 8:00 PM. The EMAR, beginning [DATE] and ending [DATE], revealed the resident did not receive the [MEDICATION NAME] medication until [DATE] when the medication was placed on the POS and EMAR. The EMARs for [DATE] through [DATE] did not have the [MEDICATION NAME] listed to be administered to the resident. On [DATE] at 1:18 PM, interview with Licensed Practical Nurse (LPN) #6 revealed the POS came from the EMAR. The LPN stated if a medication was not in the EMAR, then it also would not be on the POS. She stated Resident #5's [MEDICATION NAME] was not on the POS for several months. The LPN stated the resident's [MEDICATION NAME] was started [DATE] in the EMAR, upon readmission to the facility, and stopped [DATE]. She stated if the medication was not listed on the EMAR then the medicine would not be administered to the resident. The LPN stated the nurse receiving the physician order [REDACTED]. She stated the Nurse Leader on the unit was responsible to verify the orders entered into the EMAR were correct; however, the unit was without a Nurse Leader. The LPN stated without a Nurse Leader the nurse on the next shift should check the information. Interview, on [DATE] at 1:55 PM and 2:40 PM, and on [DATE] at 9:48 AM, 12:20 PM, and 2:52 PM, with the Director of Nursing (DON) revealed Resident #5's [MEDICATION NAME] had not been D/C'd by the physician after the resident's readmission to the facility [DATE] and when it was stopped in the EMAR on [DATE]. She stated if the medication was not on the EMAR then it would not be administered to the resident and the medication would not be listed on the POS. The DON stated Resident #5 should have received the medication from the time the facility readmitted the resident [DATE] to [DATE] when the facility began to administer the medication. She stated the House Leader was responsible to audit resident charts; however, the unit was without a House Leader since [DATE]. She stated the responsibility would fall on herself or the Assistant Director of Nursing (ADON). The DON stated Resident #5 was on a long term care unit which was audited the previous evening; however, she could not recall if anyone audited the resident's chart. The DON stated if the resident did not receive the [MEDICATION NAME] for six (6) months the resident could have had a flare up of the disease which could cause the resident pain. Interview with Resident #5's physician (MD), on [DATE] at 3:11 PM, revealed the resident should have been receiving the [MEDICATION NAME] unless there was a written order to D/C the medication. He stated without a D/C order by him, the medication should have been given and should not have been stopped. The MD stated it was a medication error if the medicine was not administered. He stated without the medication, the resident's Gout could flare up resulting in swollen joints and kidney stones. Review of the Acceptable Allegation of Compliance (AOC) on [DATE], revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review that verified care plan were updated,beginning [DATE] through [DATE]. 3. In-services were conducted from [DATE] through [DATE]. The in-services included topics of updating the care plan related to medication orders were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor for accurate processing of new orders and that care plans were updated accordingly. 5. The DON was responsible for assuring the daily review process of physician orders [REDACTED]. The State Survey Agency validated the AOC on [DATE] prior to exit as follows: 1. Record review revealed Resident #1 had been discharged on [DATE] and not scheduled to return. 2. Record review revealed chart audits were completed on [DATE] through [DATE] to ensure nursing care plans for residents were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders [REDACTED]. 3. Record review revealed an in-service was provided by ADON and Quality Consultant on [DATE] through [DATE], by review of the content of the in-service and review of the attendance logs for the in-service revealed all nursing staff attended the inservice. Interviews conducted on [DATE] with five (5) Licensed Practical Nurses: LPN #4 at 4:55 PM, LPN #2 at 6:05 PM, LPN #13 at 5:45 PM, LPN #14 at 6:33 PM, LPN #15 at 6:33 PM, two (2) Registered Nurses: RN #5 at 4:50 PM, and RN #4 at 5:57 PM, and three (3) Certified Medication Technicians (CMT)'s; CMT #1 at 11:22 AM, CMT #20 at 5:55 PM, and CMT #21 at 5:50 PM revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, and re-verification of orders in the EMAR system. Interview with LPN #3 at [DATE] at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on [DATE] at 6:33 PM, revealed she was also educated on checking for accuracy and making sure not to interpret the orders, but to write the orders exactly as the physician wrote them. 4. Record review revealed the Administrative staff conducted daily reviews of new admission and daily orders to monitor to ensure records were accurate. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily. Interview with the ADON, on [DATE] at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order [REDACTED]. Record review revealed the DON submitted all reviews to the Quality Assurance Committee. 5. Review of the care plan audit updates and weekly review information given to the QA committee revealed the documents were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), (Nursing, Activities, Social Services and Dietary), on [DATE] at 2:03 PM, revealed the interdisciplinary team met daily to review audits for updates and weekly review of all information obtained through out the week.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to act on pharmacy recommendations for one (1) of thirty-eight (38) sampled residents (Resident #5) and the Consultant Pharmacist failed to identify medication transcription errors through the medication regimen review for three (3) of thirty-eight (38) sampled residents (Resident #1, #31 and #35). On [DATE] the facility admitted Resident #1 with an order for [REDACTED]. The admitting Licensed Practical Nurse (LPN) #3 altered the physician's order by adding to the directions to administer the antibiotic "after HD on HD", (after hemodialysis on hemodialysis days). This order was never verified with the resident's physician; the dialysis center was not aware of the antibiotic therapy; and, staff failed to transcribe the order to the Medication Administration Record to ensure medication administration occurred. Record review revealed no documented evidence Resident #1 received the antibiotic from [DATE] to [DATE], twenty-four (24) of the twenty-eight (28) days, as ordered by the physician. On [DATE], the resident developed a mental status change and was transferred to the hospital and admitted with an impression of Toxic Metabolic [DIAGNOSES REDACTED] secondary to gram-positive cocci Septicemia with Bacteremia, likely a recurrence of underlying MSSA Sepsis. The resident did not return to the facility, but was transferred to another local Long Term Care facility and expired on [DATE]. The facility's failure to have an effective system in place to ensure the Pharmacist identified medication transcription errors through the medication regimen review has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] and the Immediate Jeopardy was determined to be removed on [DATE] as alleged, prior to exit. The scope and severity was lowered to a "D" while the facility continues to implement and monitor quality assurance measures. The findings include: Review of the facility policy Consultant Pharmacist Services Provider Requirements, not dated, revealed the Consultant Pharmacist (CP) would evaluate the process of reconciling and administering all medications. The CP would also assist to identify and evaluate medication related issues, including the prevention and reporting of medication errors. Additionally, the CP would review the Medication Administration Record (MAR) monthly to ensure proper documentation of medication orders and administration of medications to residents. Review of the facility policy Medication Regimen Review, not dated, revealed the facility would assure the CP had access to resident medical records. The medication regimen review (MRR) would be conducted at least monthly by the CP. The CP would use a variety of sources to conduct the MMR including the resident's Medication Administration Record (MAR). Additionally, the CP's evaluation included review of medication errors. Review of the facility policy Documentation and Communication of Consultant Pharmacist Recommendations, not dated, revealed the CP would document potential or actual medication related problems and other MRR findings appropriate for nursing review. Recommendations should be responded to prior to the next MRR. Additionally, recommendations would be acted upon and documented by facility staff. Review of the CP Agreement, dated [DATE], revealed the pharmacy would provide the facility with a medication administration system and software interface with EMAR system when acquired by the facility. Additionally, the facility would provide the pharmacy access to all resident records necessary for the performance of the pharmacy's duties. Although interview with CP #10, on [DATE] at 2:39 PM, revealed the software to interface with the facility's EMAR system had never been completed, this prevented the pharmacy consultants access to the facility's POS and EMARs during the monthly medication regimen reviews. 1. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's BIMs score at a twelve (12) which revealed Resident #1 was interviewable. Review of the Discharge Summary, dated [DATE], revealed Resident #1 was to start Cefazolin two (2) grams intravenously (IV) daily for twenty-eight (28) days. Review of Physician Orders, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 documented Resident #1 was to receive Cefazolin 2 grams intravenous daily after hemodialysis on hemodialysis days. However, the resident received dialysis three times a week and not daily. Review of the [DATE] and [DATE] Medication Administration Record revealed the Cefazolin two (2) grams was not transcribed to be administered. Interview with LPN #3, on [DATE] at 3:56 PM, revealed she admitted Resident #1. LPN #3 stated she wrote the hemodialysis on hemodialysis days in parenthesis and that no doctor gave her the order to do so. She stated she probably should not have added to the order from the discharge summary, but typically a lot of the dialysis patients received their antibiotics in dialysis and wanted to make sure it was clarified in the computer. LPN #3 stated that the pharmacy normally received a copy of the discharge summary and the Physician Order sheet. Review of an e-mail sent by the Pharmacy Staff to the ADON, on [DATE] at 4:47 PM, revealed the pharmacy only sent one (1) dose on [DATE] from the discharge summary. Interview with the Pharmacy Consultant, on [DATE] at 11:34 AM, revealed they had sent the one dose based on the discharge summary so the medications would be ready for the resident when they arrived to the facility. However, the antibiotic was never transcribed to the POS and no further doses were sent. Review of the Medication Regimen Review, revealed a pharmacy review was completed on [DATE] by the Pharmacy Consultant; however, it did not identify the resident was currently on an antibiotic. Further interview with the Pharmacy Consultant, on [DATE] at 11:34 AM, revealed when she completed a pharmacy review she looked for drug interactions, gradual dose reductions, labs and what was necessary for the patient. The Pharmacy Consultant stated when she received a new patient she did not generally look at the discharge orders, because the Doctor may change the orders. The Pharmacy Consultant stated she looked at the new orders and the verified orders because a lot of medications may change. However, did not see the order for the antibiotic at dialysis. 2. Review of the clinical record for Resident #5 revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. The physician order sheet (POS), upon readmission [DATE], revealed the resident was to receive Allopurinol 200 mg every bedtime for Gout. Additionally, the POS for [DATE] through [DATE] revealed the Allopurinol was not listed to be administered. Review of the physician orders revealed there was no discontinue (D/C) order for the Allopurinol for Resident #5. Review of the Consultant Pharmacist Communication to Nursing, dated [DATE], [DATE], and [DATE], revealed Resident #5 was readmitted on [DATE] with Allopurinol 200 mg every bedtime, and this was being filled by the pharmacy per the physician order. Additionally, the Allopurinol was not found on the POS and the facility was requested to ensure the medication was on the POS and the MAR. Review of Resident #5's electronic record revealed a facility nurse entered Allopurinol 200 mg to be given every bedtime into the electronic record to begin the medication on [DATE] at 10:03 PM and stop the medication on [DATE] at 8:00 PM. The EMARs for [DATE] through [DATE] did not have the Allopurinol listed to be administered to the resident. Continued review of the EMAR, beginning [DATE] and ending [DATE], revealed the resident did not receive the Allopurinol medication until [DATE]. The unit nurse transcribed the medication on to the POS and EMAR, based on the pharmacy's recommendation made on [DATE] to place the medication on the EMAR. However, review of the pharmacy Fill History, from [DATE] through [DATE], revealed four hundred forty-six (446) doses of Allopurinol were dispensed to the facility for Resident #5. One hundred forty-six (146) doses were returned to the pharmacy by the facility, leaving three hundred (300) doses of Allopurinol in the facility to be administered to Resident #5. Interview with CP #2, on [DATE] at 10:43 AM, revealed the CP used their own computer system when conducting monthly reviews, which was different from the facility's electronic charting system. He stated the POS was included in the monthly review; however, the CP did not review the resident EMARs. The CP stated Consultant Pharmacists did not review the electronic record or EMARs. He stated the CP and the pharmacy had no way to know if a medication had been administered. Additionally, if a medication was not listed on the POS, then it would