Every finding on record at Signature Healthcare of East Louisville

Based on observation, interview, record review and review of facility's policy, the facility failed to develop and implement the care plan for one of three sampled residents, Residient (R) 1. On 01/22/2024, R1 became a ward of the state and was deemed as wholly disabled. She required assistance with managing both her personal and financial affairs. The facility, however, failed to develop the resident's care plan to include her becoming a ward of the state. On 09/17/2024, the resident exhibited exit-seeking behaviors and was placed on 15 minute checks, however, the facility failed to develop the resident's care plan to include the exit-seeking behaviors. Further, interview with facility staff revealed the resident roamed throughout the facility with personal items in her wheelchair or on her walker and verbalized delusions of going home. The facility, however, failed to develop the resident's care plan to include her behaviors of roaming and expressions of wanting to leave the facility. On 11/27/2024, exact time unknown, R1 exited the facility through the main entrance after informing the employee working at the reception desk that she was going to step outside. The employee working the reception desk allowed R1 to exit the facility. At approximately 12:15 PM, R1 was observed by a visitor to be walking with a rolling walker on the sidewalk approximately 0.2 miles from the facility. The visitor notified the facility staff who immediately started to search for the resident. The facility's failure to develop and implement a care plan that reflected the resident's healthcare needs, has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy (IJ) was identified on 12/23/2024 and was determined to exist on 11/27/2024, with deficiencies cited at 42 CFR 483.21, Comprehensive Resident Centered Care Plans, F656, at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on 12/23/2024. The facility provided an acceptable IJ Removal Plan on 12/26/2024 at 7:56 PM, alleging removal of the IJ on 12/24/2024. The survey team conducted an IJ Removal and Partial Extended Survey on 01/02/2025 through 01/03/2025. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 12/24/2024. Remaining non-compliance continued at a S/S of a D at F656. Refer to F689 The findings include: Review of the facility's policy, Comprehensive Care Plans revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measureable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Further review of the policy revealed the Comprehensive Care Plan was designed to incorporate identified problem areas, risk factors associated with identified problems, and would be revised as necessary with changes. Review of the facility's policy, Elopement revised 09/12/2024 revealed the intent of the policy was to ensure reisdents' safety and protect their rights and dignity. The policy indicated the resident would be evaluated for elopement risk upon admission and reevaluated as needed including residents displaying exit-seeking behaviors. The policy continued and stated a care plan would be developed with interventions in place for each resident identified as an elopement risk. Closed record review of R1's facility Face Sheet revealed the facility admitted R1 on 10/31/2023 with a primary diagnosis of fracture of unspecified part of neck of left femur, subsequesnt encounter for fracture with routine healing. Additional diagnoses included vascular dementia, moderate, with psychotic features which was added after admitting to the facility. Review of R1's Guardianship documents revealed R1 was declared to be wholly disabled for managing both personal and financial affairs on 01/22/2024, including the right to vote due to a history of strokes. Review of R1's Nurses' Note, dated 09/17/2024, revealed the resident was placed on 15 minute checks due to exhibiting exit-seeking behaviors. Review of the Annual Minimum Data Set (MDS) assessment with the Assessment Reference Date (ARD) of 11/07/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The score indicated R1 was cognitively intact. Further review of the MDS indicated R1 was independent in ambulation with use of a rolling walker and capable of ambulation to the maximum assessed distance of 150 feet. Further review of the MDS revealed R1 did not exhibit any behavioral symptoms that included wandering and delusions during the assessment period. Review of the Comprehensive Care Plan that included all active and resolved problem statements revealed R1 was care planned for elopement with a start date of 11/27/2024. Further review of the Comprehensive Care Plan revealed the resident's having a newly appointed State Guardian on 01/22/2024 was not included on the plan of care or how the state guardianship could affect the resident's care, e.g., affecting the resident's right to vote, make decisions on where the resident lived, major health decisions, etc. Ongoing review of the Comprehensive Care Plan revealed it was completed without mention of significant behaviors that included roaming the building with personal items packed, delusional verbalizations, or the required level of supervision. Further review of the care plan revealed the facility failed to develop an exit-seeking care plan for the resident when she exhibited the behaviors on 09/17/2024. R1 was not present in the facility for observation or interview. In an interview with R1's State Appointed Guardian (SAG) on 12/20/2024 at 10:14 AM, the SAG stated the resident's whereabouts were to be always known by her as the Guardian and R1 would not be permitted to leave the building without supervision. SAG stated while R1 may be able to appropriately answer questions, there were medical and psychological reasons that had led to the resident requiring a state guardian. In an interview with the Activities Assistant (AA), he stated on 12/18/2024 at 3:45 PM that R1 would roam the facility and would not be safe to leave the facility without supervision. AA stated he knew R1 and due to R1's cognitive status and constant motion, R1 needed to be supervised at all times and would not be safe to be outside without supervision. In an interview with the Social Services Assistant (SSA) on 12/19/2024 at 9:45 AM, the SSA stated she knew R1 and was aware R1 was under State Guardianship and would require supervision to leave the facility. The SSA stated R1 was homeless and living on the streets prior to being admited to the facility and would exhibit behaviors that included roaming the facility with personal belongings packed up. She stated the resident's BIMS score was not an accurate depiction of judgement, insight, and decisional capacity. The SSA stated R1 had delusions of having a home to go to and had requested the SSA to call the Sheriff to come get her and take her home or to call the Salvation Army to come get her. In an interview with Licensed Practical Nurse (LPN) 6 on 01/03/2025 at 1:43 PM, LPN 6 stated she usually worked on the 200 Hall where R1's room was located. LPN 6 stated while she had observed R1 standing at the door talking to herself with delusions, she stated she had not observed R1 attempt to go out and added that everyone knew to keep their eye on R1. In an interview with the MDS Nurses, (MDS 1 and MDS 2), on 01/03/2025 at 11:55 AM, both indicated they participated in the development of the care plans and gained information regarding the residents through record review, documentation in the progress notes, observations, and assessments. MDS 2 stated if a new behavior or an event was documented in the progress notes, it would be added to the care plan. However, record review revealed the facility failed to care plan for R1 becoming wholly disabled on 01/22/2024 and failed to care plan for the resident's exit-seeking behaviors, documented on 09/17/2024. In further interview, with the MDS Nurses, on 01/03/2025 at 11:55 AM, MDS 1 stated additional sources of information may come through attending the morning meeting when residents and facility events were discussed. Both MDS 1 and MDS 2 indicated they recently started their employment at the facility in the past six to eight weeks. In an interview with the Director of Nursing (DON) on 12/17/2024 at 1:30 PM, the DON stated she had no knowledge of any previous attempts of R1 exiting the building [facility]. Further, she stated an elopement care plan was initiated on 11/27/2024 and included the intervention of 1:1 observation. In an interview on 12/17/2024 at 4:39 PM, the Administrator advised that R1 was not authorized to leave the building. The Administrator added he had experience with only one resident with a State Guardian in the past. The facility provided an acceptable removal action plan on 12/26/2024 at 7:56 PM that read verbatim: [Facility Name] 12.23.2024 Abatement Plan for F 689 and F 656 Resident #l's medical record was updated to include guardian information upon being appointed a state guardian. The guardian was invited to attend a care conference, and the State guardian attended the meeting on 4/1/2024. Most recent BIMS score of 15, dated 11/06/24, completed by MDS nurse. Upon Resident #l's return to the facility, the Signature Care Consultant completed a skin, psychosocial, and pain assessment on 11/27/2024 at 1:05 p.m. No issues were noted. Resident #1 was placed on 1:1 supervision on 11/27/2024 and remained 1:1 until discharge on [DATE] from the facility. Resident #l's care plan was updated to include 1:1 as an intervention by the Social Services on 11/27/2024. On 11/27/2024, Social Services completed an exit seeking elopement observation (name of assessment in electronic health record)and deemed resident #1 at risk for elopement. Social Services initiated an elopement care plan on 11/27/2024 Social Services added Resident #1 to the elopement binder on 11/27/2024. On 11/28/2024, the [Facility Corporation] Consultant educated the identified receptionist on reviewing the elopement binder before allowing unsupervised residents out of the facility. 1. (Corrective actions for identified residents affected by the deficient practice.) Resident# 1 was admitted to the facility on [DATE]. Resident #1 was appointed a state guardian on 1/22/24. [Facility Name] 12.23.2024 Abatement Plan for F 689 and F 656 1. (Corrective actions for identified residents affected by the deficient practice.) Resident# 1 was admitted to the facility on [DATE]. Resident #1 was appointed a state guardian on 1/22/24. Resident #l's medical record was updated to include guardian information upon being appointed a state guardian. The guardian was invited to attend a care conference, and the State guardian attended the meeting on 4/1/2024. Most recent BIMS score of 15, dated 11/06/24, completed by MDS nurse. Upon Resident #l's return to the facility, the [Facility Corporation] Consultant completed a skin, psychosocial, and pain assessment on 11/27/2024 at 1:05 p.m. No issues were noted. Resident #1 was placed on 1:1 supervision on 11/27/2024 and remained 1:1 until discharge on [DATE] from the facility. Resident #l's care plan was updated to include 1:1 as an intervention by the Social Services on 11/27/2024. On 11/27/2024, Social Services completed an exit seeking elopement observation (name of assessment in electronic health record)and deemed resident #1 at risk for elopement. Social Services initiated an elopement care plan on 11/27/2024 Social Services added Resident #1 to the elopement binder on 11/27/2024. On 11/28/2024, the [ Facility Corporation] Consultant educated the identified receptionist on reviewing the elopement binder before allowing unsupervised residents out of the facility. [Facility Corporation] has a policy for elopement, and this was reviewed by the [NAME] President of Clinical Services on 11/27/2024, and no changes were needed. Signature does not have a specific policy for guardianship. 2. (Identification of other residents who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur.) All residents have the potential to be affected. On 11/27/2024, the facility had a Census of 109 in-house Residents. Unit Managers completed a head count on 11/27/2024 at 12:42 pm. All 109 residents were accounted for. The plant operations director checked the exit doors to ensure they worked adequately on 11/27/2024 at 3:15 p.m. No Issues were identified. Facility Administrator reviewed last 3 elopements drills conducted on 10/17/2024, 10/30/24, and 11/24/24 and no concerns noted. There were 109 Current facility residents on 11/27/2024, and all 109 current residents were reassessed on 11/27/2024 for exit-seeking observations by Social Services. Any residents identified as at risk for exit seeking their care plans reviewed and revised as indicated. Any residents identified as at risk were placed in the elopement binder. Resident #1 was the only new resident identified as at risk for elopement from the assessments completed. This audit was completed on 11/27/2024. [Facility Corporation] Consultant (SCC) conducted a 30-day (10/27/2024 - 11/27/2024) look back in the EMR on all events in the facility for exit-seeking behaviors; this was completed on 11/27/2024 with no concerns identified. [Facility Corporation] Care Consultant (SCC) completed a 30-day (10/27/2024 - 11/27/2024) review of progress notes for exit-seeking behaviors and/or elopement identified in the EMR for all residents. This audit was completed by 11/27/2024. No concerns were identified. From 11/27/24 to 12/23/24, the floor nurse assessed 23 new admissions for exit seeking; none were identified as at risk for exit seeking. On 12/23/2024, the MOS nurse prepared a list of the seven state guardians' residents. The MOS support implemented a state-appointed guardianship care plan for all seven identified residents on 12/23/2024. Per the plan of care, the residents are not allowed to leave the facility unsupervised. 3. (Measures put in place and systemic changes you will make to ensure that the deficient practice does not reoccur.) The Systemic Change sign posted by the Facility Administrator on the entry door states that authorized residents are only permitted beyond this point on 11/27/2024. The [Facility Corporation] Consultant educated the facility administrator and DON on the Elopement Policy (the policy includes how often residents are assessed for risk for elopement), Leave of absence policy, Comprehensive Care Plan Policy, Safety and Supervision of Resident Policy, and Change of Condition Policy. All policies named were reviewed in their entirety. This was started on 11/27/2024 and completed on 11/27/2024. A posttest was given to the facility Administrator and DON after the education was provided on 11/27/2024. A score of 100 percent was obtained on the posttest by the Administrator and DON. The [Facility Corporation] Consultant, Director of Nursing, Administrator, or Unit Manager (UM) completed an in-service with all staff currently present or working in the facility on the Elopement Policy, Leave of absence policy, Comprehensive Care Plan Policy, Safety and Supervision of Resident Policy, and Change of Condition Policy. All policies named were reviewed in their entirety. Education was started on 11/27/2024 and completed on 11/27/2024. A post-test was given to these staff members after the education was provided. A score of 100 percent was required, and anyone not receiving a score of 100 percent was re-educated and then provided with another post test. This process continued until a 100 percent score was obtained. All staff who have not yet received the education will have this completed before the start of their next scheduled shift. This process will continue until all staff have received the education. All newly hired staff will receive training upon new hire orientation. All agency staff will receive education before the start of the shift. The Independent Risk Manager and [NAME] President of Clinical Services educated the Facility Administrator, Director of Nursing, Special Projects Administrator, Business Office Manager, HR Business Partner, Plant OPS Assistant, Environmental Services Manager, Plant Operations Director, Dietary Services Manager, Life Enrichment Director, Environmental Account manager, Unit Managers, MDS coordinators, Admissions Director, Rehabilitation Manager, Social Services, and Signature Care Consultant on needing to notify the State Guardian if their resident attempts and/or requests to leave facility unsupervised for approval. This was completed on 12/20/2024. A posttest was provided on 12/20/2024. A score of 100 percent was obtained on the post-test by Facility Administrator, Director of Nursing, Special Projects Administrator, Business Office Manager, HR Business Partner, Plant OPS Assistant, Environmental Services Manager, Plant Operations Director, Dietary Services Manager, Life Enrichment Director, Environmental Account manager, Unit Managers, MDS coordinators, Admissions Director, Rehabilitation Manager, Social Services, and Signature Care Consultant. The Facility Administrator, Director of Nursing, Special Projects Administrator, Business Office Manager, HR Business Partner, Plant OPS Assistant, Environmental Services Manager, Plant Operations Director, Dietary Services Manager, Life Enrichment Director, Environmental Account manager, Unit Managers, MDS coordinators, Admissions Director, Rehabilitation Manager, Social Services, and Signature Care Consultant completed an in-service on needing to notify the State Guardian if their resident attempts and/or requests to leave the facility unsupervised for approval with all staffcurrently present or working in the facility on Education was started on 12/20/2024 and completed on 12/22/2024. A post-test was given to these staff members after the education was provided. A score of 100 percent was required, and anyone not receiving a score of 100 percent was re-educated and then provided with another post-test. This process continued until a 100 percent score was obtained. All staff who have not yet received the education will have this completed before the start of their next scheduled shift. This process will continue until all staff have received the education. All newly hired staff will receive training upon new hire orientation. All agency staff will receive education before the start of the shift. Starting on 11/28/2024, [Facility Corporation] Consultant, DON, ADON, or UM's will audit five random resident's progress notes looking for exit-seeking behaviors, 5x a week for two weeks, then 3x a week for two weeks, then weekly x 4 weeks, and then monthly until substantial compliance is achieved. Audits are to be performed on random shifts, including evenings and weekends. All results will be forwarded to the Quality Assurance Performance Improvement (QAPI) committee for further review and suggestions. Starting on 12/23/2024, [Facility Corporation] Consultant, DON, or UM's will audit all new admissions with an appointed State guardian to ensure a care plan is developed to include the State appointed guardian is notified if the resident requests or attempts to leave unsupervised 5x a week for two weeks, then 3x a week for two weeks, then weekly x 4 weeks, and then monthly until substantial compliance is achieved. Audits are to be performed on random shifts, including evenings and weekends. All results will be forwarded to the Quality Assurance Performance Improvement (QAPI) committee for further review and suggestions. 4. Describe the Quality Assurance & Process Improvement Program that will be implemented (track and trend data over time to ensure the action plan meets the initially identified goal). An Ad Hoc Quality Assurance meeting was held on 11/27/2024 with the Medical Director, the Facility Administrator, and the Director of Nursing regarding the review of resident #1 return to the facility on [DATE]. The facility administrator presented the plan and information at the QAPI meeting on 11/27/2024. The Facility Medical Director was notified on 11/27/2024 by the facility administrator of the event. The Medical Director reviewed the plan and made no further suggestions. The medical director stated the plan was appropriate and would be effective. Starting on 11/27/2024, the Facility Administrator will hold a Quality Assurance meeting weekly for 4 weeks; then, it will decrease to monthly for recommendations and further follow-up regarding the above-stated plan. Moving forward, the facility administrator will continue to be the person who presents the information and audits at the QAPI Meetings , and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing , Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MOS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for the implementation of this plan. An Ad Hoc Quality Assurance meeting was held on 12/23/2024 with the Medical Director, the Special Projects Administrator, the Director of Nursing , the Signature Care consultant , the [NAME] President of Clinical Services, and the Clinical Reimbursement Specialist. Regarding the plans formulated and implemented on 12/23/2024. The Special Projects Administrator presented the plan and information at the QAPI meeting on 12/23/2024. The Facility Medical Director was notified on 12/23/2024 by the facility administrator of the immediate jeopardy and the abatement plan. The Medical Director reviewed the plan and made no further suggestions. The medical director stated the plan was appropriate and would be effective. Starting on 12/23/2024, the Facility Administrator will hold a Quality Assurance meeting weekly till compliance; then, it will decrease to monthly for recommendations and further follow-up regarding the above stated plan. Moving forward, the facility administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing , Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MOS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for the implementation of this plan. The jeopardy removal date is 12/24/2024.