not be on the EMAR, as the nurses generate the POS from the EMAR. Interview, on [DATE] at 1:50 PM, interview with CP #1 revealed the original recommendation for Resident #5's Allopurinol was made in February 2013. On [DATE] the recommendation was still pending facility follow-up. She stated in [DATE] the Allopurinol was not identified again as at times the pharmacy recommendation could still be pending. The CP stated in [DATE] the pharmacy did not address with the facility that Resident #5's Allopurinol was still not listed on the POS or EMAR. The CP stated she did not have access to the facility EMAR and she worked in another room from the facility computer. She stated she did not get into the electronic chart when at the facility. She stated nursing entering physician orders into the electronic chart was problematic as pharmacy would not have pharmaceutical oversight. The CP stated no one at the facility had informed her of a computer problem with the electronic chart or EMAR. 3. Review of the clinical record for Resident #31 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission physician order sheet (POS), dated [DATE], revealed Resident #31 had Lasix (a drug used to remove extra fluid) 40 milligrams by mouth daily ordered. Further review of Resident #31's physician orders revealed a telephone order dated [DATE] to increase Lasix to 40 milligrams daily and to add Lasix 20 milligrams by mouth daily for three (3) days. Review of the Electronic Medication Administration Record (EMAR) revealed the Lasix 40 milligram order was on the EMAR twice (a duplicated order) and the duplicated Lasix 40 milligrams was documented as having been given twice on [DATE], [DATE], once on the [DATE] and twice on [DATE]. Review of the pharmacy monthly regimen review, dated [DATE], revealed no recommendations for physician clarification pertaining to the Lasix 40 mg. Review of the notes attached to the EMAR revealed The Certified Medication Technician (CMT) administered the routine 40 mg dose of Lasix and held the duplicated dose on [DATE] as the CMT assigned to administer those medications had recognized the duplicated order. On [DATE] at 1:40 PM, interview with CP #7 revealed the facility policies and contract for pharmacy services and the CPs were from the nursing home in the old building, and had not been revised since the facility moved to the new building. She stated if nurses enter information into the electronic chart and EMAR, no one from pharmacy would be aware if information was keyed incorrectly, or entered for the wrong resident. The CP stated she did not have access to the facility's electronic chart and EMAR. She stated it was important for the CP to review the EMARs to ensure resident's medications were received and documented. The CP stated the facility could print the EMARs for the CP to review during the Medication Regimen Review. Interview, on [DATE] at 2:52 PM, with the Director of Nursing (DON) revealed she was unaware if pharmacy had access to the facility's electronic chart and EMAR. She stated the CP could review the EMAR if requested. 4. Review of the clinical record for Resident #35 revealed the facility admitted the resident on [DATE], to the Dementia Unit with [DIAGNOSES REDACTED]. Review of the resident's admission orders [REDACTED]. However, review of the Electronic Medication Administration Record (EMAR) revealed the facility entered the order and the resident received Vitamin B-12 at 250 mcg orally every day. Continued review of the resident's record revealed pharmacy completed a Medication Regimen Review, dated [DATE], but did not address that there was a medication discrepancy between the orders and the EMAR. A clarification order was written by the Assistant Director of Nursing (ADON), on [DATE], for the Vitamin B-12 at 1000 mcg which was thirty-four (34) days after the discrepancy occurred. Interview with Licensed Practical Nurse (LPN) #12, on [DATE] at 3:40 PM, revealed she did input admission orders [REDACTED]. Interview with Consulting Pharmacist #10, on [DATE] at 4:22 PM, revealed comparing orders against the actual EMAR was not part of their contract. The pharmacist revealed they do a regimen review and not a medical record review. Continued interview, on [DATE] at 4:50 PM, revealed he was not sure what the policy and procedure, or contract stated regarding resident reviews. The pharmacist stated he would have to read their policies again. Review of the Acceptable Allegation of Compliance (AOC) on [DATE], revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] and did not return. 2. For the facility to identify other residents that might be affected, the quality assurance consultants, under recommendation of the Quality Assurance Committee, completed a chart review that verified care plan were updated,beginning [DATE] through [DATE]. 3. In-services were conducted from [DATE] through [DATE]. The in-services included topics of updating the care plan related to medication orders were conducted by the ADON, the Quality Consultant, and the Nursing House Supervisor under the direction of DON. The in-services were attended by all licensed practical nurses and registered nurses. 4. The DON, ADON, Administrative Nurse Consultant and other professional consultants were conducting daily reviews of new admissions and daily orders to monitor for accurate processing of new orders and that care plans were updated accordingly. 5. The DON was responsible for assuring the daily review process of physician orders and care plan updates as discussed were audited and reported for weekly review by the Quality Assurance Committee. The State Survey Agency validated the AOC on [DATE] prior to exit as follows: 1. Record review revealed Resident #1 had been discharged on [DATE] and not scheduled to return. 2. Record review revealed chart audits were completed on [DATE] through [DATE] to ensure nursing care plans for residents were up to date. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily to include physician orders and medication administration records. Interview with the interim DON (Consultant), on [DATE] at 12:30 PM, revealed she had completed all chart audits from [DATE] to [DATE] by looking at physician orders and medication administration records. 3. Record review revealed an in-service was provided by ADON and Quality Consultant on [DATE] through [DATE], by review of the content of the in-service and review of the attendance logs for the in-service revealed all nursing staff attended the inservice. Interviews conducted on [DATE] with five (5) Licensed Practical Nurses: LPN #4 at 4:55 PM, LPN #2 at 6:05 PM, LPN #13 at 5:45 PM, LPN #14 at 6:33 PM, LPN #15 at 6:33 PM, two (2) Registered Nurses: RN #5 at 4:50 PM, and RN #4 at 5:57 PM, and three (3) Certified Medication Technicians (CMT)'s; CMT #1 at 11:22 AM, CMT #20 at 5:55 PM, and CMT #21 at 5:50 PM revealed they were educated on standards of practice, transcription process, communication to pharmacy, medication error process, and re-verification of orders in the EMAR system. Interview with LPN #3 at [DATE] at 1:37 PM, revealed she was educated on the transcription process, standards of practice, communication and ensuring re-verification of orders in the EMAR system. Interview with LPN #16 on [DATE] at 6:33 PM, revealed she was also educated on checking for accuracy and making sure not to interpret the orders, but to write the orders exactly as the physician wrote them. 4. Record review revealed the Administrative staff conducted daily reviews of new admission and daily orders to monitor to ensure records were accurate. Interview with the DON, on [DATE] at 12:21 PM, revealed she reviewed the admission and readmission's orders daily. Interview with the ADON, on [DATE] at 10:35 AM, revealed she made copies of discharge summaries, written admission physician order sheet and then compared these documents to the computer to ensure items were correct and matched. Record review revealed the DON submitted all reviews to the Quality Assurance Committee. 5. Review of the care plan audit updates and weekly review information given to the QA committee revealed the documents were completed and reviewed by the Committee. Interview with the Interdisciplinary Team (IDT), (Nursing, Activities, Social Services and Dietary), on [DATE] at 2:03 PM, revealed the interdisciplinary team met daily to review audits for updates and weekly review of all information obtained through out the week.

Based on observation, interview, record review, review of the facility's Abuse and Neglect Policy and Procedure, Incident Form, and the facility's investigation, it was determined the facility failed to protect one (1) of five (5) sampled residents, Resident #2, from verbal, physical and emotional abuse. On 05/04/11 Certified Nursing Assistant (CNA) #4 told Resident #2 that he/she did not have to use the bathroom, after the resident had just requested to be taken to the bathroom. CNA #4 was heard to say she did not "have time for this" and that Resident #2 was going to give her a nervous breakdown. CNA #4 was also heard to tell Resident #2 that what he/she did need was to get back in bed. CNA #4 then grabbed the resident out of his/her wheelchair forcefully and tossed the resident onto the bed, hitting his/her right leg against the bed rail. The resident responded with an "ow". CNA #4 then got about six (6) inches from the face of Resident #2 and stated "I didn't hurt you, did I? I haven't been mean to you, have I?" Resident #2 expressed pain, and redness was exhibited on his/her right leg