Based on observation, interview, record review, facility document review, facility policy review and Google Maps review, the facility failed to provide residents with adequate supervision to prevent elopement for one of three sampled residents, Resident (R)1. R1 became a ward of the state on 01/22/2024 and although the resident had a Brief Interview of Mental Status (BIMS) score of 15 (indicating cognitively intact), the resident was legally deemed wholly disabled for managing both personal and financial resources, including the right to vote, and required supervision when leaving the facility. The facility, however, failed to ensure staff were aware the resident could not exit the facility unsupervised. On 11/27/2024, exact time unknown, R1 exited the facility through the main entrance after informing the employee working at the reception desk that she was going to step outside. The employee working the reception desk allowed R1 to exit the building. At approximately 12:15 PM, on the same day, R1 was observed by a visitor to be walking with a rolling walker on the sidewalk. The resident crossed a three-lane road, then walked on the sidewalk, which was 0.2 miles from the facility. The facility's failure to correctly identify R1 as being unauthorized to exit the facility and to follow the established system to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/23/2024 and was determined to exist on 11/27/2024, in the area 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 12/23/2024. The facility provided an acceptable IJ Removal Plan, on 12/26/2024 at 7:56 PM, alleging removal of the IJ on 12/24/2024. The State Survey Agency (SSA) conducted an IJ Removal and Partial Extended Survey on 01/02/2025 through 01/03/2025. The SSA validated the IJ had been removed on 12/24/2024 with the remaining non-compliance at a S/S of a D for F689. The findings include: Review of the facility policy titled, Safety and Supervision of Resident, last reviewed/revised date of 09/15/2023, revealed the resident safety and the supervision would be appropriate based on the individual resident needs, as well as, through identified safety risks and hazards. Additionally, the policy stated it would include a combination of employee training, employee monitoring, and reporting processes to mitigate or remove the hazards to the extent possible. Continued review of the policy, dated 09/15/2023, revealed the information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS) would be utilized to target interventions, to reduce the potential for accidents, and to monitor the effectiveness of the interventions. Review of the facility policy titled, Elopement, reviewed and revised date of 09/12/2024, revealed residents would be evaluated for risk of elopement and preventative interventions implemented for those identified as an elopement risk. Further review of the policy revealed each resident should be evaluated upon admission and reevaluated as needed. The policy further revealed residents displaying exit-seeking behavior would be evaluated for elopement risk as well as residents with a known history of substance use disorder. The policy identified that an elopement risk binder would be kept at a secure location known by stakeholders and routine checks of the entrance and exit doors would be completed to ensure their proper functioning. Review of the facility policy titled, Resident Leave of Absence, review and revision date of 11/07/2018, stated the organization promotes person-centered care and affords leave from the facility based on physician approval. A leave of absence (LOA) was defined as a period the resident was away from the facility while maintaining the status of the resident. The Guideline of the policy identified that a resident may be afforded leave based on physician orders and approval, appropriate supervision by a responsible party when indicated and instructions provided to the responsible party for care and medication administration. Ongoing review of the guideline stated a resident who wished to take an unsupervised leave of absence may do so contingent on a completed and signed written Release of Responsibility for Leave of Absence form, approval of the Licensed Health Professional, Documentation of Interdisciplinary agreement, and inclusion of the leave of absence in the care plan. On 12/20/2024 at 11:20 AM the facility Special Projects Administrator stated the facility had no policy that identified specific considerations for residents assigned a State Guardian. Closed Record Review of R1's Face Sheet located in the closed medical record, revealed the facility admitted the resident on 10/31/2023 with diagnosis of vascular dementia, moderate, with psychotic features, and cognitive communication deficit. Continued review of R1's closed medical record revealed the resident had been under state guardianship and deemed wholly disabled to manage both personal and financial affairs on 01/22/2024, including the loss of the right to vote. Review of the Admission assessment dated [DATE] revealed the resident was assessed on admission for elopement risk. The elopement assessment noted on 10/31/2023, R1 to be ambulatory without wandering into unsafe areas, not making statements about leaving, and not demonstrating behaviors that may indicate an attempt to leave the facility and was not found to be an elopement risk. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2023 indicated a Brief Mental Status Score (BIMS) of 11 out of 15 indicating the resident had moderate cognitive impairment. Further review of the MDS indicated the resident required moderate assistance to ambulate 10 feet and utilized a wheelchair for mobility and did not exhibit any behavioral symptoms, including wandering, during the assessment period. Further review of the MDS revealed the resident did not exhibit any behavioral symptoms, including wandering, required moderate assistance to ambulate 10 feet, and utilized a wheelchair for mobility. Review of R1's Nurse's Note, dated 09/17/2024, revealed the resident exhibited exit- seeking behaviors when she had an associated urinary tract infection. R1 was placed on 15-minute checks until the exit-seeking behaviors resolved. Review of the Annual comprehensive MDS with an ARD date of 11/07/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident was cognitively intact. Further review of the MDS indicated R1 was independent in ambulation with use of a rolling walker and capable of ambulation to the maximum assessed distance of 150 feet and resident did not exhibit any behavioral symptoms that included wandering during the assessment period. Continued review of the annual comprehensive MDS, dated [DATE], revealed the resident was independent in ambulation with use of a rolling walker with the assessment tool indicating R1 was able to independently ambulate the maximum distance on the assessment tool of 150 feet using a walker. Review of the Comprehensive Care Plan that included all active and resolved problem statements revealed R1 was care planned for elopement with a start date of 11/27/2024. Further review of the Comprehensive Care Plan revealed the resident having a newly appointed State Guardian on 01/22/2024 was not included on the plan of care or how the state guardianship could effect resident care, e.g., affecting the resident's right to vote, make decisions on where the resident lived, major health care decisions, etc. Additionally, the care plan did not include the resident's exit-seeking behavior noted 09/17/2024, in which the resident was placed on 15 minute checks. Observation of the facility initiated on 12/16/2024 at 6:30 PM, revealed the front entrance of the facility was accessible via a doorway which had a locked keypad. The front entrance opened into an office area and the residential areas/hallways were accessible through another doorway with a locked keypad. The second interior keypad doorway was observed to be locked on 12/16/2024 at 6:45 PM upon initiation of the investigation and required staff assistance to pass through the doorway. On 12/17/2024 through 12/20/2024 the second door was observed to be unlocked during business hours 8:00 AM through 5:00 PM while the reception desk was attended. Residents and Visitors would require the assistance of a staff member to enter the code to exit through both keypad locking doors after business hours. Review of the facility investigation revealed that on 11/27/2024 at 12:15 PM a visitor to the facility reported to staff that she saw someone she recognized to be a resident, outside the facility unaccompanied and unsupervised. Per the investigation, upon notifying staff, multiple staff went outside to search for R1. Ongoing review of the facility investigation revealed staff reported upon exiting the facility to search for R1, R1 was visualized walking with a walker on the sidewalk. Staff approached and talked to the resident, then assisted R1 back into the facility. The facility investigation revealed R1 re-entered the facility at approximately 12:25 PM. The State Surveyor drove to the location where R1 was first reportedly seen by the facility visitor, the route was also verified by Google Maps, and was noted to be 0.2 miles from the facility. Google Maps indicated it was a six (6) minute walk from the facility. R1 was not observed or interviewed as she had transferred to another facility with a locked dementia unit on 12/16/2024. In an interview with Receptionist 1, on 01/03/2025 at 1:40 PM, she stated she had walked with the resident back to the facility. Per the interview, the resident had crossed the three (3) lane road and had walked an additional approximate distance of 30 feet on the sidewalk. She stated the resident had crossed the three-lane road at the red light and the resident told her she knew how to push the button to cross the road. The Weather Underground, a website that reports current and historical weather conditions for a specific city location, revealed the temperatures on 11/27/2024 was between 54 - 59 degrees Fahrenheit (F) in this location. In an interview with R1's State Guardian, on 12/20/2024 at 10:14 AM, she stated R1 was a ward of the state and was deemed wholly disabled. She stated the resident was not capable of managing her own resources and required supervision when leaving the building. In an interview with the Human Resources Specialist (HRS) on 12/19/2024 at 9:12 AM, she stated that on the day of the incident [11/27/2024] she worked the receptionist desk. She stated she was relieving the receptionist and had been doing a little bit of everything that included answering the phone, transferring calls, and pushing the button to let someone out of the facility. Per the interview, she stated the facility's Thanksgiving Luncheon was taking place at the time. The HRS stated she knew R1 and had talked to her before, even earlier in the day on 11/27/2024. The HRS stated R1 seemed like her normal self. She said R1 came to the desk and stated she was going to step outside. Per the HRS, she was aware of the resident's sign out book and the elopement book but did not check either before allowing the resident to exit the building. In further interview, on 12/19/2024 at 9:12 AM, the HRS stated there was a lot going on and she assumed R1 had signed out on the facility sign out sheet and opened the door and allowed R1 to leave the building without supervision. The HRS stated she did not recall R1 being in the elopement book. HRS stated that while she didn't look in the book that day, she had looked in it before. The HRS stated she was not sure of the exact time R1 exited the building but stated she thought the resident was gone from the building approximately 10 minutes when it was determined that R1 had exited the building and thought approximately 15 minutes had passed when R1 returned. HRS stated R1 did not appear any different when she returned. She stated that after the event, education was started with everyone in the building, the elopement books were checked to ensure they were on the halls. She stated the facility posted signs which advised staff not to let residents out of the facility. However, she stated she was unaware of how long the signs had been in place. HRS stated that she had never seen R1 with exit seeking behaviors. In an interview on 12/17/2024 at 2:00 PM, Certified Nursing Assistant (CNA) 2, stated she knew who R1 was and stated she worked on 11/27/2024, but she was not assigned to the resident. She reported the resident left the facility independently during the Thanksgiving Family luncheon and reported that a family member visiting another resident informed staff that they had seen R1 at the red light with her walker. CNA 2 stated that she and CNA 3 immediately ran outside and started to look for R1. CNA 2 stated CNA 3 found the resident and stated R1 wanted to walk back to the facility. CNA 2 stated R1 was placed on 1:1 supervision upon return to the facility. CNA 2 reported R1 did not have any injury. In an interview on 12/17/2024 at 3:52 PM, CNA 3 stated a family member approached him on 11/27/2024 during the Thanksgiving luncheon and told him they had seen a female wearing glasses using a walker outside on the sidewalk. CNA 3 stated he immediately informed the nearest nurse and then went outside on foot running toward the church and saw R1 walking on the sidewalk. CNA 3 stated he caught up with her and she turned toward him when he called her name. CNA 3 stated the resident stated she was going to the doctor to see about her ear. CNA 3 reported that another employee [Receptionist 1] had gotten in her car and drove to assist with looking for R1. CNA 3 reported that R1 declined to ride in the car back to the facility but wanted to walk back with the Receptionist 1 and CNA 3 drove the car back to the facility. CNA 3 reported the resident had no injuries and did not experience a fall. CNA 3 stated the resident was placed on 1:1 supervision and leadership instructed staff to give R1 space but to watch her continually. CNA 3 stated the leadership began educating staff regarding elopement and Code Green, which was an overhead page to alert employees that a resident was missing and to begin looking for the missing resident. In an interview with the Receptionist 1 on 12/17/2024 at 2:40 PM, she indicated that she was coming into work for her 1:00 PM shift on 11/27/2024 and after entering the building, she learned R1 had left the building unattended. The Receptionist 1 stated she used her personal vehicle to help in the search for R1. The Receptionist stated she walked back with R1 to the building after R1 declined to ride back in the car. Per the Receptionist, she had no knowledge of any injury to R1 as a result of the incident. In an interview with Licensed Practical Nurse 6 (LPN 6) on 01/03/2025 at 1:43 PM, LPN 6 stated she regularly worked on the 200 hall were R1 resideed. She stated she was familiar with R1. LPN 6 stated R1 would roam within the facility with her personal items and stated she never saw her try to get out. LPN 6 stated she had seen R1 standing at the door looking out and talking to herself with delusional verbalizations. LPN 6 went on to say that R1 would sometimes lay on the couch in the sunroom, kept to herself, and did not wander into other people's rooms. LPN 6 stated everyone kind of knew to watch her. In an interview with the Activities Assistant (AA) on 12/18/2024 at 3:45 PM, he stated that he knew R1 and that due to her cognitive status and behavior of being in constant motion, and needing to be observed at all times, R1 was not permitted to go outside unassisted. The AA went on to say that residents were taken out onto the porch with supervision when weather permitted for activities such as exercises. He stated R1 was permitted to go outside during the supervised smoking times in the enclosed supervised smoking area to allow for additional time outdoors. In an interview with the Assistant Business Office Manager (ABOM), on 12/19/2024 at 10:11 AM, she stated she had been employed with the facility for approximately two (2) weeks. ABOM stated that during her onboarding process she received training regarding the elopement binder and the smoker's box with the list of residents who were allowed to go out of the facility unsupervised. ABOM went on to say that if she was not familiar with a resident, she would get someone to verify the resident before allowing a resident to leave the facility. She also stated that residents who leave the facility were to sign out when they leave. In an interview with the Business office Manager (BOM) on 12/20/2024 at 12:44 PM, she stated that she had been employed at the facility since October 2024. The BOM stated that she would check the elopement binder and check with administration or nursing before allowing a resident to exit the building. She added that if a resident was under State Guardianship, then the State Guardian made the final decision regarding a resident [ability to leave the facilty unspervised]. In an interview on 12/19/2024 at 9:45 AM, the Social Services Assistant (SSA) stated she knew R1 and the resident had a history of being homeless prior to being admitted to the facility. She stated the resident would keep her personal items with her as she roamed in the facility. Per the interview, the SSA stated R1 had in the past asked her to call the sheriff's office to take her to her home or the Salvation Army to come get her. The SSA stated that although R1 did not make attempts to leave the facility after being advised that she could not leave, the resident would verbally voice being upset with not being able to leave. The SSA stated R1 did not have a home to go to and that was a delusion. Further, she stated the BIMS score was not an accurate depiction of judgement, insight, and decisional capacity. The SSA stated she was aware R1 had a State Guardian and would require supervision if R1 left the building. In a phone interview with the Primary Care Physician (Physician/Medical Director) for R1 who also serves as the facility Medical Director on 12/19/2024 at 11:15 AM, he stated that he was informed that R1 had left the building without supervision on 11/27/2024 and was returned to the building on 11/27/2024. On further inquiry with the Physician/Medical Director, he stated he was aware that R1 was under State Guardianship, however, he stated he was not aware that an individual under State Guardianship was not eligible to leave the facility without supervision. In an interview with the Director of Nursing (DON) on 12/17/2024 at 1:30 PM, the DON stated that she was notified of the event on 11/27/2024 and notified the Administrator and the Regional Support nurse. The DON stated an investigation was started. She stated R1 had no previous attempts to exit the building to her knowledge. She reported elopement risk assessments were completed quarterly and with a significant change. In an interview on 12/17/2024 at 4:39 PM, the Administrator reported that a facility visitor had alerted staff that a resident was seen outside the facility without supervision. He reported that staff responded, and the resident returned after about 10 minutes. The Administrator stated R1 told him she was trying to go to the bus station to go to a doctor's appointment. He reported there was no previous history of the resident trying to leave the facility. Per the interview, the Administrator stated R1 was not authorized to sign out of the building [facility].

Based on observation, interview, and review of standard of practice reference, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six sampled residents, Resident (R) 65. Observation of medication administration revealed Registered Nurse (RN) 7 failed to perform hand hygiene after administering medications for the resident, and prior to preparing medications for another. The findings include: Review of the facility's reference book, Fundamentals of Nursing, 10th Edition, by [NAME] and [NAME], pages 439 and 618, revealed the most effective basic technique for preventing and controlling the transmission of infection was hand hygiene. Per review, hand hygiene was defined as a general term that applied to four techniques: handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand anti-sepsis. Continued review revealed handwashing was defined as the vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing and stream of warm water for 15 seconds. Review revealed the fundamental principle behind handwashing was removing microorganisms mechanically from one's hands. Further review revealed if hands were not visibly soiled, using an alcohol based, waterless, antiseptic agent for routinely decontaminating hands in clinical situations. Review further revealed clinical situations in which antiseptic hand rubs were before, after, and between direct patient contact such as taking a pulse. Additionally review of the reference revealed hand hygiene should be performed both before and after medication administration. Observation of medication administration for R65 on 08/22/2024 at 8:35 AM, revealed RN 7 failed to wash or sanitize his hands before preparing the resident's medications. Per observation, RN 7 also failed to don gloves to administer insulin. During interview at the time of observation, RN 7 stated the reason hand hygiene was necessary was to prevent spread of infection. During interview with Licensed Practical Nurse (LPN) 11 on 08/23/2024 at 9:45 AM, she stated it was expected for staff to wash their hands or use hand sanitizer between residents. She further stated hand hygiene was important to prevent cross contamination. During interview with LPN 7 on 08/23/2024 at 9:52 AM, she stated hand washing or using hand sanitizer was necessary when providing care between residents, including giving medications. She further stated hand washing was important to help prevent infection. During interview with LPN 12 on 08/23/2024 at 10:15 AM, she stated staff giving medications should wash or sanitize their hands between residents. In addition, she stated staff should also wash or sanitize their hands before medication preparation and then again when exiting the resident's room to prevent spread of infection. During interview with the Assistant Director of Nursing (ADON) on 08/23/2024 at 2:15 PM, she stated her expectation was for staff to follow the facility's medication administration policy. The ADON further stated handwashing helped prevent spreading infections. During interview with the DON on 08/23/2024 at 5:35 PM, she stated she expected nurses to follow the facility's medication administration policy and standard of practice. She additionally stated that included handwashing between residents. During interview with the Administrator on 08/23/2024 at 6:36 PM, she stated she did not want to speculate on the risks associated with not using sanitizer or washing hands. She further stated however, she did expect staff to follow the protocol and accepted practice.

Based on observation, interview, review of the U.S. Food and Drug Administration (FDA) Food Code, 2022, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety. During observation on [DATE] of the kitchen walk in refrigerator, multiple produce items were rotting. Additionally, multiple sleeves of bread were found with no label or expiration date. Also, leftover tomatoes were observed in container with no use by date. The findings include: Review of the facility's policy, Food Storage: Cold Foods, revised ,d+[DATE], revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy, Food Storage: Dry Goods, revised ,d+[DATE], revealed all dry goods were to be appropriately stored in accordance with the FDA Food Code. Further review revealed storage areas were to be neat, arranged for easy identification, and dates marked as appropriate. Review of the FDA Food Code 2022, revealed containers holding food or food ingredients removed from the original packages for use in the food establishment, were to be identified with the common name of the food, except containers holding food readily and unmistakably recognized. Per policy review, packaged foods were required to conform to specific labeling laws. Continued review revealed foods packaged within the food establishment must also conform to the appropriate labeling laws, be accurate, and not misleading. Policy review revealed refrigerated, ready-to-eat, time/temperature control for safety, food prepared and held in a food establishment for more than 24 hours was to be clearly marked to indicate the date or day by which the food was to be consumed. Further review revealed refrigerated, ready-to-eat, time/temperature control for safety food prepared and held was also to be discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days, with the day of preparation counted, or the day of opening the original container, noted as Day 1. (1) Observation on [DATE] at 9:38 AM, during kitchen tour, revealed four small bowls of applesauce, undated, in the stand-up refrigerator. Continued observation also revealed slices of tomatoes in a pan, covered with no label or date. (2) Observation of the walk-in refrigerator, revealed a ham, noted as packed on [DATE], with no delivery date on the unopened box, and bacon noted as packed [DATE], opened [DATE], but with no expiration date documented. Review of the labeling information noted to keep the meat frozen until used. Continued observation in the walk-in refrigerator revealed celery, delivered [DATE], that was brown and softening on the ends, and a box of tomatoes, with one tomato rotted on one side. Observation also revealed one watermelon that was cracked open, in a box that was wet with (juice) saturation. Further observation in the walk-in refrigerator revealed 33 packages of prepared red apple slices in individual packs with expiration date of [DATE], and a box of eight cucumbers, delivered on [DATE] with five of the eight cucumbers being soggy and spongy. (3) Observation in the dry storage area of the kitchen revealed a package of cornstarch, delivered [DATE], with packaging description that indicated best if used by [DATE]. Continued observation of the dry storage revealed three sleeves of thick bread loaves, and four sleeves of hot dog buns, stored with no further packaging, nor labeled or dated. During interview with the District Certified Dietary Manager (CDM) on [DATE] at 10:35 AM, she stated she was covering for the facility's CDM, also known as the account manager, who was not working that week. She stated the facility went by the policy for how long to store food items. She further stated the account manager was responsible to do a walk through daily to check for decaying produce. Additionally, the CDM stated expired or spoiled food items served to residents may increase their risk of illness. During interview with the Healthcare Services Registered Dietician (RD) on [DATE] at 11:30 AM, he stated daily tasks were posted by the tray line for dietary staff. He further stated it was a CDM task to conduct a check of produce quality and for expiration dates for any food item. During interview with the Senior Director of Operations (SDO) on [DATE] at 11:15 AM, he stated his expectation was expiration dates on food packaging were followed. He stated the facility followed labeling and dating sheets, and produce was a different matter, but the CDM should be checking food items and discarding food if it appeared degraded. During interview with the Administrator on [DATE] at 6:36 PM, she stated there were guidelines and protocols that needed to be adhered to for proper food storage. She stated she did not want to speculate on the protocols; however, they were in place for a reason and staff should follow them.

Based on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws for one (1) of three (3) facility medication storage refrigerators. In addition, the facility also failed to ensure medications were secured during medication administration for 1 medication cart. Observation of the medication room on the facility's 100 unit revealed a personal lunch bag with food and drinks stored inside the locked medication refrigerator located in the room. Additionally, observation revealed Registered Nurse (RN) 7 prepared a resident's medications, then stepped away from the medication cart leaving the pills in a medication cup unattended, and out of view of staff. The findings include: Review of the facility policy, Medication Administration, last revised 6/24/2024, revealed medications were administered as prescribed in accordance with manufacturers' specifications. Continued review revealed medications were also administered in accordance with good nursing principles and practices, and only by persons legally authorized to do so. Further review revealed medications were to be administered at the time they were prepared. Review of the facility policy, Medication Storage, dated 01/2023, revealed medications and biologicals were to be stored properly, following the manufacturer's, provider's, or pharmacy recommendations. Per review, proper storage of medications and biologicals was to maintain their integrity and to support safe effective drug administration. Continued review revealed the medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy revealed the provider pharmacy was to dispense medications in containers that met state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). In addition, policy review revealed medications were to remain in the pharmacy containers and were to be stored in a controlled environment. 1. Observation on 08/22/2024 at 8:35 AM, of Registered Nurse (RN) 7 during medication administration for Resident (R)65, revealed he prepared the residents' morning medications. Per observation, R65's medications included: Aspiring 81 milligrams (mg) oral (po), Isosorbide (used to treat angina) 30 mg po, Jardiance (used to treat high blood sugar in Type 2 diabetics) 25 mg po and Protonix 40 mg po. Continued observation revealed RN 7 opened and placed the medications in a medication cup on top of the medication cart. Further observation revealed RN 7 then stepped away from the medication cart, going to the medication room, and leaving R65's pills unattended on top of the cart. During interview with RN 7 on 08/22/2024 at 8:35 AM, he stated he had left R65's medication unsecured; however, the State Survey Agency (SSA) Surveyors were standing by the cart. He further stated the reason medications should not be left unattended was that a resident could access and take pills that were not intended for them. During interview with Licensed Practical Nurse (LPN) 11 on 8/23/2024 at 9:45 AM, she stated she must never leave medications unattended. She stated if she had to step away from her medication cart, then she took any prepped medications with her. In further interview, she stated it was not safe to leave medications unsecured (at any time) because a resident might take them. During interview with LPN 7 on 8/23/2024 at 9:52 AM, she stated medications should never be left unattended. During interview with LPN 12 on 8/23/2024 at 10:15 AM, she stated nurses should never leave medications unattended because it could be unsafe for other residents. During interview with the Assistant Director of Nursing (ADON) on 08/23/2024 at 2:15 PM, she stated medications should never be left unattended. She stated this was because anyone, including residents, could take those medications not intended for them. The ADON stated if a resident took medication not intended for them they could possibly take something they were allergic to or have an adverse reaction from that medication. She stated her expectation was that nurses and Certified Medication Technicians (CMTs) not leave any medications unattended and they should follow the facility's medication administration policy. During interview with the Director of Nursing (DON) on 08/23/2024 at 05:35 PM, she stated medications should never be left unattended. She said the nurse should either take prepared medications with them if they must step away from the medication cart or lock them in an area of the cart until they returned. In further interview she stated you never know who could come by and pick the medications up. The DON stated it was necessary to ensure medications were secure and not put anyone at risk. She further stated the risks (of medication being left unattended) would depend on the person and the medications, but there was the potential the person could have an allergic reaction or other adverse reaction. During interview with the Administrator on 08/23/2024 at 6:36 PM, she stated it was never acceptable to leave medications unattended. She stated she did not want to speculate on associated risks (of medications left unattended), but the protocol was to never leave medications unattended and she expected the staff to follow that. 50000 [NAME] 2. Additional review of the facility policy titled, Storage of Medication dated 01/2023, revealed refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications. Continued review revealed all medications should be segregated from fruit juices, applesauce, and other foods used in administrating medications. Review further revealed any other foods, such as employee lunches and activity department refreshments, should not be stored in the medication refrigerator. Observation on 08/22/2024 at 4:00 PM, during performance of the medication storage and labeling task, revealed a personal lunch bag stored in the locked medication refrigerator in the medication room on the 100 unit. Continued observation revealed when opened the lunch bag contained a bag of potato chips, a can of Dr. Pepper, and a water bottle. When asked in interview, at the time of observation, RN 2 stated it was a staff person's lunch bag and should not have been in the medication refrigerator. RN 2 stated that refrigerator was only to be used for medication (storage). The SSA Surveyor asked RN 2 what the concern of having food stored in the medication refrigerator was, and she stated it could contaminate the medication in the fridge or the medication could contaminate the food which could be consumed. RN 2 stated that the facility policy for the medication refrigerator was for it to only be used for residents' medication and biologicals storage. Further observation revealed RN 2 removed the lunch bag from the refrigerator, locked it and removed the lunch bag from the medication room. In interview with LPN 1 on 08/22/2024 at 11:30 AM, she stated no food was permitted to be stored inside the medication refrigerators due to risk of contamination of the medications as well as potential contamination to the food products. LPN 1 stated food items used for administering medications was not allowed to be stored in the medication refrigerator and the facility policy was to store those foods in a separate refrigerator only intended for resident food items. In interview with RN 3 on 08/22/2024 at 4:26 PM, she stated the facility policy prohibited any food from being stored in the medication refrigerators throughout the facility. RN 3 stated food could contaminate the medications and/or the biologicals, and the food could also become contaminated from the medications or biologicals. In interview with the DON on 08/23/2024 at 2:37 PM, she stated the facility had three (3) medication storage refrigerators. She stated only the nurse assigned to the medication cart on a unit and the unit managers had keys to the locked medication room and locked medication storage refrigerators in the rooms. The DON stated the policy of the facility was no food storage in medication refrigerators was allowed at any time for any reason. She stated the expectation was for all staff to follow all (facility) policies at all times. The DON further stated education would be provided to staff on the (facility's) medication storage policy. In additional interview, she stated if the owner of the lunch bag was identified that person would receive one on one coaching on the policy, along with the risks of storing food in a medication refrigerator. In interview with the facility Administrator on 08/23/2024 at 6:30 PM, she stated all medication storage rooms and refrigerators should be locked at all times, with only licensed personnel who administered medication on that unit having the keys to access the rooms and refrigerators. In further interview, the Administrator stated no food items should be stored in the medication refrigerators. She additionally stated the facility had designated refrigerators for food storage for residents and staff, and it was the expectation for all employees to follow the facility's policies.

Based on interview, personnel record review, and facility policy review, the facility failed to ensure it had a process in place to ensure contracted employees had the Kentucky Adult Caregiver Misconduct Registry checked as required by KRS 209.032 for 2 of 5 employee files sampled. The findings include: Review of the facility policy Abuse, Neglect, and Misappropriation of Property revised 09/15/2023 revealed the facility included screening to provide protection for the health, welfare, and rights of each resident residing in the facility. Continued review revealed the screening included conducting criminal background checks and a search of the State Nurse Aide Abuse Registry. Review further revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the screening. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Dietary Aide (DA) 2 revealed she was employed by the facility through a contracted company on 05/03/2024. Further revealed no documentation noting the facility conducted the check of the Kentucky Adult Caregiver Misconduct Registry (KACMR) for DA 2 as required. 2. Review of the laundry employee's personnel file revealed she was employed at the facility through a contracted company on 08/05/2024. Further review revealed no documentation indicating the facility provided the check of the KACMR for Laundry employee as required. In interview with the Director of Nursing (DON) on 08/23/2024 at 5:34 PM, she stated she reviewed contracted employees' personnel information related to education and tuberculosis (TB) checks. She stated she was unaware if anyone verified the KACMR checks were completed as required as those checks were not clinical. The DON stated the purpose of completing the KACMR checks was to see if potential new employees had a report of abuse in a prior setting against them. She stated this was to ensure safety of residents with the new employee coming into the facility. Additionally, she stated the facility would not have employees in their building with a finding of abuse against them. The DON further stated if the KACMR checks were not completed there was a risk to residents' safety. In interview on 08/23/2024 at 6:27 PM, the Administrator stated the facility did not have a Human Resources employee. She stated her expectation for contracted employees potentially working at the facility, was for the contract agency to check them to ensure the contracted employee was ready for employment. The Administrator stated the KACMR was to be completed before a potential employee was hired. She stated the KACMR check was a regulated, mandated law in Kentucky and the facility would not allow their own employee to work if the check was not completed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #6), were protected from resident-to-resident abuse. On 11/10/2020, Resident #6 and Resident #7, of whom were roommates, were in a verbal altercation which lead to Resident #7 striking Resident #6 with his/her reacher. The findings include: Review of the facility's policy on Abuse, Neglect and Misappropriation of Property, revised 05/08/2019, revealed the organization's intention was to prevent the occurrence of abuse. The facility ensured all alleged violations of federal, or state laws involving abuse were investigated, and reported immediately to the Facility Administrator, State Survey Agency, and other appropriate State and local agencies in accordance to Federal and State law. The facility administrator or designee directed a reasonable investigation of each alleged violation. Review of the facility Event Report, dated 11/10/2020 at 5:00 PM, revealed a resident-to-resident altercation occurred between Resident #6 and Resident #7. The report revealed Resident #7 used his/her aluminum reacher to strike Resident #6. The witness was Registered Nurse (RN) #2, whom initiated the event report. The event report identified the Director of Nursing (DON) as the investigator. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/19/2018 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], revealed resident was assessed to have a Brief Interview of Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Review of Resident # 6's clinical record revealed the facility admitted the resident on 08/15/2006 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9), indicating the resident was cognitively intact. Interview with Resident #6, on 01/06/2021 at 1:00 PM, revealed Resident #7 called him/her a bunch of names, and hit him/her with a grabby thing (reacher device). The resident stated he/she was separated from Resident #7 when a nurse, (name unknown) who witnessed the incident, came into his/her room. Interview with Certified Nurse Aide (CNA) #2, on 01/07/2021 at 3:00 PM, revealed she was present when Resident #6 was removed from Resident #7's room during the altercation. She stated she heard staff call for assistance, and she responded to the call. She revealed Registered Nurse (RN) #2 was present and separated the two (2) residents upon her arrival to the residents' room. Interview with Registered Nurse (RN) #2, on 01/07/2021 at 11:50 AM, revealed she witnessed the altercation between Residents #6 and #7. She stated she was administering medications to residents in the area when staff brought Resident #6 to the room in a wheelchair. She revealed she stepped into the corridor to the medication cart when she heard Resident #6 and #7 hollering at each other and heard a thump sound. She rushed into the room and saw Resident #7 holding his/her reacher device, hitting at Resident #6. She stated she intervened, and called out for assistance to separate the two (2) residents. She stated she notified the Director of Nursing (DON) immediately for further direction with the residents and their needs. Interview with the Director of Nursing (DON), on 01/07/2021 at 4:50 PM, revealed the facility reassigned residents to other rooms related to the current pandemic. She stated the facility did not complete a Roommate assessment, prior to moving Resident #6 and Resident #7 into their room. She further stated the altercation occurred during the process of moving the residents, which made Resident #7 angry/upset. The DON revealed she has since moved Resident #6 and Resident #7 to separate rooms to ensure the safety of the residents. Interview with the Administrator, on 01/06/2021 at 10:10 AM, revealed the DON followed up with investigating the allegations of abuse related to Resident #6 and Resident #7. She stated it was the facility's process to assess the residents for compatibility prior to transferring the residents into rooms with one another. An additional interview, on 01/08/2021 at 5:10 PM, revealed it would have been her expectation that staff would have completed a Roommate Assessment, prior to transferring Residents #6 and #7, to prevent potential resident-to-resident abuse.

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system in place to ensure each resident received adequate monitoring and supervision to prevent elopement for one (1) of nine (9) sampled residents (Resident #1). The facility admitted Resident #1, on 03/11/2020, with diagnoses of Malignant [CONDITION(S)], History of Seizures, and [CONDITION(S)]. Interviews revealed the resident had poor decision-making abilities and had a state appointed Legal Guardian. Interviews and record review revealed the resident exhibited exit-seeking behaviors. On 05/19/2020, 06/16/2020, and 08/13/2020 Resident #1 was assessed as being at risk for elopement. However, there was no documented evidence the facility implemented increased supervision and monitoring of the resident. Interview with staff revealed Resident #1 was last observed by State Registered Nurse Aide (SRNA) #3 in his/her room between 1:00 AM and 1:30 AM, on 08/24/2020. Further interview with staff revealed they did not monitor, check, or look in on Resident #1 at any other time until 8:00 AM on 08/24/2020, when the Nurse went into the resident's room to administer his/her medication. At that time, Resident #1 was not in his/her room. The facility initiated a search but was unable to locate Resident #1. Later that morning, Resident #1 telephoned the facility and stated he/she had left the facility; was safe; and was not returning to the facility. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 09/03/2020 and determined to exist on 08/24/2020, in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F-656 and 42 CFR 483.25 Quality of Care, F-689, both at a Scope and Severity (S/S) of a J. Substandard Quality of Care was identified at 42 CFR 483.25. The facility was notified of the Immediate Jeopardy on 09/03/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 09/14/2020, alleging removal of the Immediate Jeopardy on 08/26/2020. The State Survey Agency validated the AoC on 09/18/2020 and determined the facility was still implementing corrective action on 08/31/2020; therefore, determined the Immediate Jeopardy was removed on 09/01/2020, prior to exit on 09/18/2020, with remaining noncompliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Safety and Supervision of Residents, last reviewed 05/31/2020, revealed staff would make routine resident checks to help maintain resident safety and well-being. In addition, resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. Further review of the policy revealed routine resident checks by nursing staff involved entering the resident's room and/or verifying the resident's location on the unit to determine if the resident's needs were being met, identifying any change in the resident's condition, identifying any resident concerns, seeing if the resident was sleeping or if the resident needed toileting assist, etc. Further review of the policy revealed a resident-oriented approach to safety was used by staff to identify specific risk factors for residents, including information obtained from the medical history, resident observation, and the Minimum Data Set (MDS). In addition, the policy stated the interdisciplinary team (IDT) would analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. Then, the care team would target interventions to reduce the potential for accidents or hazards for that resident. Further review of the policy revealed interventions implemented would include communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring interventions were implemented and documented. In addition, after interventions were implemented, they were monitored for effectiveness. Per policy, this monitoring included ensuring interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. Review of the facility's policy titled, Missing Resident, last revised 01/24/2020, revealed missing residents needed to be located quickly using several guidelines. Per policy, these guidelines included: notify the charge nurse and nursing staff when a resident was suspected of being missing; notify the supervisor, Director of Nursing (DON), Administrator, Regional Vice-President (RVP) and Signature Care Consultant (SCC); staff would announce overhead Code Green to alert staff of the missing resident; activate the Incident Command System (ICS) to manage the incident; identify the missing resident to staff and a staff member would immediately check all exit doors; conduct an exhaustive search of the interior of the facility; assign two (2) or more staff to check the area immediately outside the facility including the parking lots and the grounds surrounding the facility; assign available staff to begin a search of the neighborhood. Further review revealed if the resident had not been found after an exhaustive search of the facility and immediately outside, the person in-charge would notify the police or local law enforcement agency, the family or responsible party, the Attending Physician, and other regulatory agencies as required by law. Per policy, when law enforcement arrived, the authorities might assume command and direction of the search for the resident. Further review of the policy revealed an Ad Hoc Quality Assurance meeting would be conducted with a complete and thorough root cause analysis (RCA) of the elopement to prevent reoccurrence, ensure policies, procedures and systems were effective, and to protect other residents. The focus of the RCA would be to identify deficient practice and to identify actions to be taken to prevent the incident from happening again. Per policy, all RCA information would be summarized and discussed at the next Quality Assurance (QA) meeting with records kept of all incidents so that trends and risks could be identified and reduced. Other QA functions could include random testing of door and personal alarm systems, mock drills to test compliance of the plan, and review and update of policies and procedures as needed. Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/2020. Admitting diagnoses included Malignant Neoplasm of Brain, Anxiety Disorder, Adjustment Disorder with Mixed Anxiety Disorder and Depressed Mood, Seizures, [CONDITION(S)], and [CONDITION(S)]. Review of Social Services Notes, dated 03/24/2020, revealed Resident #1 had spoken to the Social Services Director (SSD) about not wanting to be at the facility or any other long-term care (LTC) facility. Further review revealed Resident #1 told the SSD he/she was not happy and just wanted to leave, maybe to a half-way house. Interview, on 09/03/2020 at 4:07 PM, with the SSD revealed she explained to Resident #1, because he/she had a State Guardian, she would to talk to the Guardian about that request and reminded him/her there was a court hearing the following month about restoring his/her rights. Review of Resident #1's Elopement Risk Evaluation (ERE), dated 05/19/2020, revealed Resident #1 was an elopement risk. Per the ERE, on 05/19/2020 at 3:35 AM, Resident #1 demonstrated exit-seeking behaviors, as determined by the Nurse answering yes to Question #4, pacing back and forth and requesting to go outside and assist the employee. Nursing documentation indicated the Nurse reviewed the parking lot area, through a window, and there was not an employee in the parking lot. The ERE stated Resident #1 was re-directed and put on fifteen (15)-minute observations throughout the remainder of the night. Review of the Elopement Risk Evaluation form revealed that a Yes answer to Question #4 (demonstration of exit-seeking behavior), Question #5 (wandering oblivious to safety needs) or Question #6 ( have an exit-seeking history), automatically placed the resident at risk for elopement. Review of Resident #1's Fifteen (15)-Minute Observation Sheet revealed he/she was kept on the required 15-minute observations until 6:30 AM on 05/19/2020. Review of Resident #1's Interim Care Plan, initiated by the Nurse on 05/19/2020, revealed he/she had a problem of pacing back and forth and asking to go out. The goal was the resident would not elope from the facility and his/her location would be monitored on an ongoing basis through the next review date of 08/19/2020. Per the Interim Care Plan, interventions to prevent elopement included using a resident identifier so staff was aware of the elopement risk, re-evaluating Resident #1's elopement risk at least quarterly, and fifteen (15)-minute checks until the AM of 05/19/2020. Review of minutes from an interdisciplinary team (IDT) meeting conducted on 05/21/2020, revealed Resident #1's behavior on 05/19/2020 was discussed. The decision was made to continue the elopement risk interventions and evaluate at the next Quarterly Assessment, due on 08/13/2020. Review of subsequent ERE's, dated 06/01/2020 and 08/13/2020 (Quarterly), revealed the facility continued to assess Resident #1 as an elopement risk. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview Mental Status (BIMS) of thirteen (13), indicating he/she was cognitively intact, and no verbal/physical behaviors that occurred one (1) to three (3) days during the look back period of seven (7) days. The MDS stated there were no wandering behaviors identified. Review of the next Quarterly MDS, dated [DATE], revealed Resident #1 was assessed with a BIMS of fourteen (14, cognitively intact) and no behaviors, including wandering, were identified. Interviews with MDS Nurse #1 and MDS Nurse #2, on 09/03/2020 at 4:15 PM, revealed both had been in their positions for a short time. Both stated the MDS assessment did not assess the resident's risk for elopement, only wandering, and during the seven (7) day assessment period, Resident #1 was not assessed with wandering behaviors. Continued interview revealed the MDS only addressed safety/supervision in relation to activities of daily living (ADL) in the residents' Comprehensive Care Plan and they would not be involved in an elopement Care Plan or a safety/supervision interventions related to elopement behaviors, that would be the responsiblity of the Nurse completing the Elopement Risk Assessment. Review of the Comprehensive Care Plan, dated 08/13/2020, revealed a problem of Resident #1 being at risk for elopement. The goal was that he/she would remain safely within the environment. Further review revealed interventions included to complete elopement observations quarterly and with significant changes and to monitor behaviors of verbalizing intent to leave the facility or pushing on the exit doors. Review of Nursing Progress Notes, dated 05/20/2020 through 08/24/2020, revealed no documented evidence the staff increased monitoring and supervision for Resident #1 after he/she was determined to be an elopement risk, on 05/19/2020, 06/01/2020, and 08/13/2020. Review of the facility's Long-Term Care (LTC) Facility-Self Report Form, dated 08/24/2020 and signed by the Administrator, revealed, on 08/24/2020 at 1:00 AM, Resident #1 was seen in his/her room. Then, on 08/24/2020 at 8:00 AM, a Nurse entered the resident's room to administer medication, but the resident was not there and was unable to be located on the unit; the Nurse Supervisor was notified. At this point, on 08/24/2020, the facility initiated its Code Green policy/procedures. Per the report, on 08/25/2020, Resident #1's State Guardian contacted the facility and stated Resident #1 was safe and in Indiana, but the resident would not divulge his/her specific location. Review of the facility's five (5) day Verification of Investigation Final Report, dated 08/28/2020 and signed by the Administrator, revealed, on 08/24/2020 at approximately 8:00 AM, Resident #1 was discovered not to be in his/her room. It was documented the day shift nurse (unable to interview related to a family emergency) went into Resident #1's room with medications, and he/she was not there. After searching Resident #1's room and a facility wide search and head count, a Code Green (missing Resident) was called. The surrounding grounds and neighborhood were searched, in conjunction with a staff member going to Resident #1's last known address, to try to locate the resident. The resident was not located. In addition, there were no known witnesses to Resident #1 exiting the facility. Review of available camera footage did not reveal Resident #1 in any of the frames. The camera footage was from the outside cameras aimed at the parking lot; the inside cameras that showed the hallway the resident resided on; the inside cameras aimed at the exit doors; and the camera aimed at the door coming from residents' rooms into the Main lobby. An additional review of the video footage did not reveal any resident or staff coming through the doors and heading toward the front door. Observation with the Maintenance Director, on 08/28/2020 at 11:01 AM, of Resident #1's room window and an empty room (room 105) window, revealed the windows had 5/16 inch screws in the slide track to prevent the windows from raising more than six (6) inches. Additional observation revealed the facility was also installing new replacement windows that had the ability to tilt out for cleaning; however, the new windows were having screws placed so that the tilting mechanism was inoperable, and the new windows could not tilt out. During the observation, the Maintenance Director stated Resident #1's room had a new window installed on 08/11/2020 or 08/12/2020. Observation with the Independent Risk Manager (IRM), on 09/02/2020 at 2:40 AM, of Resident #1's room new windows revealed they did not slide down from the top nor did they tilt inward, as originally designed. Observation revealed a screw had been placed in each tilt release mechanism to prevent the tab from retracting so the window could not be tilted inward for easier cleaning. Observation with the IRM revealed when the IRM attempted to dislodge the tilting mechanism to disengage the tab to allow the window to tilt inward, she was unable to do so. Interview with the Maintenance Director, on 08/28/2020 at 11:41 AM, revealed that since becoming as the Director in January 2020, it was his practice to do daily door and weekly window checks. Because of COVID-19 restrictions, he stated the only way in or out of the facility was the Main Entrance. He continued by stating, on the morning of 08/24/2020, he heard the Code Green alert. At that time, the interior building search was started, and he made sure all the doors were locked and the alarms were working. Per interview, when the resident was not found from the interior search, the exterior search was started; the campus was divided into search grids, two (2) staff drove in opposite directions in the immediate neighborhood, and the woods adjacent to the facility was searched. He stated a staff member drove to Resident #1's last known address, but were not able to locate the resident there. He stated that review of the video from the outside cameras, aimed at the parking lot did not reveal the resident. Continued interview revealed that review of various interior cameras, specifically those that showed the hallway the resident resided on, the cameras aimed at the exit doors, and the camera aimed at the door coming from the resident rooms into the Main lobby, did not reveal Resident #1 on any of the footage. Further interview revealed he changed all the door codes and held elopement drills for available staff on 08/24/2020. Interview with Resident #1 was attempted, on 09/02/2020 at 5:32 PM, per telephone call. A voicemail could not be left, and the phone rang until it disconnected the call. Interview with the Day Shift Nurse on 08/24/2020 who discovered Resident #1 was missing could not be conducted because he/she was unavailable due to a family emergency. Interview with State Registered Nurse Aide (SRNA) #2, on 08/27/2020 at 1:54 PM, revealed he used to work night shift and knew that Resident #1 did not like to be awakened if already asleep at night and kept to himself/herself. Continued interview revealed resident rounds should be made every (2) hours. Interview with SRNA #3, on 08/28/2020 at 7:00 AM and 09/01/2020 at 6:45 AM, revealed she had peeped in on Resident #1, while making rounds, at approximately 1:00 AM. She stated she should have made regular rounds on Resident #1, but she knew he/she had [CONDITION(S)] and did not like to be bothered if asleep. Per interview, there was nothing unusual about Resident #1's behavior during her shift (works nights) to set off a red flag, such as exit-seeking behaviors on 08/24/2020. She stated there were no audible alarms the night of 08/24/2020, and she was aware of the process to begin if alarms did sound or a resident was unable to be located. SRNA #3 stated there had not been any education about Resident #1's level of supervision, given that he/she was an elopement risk. Interview with RN #2, on 08/28/2020 at 7:30 AM and 08/31/2020 at 6:33 AM, revealed she had last seen Resident #1, on 08/23/2020 at approximately 9:00 PM, (works (twelve)12 hour shifts), to administer medications. She stated there were no audible alarms the night of 08/24/2020, and he/she displayed his/her usual behaviors. Per interview, the resident had [CONDITION(S)] and did not like to be bothered if asleep. RN #2 stated all the facility's windows would only go up about six (6) inches. The RN stated she was aware of what to do if a door alarm sounded on her shift. She also stated care plans should reflect safety interventions for residents that eloped, and no education had been given on a supervision level for Resident #1. Interview with Licensed Practical Nurse (LPN) #1, on 09/01/2020 at 7:10 AM, revealed she took care of Resident #1 upon his/her return from the hospital, while the resident was in quarantine. She stated the resident was an insomniac, did not like to be bothered if asleep, and would walk up and down the halls for exercise. However, LPN #1 stated rounds would still need to be made at least every (2) hours, regardless of the resident's request, to ensure resident safety or to see if there was an unmet need. She stated care plans should reflect those interventions. Per interview, LPN #1 worked the first shift on 08/24/2020, arriving at the facility around 6:30 AM, and she heard no alarms. Interview with SRNA #5, on 09/01/2020 at 7:30 AM, revealed she worked the night shift, starting on 08/23/2020 going into the morning of 08/24/2020, and there were no audible alarms during that time. The SRNA stated resident rounds should be made every (2) hours, and she was aware of the Code Green process. Interview with RN #3, on 09/01/2020 at 11:21 AM, revealed she was not working the day of 08/24/2020. RN #3 stated Resident #1 and several other residents did not want to be bothered by staff, but her goal was to see her assigned residents at least every hour. She stated Resident #1 wanted to be in control and would become agitated if routines were deviated. RN #3 stated care plans and updates were necessary to ensure staff were aware of interventions to provide care and keep residents safe. Further interview revealed walking rounds at change of shift was a facility expectation, but it depended on what was going on, rounds may or may occur. In addition, RN #3 stated there had not been any education provided regarding Resident #1's level of supervision. Interview with RN #4, on 09/01/2020 at 1:29 PM, revealed she would see all residents who resided on her hall during medication pass, during meals, and in between. She stated the observations were to make sure residents were safe and their needs were being met. Per interview, RN #4 was aware there was an elopement book at each nurse's station and the reception desk. She stated there had not been any education regarding the supervision level for Resident #1. In addition, she stated care plans should reflect interventions needed to provide care for and to keep residents safe. RN #4 stated she would try to make walking resident rounds at change of shift, which was usually not possible. Interview with SRNA #6, on 09/01/2020 at 1:45 PM, revealed the Resident Care Card would state if the resident was an elopement risk. Further interview revealed she was working day shift on 08/24/2020 and heard the Code Green alert. SRNA #6 stated she searched all the rooms in her area, closets, shower rooms, every nook and cranny. She stated the windows in residents' rooms do not go up but about six inches. SRNA #6 stated there was an elopement book at each nurse's station. She stated there had not been any education regarding Resident #1's level of supervision related to his/her elopement assessment, and she made sure to do walking rounds at change of shift. Interview with LPN #3, on 09/03/2020, at 2:00 PM revealed she had been working as a SRNA on dayshift, on 08/24/2020. She stated the normal routine was to receive verbal report from the off going shift but the facility's expectation was for walking rounds to be made. However, that was not always possible depending on what was happening at shift change. LPN #3 stated she remembered that she had not made it to Resident #1's room while making her rounds, when she heard the Code Green announcement for a missing resident. She remembered Resident #1 was an elopement risk, but she had not observed him/her with any exit-seeking behaviors. Interview with Resident #1's State Guardian, on 09/02/2020 at 8:16 AM, revealed she had only been Resident #1's Guardian for approximately two (2) months. The Guardian stated the facility had notified her of Resident #1's elopement on 08/24/2020. Further interview revealed she talked to the resident the morning of 08/25/2020 and Resident #1 told her that he/she would not be returning to the facility and was safe. The Guardian stated she was trying to keep Resident #1 in a controlled environment until after the court hearing in October 2020 to see if Guardianship could be rescinded. Interview with the Social Services Assistant, on 09/02/2020 at 1:05 PM and 09/03/2020 at 3:55 PM, revealed Resident #1's admission was originally short-term, and there were no plans to transfer him/her to another facility. On 07/06/2020, Social Services had spoken to Resident #1's State Guardian, who wanted him/her to be long-term, despite treatment therapies ending. Continued interview revealed she had completed an elopement risk evaluation, on 08/13/2020, and based on the yes response to Question #4, which asked if the resident had exit-seeking behaviors, Resident #1 should have had a safety/supervision care plan. She stated that it was her perception if a resident stopped to look out a window or door, and had been assessed as an elopement risk, he/she was possibly exit-seeking, and a care plan should be initiated, if not already in place. The Social Services Assistant also stated that the components of poor decision- making skills, and the ability to ambulate independently factored into her decision to assess Resident #1 as an elopement risk on 08/13/2020. Interview with the Social Services Director (SSD), on 09/02/2020 at 1:14 PM and again on 09/03/2020 at 4:07 PM, revealed her department had spoken with Resident #1's State Guardian on 07/06/2020. She stated, at that time, the Guardian requested Resident #1 to stay in long-term care until the Court hearing to decide if Guardianship was to be continued or dropped. The SSD stated Resident #1 should have had a safety/supervision care plan, and her department could initiate and update a behavior care plan as needed. Interview with Receptionist #1, on 09/03/2020 at 4:30 PM, revealed the front door used a key system to allow for entry/exit after business hours. Since COVID-19 restrictions had been in place, the front door was locked at all times. Continued interview revealed when there was a staff member operating the desk, the key system was turned on which activated a button under the desk to allow staff entry or resident entry when coming back from an appointment. She stated that when she left, at approximately 7:00 PM, the key system would be turned off, and the button under the desk would be inactive. Further interview revealed she would give the key to the Charge Nurse after hours when nobody would be sitting at the desk. Interview with the Director of Nursing (DON), on 09/02/2020 at 2:30 PM, revealed the facility did not have a formal policy on change of shift report. The facility expected staff to make walking rounds at change of shift, but this was not monitored for compliance. She stated the benefit of walking rounds was that both staff had an observation of the resident to ensure safety or to ensure needs were met. Per interview, a potential outcome of not making change of shift walking rounds was staff was not aware of the resident's location, safety status, or if there was an unmet need. She continued by stating Resident #1's situation was not typical because he/she had completed all treatments and was basically ready for discharge. However, she stated the State Guardian wanted Resident #1 to remain in long-term care until the Court hearing about Guardianship, which had been pushed back because of COVID-19 restrictions, from April 2020 to October 2020. The DON stated Resident #1 had not had any exit-seeking behaviors since the incident, on 05/19/2020, he/she had only made statements to the effect that he/she just did not want to be at the facility. In addition, the DON stated she felt Resident #1's care plan reflected elopement assessments. She stated if it had been any other resident besides Resident #1, she was confident a safety/supervision care plan would have been initiated. However, given that Resident #1's situation of still being in the facility after [CONDITION(S)] treatments were completed, there having been no further incidents, and State Guardianship wanting him/her in a facility while waiting on the Court System to decide if Guardianship was going to be removed, a safety/supervision care plan was not instituted. Per interview, in hindsight, based on the elopement risk assessments and safety/supervision policy, she stated Resident #1 should have had a safety/supervision care plan. The DON stated Resident #1 had been assessed with poor decision-making skills on admission, following brain surgery for a tumor. Interview with the Administrator and the CC (Care Consultant) in attendance, on 09/03/2020 at 10:30 AM, revealed she called Resident #1, on 09/02/2020 at 3:40 PM. Per interview, when queried about how the resident exited the facility, Resident #1 stated he/she used the button, under the desk, to open the door and left via the front door. The Administrator stated after the phone call, the video footage from the front door was reviewed from a period of 9:00 PM to 8:00 AM, and there were no observations of Resident #1 coming through the doors leading from the residents' rooms toward the front door. Additional interview with the DON, on 09/03/2020 at 11:18 AM, revealed, related to the components of the elopement policy, Resident #1 may have triggered for poor decision-making skills and wandering behaviors based on the assessor's perception of Resident #1 and his/her routine of walking around the halls and stopping to look out the doors/windows. She continued by stating, related to the safety/supervision policy and the elopement assessments and policy, there should have been a safety/supervision care plan initiated, with interventions to include rounding to ensure resident safety, despite staff attempting to honor the resident's wishes of only peeping in on him/her during the night. She stated the facility followed standards of practice (SOP) for rounding at least every two (2) hours on all residents, or as ordered. She continued by stating that based on policy and SOP, staff should have rounded on Resident #1 every (2) hours, regardless of his/her request to be left alone at night. Interview with the Administrator and the CC in attendance, on 09/03/2020 at 4:50 PM, revealed Resident #1's most recent elopement risk assessment or ERE and care plan did not coincide, and the care plan did not have resident centered interventions and did not reflect his/her current safety/supervision status. She further stated she felt Resident #1 was an isolated situation because of his/her high degree of independence with routine care and high level of functioning. Continued interview revealed the Administrator stated Resident #1 had not had any further exit-seeking behaviors since 05/19/2020, but the facility failed to provide safety and supervision for Resident #1, whom the facility assessed as an elopement risk, by not providing rounds every (2) hours as per the safety/supervision policy. The facility provided an acceptable credible Allegation of Compliance (AoC) on 09/14/2020 that alleged removal of the Immediate Jeopardy (IJ) on 08/26/2020. Review of the AoC revealed the facility implemented the following: 1. The Administrator and Director of Nursing (DON) conducted staff interviews, including all staff that worked 08/23/2020, between the hours of 9:00 PM and 9:00 AM on 0/24/2020. These interviews were completed to determine any observations they may have had of Resident #1 and investigate to determine the Root Cause. These interviews were conducted on 08/24/2020. Camera footage reviews, staff interviews and door alarm reviews were conducted on the morning of 08/24/2020 by Care Consultant, Administrator and Maintenance Director. 2. Charge Nurses verified the Census immediately by conducting a head count of residents and their whereabouts. 3. Maintenance Supervisor checked all windows, doors and alarms, and changed the existing door codes on 08/24/2020. 4. The Administrator, Risk Manager and Signature Care Consultant (SCC) reviewed camera footage of the Main Entrance, 100 Unit exit door and parking lot, during the period of 1:00 AM - 8:00 AM, on 08/23/2020. 5. The Interdisciplinary Team (IDT), which included DON, ADON, Social Services and Activities Director reviewed elopement Binders. 6. Elopement Risk assessments were completed on all residents by Social Services on 08/24/2020; and at that time there were a total of seven (7) residents in the facility that were assessed as being at risk for elopement (Residents #2, #3, #4, #6, #7, #8, and #9). Elopement Binders and Care Plans were reviewed and updated on 08/24/2020 to reflect interventions to include monitoring and/or supervision levels required related to elopement risk. 7. The DON educated Staff Development Coordinator (SDC) on elopement and rounding (change of shift communication from outgoing to incoming staff) and the expectation that residents be checked on every two hours. The SDC then initiated same education, on 08/24/2020, to all staff including nursing, housekeeping, dietary, therapy, business office and MDS staff related to rounding, checking residents every two hours and the procedure for locking the front door after hours which required a key to open. 8. The DON, SDC, Charge Nurse #1, Charge Nurse #2 and Medical Records Director provided additional education to nurses related to change in condition with emphasis on notification to State Guardian,