from being hit against the side rail during the transfer. The facility's failure to ensure the rights of the residents to be free from abuse resulted in actual harm to Resident #2. The findings include: Review of the facility's Abuse and Neglect Policy and Procedure, revised October 2011, revealed verbal abuse was oral or gestured language that included disparaging or derogatory terms to the resident. Physical abuse included hitting, slapping, pinching, scratching, spitting, holding a resident roughly, etc. It also included controlling behavior through corporal punishment. Emotional abuse was defined as, but was not limited to, humiliation, harassment, and threats of punishment or deprivation. Additionally, the facility was to ensure prevention techniques were implemented in the center such as, identify, correct and intervene in situations where abuse and/or neglect was more likely to occur. Review of the facility's investigation revealed an incident, dated 05/04/12, in which a caregiver, CNA #4, was overheard and then observed by Registered Nurse (RN) #1 to verbally and physically abuse Resident #2. A statement from RN #1 revealed she had overheard CNA #4 tell Resident #2 that he/she did not have to use the bathroom, after the resident had just requested to be taken to the bathroom. CNA #4 was heard to say she did not "have time for this" and that Resident #2 was going to give her a nervous breakdown. CNA #4 was also heard to tell Resident #2 that what he/she did need was to get back in bed. RN #1 then entered the room of Resident #2 and observed CNA #4 grab the resident out of his/her wheelchair forcefully and toss the resident onto the bed, hitting his/her right leg against the bed rail. The resident responded with an "ow". RN #1 then told CNA #4 that it was not appropriate to talk to or treat a resident in that manner. RN #1 revealed CNA #4 then got about six (6) inches from the face of Resident #2 and stated "I didn't hurt you, did I? I haven't been mean to you, have I?" Resident #2 revealed he/she did not want CNA #4 to come back to take him/her to the bathroom because CNA #4 was impatient and mean to him/her. A skin assessment by RN #1 of Resident #2's right leg, revealed redness to the area which came in contact with the bed rail. In addition, a statement by the Director of Nursing, dated 05/04/12, revealed CNA #4 was terminated for verbal abuse and rough handling. Interview, on 05/11/12 at 10:00 AM, with RN #1 revealed there was discoloration to the outside of the right leg of Resident #2 where he/she had hit his/her leg when being tossed onto the bed by CNA #4. RN #1 stated Resident #2 was "definitely fearful of the CNA," referring to CNA #4. The incident occurred at the change of shift and the CNA clocked out and left the building. The incident was reported to administration and an investigation was initiated. Interview, on 05/10/11 at 6:30 AM, with the RN, Nurse Leader of the Walters House, revealed the incident had occurred at the change of shift around 6:30 AM. She revealed while making her rounds, RN #1 told her CNA #4 had physically and verbally abused a resident. She further revealed there was a reddened area to the leg of Resident #2 immediately after the incident. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 04/20/12 with [DIAGNOSES REDACTED]. The resident had fractured his/her left knee cap, had surgery, and was in the facility for rehabilitation. The facility assessed the resident as cognitively impaired. Observation of Resident #2, on 05/10/12 at 9:40 AM, revealed the resident in the room, laying in bed sleeping, in an upright position at 45 degrees. The resident's call light cord was attached to the lanyard around his/her neck. Continued observation, on 05/11/12 at 11:05 AM, revealed the resident up in a wheelchair with a splint in place to the left leg. During the observation the resident stated his/her left knee (fractured prior to admission) was hurting; however, could not state the day, the date or the history of the injury to the left knee. There were no visible bruises or additional injuries noted. Interview, on 05/11/12 at 8:15 AM, with the daughter of Resident #2 revealed the resident had been calling her everyday for the past two (2) weeks at about 8:30 AM crying and saying he/she needed to go to the bathroom. The daughter said she had asked the resident if the call light was being used and the resident revealed there was an employee who was mean to him/her. The daughter revealed she was told the employee would tell the resident "I can't help you right now," and then walk out of the room. The daughter stated she did not report this to anyone because the resident had a [DIAGNOSES REDACTED]. Attempted interview via telephone with CNA #4, on 05/10/12 at 8:50 AM, was unsuccessful.