Based on interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to revise the Comprehensive Resident Centered Care Plan to include instructions to provide adequate monitoring and supervision to prevent elopement for one (1) of nine (9) sampled residents (Resident #1). The facility admitted Resident #1, on 03/11/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews revealed the resident had poor decision-making abilities and had a state appointed Legal Guardian. Interviews and record review revealed the resident exhibited exit-seeking behaviors. On 05/19/2020, 06/16/2020, and 08/13/2020, the facility assessed Resident #1 as being at risk for elopement. An elopement-risk care plan was developed; however, there was no documented evidence the facility revised the Comprehensive Resident Centered Care Plan with interventions to increase the level of monitoring and supervision required to prevent Resident #1 from eloping. On 08/24/2020, interview with staff revealed Resident #1 was last observed in his/her room by State Registered Nurse Aide (SRNA) #3 between 1:00 AM and 1:30 AM. Further interviews with staff revealed they did not monitor, check, or look in on Resident #1 at any other time until 8:00 AM on 08/24/2020, when the Nurse went into the resident's room to administer his/her medication. At that time, Resident #1 was not in his/her room. The facility initiated a search but was unable to locate Resident #1. Later that morning, Resident #1 telephoned the facility and stated he/she had left the facility; was safe; and was not returning to the facility. The facility's failure to have an effective system in place to ensure each Comprehensive Resident Centered Care Plan was revised to include increased monitoring and supervision to prevent elopement for at-risk residents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 09/03/2020 and determined to exist on 08/24/2020, in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F-656 and 42 CFR 483.25 Quality of Care, F-689, both at a Scope and Severity (S/S) of a J. Substandard Quality of Care was identified at 42 CFR 483.25. The facility was notified of the Immediate Jeopardy on 09/03/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 09/14/2020, alleging removal of the Immediate Jeopardy on 08/26/2020. The State Survey Agency (SSA) validated the AoC on 09/18/2020 and determined the facility was still implementing corrective action on 08/31/2020. Therefore, the SSA determined the Immediate Jeopardy was removed on 09/01/2020, prior to exit on 09/18/2020, with remaining noncompliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance Performance Improvement (QAPI) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Elopement/Wandering, last reviewed 05/30/2018, revealed the facility would identify residents who were at risk for wandering/elopement behavior. Further review revealed guidelines to identify those residents included completing an elopement/wandering assessment on admission and quarterly thereafter; any resident that displayed significant wandering behavior would be assessed for elopement/wandering risk and care planned appropriately; care plans and individual behavior plans would address wandering as a specific problem, with approaches and patterns identified (if any), and the causes determined would be addressed. Additional review of the policy revealed a wandering/elopement notebook of identified at-risk residents that contained pictures and pertinent demographic information would be maintained by Social Services and kept at the Nurse's Stations and the Receptionist's desk. Updates to the notebooks were to be done at least quarterly. Review of the facility's policy titled, Safety and Supervision of Residents, last reviewed 05/31/2020, revealed a resident-oriented approach to safety was used by staff to identify specific risk factors for residents, including information obtained from the medical history, resident observation, and the Minimum Data Set (MDS). In addition, the policy stated the interdisciplinary team (IDT) would analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. Then, the care team would target interventions to reduce the potential for accidents or hazards for that resident. Further review of the policy revealed interventions implemented would include communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring interventions were implemented and documented. In addition, after the interventions were implemented, they were to be monitored for effectiveness. Per policy, this monitoring included ensuring interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. Review of the facility's policy titled Comprehensive Care Plans, last revised on 07/19/2018 revealed a Person Centered Comprehensive Care Plan that included objectives and timetables to meet the resident's medical, nursing, mental and psychological needs would be developed for each resident. The care plan would include how the facility would assist the resident to meet their needs, goals and preferences. Continued review revealed person centered care plan meant the facility focused on the resident as the center of control and supported the resident in making his or her own choices. Further review revealed the nurse or interdisciplinary team (IDT) would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. The policy also stated that care plans would be on-going and revised as information about the resident and the resident's condition changed. Review of Resident #1's medical record revealed the resident was admitted by the facility on 03/11/2020. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Elopement Risk Evaluation (ERE), dated 05/19/2020, revealed the resident was an elopement risk. Per the ERE, on 05/19/2020 at 3:35 AM, Resident #1 demonstrated exit seeking behaviors by pacing from room to door then going to the Nurse on duty and stating there was an employee in the parking lot with a flat tire. Resident #1 requested to go outside and assist the employee. Nursing documentation indicated the Nurse reviewed the parking lot area, through a window, and there was not an employee in the parking lot. The ERE stated Resident #1 was re-directed and put on fifteen (15)-minute observations throughout the remainder of the night. Review of the ERE form revealed a yes answer to Question #4 (demonstration of exit-seeking behavior), Question #5 (wandering oblivious to safety needs) or Question #6 ( have an exit-seeking history), automatically placed the resident at risk for elopement. Review of Resident #1's Interim Care Plan, initiated by the Nurse on 05/19/2020, revealed he/she had a problem of pacing back and forth and asking to go out. The goal was the resident would not elope from the facility, and his/her location would be monitored on an ongoing basis through the next review date of 08/19/2020. Per the Interim Care Plan, interventions to prevent elopement included using a resident identifier so staff was aware of the elopement risk, re-evaluating Resident #1's elopement risk at least quarterly, and fifteen (15)-minute checks until later in the morning of 05/19/2020. Review of minutes from an interdisciplinary team (IDT) meeting, on 05/21/2020, revealed Resident #1's behavior on 05/19/2020 was discussed. The decision was made to continue elopement risk interventions and evaluate at the next Quarterly Assessment, due on 08/13/2020. Review of subsequent ERE's, dated 06/01/2020 and 08/13/2020 (Quarterly), revealed the facility continued to assess Resident #1 as an elopement risk. Review of the Comprehensive Resident Centered Care Plan, dated 08/13/2020, revealed a problem of Resident #1 being at risk for elopement. The goal was that he/she would remain safely within the environment. Interventions included to complete elopement observations quarterly and with significant changes and to monitor behaviors of verbalizing intent to leave the facility or pushing on the exit doors. However, there was no documented evidence the Care Plan included interventions related to the level of supervision required for Resident #1. Review of Nursing Progress Notes, dated 05/20/2020 through 08/24/2020, revealed no documented evidence the staff increased monitoring and supervision for Resident #1 after he/she was determined to be an elopement risk, on 05/19/2020, 06/01/2020, and 08/13/2020. Review of the facility's Long-Term Care (LTC) Facility-Self Report Form, dated 08/24/2020 and signed by the Administrator, revealed, on 08/24/2020 at 1:00 AM, Resident #1 was seen in his/her room. Then, on 08/24/2020 at 8:00 AM, a Nurse entered the resident's room to administer medication, but he/she was not there and was not located on the unit; the Nurse Supervisor was notified. Further review of the report revealed, at 9:00 AM, Resident #1 called the Administrator and stated he/she was safe and would call in an hour to arrange for pickup of his/her belongings. Per report, on 08/25/2020, Resident #1's State Guardian contacted the facility to inform that Resident #1 was safe and in Indiana, but the resident would not divulge his/her specific location. Interview with Registered Nurse (RN) #1, on 08/27/2020 at 1:41 PM, revealed she had not observed Resident #1 with exit-seeking behaviors nor had she heard him/her make statements about leaving. RN #1 stated the care plan should be updated as needed to reflect safety interventions for any resident. Interview with SRNA #3, on 08/28/2020 at 7:00 AM and 09/01/2020 at 6:45 AM, revealed she had peeped in on Resident #1, while making rounds between 1:00 AM and 1:30 AM on 08/24/2020. SRNA #3 stated there had not been any education about Resident #1's level of supervision, given that he/she was an elopement risk, such as the need for frequent observation and monitoring or at least every two (2)hours when rounding was supposed to be done. Interview with RN # 2, on 08/28/2020 at 7:30 AM and on 08/31/2020 at 6:33 AM, revealed she had last seen Resident #1, on 08/23/2020 at approximately 9:00 PM, (works 12 hour shifts), to administer medications. She stated care plans should reflect safety interventions for residents that were at risk for elopement, but no education had been given on a supervision level for Resident #1. Interview with Licensed Practical Nurse (LPN) #1, on 09/01/2020 at 7:10 AM, revealed she had taken care of Resident #1. She stated resident rounds should have been made on him/her every two (2) hours to ensure the resident's safety and to ensure his/her needs were met. Per interview, Resident #1's care plan should have reflected that intervention. Interview with RN #3, on 09/01/2020, at 11:21 AM, revealed RN #3 was not working the day of 08/24/2020. She stated care plans and updates were necessary to ensure staff was aware of interventions to provide care and keep residents safe. In addition, RN #3 stated there had not been any education provided regarding Resident #1's level of supervision. Interview with RN #4, on 09/01/2020 at 1:29 PM, revealed she would see all residents on her hall during medication pass, meals and in-between. The observations were to make sure residents were safe and their needs were being met. She stated she was aware there was an elopement book at each Nurse's station and at the Receptionist's desk. RN #4 stated care plans should reflect interventions to provide care for residents and to keep them safe. Interview with SRNA #6, on 09/01/2020 at 1:45 PM, revealed there had not been any education regarding Resident #1's level of supervision related to his/her elopement assessment. Interview with the Social Services Assistant (SSA), on 09/02/2020 at 1:05 PM and 09/03/2020 at 3:55 PM, revealed it was her perception if a resident had been assessed as an elopement risk, a safety/supervision care plan should be initiated if not already in place. Interview with the Social Services Director (SSD), on 09/02/2020 at 1:14 PM and again on 09/03/2020 at 4:07 PM, revealed Resident #1 should have had a safety/supervision care plan which would have required Resident #1 to have been monitored at night at least every two (2) hours or more frequently. She stated her department could initiate and update behavior care plans as needed. Interview with the Director of Nursing (DON), on 09/02/2020 at 2:30 PM, revealed she felt Resident #1's care plan reflected elopement assessments. Resident had not had any significant elopement behaviors since the incident of 05/19/2020. She stated that if it had been any other resident besides Resident #1, she was confident a safety/supervision care plan would have been initiated. However, given that Resident #1's situation of being there after [CONDITION(S)] treatments were completed, there were no further incidents, and State Guardianship wanted him/her in a facility while waiting on the Court System to decide if Guardianship was going to be removed, a safety/supervision care plan was not instituted. However, she stated, in hindsight, based on elopement risk assessments and the facility's safety/supervision policy, Resident #1 should have had a safety/supervision care plan which would have ensured he/she was frequently monitored during the night or at least every two (2) hours with rounds. Interview with the Administrator and the Care Consultant (CC) in attendance, on 09/03/2020 at 4:50 PM, revealed Resident #1's most recent elopement risk assessment or ERE and care plan did not coincide. Further interview revealed the care plan did not have resident centered interventions and did not reflect his/her current safety/supervision status. She further stated she felt Resident #1 was an isolated situation because of his/her high degree of independence with routine care and high level of functioning. Continued interview revealed Resident #1 had not had any further exit-seeking behaviors since 05/19/2020, but the facility failed to provide safety and supervision for Resident #1, whom they assessed as an elopement risk, by not providing rounds every (2) hours as per the safety/supervision policy. Further interview revealed the Comprehensive Resident Centered Care Plan should have contained elopement risk interventions. The facility provided an acceptable credible Allegation of Compliance (AoC) on 09/14/2020 that alleged removal of the Immediate Jeopardy (IJ) on 08/26/2020. Review of the AoC revealed the facility implemented the following: 1. The Administrator and Director of Nursing (DON) conducted staff interviews, including all staff that worked 08/23/2020, between the hours of 9:00 PM and 9:00 AM on 0/24/2020. These interviews were completed to determine any observations they may have had of Resident #1 and investigate to determine the Root Cause. These interviews were conducted on 08/24/2020. Camera footage reviews, staff interviews and door alarm reviews were conducted on the morning of 08/24/2020 by the Care Consultant, Administrator and Maintenance Director. 2. Charge Nurses verified the Census immediately by conducting a head count of residents and their whereabouts. 3. The Maintenance Supervisor checked all windows, doors and alarms, and changed the existing door codes on 08/24/2020. 4. The Administrator, Risk Manager and Signature Care Consultant (SCC) reviewed camera footage of the Main Entrance, 100 Unit exit door and parking lot, during the period of 1:00 AM - 8:00 AM, on 08/23/2020. 5. The Interdisciplinary Team (IDT), which included the DON, ADON, Social Services and Activities Director reviewed elopement Binders. 6. Elopement Risk assessments were completed on all residents by Social Services on 08/24/2020; and at that time there was a total of seven (7) residents in the facility that were assessed as being at risk for elopement (Residents #2, #3, #4, #6, #7, #8, and #9). Elopement Binders and Care Plans were reviewed and updated on 08/24/2020 to reflect interventions to include monitoring and/or supervision levels required related to elopement risk. 7. The DON educated the Staff Development Coordinator (SDC) on elopement and rounding (change of shift communication from outgoing to incoming staff) and the expectation that residents be checked on every two (2) hours. The SDC then initiated the same education, on 08/24/2020, to all staff including nursing, housekeeping, dietary, therapy, business office and MDS staff related to rounding, checking residents every two (2) hours and the procedure for locking the front door after hours which required a key to open. 8. The DON, SDC, Charge Nurse #1, Charge Nurse #2 and Medical Records Director provided additional education to nurses related to change in condition with emphasis on notification to State Guardian, regardless of cognition level. The SDC and DON validated learning by reviewing the posttests and verbal feedback. 9. On 08/24/2020, the MDS Nurses, Nurse Managers and Clinical Consultants audited Care Plans and SRNA care records for all residents to ensure they were current, accurate and reflected resident supervision needs and were person centered for that resident. 10. On 08/24/2020, the Ad Hoc Quality Assurance Team to include the Medical Director met to discuss the event and actions taken. 11. Beginning 08/24/2020 through 08/25/2020, the facility conducted elopement drills every shift. 12. Residents identified as elopement risks on any assessment would be reviewed in daily Clinical Meeting starting 08/25/2020 to ensure the Care Plans reflected the level of risk, were individualized and preventive measures in place. Clinical Meeting participants included Nurse Managers, Social Services, Medical Records and MDS Nurses. 13. Starting 08/25/2020, the DON, ADONs, and Unit Managers will be monitoring compliance of use of 24-hour report and rounds being made during the change of shift report to monitor residents daily. Rounding sheets would be implemented as a working tool for staff. Charge Nurses would be responsible to ensure staff compliance was completed during walking rounds. Also starting 08/25/2020, the IDT would validate rounding sheets during the clinical meeting Monday-Friday and on the weekends, rounding observations for Saturday/Sunday would be the responsibility of the Weekend Manager and/or the Receptionist. Walking round shift report was an expectation of the facility. 14. Starting on 08/25/2020, door alarms and windows will be checked daily by the Plant Operations Manager. 15. Starting 08/25/2020 the DON and/or SDC would maintain compliance and would implement ongoing re-education and/or coaching as necessary. Staff would not be able to work until they had received the education. New hires would receive education in orientation prior to an assignment. Flex Path employees (Corporation Work Pool) would receive training prior to working at the facility by the SDC or DON. The SDC would validate and track the training and education. 16. The results of all audits and re-education of these systems would be reviewed during the facility's QAPI meetings. QAPI participants included the Administrator, DON, Admission Director, Business Office Manager, Activities Manager, Dietary Manager and MDS Nurse. QAPI meetings were held 08/24/2020 to review the corrective plan and on 08/25/2020 to audit corrections. Meetings will continue weekly until the removal of Immediate Jeopardy (IJ). Per the AoC, the facility alleged abatement of the IJ on 08/26/2020; however, the State Survey Agency validated the implementation of the facility's AoC and determined the IJ was abated on 09/01/2020 as the facility was still implementing corrective action on 08/31/2020: 1. Interview with the Administrator and the DON on 09/18/2020 at 9:00 AM revealed, she and the DON interviewed the assigned staff that were working on the evening of 08/23/2020 and morning of 08/24/2020. The interview revealed SRNA #3 stated she only checked on Resident #1 at 1:00 AM on 08/24/2020 as the resident preferred to not be disturbed through the night. Further interview revealed she and the Maintenance Director reviewed the video footage of the doors to view for Resident #1's exit. 2. Review of the Unit Resident Roster sheets dated 08/24/2020, revealed the residents' whereabouts were verified by nursing staff and indicated if a resident was out of the building for an appointment. Interviews with Licensed Practical Nurse (LPN) #3, on 09/16/2020, at 4:28 PM, revealed she verified residents were accounted for on 08/24/2020, during the Code Green (missing resident). Interviews with Restorative Aide #1, on 09/17/2020, at 9:35 AM, SRNA #8, on 09/17/2020, at 10:08 AM, and SRNA #10, on 09/17/2020, at 11:13 AM, revealed they ensured the residents' whereabouts using the Unit Census Sheets. 3. Review of the TELS, (the electronic Maintenance system logs), used by the facility, to track maintenance tasks, dated 08/24/2020 revealed Maintenance conducted door, alarm and window checks. Observations of resident windows with the Maintenance Director, on 08/28/2020 starting at approximately 10:45 AM, revealed residents' windows had screws inserted in them to prevent them from raising more than six (6) inches and to prevent them from tilting out. Interview with the Maintenance Director on 08/28/2020, at 11:08 AM, revealed he conducted door alarm checks on 08/24/2020 and changed the existing door codes. Further interview revealed he also did window checks to ensure none of the windows raised more than (6) inches or tilted out. The checks were documented in the TELS. Interview with Receptionist #1, on 09/03/2020, at 4:30 PM, revealed the front door used a key system to allow for entry/exit after business hours. Since COVID-19 restrictions had been in place, the front door was locked at all times. Continued interview revealed when there was a staff member staffing the desk, the key system was turned on which activated a button under the desk to allow staff entry or residents coming and going from appointments. She stated that when she left at approximately 7:00 PM, the key system would be turned off and the button under the desk would be inactive. Further interview revealed she would put the keys in an Interview with Receptionist #1 on 09/17/2020, at 4:17 PM, revealed she wanted to clarify her statement from the interview on 09/03/2020. She stated she would put the key in the drawer until the end of her shift. She would lock the door and take the key with her anytime she had to leave the desk and there was no one to relieve her. 4. Interview with the Administrator and Signature Care Consultant (SCC), on 08/28/2020, at 10:43 AM and 10:52 AM, respectively, revealed they had reviewed the camera footage, specifically the front door, all side exits and the hall that Resident #1 resided on, as well as the parking lot, from 1:00 AM through 8:00 AM, on 08/24/2020. They stated that Resident #1 was not observed on any of the footage. Continued interview with Administrator, on 09/03/2020, 10:30 AM revealed on 09/02/2020, at 3:40 PM, she was able to contact Resident #1. When she inquired about the method of egress, Resident #1 stated he/she left through the front door around 5:00 AM. She stated Resident #1 stated he/she pushed the button at the desk to open the door and disable the alarm. Continued interview at that time with the Administrator and SCC revealed they then reviewed the camera footage of 08/24/2020 from 9:00 PM - 8:00 AM again, focusing on the camera that would show anyone coming from resident rooms towards the front door. Again, Resident #1 nor any other individual was visible on any footage. Further interview with the Administrator revealed Resident #1 could have observed the door entry system while waiting in the Lobby for appointment transport. 5. Interviews with the DON, on 09/16/2020, at 11:10 AM and Social Services Director (SSD), on 09/17/2020, at 9:40 AM revealed they had reviewed the elopement binders at each nursing station and at the front desk to ensure they contained pictures and information of the known elopement risk residents. 6. Review of the Elopement Risk Assessments revealed all residents were re-assessed on 08/24/2020 by the Social Services Director (SSD). Based on the assessments, there were a total of seven (7) residents at that time that the facility had assessed to be at risk for elopement. Review of the Elopement Binders revealed there was a total of seven (7) residents identified at risk for elopement (#2, #3, #4, #6, #7, #8, and #9) in the binders on 08/25/2020. Review of the Care Plans revealed they had all been reviewed and updated on 08/24/2020 to reflect monitoring and supervision. However, review of Resident #2's Care Plan revealed no documented evidence the Care Plan was reviewed until 08/31/2020. Interview with the Social Service Director, on 09/18/2020 at 9:40 AM revealed she re-assessed all the residents for elopement risk, finding a total of seven (7) in house residents that were at risk for elopement. She stated she updated the Elopement Binders; however, she was not assigned to review and update the care plans per the AoC. She stated the MDS Nurse was responsible for reviewing and updating the Care Plans related to elopement. 7. Review of education on elopement, missing person, rounding process and the procedure for the front door locking system after hours revealed the DON had educated the SDC on 08/24/2020. Continued review revealed the SDC then educated all staff to include Nursing, Housekeeping, Dietary, Business Office, Therapy and MDS. Review of the sign in sheets revealed a total of seventy-six (76) staff working on 08/24/2020 received the education. Interview with the DON, on 09/16/2020, at 11:10 AM, revealed she had received training related to elopement, missing resident and rounding from the Care Consultant on 08/24/2020. Further interview revealed she then trained the SDC on elopement, missing resident and rounding, and the procedure for the front door locking system as part of the Train the Trainer System. Interview with the SDC on 09/18/2020 at 8:30 AM, revealed she received the education from the DON and began educating all staff working on 08/24/2020. Interview with the Restorative Program Manager, on 09/16/2020, at 3:10 PM, and Restorative Aide #1, on 09/17/2020 at 9:35 AM, revealed they had received education related elopement, the rounding process, missing resident, 24-hour report and the front door locking system after hours. Interview with Registered Nurse (RN) #5, on 09/16/2020, at 3:15 PM, RN #3, on 09/16/2020, at 3:54 PM, and Licensed Practical Nurse (LPN) #3, on 09/16/2020, at 4:28 PM revealed they received education related to elopement, rounding process, missing resident, 24-hour report and the front door locking system after hours. Interview with the Director of Environmental Services (EVS) and Laundry, on 09/16/2020, at 4:20 PM revealed he had received education on elopement, missing residents and then trained the rest of his staff. Interview with Laundry Aide #1, on 09/16/2020 at 4:13 PM, revealed he received training on elopement and missing resident when he returned to work, prior to being allowed to work. Interview with Respiratory Therapist #1, on 09/16/2020, at 4:38 PM, revealed she had received training on elopement and missing resident. Interviews with EVS #1, on 09/17/2020, at 10:47 AM and EVS #2, at 10:52 AM revealed they had training on elopement and missing residents. Interviews with SRNA #8, on 09/17/2020, at 10:58 AM, SRNA #9, on 11:05 AM, SRNA #10, on 09/17/2020, at 11:13 AM revealed they had received education on elopement, rounding, missing residents, and the front door locking system after hours. Interviews with Dietary Aide #1, on 09/17/2020, at 12:50 PM and Dietary Aide #2, on 09/17/2020, at 12:58 PM, revealed they had received education on elopement and missing residents. Review of education sign-in sheets, dated 08/24/2020, revealed one hundred (100) out one hundred fourteen (114) staff members received education on elopement, missing residents and rounding. 8. Interviews with the DON, on 09/16/2020, at 11:10 AM and the SDC, on 09/18/2020, at 8:30 AM, revealed additional education was provided for Nurses related to change in condition with emphasis on notification to State Guardians regardless of resident cognitive status. Further interview revealed education would be ongoing as staff were scheduled to work and they would be responsible to train the staff prior to being allowed to work. Further interview revealed an active employee roster was in use to ensure all staff received education. Continued interviews revealed they validated education by reviewing the post-test, verbal questioning and validating accurate responses. 9. Review of the Care Plans for Residents #3, #4, #6, #7, #8, and #9, who had been assessed to be at risk for elopement, revealed they had been reviewed and revised to include person centered interventions related to monitoring and supervision. However, review of the Elopement Care Plan for Resident #2's revealed no documented evidence the Care Plan was reviewed and revised with monitoring and supervision interventions until 08/31/2020. Interview with Social Services Director (SSD), on 09/17/2020, at 9:40 AM, revealed it had been her understanding that the MDS Nurse would review resident Care Plans and SRNA care cards to ensure accuracy and development of individualized, person centered interventions that reflected a resident's monitoring and supervision needs. Interviews with MDS Nurse #1 and MDS Nurse #2 on 09/18/2020, at 10:58 AM, revealed on 08/24/2020 they reviewed Care Plans to ensure each resident that was assessed to be an elopement risk had an elopement Care Plan, but they did not review to ensure they included monitoring and supervision that was person centered for each resident. Further interview revealed they were only responsible to update care plans for safety/supervision as it related to Section G of the Minimum Data Set (MDS) assessment for activities of daily living (ADLs). They stated they didn't know why the Care Plan for Resident #2 was not reviewed until 08/31/2020. 10. Review of Ad Hoc meeting minutes, with sign in sheet, dated 08/24/2020, revealed a summary of the events on 08/24/2020 was discussed, along with tasks and education completed on that day. Interviews with the DON, on 09/16/2020, at 11:10 AM, the SDC on 09/18/2020, at 8:30 AM, Administrator on 09/18/2020, at 3:40 PM; and, the CC on 09/18/2020, at 3:52 PM, verified they were all in attendance at the QAPI meeting held on 08/24/2020 and the action plan and education were discussed. Further they validated the Medical Director was involved in the meeting by phone. 11. Review of Elopement Drills dated 08/24/2020 - 08/25/2020, with sign-in sheets revealed the drills were held. Interviews with Registered Nurse (RN) #5, on 09/16/2020 at 3:15 PM, RN #3, on 09/16/2020 at 3:54 PM, and Licensed Practical Nurse (LPN) #3, on 09/16/2020 at 4:28 PM, SRNA #8, on 09/17/2020 at 10:58 AM, SRNA #9, on 09/17/2020 at 11:05 AM, SRNA #10, on 09/17/2020 at 11:13 AM re [TRUNCATED]

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition service for 96 residents nine (nine residents received tube feeding) of 105 residents who received meals at the facility. Review of the Resident Census and Conditions of Residents, signed by the DON (Director of Nursing) on 11/12/19 revealed there were one hundred five (105) total residents and nine (9) residents received tube feeding. Observation and interview revealed there was not enough dietary staff to ensure meals were served to residents in a timely manner, per the facility posted meal times. (Refer to F[AGE]9). In addition, resident food allergies and intolerances were not followed for Resident #[AGE] with regards to gluten free diet and dietary staff interview revealed no training on gluten free diets. (Refer to F[AGE]6). Frosted Spice Cake was not served per the menu on 11/12/19, per interview, due to lack of staff (Refer to F[AGE]3). The Findings Include: Review of facility policy titled Staffing Schedules, dated revised 10/22/18, revealed schedules were created to provide the work force necessary for accomplishment of identified output. Review of the facility Meal Times, undated, revealed the lunch meal times for the Gold/Main Dining Room was at 12:30 PM. Further review revealed 200 Hall lunch was at 11:30 AM. Per the Meal Times document, Trays would be delivered by posted time. Review of the Menu dated Tuesday, November 12, 2019, revealed the lunch menu items were Chicken Burrito, Latin Flavored Corn, Southwest Salad, Tortilla Chips and Salsa, Frosted Spice Cake, and Choice of Beverage. Review of the facility policy Food Allergy/Intolerance Awareness, dated revised 0[DATE], revealed food that accommodates resident allergies, intolerances, and preferences should be prepared and served. Continued review of the policy revealed a food substitute for the food allergy, intolerance, or preference should be consistent with the usual or ordinary food item provided to the community. Observations on 11/12/19 at 1:08 PM, revealed residents were being served drinks in the Dining Room. Observations revealed residents in the Gold Dining area were being served on 11/12/19 at 1:50 PM, which was past the Meal Times schedule of 12:30 PM. Observations revealed the food cart arrived on the 200 unit at 1:50 PM on 11/12/19, which was past the Meal Times schedule of 11:30 AM. Observation of the lunch meal service on 11/12/19 revealed Frosted Spice Cake was not served to residents with the lunch meal, per the menu. Observation on 11/12/19 at 10:57 AM, revealed the Dietitian assisted kitchen staff with washing dishes. Observation during the tray line beginning on 11/13/19 at 11:30 AM, revealed Dietary Aide #2 was observed to place regular bread on the tray for Resident #[AGE], and placed the tray on the cart for delivery. Interview with Dietary Aide #2 at the time revealed she stated the bread she placed on the resident's tray was regular bread. After the surveyor stopped the line and asked Dietary Aide #2 about the bread, the Cook told Dietary Aide #2 to remove the bread from Resident #[AGE]'s tray. Continued observation revealed there was no additional/gluten free bread placed on the resident's tray. Interview with Dietary Aide #2, on 11/15/19 at 10:24 AM, revealed she had been employed at the facility for three (3) years. Continued interview revealed she did not know about gluten free bread, just about cereal and lactose free milk. Per interview she had not received training to specifically know what a resident could or could not have on a gluten free diet and she did not know if the facility had gluten free bread. She stated that in past, cooks marked bread gluten free. Further interview with Dietary Aide #2, revealed everyone was doing extra in the kitchen due to not having enough staff, and it took longer to complete tasks when short staffed. Continued interview revealed the Dietary Manager had to make sure menus were followed. Per interview, if there was not enough dessert, she would provide something else and on 11/12/19, the Frosted Spice Cake was supposed to be made the night before but it was not prepared due to short staffing. Interview with the Dietary Manager (DM), on 11/15/19 at 10:37 AM, revealed he began employment as the DM on Monday, [DATE]. Continued interview revealed the kitchen had a staff shortage, and there was supposed to be three (3) full time staff and now were only two (2) full time staff. Per interview, he believed there had been a staffing shortage for several weeks. Continued interview revealed the Frosted Spice Cake on the lunch menu for 11/12/19, was supposed to have been made the night before; however, the kitchen was short staffed so it did not get made. Per interview, resident diets should be followed, and the facility had gluten free bread. Continued interview revealed Resident #[AGE], who was ordered a gluten free diet, should have received gluten free bread and should not receive regular bread, because regular bread could make the resident sick. Continued interview with the DM revealed staffing shortage had caused issues, such as meals not served timely to residents. He indicated the budget calls for 3 staff for the AM shift and 3 for the PM shift, consisting of one (1) cook and two (2) dietary aide each shift. He further stated the facility had only two (2) people to pick from. He indicated he had been in contact with corporate recruiting staff, and there were four (4) to six (6) new staff in orientation starting the following week. Further interview revealed the Dietitian was assisting with washing dishes on 11/12/19, to be able to get dishes washed for the next meal. Per interview, if the kitchen was staffed, he would be an extra set of eyes and supervision, rather than serving the tray line and that he was unable to do that when he was cooking or cleaning. Interview by phone with the Dietitian, on 11/16/19 at 4:57 PM, revealed she had been employed at the facility for six (6) to seven (7) months, and there had been turnover and lack of dietary management in the kitchen. Per interview, the dietary department was short staffed on 11/12/19 and she helped wash dishes. Continued interview revealed the dietary aide told her she substituted fruit with cinnamon for the Frosted Spice Cake which was on the menu on 11/12/19, but did not elaborate as to the reason the Frosted Spice Cake was not served, per the menu. Per interview, dietary staff had been challenged as they didn't know how to do things or what to do, and meals had been late since the assistant DM left about a month ago, as the facility was trying to fill positions. Continued interview revealed late meals could cause blood sugar drops or could cause stomach issues for residents. Per interview, menus should have been followed and residents on gluten free diets should receive gluten free bread, as regular bread could cause bloated belly, diarrhea, inflammation, or potential constipation. Per interview, she indicated staff needed a review on diets and felt this would be accomplished since the facility has a new DM. Interview with the Director of Nursing (DON), on 11/16/19 at 9:30 AM, revealed she had been employed at the facility for six (6) weeks and stated the dietary department had been a concern. Per interview, she was not aware residents did not get Frosted Spice Cake, per the menu on 11/12/19, and menus should be followed. Further interview revealed she was aware meals arrived late and residents had complained. Per the DON, late meals could result with [DIAGNOSES REDACTED] for diabetic residents. Continued interview revealed she was informed dietary staff placed regular bread on Resident #[AGE]'s tray and stated Resident #[AGE] had gluten intolerance. Per the DON, Resident #[AGE] should not have had regular bread placed on the tray, but should have received gluten free bread; however, she stated non medial staff would not know this without training. Continued interview revealed the facility was working on staffing for the kitchen and she thought there were kitchen staff in orientation this week. Interview with the Administrator, on 11/16/19 at 4:20 PM, revealed she was aware of dietary issues in kitchen. Further interview revealed the facility had a new DM, who started this week, and the DM had not had time to provide education. Per interview, on 11/12/19, there were two (2) Dietary Aides and the DM, who was also the cook for that date. Per interview, there typically should be the DM and 3 staff. Further interview revealed it was her expectation that staff follow policies and procedures of the facility.

Based on observation, interview, and record review it was determined the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Review of the facility posted Meal Times, which was not dated, revealed the lunch meal was to be served to the Gold/Main Dining Room at 12:30 PM. Observations during the meal service on 11/12/19 revealed the lunch meal was served late. Interviews with Resident's #18, #22, #28, and #155, revealed meals were often served late. Interview with Resident #155 revealed he/she would refuse prescribed short acting [MED] until he/she knew for sure the trays were on the unit, due to the short acting [MED] would make his/her sugar drop. The findings include: Review of the facility Meal Times, undated, revealed the lunch meal times for the Gold/Main Dining Room was at 12:30 PM. Further review revealed 200 Hall lunch was at 11:30 AM. Per the Meal Times document, Trays will be delivered by posted time. Review of the policy Staffing Schedules, dated revised 10/22/18, revealed schedules were created to provide a work force necessary for the accomplishment of the identified output. Observations on 11/12/19 at 1:08 PM, revealed residents were being served drinks in the Dining Room. Observations revealed facility staff were serving residents in the Gold Dining area, on 11/12/19 at 1:50 PM, which was past the Meal Times schedule of 12:30 PM. Observations revealed the food cart arrived on the 200 unit at 1:50 PM on 11/12/19, which was past the Meal Times schedule of 11:30 AM. Observation, on 11/15/19 at 8:15 AM, during the medication pass revealed Resident #155 would not let the nurse administer the short acting [MED] until the breakfast trays were brought to the unit. Interview with Resident #155, on 11/15/19 at 8:15 AM, revealed she was alert and oriented. Interview further revealed the short acting [MED] will make her sugar drop and she would get shaky. Resident #155 revealed that the trays on the unit sometimes did not get delivered until around 10:00 AM or 10:30 AM and by that time her sugar would drop too low so she refused to take the short acting [MED] until she knew for sure the trays were on the unit. Record review of the face sheet for Resident #155 revealed the facility admitted he/her on 10/22/19 with [DIAGNOSES REDACTED]. Record review of the physician orders [REDACTED]. Interview with Resident #18, on 11/12/19 at 12:14 PM, revealed meals were often late. Review of the clinical record revealed the facility admitted Resident #18, per the face sheet, on 07/06/17. [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident was assessed as having a BI[CONDITION] score of twelve (12) of fifteen (15). Interview on with Resident #22, 11/13/19 at 9:18 AM, revealed they were supposed to get their lunch meal at noon, when things were going right. Resident #22 revealed the kitchen had been messed up for quite awhile because they do not have enough staff and there was no one to oversee it. Resident #22 revealed last evening they did not get their supper tray until 6:30 PM. Resident #22 revealed you never know what food you were going to get. Resident #22 stated he/she would fill out a menu and if they did not have the food they would just anything. Resident #22 revealed a third of the time they run out of what was on the menu and would just serve them anything. Resident #22 stated he/she felt they should at least get a heads up of what they were about to eat. Record review of the clinical record revealed the facility admitted Resident #22 on 10/10/16 with [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/19 revealed a Brief Interview of Mental Status (BI[CONDITION]) of fifteen (15) which meant the resident was not cognitively impaired. Record review of the physician orders [REDACTED].#22 had [MEDICATION NAME] sliding scale ordered to be given before meals. Resident #22 also had other medications for Diabetes order which included, [MEDICATION NAME] 500 milligrams (mg) to be given twice a day and [MEDICATION NAME] [MED] twenty one (21) units to be given subcutaneous twice a day, Interview with Resident #28, on 11/12/19 at 12:00 PM and 11/14/19 at 12:28 PM, revealed meals were late and sometimes he/she did not receive lunch until 2:30 PM. Record review revealed the facility admitted Resident #28 on 05/23/19 with [DIAGNOSES REDACTED]. Continued review revealed the facility assessed Resident #28 as having a BI[CONDITION] (Brief Interview Mental Status) score of fourteen (14) out of fifteen (15) on the MDS assessment dated [DATE], indicating the resident was cognitively intact. Record review revealed the resident's ordered diet was regular liberalized renal double protein. Interview with Certified Nursing Assistant (CNA) #6, on 11/15/19 at 11:26 AM, revealed the past three (3) weeks or so, meals had been late due to a kitchen staffing shortage. Interview with Dietary Aide #2, on 11/15/19 at 10:24 AM, revealed dietary services had experienced short staffing for about 2 months and sometimes meals were delivered late. Continued interview revealed everyone was doing extra in the kitchen due to not enough staff. Per interview, depending on how many staff were working, or if there were staff who did not know how things were done, such as staff whom came from another facility/building, it took longer to complete tasks. Interview with the Dietary Manager (DM), on 11/15/19 10:37 AM, revealed the dietary department was short staffed and he believed staffing had been short for several weeks. Per interview, there were three (3) full time staff and now there were only two (2) full time staff. The DM stated staffing problems had caused issues, such as meals not served timely to residents. He indicated the budget calls for 3 staff for the AM shift and 3 for the PM shift, consisting of one (1) cook and two (2) dietary aide each shift. He further stated the facility had only two (2) people to pick from. He indicated he had been in contact with corporate recruiting staff, and there were four (4) to six (6) new staff in orientation starting the following week. Further interview revealed the Dietitian was assisting with washing dishes on 11/12/19, to be able to get dishes washed for the next meal. Interview with the Dietitian by phone, on 11/16/19 at 4:57 PM, revealed there had been staff turnover and the facility was trying to fill the voids. Continue interview revealed there had been a lack of dietary management in dietary services but stated the facility now had a new DM. Further interview revealed meals had been late since the prior assistant DM left, about a month or so ago. She indicated the kitchen was short staffed on 11/12/19 and she helped wash dishes. Continued interview revealed late meals could cause a problem with diabetic residents as their blood sugar could drop. Interview with the DON, who stated she had been employed at the facility for six (6) weeks, on 11/16/19 at 9:30 AM revealed dietary has been a concern, and she was aware that meals were arriving late and resident had complaints about the late meals. Continued interview revealed late meals could be a problem and could result with [DIAGNOSES REDACTED] for diabetic residents. Interview with the Administrator, on 11/16/19 at 4:20 PM, revealed she was aware of dietary issues in the kitchen. She indicated the facility had been working on the schedule and should have three 3 staff on the AM shift and three (3) staff on the PM shift. Per interview, the new DM has not had time to provide education to staff and just started this week. She indicated it was her expectation that facility policies and procedures be followed.

Based on observation, interview and review of the facility's Policies, it was determined the facility failed to prepare, store, distribute and serve food in accordance with professional standards for food service safety. Observation of the kitchen, on [DATE] revealed low fat cottage cheese with an open date [DATE], and turkey, which was labeled with two labels, one label documenting use by [DATE] and one label with the date [DATE], and a use by date of [DATE]. Continued observation revealed chocolate pudding, dated to use by [DATE], an opened gallon of 2 percent milk with manufacturer use by date of [DATE], and potato salad opened [DATE]. Furthermore, observation on [DATE] revealed ground pepper and ginger powder opened with no date, ground cumin dated opened [DATE], Mediterranean ground oregano labeled [DATE], and black pepper, which was not dated and the label was such that the date received could not be read. Observations revealed sugar, rice and flour bins were observed with brown substance on the containers. Moreover, observations of the walk in freezer on [DATE] revealed ice on floor and cord to the plug, with ice and frost on pre packaged pie crusts. Homestyle Chicken Breast tenders were observed in a box with the inner bag opened, unsealed, and undated, and turkey sausage patties were observed in a box inside an inner plastic bag, and the plastic bag was observed open, unsealed, and undated. In addition, observation of the 100 Unit Nourishment refrigerator on [DATE] revealed a tuna sandwich and a chicken sandwich wrapped, with no dates on either sandwich. The findings include: Review of the facility policy Refrigerated Storage Quick Reference Guide, dated revised [DATE], revealed cottage cheese was good for 7 to 10 days once opened. Continued review revealed potato salad was good Review of the policy Refrigerated Leftover Storage, dated revised [DATE], revealed a leftover foods should not be saved and used for human consumption if there is any doubt of the wholesome quality. Per policy a leftover was a product that has been on the meal service line one time. These timeframes were not only used to control sanitation but the quality of the food also. Further review revealed date container with use by date. Review of the policy Dry Storage Chart, dated revised [DATE], revealed the chart was a recommended outline of proper storage times for opened and unopened dry items and where different, follow manufacturer's directions and expiration dates. The policy noted expiration dates supercede these guidelines. Review of the facility policy Freezer Storage Chart, dated revised [DATE] revealed the document was a recommended outline of proper storage times for opened and unopened frozen items and where different, follow manufacturer's directions and expiration dates. Per policy, expiration dates supercede the guidelines. Further review of the policy revealed if frozen status is maintained and food is properly sealed, recommended storage times were the same as unopened. Review of the policy Nourishment Preparation, dated revised [DATE], revealed individual nourishments should be prepared, covered, labeled, dated and delivered to each nursing station. Per policy, nourishments stored in the nourishment refrigerator must be labeled and dated. Observations during the initial kitchen tour, on [DATE] at 9:53 AM, of refrigerated items, revealed low fat cottage cheese with an open date [DATE]. Interview with the DM at this time, revealed he just began working at the facility one (1) day ago. Further interview revealed cottage cheese was good for 7 days after opened, per policy. Review of the facility Refrigerated Storage Quick Reference Guide, dated revised [DATE], revealed cottage cheese was good for 7 to 10 days once opened. Further observation revealed cooked turkey meat in a plastic container, observed with two (2) labels, one documented a use by date of [DATE], and the second label was dated [DATE] and a use by date of [DATE]. Interview with the DM revealed the turkey was improperly labeled, so it could not be determined which dates determine when the food expired. Review of the facility policy Refrigerated Storage Quick Reference Guide revealed cooked meat was good for three (3) to four (4) days after opened. Chocolate pudding was observed with a use by date of [DATE], and an opened gallon of 2 percent milk was observed with the manufacturer use by date of [DATE]. Interview with the DM revealed these items were expired, and should have already been discarded. Further observation revealed a container of potato salad opened [DATE]. Per interview with the DM, the health department gives seven (7) days but he planned to have staff discard after three (3) days. Continued observation during the initial kitchen tour revealed ground pepper was observed opened with no date, ginger powder was observed opened with no date, ground cumin was dated opened [DATE], Mediterranean ground oregano was labeled [DATE] and black pepper was observed opened and not dated, and the date on the label was illegible. Interview with the DM revealed spices should be dated when opened and were only good for 6 months. He indicated these spices should have been discarded. Review of the policy Dry Storage Chart revealed ground spices and herbs were good for six (6) months after opening. Large sugar, rice and flour bins were observed with brown substance on the containers. Interview with the DM revealed it looked like coffee on the containers. Observation of the walk in freezer during the initial kitchen tour revealed ice was observed on the freezer floor and plug cord, and from a shelf which contained pre packaged pie crusts. The pie crusts were observed with with ice and frost on them. Interview with the DM revealed the pie crusts would have to go in trash due to having ice and frost on them. The DM stated he was unsure why the walk in freezer had ice build up. Continued observation revealed Homestyle Chicken Breast tenders were observed in a box inside an inner bag, which was observed opened, unsealed, and undated. In addition, a box of turkey sausage patties were observed opened, unsealed, and no date was observed. Interview with the DM revealed the Chicken Breast Tenders and Turkey sausage should have been submerged in plastic, labeled and dated. Observation on [DATE] at 12:42 PM, during tray line, revealed silver plate warmers fell out of warmer onto floor and staff placed them back inside oven/warmer. Continued observation revealed the Administrator was present and told the staff not to use the plate warmers, and dietary staff removed them and placed them in dish room to be washed. Observation of the 100 Unit Nourishment refrigerator, on [DATE] at 8:37 AM, with Registered Nurse (RN) #6, revealed a tuna sandwich and a chicken sandwich, observed wrapped, with no date. Further observation revealed medications were stored in the refrigerator with the food. Interview with RN #6 at this time, revealed medications should be stored in the medication refrigerator. Further interview revealed medications were not supposed to be stored with food, as this could cause contamination. Further interview revealed the sandwiches should have been dated, and if not dated, there was no way to know if they were expired, and this could cause illness. Interview with the Unit Manager on 100 Unit, on [DATE] at 3:50 PM, revealed dietary sends snacks, and the sandwiches in the nourishment refrigerator should have been be dated when received from dietary; because the food could be old or cause a resident to be sick. The Unit Manager stated she usually checked the nourishment refrigerator each morning but had not checked it yet on this date. Interview on [DATE] at 9:06 AM, with the Regional Nurse Consultant revealed normally medications were not stored with the food because it could cause contamination between the two. Continued interview revealed the sandwiches should have been dated, to determine when they expire and so staff would know when the food went bad. Interview with the DM, on [DATE] at 12:53 PM, revealed the DM reported he had contacted Maintenance to look at walk in freezer. Interview on [DATE] at 1:03 PM, with the Maintenance Director revealed he had not looked at it yet. Subsequent interview on [DATE] at 3:19 PM, revealed the facility recently had the walk in freezer resealed. He further stated the current problem was with the latch and he thought this was the cause for the frost in the freezer. He stated the latch was supposed to go in a grove and it was not automatically doing that. Interview with the DM on [DATE] at 3:25 PM revealed maintenance checked the walk in freezer and the latch at the top was causing it to not have a good seal, causing the freezer to work harder. Continued interview revealed temperatures were in range and maintenance obtaining a new part for the freezer. Continued interview with the DM, on [DATE] at 10:37 AM, revealed foods in the freezer should be sealed and wrapped to keep foreign particles out, prevent freezer burn and prevent cross contamination. Further interview revealed the foods such as the turkey in the refrigerator should have been discarded. Continued interview revealed the reason for dating food items was to assure food was safe. The DM stated if food was not dated properly, it could cause food borne illness, or could make residents sick. Interview by phone with the Dietitian, on [DATE] at 4:57 PM, revealed she had been employed at the facility for six (6) to seven (7) months, and the dietary department had experienced staff turnover and lack of dietary management. Per interview, dietary staff had been challenged as they did not know how to do things or what to do, since the assistant DM left about a month ago, and the facility was trying to fill positions. Continued interview revealed foods in the freezer should have been wrapped and dated. Further interview revealed foods should be dated when opened including dairy, and expired food and milk should have been thrown away. Further interview revealed the sandwiches in the 100 hall should have been dated. Per interview if food was not dated, this could cause food borne illness. Interview with the Director of Nursing (DON), on [DATE] at 9:30 AM and 3:41 PM, revealed kitchen sanitation should be followed and all foods should be dated and labeled. Per interview foods should be discarded when outdated. Further interview revealed nursing staff on units were responsible for checking the nourishment refrigerator, with the Unit Coordinator as back-up. Continued interview revealed the tuna and chicken sandwiches in the 100 Unit Nourishment refrigerator should have been dated. Per the DON, foods were dated to ensure they were not expired; because if expired, this could cause illness. Interview with the Administrator, on [DATE] at 4:20 PM, revealed she was aware of dietary issues in the kitchen. Kitchen sanitation and food storage issues were reported to the Administrator. Per interview, it was her expectation that staff to follow the policies and procedures of the facility.

Based on observation, record review, and interview it was determined the facility to develop and implement comprehensive care plans for six (6) of the thirty (30) sampled residents. Resident # 51 had a comprehensive care plan for following physician orders that was not implemented. Resident #51 had a physician order to send out to the emergency room and this was not done until the following day when he/she started experiencing chest pain again. Resident #9 had a comprehensive care plan for a physical therapy evaluation to be done and it was not implemented. Resident #70 was care planned for his/her leg to be wrapped with ACE wraps and this was not consistently done. Resident #90 was care planned to have labs done as ordered and this was not implemented. In addition Resident #90 was care planned to attend activities and this was not implemented. Resident #35's comprehensive care plan included heel lift boots as an intervention and observation revealed this was not implemented consistently. In addition Resident #35 care plan included a problem for activities and the interventions were not implemented. Resident #61 had a problem on the comprehensive care plan for falls and observation revealed the approach for non slip socks was not implemented consistently. In addition, Resident #51's care plan for physician notification was not followed after the resident was not transferred to the emergency room as ordered. The findings include: Record review of the facility policy titled, Comprehensive Care Plans last revised on 07/19/18, revealed each resident would have a person-centered comprehensive care plan that would include how the facility would assist the resident to meet their needs. Record review further revealed each comprehensive care plan was developed to identify problems, incorporate risk factors, reflect treatment goals, timetables, and aid in the prevention or decline in the residents functional status. Record review further revealed the Minimum Data Set (MDS) would be utilized to assess the clinical condition and the Care Area Assessments (CAA) were used to develop the comprehensive care plan. Record review further revealed the comprehensive care plan was ongoing and revised as needed. 1. Observation, on 11/12/19 at 11:44 AM and 11/13/19 at 12:12 PM, revealed Resident #70 did not have ACE wraps on his/her leg. Interview with Resident #70, on 11/12/19 at 11:44 AM, revealed he/she was to have ACE wraps to the left leg and staff had not applied them. Record review of the comprehensive care plan revealed a problem was listed for several non pressure open areas to the left lower extremity. Review of the goal was for the open areas to heal without complication. Record review of the approaches showed ACE wraps were to be applied as ordered. Interview with the Minimum Data Set (MDS) assistant coordinator, on 11/16/19 at 4:32 PM, revealed she was not the coordinator but the assistant and they had just hired a new MDS coordinator, but she had not stated yet. The MDS assistant coordinator revealed the purpose of the comprehensive care plan was to let staff know what problems the resident had and approaches implemented to provide the care that needed to be done and to help the situation. She revealed if an intervention was on the comprehensive care plan then it should be followed. The MDS assistant coordinator revealed the comprehensive care plan for Resident #70 included a problem for skin issues to the leg, knee, and toes and one of the approaches was ACE wraps were to be applied to the left leg. She revealed the comprehensive care plan should have been followed and the ACE wraps should have been applied as outlined in the care plan. The MDS assistant coordinator further revealed the ACE wraps would provide pressure for better circulation for the resident. She revealed if the ACE wraps were not applied it could cause the sores to worsen and could development more. Interview with the Director of Nursing (DON), on 11/15/19 at 10:30 AM, revealed Resident #70 had an order for [REDACTED]. 2. Observation, on 11/14/19 at 9:45 AM and 11/16/19 at 9:29 AM, revealed Resident #35 was lying in bed on a Recovery Pressure Mattress and did not have any heel lift boots on the feet. Record review revealed the facility admitted Resident #35 on 06/26/18 with [DIAGNOSES REDACTED]. Record review of the current physician orders for, October 16, 2019 to November 16, 2019, revealed Resident #35 was to have a Prevalon boot to the left foot at all times except when transferred or ambulated. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/19 revealed Resident #35 needed extensive assist of one person for dressing and bed mobility. Record review of the comprehensive care plan for Resident #35, revealed the resident was at risk for alteration in skin integrity because the resident was incontinent and immobile. Review of the interventions revealed Resident #35 was to have his/her heels floated while in bed. Another problem on the comprehensive care plan was for an alteration in skin integrity because Resident #35 had a Stage 1 pressure injury to the right and left heels. Review of the interventions revealed the heels were to be floated while in bed. Record review of the Certified Nursing Assistant (CNA), Care Report for Resident #35 revealed there was no indication that the resident needed heel lift boots or prevalon boots at all times. Interview with Registered Nurse (RN) #3, on 11/16/19 at 9:33 AM, revealed Resident #35 was to have heel lift boots on bilateral with a prevalon boot to the left foot except with transfers and ambulation. RN #3 went into Resident #35 room and noted he/she did not have any heel lifts boots or prevalent boots on either foot and after she looked around the room she revealed there were none in the room for him/her to wear. RN #3 revealed Resident #35 had an old wound to the left heel that had healed. RN #3 revealed the resident was at risk for the pressure area to reoccur if the heels were not floated on the bed with the prevalon boots or heel lift boots. Interview with Licensed Practical Nurse/Certified Nursing Assistant (CNA) #2, on 11/16/10 at 9:40 AM, revealed she was an LPN but was working as a CNA that day. LPN #2 revealed Resident #35 was total care and that she was not aware the resident needed heel lift boots in bed, but she would go check the CNA care book. LPN #2 revealed she could not review the kiosk to see what the resident needed but would check the CNA care plan book on the unit. LPN #2 reviewed the CNA care plan and revealed there was nothing on it to indicate Resident #35 needed any heel protectors. Interview with the Minimum Data Set (MDS) assistant coordinator, on 11/16/19 at 3:24 PM, revealed Resident #35 had a problem listed for pressure to the left and right heels and one of the interventions was to float the heels when in bed. The MDS Assistant Coordinator further revealed Resident #35 had an order for [REDACTED]. Interview with the Director of Nursing (DON), on 11/16/19 at 4:22 PM, revealed the physician orders and the comprehensive care plan should have been followed and did not know why the heel lift boots and prevalon boots were not applied as ordered. The DON stated the boots were ordered to protect Resident #35's skin because he/she was at risk for skin breakdown. Observations, on 11/12/19 at 10:49 AM, 11/13/19 at 9:45 AM, 11/14/19 at 9:43 AM, and 11/16/19 revealed Resident #35 was lying in bed and no activities were provided for the resident. Record review revealed the facility admitted Resident #35 on 6/26/18 with [DIAGNOSES REDACTED]. Record review of the quarterly MDS with an ARD of 9/06/19, revealed it was somewhat important to the Resident #35 to have books, music, new, group, and religious activities. Record review of the comprehensive care plan for Resident #35 revealed a problem was listed for activities and the goal was for the resident to be engaged in programs within his/her abilities. Record review of the approaches on the care plan revealed the facility was to provide specialized small group, sensory, and one-on-one activities. Record review of the Annual Quality of Life Lifestyle Review, dated 5/30/19, revealed Resident #35 enjoyed pet visits and listening to music, Interview, on 11/16/19 at 2:03 PM, with the Activity Assistant, revealed she had not done any activities with Resident #35 since October when the activity director left. Interview, on 11/16/19 at 3:04 PM, with the MDS Assistant Coordinator, revealed Resident #35 had a care plan for activities and the approaches should have been implemented. The MDS Coordinator revealed if the activity care plan had not been followed, then Resident #35 could have loneliness and psychosocial problems. Resident #35 would be at risk for depression if the comprehensive care plan for activities was not followed. Interview, on 11/16/19 at 4:26 PM, with the DON revealed she did not know why Resident #35 not provided activities and the care plan should have been followed. 3. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM revealed he/she was just lying in the bed in his/her room. Record review revealed the facility admitted Resident #90 on [DATE] and the [DIAGNOSES REDACTED]. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, revealed Resident #90 did not have any hearing and vision problems. Review revealed they were unable to complete the cognition portion so there was no Brief Interview for Mental Status (BI[CONDITION]) score. Record review of the functions section of the MDS revealed Resident #90 needed extensive assistance from staff for bed mobility, dressing, toileting, hygiene and he/she was totally dependent for bathing. Record review further revealed Resident #90 was incontinent of bowel and bladder. In addition, Resident #90 had impaired range of motion to both of the lower legs. Record review of the telephone physician order obtained on 11/01/19, revealed a urinalysis (U/A) with culture and sensitivity (C&S) was to be done for Resident #90. Record review of the progress notes for 11/01/19, 11/02/19, 11/03/19, and 11/04/19 revealed no documentation that a urine sample had been obtained. Record review of the comprehensive care plan revealed a problem was listed for elimination and the resident was at risk for urinary tract infections [MEDICAL CONDITION]. The goal for the problem was the resident would not exhibit signs or symptoms of a UTI. One of the approaches was for labs to be obtained as ordered by the physician. Interview with the Director of Nursing (DON), on 11/15/19 at 11:39 AM, revealed there was a telephone order for a U/A to be obtained for Resident #90 and after she reviewed the clinical record she could not find where the urine specimen had been obtained Interview with the Minimum Data Set (MDS) Assistant Coordinator, on 11/16/19 at 3:15 PM, revealed Resident #90 was at risk for a urinary tract infection [MEDICAL CONDITION] related to incontinence. Interview further revealed interventions on the care plan included, medications as ordered, labs as ordered, report results to the physician, provide incontinent care, and monitor for signs and symptoms of a UTI. The comprehensive care plan should have been followed and the U/A should have been obtained. The MDS Assistant Coordinator further revealed if the U/A was not obtained it put the resident at risk for worsening of the UTI and hospitalization . Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM, 11/13/19 at 10:47 AM and 4:05 PM revealed he/she was just lying in the bed in his/her room. Record review revealed the facility admitted Resident #90 on [DATE] and the [DIAGNOSES REDACTED]. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #90 was not to complete the cognition portion so there was no Brief Interview for Mental Status (BI[CONDITION]) score. Review of the customary portion of the MDS revealed it was somewhat important to her to look at books, listen to music, be around animals, keep up with the news, and he /she liked to do things with groups, and he/she liked religious services. Record review of the comprehensive care plan for Resident #90 revealed a problem was listed for activities. The problem noted Resident #90 was at risk for decline in activities from previous recreational interests. One goal was for Resident #90 to participate in preferred activities and he/she would participate in 1:1 visits. The approaches included 1 on 1 visits as scheduled, activities was to invite and encourage the resident to go to activity programs and 1:1 visits was to be done. Interview, on 11/16/19 at 1:29 PM, with the Activity Assistant revealed revealed she had not done any activities with Resident #90 and she did not have any log for her/him because she was busy with other residents activities. The Activity Assistant stated Resident #90 was care planned for altered activity program. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:12 PM, revealed Resident #90 had an activity care plan and the approaches included: one on one visits, pet visits, and the resident was to be invited and encouraged to attend activity programs. Interview further revealed Resident #90 could have general loneliness, feel isolated, and develop depression if not able to attend activities. The MDS Assistant Coordinator further revealed the care plan interventions outlined in the comprehensive care plan should have been implemented. Interview with the DON, on 11/16/19 at 4:26 PM, revealed the comprehensive care plan should be followed. 4. Observation of Resident #61, on 11/12/19 at 11:37 AM, revealed the resident was laying in bed and then stood up from the side of the bed with nothing on his/her feet. Observation of Resident #61, on 11/14/19 at 8:00 AM, revealed he/she was sitting on the side of the bed, trying to remove the hospital gown and did not have any shoes or socks on. Record review of the clinical record revealed the facility admitted Resident #61 on 08/15/16 with [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/19 revealed Resident ##61 had a Brief Interview of Mental Status (BI[CONDITION]) of seven (7) which meant the resident was cognitively impaired. Review further revealed Resident #61 needed supervision of one person with walking. Review of the balance section revealed Resident #61 was not steady but was able to stabilize himself/herself without human touch. Record review of the comprehensive care plan for Resident #61 revealed the resident was at risk for falls related to urinary incontinence, poor safety awareness, potential adverse reaction to psychoactive medication, and a balance deficit. Review of the approaches revealed Resident #61 was to be assisted to sit when he/she was restless, referral to physical therapy or occupational therapy, and he/she was to have non-slip socks on at all times. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:18 PM, revealed Resident #61 was at risk for falls and he/she had fallen before. The MDS Assistant Coordinator further revealed it was important for staff to follow the care plan for Resident #61 because one of the interventions was for non slip socks to be worn at all times and that meant in bed too. She revealed Resident #61 had poor balance and he/she ambulated without assistance. She further revealed the non slip socks was a measure to help prevent falls and if the resident was barefooted there was more of a risk that he/she might fall and be injured. Interview with the Director of Nursing (DON), on 11/15/19 at 11:12 AM, revealed Resident #61 had a history of [REDACTED].#61 should have non slip socks on at all times and that was one of the interventions incorporated into the comprehensive care plan and the care plan should be followed. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed her role as the administrator included overseeing the well being of the residents and making sure the facility met regulatory expectations. The Administrator revealed the Quality Assurance (QA) team met monthly. The team included the Medical Director, the DON, herself, Social Services, Maintenance, MDS Coordinator, Activities Coordinator, Medical Records, and two (2) nurses from the units. The Administrator revealed comprehensive care plans and Certified Nursing Assistant (CNA) care plans had been identified as a concern in the month of October. 5. (Refer to F689) Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Record review revealed Resident #9 had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) assessment dated [DATE], a Significant Change assessment, revealed the facility assessed Resident #9 as having a BI[CONDITION] (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Per the MDS Assessment, the facility assessed Resident #9 as independent with no setup or physical help from staff for ambulating in room and corridor. Continued review revealed Resident #9 was assessed as having one (1) fall with major injury since the prior assessment. Review of the Quarterly MDS Assessment, dated 11/04/19, revealed the facility assessed Resident #9 with a BI[CONDITION] score of nine (9) of fifteen (15). Continued review revealed the facility assessed Resident #9 as independent with no setup or physical help from staff for bed mobility, transfer, ambulating in room and corridor, and on and off the unit. Resident #9 was assessed as having no falls since the prior assessment. Record review revealed a Fall Risk Evaluation, dated 05/01/19, and the facility assessed Resident #9's score as ten (10), with a resident score of ten (10) or higher being at risk. Review of the Fall Risk Assessment Tool dated 07/26/19, after the resident sustained [REDACTED]. Review of Resident #9's Comprehensive Care Plan, revealed a plan of care for falls, dated 07/24/19, which documented the resident was at risk for fall related injury related to: previous fall, balance deficit, poor posture, potential adverse effects related to psychoactive and pain medications. Continued review of the plan of care for falls revealed a goal that resident fracture will continue to heal without complications with a target date [DATE]. Per review, interventions included remind and encourage resident not to wait too long before heading to the toilet, dated 08/16/19; and referral for screen and treatment as needed with OT and PT checked, with approach start date 07/24/19. Record review of Progress notes for Resident #9 revealed a note, dated 0[DATE] at 4:03 AM, which documented the facility transferred the resident to the emergency room , related to X-ray showing a left acute distal radial fracture. Review of the facility Fall Investigation, dated 07/24/19 and created by LPN #5, revealed Resident #9 was walking in the hallway, lost his/her balance, and fell very close to the Nurse's Station, with his/her bottom on the floor and left hand and elbow on the floor. Further review of the Fall Investigation summary revealed IDT reviewed, intervention in place, care plan updated and resident presents with Dementia, fell and attempted to break her fall and sustaining a fracture to left forearm. PT/OT evaluation was documented on the Fall Investigation. Continued review of the record revealed no documented evidence Resident #9 was evaluated by PT after the resident's fall per the facility Fall Investigation and the resident's Comprehensive Care Plan. Interview with Resident #9, on 11/13/19 at 10:22 AM, revealed he/she tripped and fell on e time and fractured his/her left wrist, and had a cast. Per interview, the resident thought it happened about a year ago. Further interview with Resident #9 revealed he/she stumbled in the hall, and someone came to the facility and took x-rays. Resident #9 stated he/she went to the doctor for the broken arm as well. Interview with Licesned Practical Nurse (LPN) #5, on 11/16/19 at 1:43 PM, revealed he was working when Resident #9 fell on [DATE] and witnessed the fall. Continued interview revealed the resident told him he/she lost balance and fell . Further interview revealed the resident was wearing shoes and able to ambulate independently. LPN #5 stated he checked the resident's ROM (range of motion) to extremities, an x-ray was completed and positive, and the resident was transferred to the hospital. Further interview revealed after the fall, he was to complete the incident/event report and fall investigation and document in the progress notes and if they find the cause of the fall, they update the care plan. He stated falls were then reviewed in the IDT meeting. LPN #5 stated ITD may do more interventions or change them. LPN #5 stated generally a PT evaluation was completed after a resident fall but he did not complete PT/OT referrals for Resident #9, and further stated the IDT must have completed the referral. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed Resident #9 should have had a PT evaluation after the fall if the care plan was revised to do this. Further interview revealed the facility has a form that anyone can complete for therapy referral and residents were usually seen by PT after a fall. Interview by phone on 11/16/19 at 7:57 PM, with the Therapy Director, revealed she could not recall receiving a referral for resident #9 for PT after the fall. Further interview revealed after Resident #9's fall on 07/24/19, she thought Therapy's only involvement was OT. Interview with the LPN Unit Manager on Unit 100, on 11/16/19 at 4:07 PM, revealed the current process was for the nurse to call the DON after a resident fall, and advise the DON of prior care plan interventions. The nurse and DON should then determine an intervention and place on the care plan at that time. She further stated if the Care Plan was updated for OT/PT, the resident should have been evaluated and the referral completed by the nurse on the unit. Interview with the Clinical Nurse Consultant, on 11/16/19 at 11:45 AM and 12:25 PM, revealed the fall was an isolated incident for the Resident #9, and stated the resident had no prior falls and no falls since. Further interview revealed she was unable to find documented evidence a PT evaluation was completed per the Care Plan after Resident #9's fall on 07/24/19, and it should have been completed or there should have been documentation as to why it was not completed. Interview with the Director of Nursing (DON), on 11/16/19 at 2:18 PM, revealed she was not sure of the process for falls at the time of Resident #9's fall, as she was not employed at the facility at the time this investigation was completed. The DON reviewed the fall investigation and Event Report/Incident Report for Resident #9 and said the reason for the investigation was to try to prevent future occurrences and change in the resident. Continued interview revealed there should have been a PT evaluation or screening, per the care plan intervention. She stated a problem with the PT evaluation not being completed, was the resident could have a decrease in functional mobility or falls. Interview with the Administrator, on 11/16/19 at 11:24 AM and 4:20 PM, revealed at the time of Resident #9's fall on 07/24/19, she was not employed at the facility. Continued interview revealed it was her expectation that interventions be put in place, and care plans be updated and followed, after a resident fall. 6. Review of Resident #51's clinical record revealed the facility original admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with [DIAGNOSES REDACTED]. In addition, resident has intellectual [DIAGNOSES REDACTED]. Review of Resident #51's annual Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief interview for Mental Status score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of Resident #51 Physician Order, date 05/14/19, revealed the physician reviewed and approved nursing home plan of care, orders and treatment plans. Review of Resident #51's Care Plan, dated 05/24/19, revealed nursing staff did not follow physician orders through notification to physician, Advanced Practice Registered for next direction for resident care. Continued review of Resident #51's care plan revealed no evidence nursing staff developed interventions directing staff to administer the physician order for [REDACTED]. Review of Resident #51's progress note, on 8/31/19 at 7:12 PM, revealed Licensed Practical Nurse #5 failed to notify physician, Advanced Practice Registered, ADON, and/or DON for next direction for resident care since classified as a non-emergency by emergency services. Continued review of resident's progress notes, revealed Resident #51 was admit to hospital the following day, 09/01/19 at 7:45 AM for chest pain. Observation of Resident #51, on 11/12/19 at 11:39 AM, resident was sleep with oxygen set on two (2) liters, laying on air mattress, fully dressed, room was free from cutter. Observation of Resident #51, on 11/13/19 at 1:10 PM, resident was observed eating lunch with another resident. Brief interview with Resident #51, revealed he enjoyed living at the facility however did not remember going to the hospital. Resident #51 continued to wear his cannula for oxygen. Interview with Resident #51, on 11/13/19 at 1:22 PM, revealed resident reported no concerns with the facility or the staff. On 11/16/19 at 3:37 PM, interview with Licensed Practical Nurse (LPN) #5, revealed he completed an assessment on Resident #51 after he/she complained of chest pain, notified the physician, and obtained an order to transport to the emergency room . LPN #5 reported emergency services (E[CONDITION]) arrived and refused to transport resident to the emergency room because the resident non-emergent status. Continued interview with LPN, revealed he failed to follow up with physician, APRN, and/or the DON to communicate E[CONDITION] did not transport Resident #51 per the plan of care. LPN #5 report he forgot the process and procedure related to care plan implementation when physician's orders were received for a change in condition. Interview with Direction of Nursing (DON), on 11/16/19 at 4:09 PM, revealed she was not the DON during Resident #51's change of condition. The DON states she was not aware staff did not follow the plan of care after the physician ordered transportation to the emergency room . The DON stated it was important for the LPN to follow up with the physician due to the initial order was not followed. Phone interview with Medical Director (MD), on 11/16/19 at 6:26 PM, revealed, if an order was given to send a resident out to the hospital for chest pain, she expected the nursing staff to follow physician orders the first time. However, if emergency services deemed the resident a non-emergency, she would expect another form of communication from the facility for review to determine if another order was warranted. Phone interview with former Unit Manager (UM) #3, on 11/16/19 at 7:46 PM, revealed Resident #51 had complained of chest pain and it was deemed necessary to contact physician/APRN and request ambulance for transport. The Unit Manager revealed she would expect nursing staff to contact the physician and/or the Director of Nursing for medical direction when the care plan was not followed. Interview with the Administrator, on 11/16/19 at 8:11 PM, revealed she notified on Monday 09/01/19, by Unit Manager #3, of Resident #51 hospitalization . She stated in her experience when emergency medical services responded to a call and deemed the resident a non-emergency, the resident would have to wait up 24-hours for transportation. She further stated nursing staff failed to contact the on-call physician, the DON, or the Administrator to make them aware of the situation per the plan of care.

Based on observations, record review, and interview it was determined the facility failed to provide an ongoing program of activities for two (2) of the thirty (30) sampled residents from the care areas. Resident #90 and Resident #35 were to have facility provided activities, however, were observed to stay in their rooms with no activities provided. The findings include: Record review of the facility policy titled, Activity Program which was last revised on 07/25/17, revealed the facility would provide an on-going activities program designed to support the interest and choice of the residents. It further revealed the activity program was to help the resident obtain the highest level of mental, physical, and cognitive needs. In addition individualized and group activities were meant to encourage meaningful interacts to enhance the resident's sense of well-being. The policy further revealed residents were invited and encouraged to participate in activities. Record review of the facility policy titled, One-to-One Activities Program with a last revised date of 07/25/17, revealed the intent of the policy was to give residents who did not leave their rooms an opportunity to participate in activities. The policy further revealed activities would be scheduled on a regular basis. The policy stated a record of the activities would be provided on the activity record sheet and would include: the date. the activity provided, the amount of time in the activity, and the resident's response to the activity. The policy further revealed one-to-one activities would directly reflect the resident's needs, interests, and hobbies. 1. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM revealed he/she was just lying in the bed in his/her room. There was a communication board in the room. Observation, on 11/13/19 at 10:47 AM, revealed Resident #90 was lying in the bed in his/her room and was asleep. Observation further revealed, on 11/13/19 at 4:05 PM, Resident #90 was in his/her room and was awake. Observation further revealed he/she did not have a television for his/her viewing, however there was a CD player on his/her side of the room and it was not turned on. Observation, on 11/14/19 at 8:40 AM, revealed Resident #90 was in the bed in his/her room, awake there and was television or cd player on. Observation, on 11/14/19 at 3:21 PM, revealed Resident #90 was lying in bed in his/her room and there was no television or cd player on. Observation, on 11/15/19 at 03:22 PM, of Resident #90 revealed he/she was lying in bed in his/her room and was looking out the door. Observation further revealed there was no television or cd player on. Observation on 11/15/19 at 3:23 PM revealed there were thirteen (13) residents sitting down in the the dining room listening to a musician sing and play the guitar. Record review revealed the facility admitted Resident #90 on [DATE] with the [DIAGNOSES REDACTED]. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, revealed Resident #90 did not have any hearing or vision problems. Review revealed they were unable to complete the cognition portion so there was no Brief Interview for Mental Status (BI[CONDITION]) score. Review of the customary portion of the MDS revealed it was somewhat important to him/her to look at books, listen to music, be around animals, keep up with the news, and he/she liked to do things with groups, and he/she liked religious services. Record review of the functions section of the MDS revealed Resident #90 needed extensive assistance from staff for bed mobility, dressing, toileting, and hygiene. Record review further revealed Resident #90 had impaired range of motion to both of the lower legs. Record review of the comprehensive care plan for Resident #90 revealed a problem was listed for activities. The problem noted Resident #90 was at risk for decline in activities from previous recreational interests. One goal was for Resident #90 to participate in preferred activities and he/she would participate in one to one (1:1) visits. The approaches included one on one visits as scheduled, activities was to invite and encourage the resident to go to activity programs and 1:1 visits was to be done. Record review of the progress notes for Resident #90 revealed, on 11/14/19, he/she had requested a visit from the chaplain because he/she was depressed, frustrated, and angry. Interview on 11/16/19 at 1:29 PM, with the Activity Assistant, revealed she had only been in the position for less than a month. She revealed the Activity Director left employment around November 2, 2019. Interview further revealed the old activity person was doing activities with Resident #90 and the last recorded activity was October 28, 2019 and that was a worship visit. The Activity Assistant revealed she had not provided any activities to Resident #90 and she did not have a log of activities for her/him, because she was busy with other residents activities. She stated Resident #90 liked to attend church, listen to music, and watch television. The Activity Assistant stated Resident #90 was care planned for an altered activity program. Interview further revealed the facility had a musician come in the day before to entertained the residents, however, she did not invite Resident #90 because he/she was in bed when she walked down the hall and did not ask staff to get him/her up. She revealed Resident #90 might have liked to attend the activity with the musician. Observation, on 11/16/19 at 1:49 PM, revealed the Activity Director and this surveyor went down to Resident #90's room. Observation with the Activity Director and Resident #90 revealed Resident #90 shook his/her head yes when asked if he/she would like to get up and go watch a movie that was going to be played. Observation further revealed when asked if he/she liked music she touched yes on the communication board and when asked if he/she liked to watch television he/she touched yes on the communication board. Observation further revealed when asked if she/he liked guitar playing and singing he/she touched yes on the communication board. Interview, on 11/16/19 at 1:49 PM, with the Activity Assistant, revealed the purpose of the activity program was to improve the residents daily life. The Activity Assistant further revealed activities kept the residents minds stimulated. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:12 PM, revealed Resident #90 had an activity care plan and the approaches included: one on one visits, pet visits, and the resident was to be invited and encouraged to attend activity programs. Interview further revealed Resident #90 could have general loneliness, feel isolated, and develop depression if not able to attend activities. Interview with Registered Nurse (RN) #3, on 11/16/19 at 2:30 PM, revealed Resident #90 could get up in a wheelchair and go to activities but right now therapy was working on a more comfortable wheelchair for him/her. RN #3 revealed Resident #90 could still participate in activities in her room. 2. Observation on 11/12/19 at 10:49 AM revealed Resident #35 was lying in bed on the left side and was asleep. Observation on, 11/13/19 at 9:45 AM, revealed Resident #35 was lying in bed and no activities had occurred. Observation on 11/13/19 at 3:49 PM, revealed Resident #35 did not have any activities going on in his/her room. Observations, on 11/14/19 at 8:47 AM, revealed Resident #35 was sitting up in bed eating his/her breakfast. Observation, on 11/14/19 at 9:43 AM, revealed Resident #35 was in his/her room with no in room activities. Observation, on 11/16/19 at 9:29 AM revealed Resident #35 was lying in bed on the back with no in activities. Record review revealed Resident #35 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the current physician orders for October 16, 2019 to November 16, 2019, revealed Resident #35 was to limit the time out of bed to one and one half hours a day for fourteen (14) days. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD), of 09/06/19, revealed Resident #35 needed extensive assist of one person for dressing and bed mobility. Resident #35 had a BI[CONDITION] score of seven (7) which indicated he/she had impaired cognition. Further review revealed it was somewhat important to the resident to have books, music, new, group, and religious activities. In addition, Resident #35 was incontinent of bowel and bladder. Record review of the annual MDS with an ARD of 06/06/19 revealed Resident #35 was totally dependent on one staff for bed mobility and needed extensive assist of one for dressing. Record review of the comprehensive care plan, revealed Resident #35 had a problem listed for activities and the goal was for the resident to be engaged in programs within his/her abilities. Record review of the approaches on the care plan revealed the facility was to provide specialized small group, sensory, and one-on-one activities. Record review of the Annual Quality of Life Lifestyle Review dated 05/30/19 revealed Resident #35 enjoyed pet visits, and listening to music, Interview, on 11/16/19 at 2:03 PM, with the Activity Assistant revealed Resident #35 would not come out of the room very much and had refused at times, but there was no documentation of the refusal of activities. Interview with the Activity Assistant revealed she had not done any activities with Resident #35 since October. The Activity Assistant revealed Resident #35 had pet therapy on [DATE] and worship service on 10/28/19 and that was the last documented activity with the resident. The assistant stated Resident #35 was nominated for an award and he/she went to that on November 7, 2019 and that was the only activity done with the resident since October 2019. The Activity Assistant revealed the old Director had done most of the one-on-one activities with the resident and since the Director was gone, she had not been able to work with Resident #35. Interview, on 11/16/19 at 2:32 PM, with Registered Nurse (RN) #3, revealed Resident #35 was limited to the amount of time he/she was allowed up in the chair because of the pressure area on the coccyx. RN #3 revealed he/she should only be up two or three hours a day but if he/she wanted to stay up longer the physician said it would be okay. RN #3 stated Resident #35 could go to activities or could have activities in the room. Interview, on 11/16/19 at 3:04 PM, with the MDS Assistant Coordinator, revealed Resident #35 had a care plan for activities and the approaches should have been implemented. The MDS Assistant Coordinator revealed if the activity care plan had not been followed then Resident #35 could have loneliness and psychosocial problems. Resident #35 would be at risk for depression if the comprehensive care plan for activities was not followed. Interview, on 11/16/19 at 4:26 PM, with the DON revealed she did not know why Resident #35 and #90 were not provided activities. Interview, on 11/16/19 at 10:12 PM, with the Administrator revealed she was not aware of any issues with activities.

Based on observation, interview, and record review it was determined the facility failed to maintain a homelike environment for two (2) of three (3) units. Observations and interviews revealed the facility had an odor of urine and the resident shower rooms for two (2) of three (3) units, had toilets with identified fecal matter. In addition, metal poles used in resident rooms were rusted and caked with white sticky matter. The findings include: The facility did not provide a policy for homelike conditions upon request. Review of the facility's policy, Maintenance Service, dated January 2005, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Observation, on 11/12/19 at 09:50 AM, revealed physical entry to the 100 hallway had an odor of ammonia. Observation, on 11/12/19 at 10:48 AM, upon physical passage through the facility door to the residential area by the dining hall entrance, revealed a strong musty ammonia odor. Continued observation of the two-hundred (200) hallway again revealed, an odor of pungent urine in the hallway of rooms, two-hundred (200) down to two hundred and sixteen (216) hall. Observations, on 11/12/19 at 11:08 AM, revealed Resident #17's room smelled of a heavy ammonia like odor. The aide placed clean linen to the residents bed. Inspection of the resident's bathroom revealed less odor in the area of the bathroom. Continued observations revealed the smell of an ammonia odor was heavily present in the general area of the hallway around Resident #17's room. Observation, on 11/12//9 at 11:43 AM, revealed upon physical entry into the residential area at the dining room entrance was an odor of ammonia. Observation, on 11/13/19 at 9:45 AM, upon entry onto two hundred (200) hallway, revealed an ammonia like odor. Entry into room Resident #17's room revealed an odor of ammonia. Review of Resident #17's clinical record revealed the resident was admitted to the facility 08/16/06 with the [DIAGNOSES REDACTED]. Review of Resident #17's quarter Minimum Data Set (MDS), on 08/17/19, revealed the resident was an extensive assist with toileting, wore briefs, and was frequently incontinent. Observation, on 11/13/19 at 4:00 PM, revealed the facility toilet for the one hundred hall (100) shower room contained brown matter adhered to the toilet seat and yellow dried matter. Continued observation revealed brown matter at the bottom to the toilet. Interview with the 100 Unit Manager, on 11/13/19 at 4:00 PM, revealed facility aides responsibilities included to clean the shower chairs and toilets when residents completed showers. She stated she checked the shower rooms daily. However, she further stated she could not identify how long the fecal matter was on the toilet. She stated toilets in the showers were to be clean. Observation, on 11/14/19 at 10:40 AM, revealed entry into Resident #17's room smelled of an ammonia like odor. Interview with Resident #17, on 11/14/19 at 10:40 AM, revealed the resident was unsure of the smell of a urine type odor in his/her room. However, the resident further stated he/she lived in the facility for over ten (10) years and would not know if there was any odors. Observation on 11/14/19 at 4:51 PM, revealed a strong odor of ammonia in the residential area at the dining hall entrance. Observation on 11/13/19 at 9:54 AM, of a black box emergency outlet, mounted on the wall in Resident #11's, was held together with tape. Interview with the Maintenance Director (MD), on 11/15/19 at 9:59 AM, revealed he noted a black box secured into a red emergency plug taped with multiple layers of clear tape, which held the box together. He stated it was an unsafe situation and a fire hazard to the facility. He stated staff were to notify the department of repair needs. However, the staff notified central supply for equipment order needs. Observations, on 11/13/19 at 3:59 PM, revealed the two-hundred (200) shower with the over the toilet high-rise chair contained dark brown matter to the inner portion of the seat ring. Further observations revealed brown matter in the bottom portion of the toilet water accompanied with white paper material. Continued observations of the Two-Hundred (200) Shower room, on 11/14/19 at 9:03 AM, revealed facility staff accompanied surveyor into the room. Observation of the shower by staff an identified used toilet paper on the floor. The staff identified the toilet over the bed chair with brown matter to the left side inner ring and loose stool identified in the toilet with white paper in the same position. Staff stated a strong odor of stool in the bathroom was present. Observations, on 11/16/19 at 11:21 AM, revealed Resident #[AGE]'s room received enteral feeding to which a metal pole held the bottle and was rust and a sticky with sticky matter to the base of pole. Continued observation revealed Resident #90's medical pole with a dried cream sticky matter, on the base of the device, and rust on the base of the pole. Continued interview with the MD, on 11/15/19 at 11:01 AM, revealed the department audits do not include metal poles. He stated the department does not inspect for safe function or condition of the resident poles. He further stated the condition of the poles could be an indication of the care and services provided in the facility. Interview with Certified Nursing Aide (CNA) #2, on 11/14/19 at 11:00 AM, revealed the aide identified the smell in the room and hallways as urine. The aide stated part of the odor was Resident #17's mattress, and it always smelled of old musty urine. The aide stated the resident was often incontinent, out of the brief, when found in his/her bed. The aide stated the resident's urine soaked into the mattress and occurred for the six (6) years the aide as an employee. The aide stated staff wiped down the residents mattress with an incontinent episode. However, the aide stated the mattress just held the odor after many years of use. The aide stated previous staff reports did not address the odor issues; so therefore staff just stopped trying to address the issue. The aide stated the facility was aware of the odors because Resident #17's room and the hallway always smelled of urine. The aide further stated the residents in the room was not recognize the odors having lived with the odors for so long it was not recognized anymore as a smell. The aide stated the facility mattress and room's odor was an issue for several residents, and the odors filtered out to the hallways. The aide further stated the facility's visitor chairs made of cloth routinely smelled of urine. The aide stated nobody wanted to live in a room or home with the constant smell of urine. Interview with Resident Family Member #3, on 11/15/19 at 4:00 PM, revealed the facility smelled like urine at all the times. The family member stated the facility did not address the dirt and smell of the resident rooms after numerous complaints to the Director of Nursing and Administrator. She stated the facility floors, beds, chairs; visitor chairs constantly looked dirty or smelled of urine. She stated the facility residents and visitors complained to the facility staff without improvements. She further stated requests for housekeeping services went on deaf ears. Interview with the Housekeeping Manager (HM) with Healthcare Services, on 11/15/19 at 9:49 AM, revealed the company provided deep cleaning services to mattresses on a rotation schedule, cleaned resident rooms, showers and all other cleaning needs. However, he stated there was a lack of adequate staff for the facility services. He stated the company made daily rounds for inspection of services. The HM stated the facility identified Resident #53's room on the 200 hallway to have strong urine odors, most of the time; and identified the mattress and un-bagged soiled clothing with urine, as the source of the odors. However, he did not complete a mattress evaluation to address odors reported from the room and the facility did not replace the mattress. The HM further stated Resident #53 soiled their clothing with urine and staff placed the soiled articles into the resident's laundry hamper without a bag. He stated the employee's hated to handle urine soaked clothing, and this was a huge reason the urine odor in the residents room was prevalent, as well as the hallway. He stated they attempted to deodorize mattress when notified. He further stated they notified maintenance if the odors persist. He stated and acknowledged the facility smelled of urine. He further stated the facility conducted a program of Ambassadors who were to advocate for the residents and this included dirty and odorous rooms. He stated the maintenance department was responsible for the order of new mattresses for residents. He stated the department audits schedule for mattress conditions were not included in the audit and not automatically changed out at a five (5) year use date. He stated housekeeping cleaned resident shower's daily. He stated the aide had to notified staff to clean toilets in the showers when soiled. He further stated facility aides placed laundry for families to complete, in bags while the facility waited for pickup. However, the facility aides placed cloths in the closet, without the placement of a bag and the lack of bagging contributed to the odors of urine throughout the facility. He further stated families complained daily of the odors of urine and the impression would be the facility lacked good care of residents. He further stated a person would not want to live in an environment at home, with odors of urine, because it smelled and could looked like an unsanitary environment. Interview with the Medical Director, on 11/15/19 at 10:30 AM, revealed staff notified the department for issues with resident mattresses. He stated if residents complain of the condition of the mattress they will change out to another mattress. He stated staff were to report mattress's with strong odors of urine. He further stated the department did not have requests for mattress changes for any resident. He stated the facility and department was aware of Resident # 53's mattress with odors of urine. However, the mattress change out did not occur as of this date but the department received the report the past couple weeks. He stated the facility was aware of the urine odors in the building. He stated the odors filter out from the resident rooms. He further stated because he worked for a long time in the facility that he did not notice the odors anymore. He stated the facility audit and tracking of mattresses did not occur and staff notified the department of issues. He further stated facility would be unappealing for residents, family, visitors, and staff with the odor of urine. He stated the facility expected the grounds to be neat and clean as well as repaired when needed. He further stated he would not like to live in a home, which smelled like urine. He stated the facility ambassador program provided feedback for residents whom were unable to vocalize issues or needs and completed two times a week. Review of daily ambassador round audit tool, undated, revealed the Quality Area has to observe and report included closets free of heavily soiled clothes, dirty poles, dirty shower rooms, and hallway with odors. Review of Housekeeping Daily Focus Calendar, undated, revealed the facility scheduled included resident equipment were cleaned on Thursdays. Interview with the Director of Nursing (DON), on 11/14/19 at 9:07 AM, revealed staff notified housekeeping if a resident mattress required cleaning when soaked with urine so the resident mattress received disinfection care. The DON stated clean linen were not to be placed on a bed mattress if the linen was soiled and mattress wet. The DON continued and stated dried urine caused odors in the resident's rooms and would come out into common resident areas. The DON stated soiled linen and clothing were to be placed in plastic bags to keep the soilage contained and decreased odors of urine. The DON further revealed she made walking rounds for audits of care and services for residents, conditions of rooms, and overall condition of the common areas of the facility. The DON further stated the condition of the facility including odors, frequently came to topic with Interdisciplinary team meetings for the facility. Interview with the Administrator, on 11/16/19 10:12 PM revealed the facility responsibility included a homelike environment. She stated the facility responsibility included compliance with all regulations for the care needs of the resident.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy for two (2) of thirty (30) sampled residents (Resident #16 and Resident #55). Record review revealed Resident #16 was transferred to the hospital for evaluation following a change of condition on 10/31/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. Review of the medical record revealed Resident #55 was sent to the hospital for evaluation following a change of condition on 09/25/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. The findings include: Review of the facility's Facility Bedhold Policy, dated revised 11/12/18, revealed the facility would notify the resident/responsible party of the facility's bed hold and readmission policies at admission and anytime a resident was transferred to the hospital or goes out on therapeutic leave. Continued review of the policy revealed the facility's bed hold and re-admission policies would be discussed with the resident/responsible party and the facility would provide written notice of the bed hold and re-admission policies before a resident's transfer to the hospital or for overnight therapeutic leave and included in the resident's transfer packet. The facility's clinical team would facilitate the resident's transfer packet. The facility's Social Worker or Licensed Nurse would document verbal and written notification in the medical record. Per policy, in an emergency, time of admission or time of transfer may mean up to twenty-four (24) hours. 1. Review of the clinical record revealed the facility admitted Resident #16 on 0[DATE]. Resident #16 had [DIAGNOSES REDACTED]. Review of the progress notes dated 10/31/19 revealed the resident yelled and screamed he/she was in pain with complaint of abdominal pain, the ARNP/MD (Advanced Registered Nurse Practitioner/Medical Doctor) was notified and the resident was transported to the Emergency Department. Per the documentation, Resident #16 returned to the facility on [DATE]. There was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. 2. Review of the clinical record for resident #55 revealed the facility admitted Resident #55 on 07/15/15. [DIAGNOSES REDACTED]. Review of the progress notes dated 09/25/19 revealed Resident #55 was sent to the hospital emergency department for a change in condition, and returned to the facility on [DATE]. There was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. Interview with the 100 Hall Unit Manager, on 11/16/19 at 3:50 PM, revealed she had been employed as Unit Manager for three (3) weeks. Continued interview revealed the nurse sending the resident out should call and ask family and tell family the reason the resident was being sent out and there should be a form that was completed with information on the bed hold. Further interview revealed she was unsure of who sent written information regarding the bed hold to the resident's family. Interview with the facility Clinical Nurse Consultant, on 11/15/19 at 4:04 PM, revealed the facility could not find any documentation the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy for Resident #16 or Resident #55 when each resident was sent to the hospital emergency department. Interview with the Director of Nursing (DON), on 11/16/19 at 9:43 AM, revealed the nurse's should have completed the document for bed holds, with the written information related to the facility's Bed-hold Policy. Continued interview revealed the written information related to the facility's Bed-hold Policy should have then been sent to medical records, and medical records should send the bed hold document to the resident's representative/family, and place a copy in each resident's chart. Continued interview with the DON, revealed if written information related to the facility's Bed-hold Policy was not completed, the resident/responsible party/family would not be made aware of potential bed hold. The DON further stated the resident/responsible party/family have to be made aware of the option to hold the bed, because they may choose not to hold the bed, but without the documented bed hold notification form, they would not know. Continued interview with the DON, revealed not informing residents/responsible parties of the written information related to the facility's Bed-hold Policy, could cause an issue when the resident returned to the facility, if a bed was not available, due to not given the option to hold the bed. Interview on 11/16/19 at 4:20 PM with the Administrator revealed she expected resident care to be provided. Continued interview revealed it was her expectation the staff follow the policies and procedures of the facility.

Based on interview, record review and policy review it was determined the facility failed to disclose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/17/19 Resident # 255 was accepted by the facility for admission. On 10/07/19, the resident was sent to the hospital and was diagnosed with Carbapenem-Resistant Enterobacteriaceae (CRE). On 10/10/19 the hospital attempted to release the resident back to facility and the facility refused. Further review revealed a facility sputum result on 09/17/19 notified the facility of the organism of Pseudomonas Aeruginosa and noted on the printed results to the facility the organism was a Carbapenem Resistant Pseudomonas and was sent to the Department of Health for further tests. The findings include: Review of the policy, Stance on Resident Admission with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The guidelines noted the contact precautions were more of a challenge, and incontinence and a draining would increase the risk. Furthermore, the policy noted it would be difficult to ensure a private room would be available. Review of the policy, Transfer Discharge Notice, revised 09/05/18, revealed the facility may not discharge a resident unless the needs and welfare cannot be met or other residents' lives or safety were endangered. To demonstrate any of these reasons the facility must provide documentation by the physician. In addition, if any notice changes occur before transfer the resident was to be updated. Furthermore, if the resident is under Medicaid, the facility will provide notice to the resident of the readmission policies prior to the transfer for hospitalization . Review of the policy, Isolation, revised 10/2018, revealed the facility was to provide for droplet isolation residents a single room. Staff were to wear protective equipment with contact or entrance into the room. In addition, the facility would refer to the Centers for Disease Control and Prevention (CDC) for recommendations. Review of the policy, Facility Bed Hold, reviewed 11/16/18, revealed the facility Medicaid residents who exceed the bed hold days the resident will be readmitted to the facility immediately or as the first bed became available. Review of the Facility Assessment, dated 12/2018, revealed the facility benchmark for isolation was high. The facility assessment revealed the facility provided staff with competencies for services which included isolation and was noted to have adequate staff to meet the need of residents who required isolation. Furthermore, the facility assessment revealed adequate staff was noted under diseases, conditions, and treatments for infections and isolation needs of a resident. Review of Resident #255's clinical record revealed the facility accepted the resident on 07/18/19 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #225 signed Bed Hold agreement, dated 08/29/19, revealed the resident requested the facility hold his/her bed space and accepted the responsibility of payment for the bed hold. Review of lab results, dated 09/17/19, revealed the facility sent a respiratory culture of sputum for analysis. The results were revealed to be [CONDITION(S)] Resistant Staphylococcus and the organism of Pseudomonas Aeruginosa which was defined as Carbapenem Resistant Pseudomonas and required further tests. Review of Resident #255's nurses note, on 08/31/19, revealed the facility initiated isolation and removed the roommate from the room to allow for reverse isolation for a white blood cell count of one point eight (1.8). The facility's nurse last notation of reverse isolation was on 09/09/19. Further review of the facility nurses note revealed, on 10/07/19, the facility placed Resident #255 in contact isolation for an infection of the respiratory track. Continued review of Resident #255's nurse's note, on 10/07/19, the facility was notified by [CONDITION(S)] of transfer of the resident to an acute facility for evaluation of excessive fluid. Further review of the facility nurses note, on 10/10/19, the Director of Nursing (DON) noted the facility was contacted by the health department in regard to the CRE growth confirmed at the hospital for the resident. The DON noted the resident was in isolation while present in the facility prior to the transfer. The health official instructed the facility to continue contact isolation for the resident when returned from the hospital. Interview with Admission Director, on 11/15/19 at 02:28 PM, revealed the facility liaison's completed admission paperwork with residents prior to physical admission to the facility. He stated the facility did not provide a list to potential admission residents of reasons or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated if the facility provided care and was sent to the hospital the facility would readmit the resident. He stated the facility was unable to accommodate Resident #255's needs for isolation with the CRE infection. He stated the reason the resident was not readmitted and discharged was to be noted in the chart by the physician. He stated the facility had open beds for admissions and the facility accepted patients on a routine basis with infections whom required isolation. He stated the facility previously provided a single room and isolation during the course of the resident's stay before transfer on 10/07/19. He further stated he was unaware why the facility was unable to meet the need for the resident. Interview with the DON, on 11/15/19 at 02:55 PM, revealed the facility was unable to readmit residents with CRE which she learned on 11/15/19. She stated the facility would have to provide a single room and provide isolation and symptom management for CRE residents. She stated the facility provided this to the resident before the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility was notified no specific cleaning or monitoring was required for other residents since the resident was already in isolation. She stated the facility trained staff and completed competencies for isolation procedures, protective equipment use, and hand hygiene. She stated the facility staff were well educated on isolation techniques. Interview with Family Member #4, on 11/15/19 at 03:35 PM, revealed the facility provided Resident #255 with isolation for most of the his/her admission while in the facility. She stated the resident remained in isolation after transfer to the hospital. She stated the facility did not call her to inform her as to why the facility refused to reaccept the resident for notification as Power of Attorney. She further stated she was not informed by letter correspondence nor did a representative come to the room at the hospital for the facility/corporation to explain the reason for the refusal. Interview with the Administrator, on 11/16/19 at 07:11 PM, revealed the facility followed the policy for CRE and was a Signature Policy for admissions and readmissions. She stated Resided #255 stay at the facility required the facility to provide isolation for most of the time of his/her admission. She stated the facility was able to provide isolation and single rooms when warranted. She stated she was informed the health department made no recommendations on follow-up to the residents prior room for deep environmental cleaning. She stated she was unsure if Signature liaison's discussed with potential resident's the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, she stated it was the responsibility of the facility or corporation to inform residents prior to admission of the policy of CRE. The administrator further stated she was not aware of what the difference was for care with CRE other than it was company.

Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for three (3) of the thirty (30) sampled residents. Resident #55 had a care plan for elimination however it was not revised to include the Foley catheter. Resident #[AGE] had a care plan for nutrition however it was not revised to include the gluten free and lactose free allergies. Resident #9 had a care plan that was not updated to include dental status. The findings include: Record review of the facility policy titled, Comprehensive Care plans last revised on 07/19/18, revealed a person-centered comprehensive care plan would be developed for each resident and that would assist the facility on how to meet the residents needs. Record review further revealed the care plans were ongoing and revised as the resident had changes. The policy further revealed the nurse/Interdisciplinary Team was responsible for updating the care plans. 1. Interview with Resident #[AGE] during the initial tour, on 11/13/19 at 9:55 AM, revealed the kitchen could not get the meals straight. Resident #[AGE] stated he/she had to have lactose free and gluten free food and he/she cannot drink regular milk or eat white bread and he/she did not think the dietary department understood that. Resident #[AGE] revealed they brought him/her regular milk today and it had to be sent back. Resident #[AGE] stated if he/she had drank the regular milk she/he would have had diarrhea and sometimes vomiting. Record review of the face sheet for Resident #[AGE] revealed the facility admitted the resident on 11/06/19 with [DIAGNOSES REDACTED]. The record revealed Resident #[AGE] was allergic to gluten. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/19, revealed Resident #[AGE] had a Brief Interview of Mental Status (BI[CONDITION]) of twelve (12) which meant the resident was not cognitively impaired. Record review further revealed Resident #[AGE] was visually impaired and needed supervision with set up help for eating. Record review of the comprehensive care plan revealed a problem for nutritional status was addressed related to fluid restrictions and Irritable Bowel Syndrome. Diet as ordered was one of the interventions. Review of the comprehensive care plan revealed there was no indication Resident #[AGE] had any food allergies and no interventions incorporated with the care plan to address the gluten free diet and lactose free diet. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:48 PM, revealed there was a care plan for nutrition and the problem was because Resident #[AGE] was at risk for decline in nutrition. Interview further revealed the care plan had interventions for monitoring intakes, weights, diet: however she did not see allergy issues addressed. Interview further revealed Resident #[AGE]'s care plan should have addressed food allergies. The MDS Assistant Coordinator further revealed Resident #[AGE] needed [MEDICATION NAME] free and gluten free foods but it was not included on her/his care plan and it should have been. The MDS Assistant Coordinator revealed the care plan informed the staff of what special diet the residents were on. The MDS Assistant Coordinator revealed she did not know why the food allergies was not addressed on the nutrition care plan and it should be. The MDS Assistant Coordinator stated she had several people doing the care plans and whoever did Resident #[AGE]'s did not address allergies. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed they recognized they had a problem with comprehensive care plans and Certified Nursing Assistant (CNA) care plans in October 2019. 2. (Refer to F690) Review of the clinical record revealed the facility admitted Resident #55 on 07/15/15. [DIAGNOSES REDACTED]. Further review revealed the resident received hospice services. Continued record review revealed Resident #55 was re-admitted to the facility on [DATE], with a Foley catheter, and there was no documented evidence of a Physician's Order for the Foley Catheter after the re-admission, and no evidence the Comprehensive Care Plan was revised to include interventions for car or monitoring the Foley catheter. Review of the Quarterly MDS (Minimum Data Set) Assessment, dated 09/22/19 revealed Resident #55 was assessed as rarely/never understands/understood, and no BI[CONDITION] score was assessed. Resident #55 was assessed by the facility as severely impaired for cognitive skills of daily decision making. The facility assessed Resident #55 as requiring total dependence of one staff for bathing and was assessed always incontinent of urine and bowel. Per the MDS, the resident was not assessed as having an indwelling catheter. Review of the progress notes dated 09/25/19 revealed Resident #55 was transferred to the emergency department for a change in condition, and was re-admitted to the facility on [DATE]. Further review of the progress notes, dated 09/27/19, revealed Resident #55 returned to the facility with a Foley catheter. Review of the Comprehensive Care Plan revealed a problem dated 07/04/19, for elimination and noted the resident had a potential for complications related to bowel and bladder incontinence and the resident was at risk for falls, skin breakdown, and UTI (urinary tract infection). Further review revealed a goal that the resident would not experience complications related to bowel and bladder incontinence with a goal date of [DATE]. Interventions included provide incontinence care after each incontinent episode, report signs of UTI, use briefs for incontinent care, and report any signs of skin breakdown. Continued review of the Comprehensive Care Plan revealed no documented evidence the plan of care was reviewed or revised to include care for the Foley catheter when Resident #55 returned to the facility on [DATE] through the survey. Review of the Physician's Order's and past orders for Resident #55 revealed no evidence of an order for [REDACTED]. Review of the Electronic Medication Treatment Record revealed no documented evidence the resident's Foley catheter was monitored or care provided related to the Foley catheter when the resident returned from the hospital with the Foley catheter on 09/27/19. Observations of Resident #55, on 11/12/19 at 12:43 PM, revealed the resident was in bed on his/her back, with eyes closed. Catheter tubing was observed with pale yellow urine in tubing to covered bedside drainage bag. Observations on 11/12/19 at 2:20 PM, 4:16 PM, on 11/13/19 at 9:56 AM and 3:50 PM, on 11/14/19 at 8:54 AM, and 11/15/19 10:16 AM, revealed the resident continued to have the catheter to bedside drainage. Observation of Resident #55's catheter, on 11/16/19 at 2:03 PM, with RN #6, revealed no leg strap securing the catheter. Interview with RN #6 at that time revealed if the resident had a leg strap, it would anchor the catheter to his/her leg better. The catheter bag was observed with approximately 100 cc urine in bag and per RN #6 interview. Continued observation revealed the area around the glans with yellowish white crusty substance in an amount that the nurse manually moved with her finger, and odor was noted when she moved the substance. Continued observation revealed a reddened extended area, approximately one (1) cm on the distal penis shaft on right side. RN #6 stated the resident had a growth that was removed from this area, and it is growing back. RN #6 revealed nursing was responsible for catheter care and she had not done catheter care at this time. RN #6 stated she thought the resident might have something like yeast or fungal and also stated she was unsure if today was the resident's scheduled bath day. Further interview with RN #6 revealed the nurse aides would change the resident's brief if the resident had a bowel movement or if it was bath day, and the aides empty the catheter collection bag. Review of a subsequent progress note, dated 11/16/19 at 2:13 PM, documented by RN #6, revealed the nurse cleaned around penis and noted some white exudate around base of head of penis with slight odor noted. Continued review of the note revealed that after the area was cleaned, the area was slightly red and she notified the NP of this and received and noted order to use TAO (Triple Antibiotic Ointment) PRN as needed. Review of Resident #55 Prescription order revealed an order dated 11/16/19 for Triple Antibiotic Ointment topical as needed. Interview with SRNA #7, on 11/16/19 at 02:03 PM, revealed she was the aide assigned to Resident #55 on this date. Continued interview revealed she was to empty the catheter bag at the end of shift. SRNA #7 indicted she does not clean the catheter unless bowel movement was on it; however she stated with the resident's bath, she would clean around the area and clean the penis. SRNA #7 stated she checked the resident to make sure the resident had not had a BM (bowel movement) today, and he/she had not and stated she hasn't looked at that area (catheter or penis) today. Interview with RN #6, on 11/16/19 at 8:45 AM, revealed she had worked with Resident #55 in past and was assigned his care today. Continued interview revealed when Resident #55 returned from the hospital with a catheter, the nurse should clarify with the Physician to continue the catheter, and the care plan should be updated because the resident requires catheter care. Continued interview revealed she thought catheter care was done every shift and check to make sure nothing crimped. RN #6 stated the aides do catheter care/perineal care and empty every shift. Continued interview with RN #6 revealed she reviewed the EMR for Resident #55. Per interview, there was no physician's order for the catheter when the resident returned to the facility on [DATE], no treatment noted on the Treatment Record, and nothing documented in the progress notes regarding care or treatment of [REDACTED].#6 stated there was no documentation on the Care Plan to address Resident #55's catheter. Continued interview revealed Resident #55's catheter should have been monitored. RN #6 indicted potential problems with a catheter not being monitored could be UTI, if the catheter was not cared for properly; or the resident could become distended or the catheter may not be in place anymore, if the resident was not having urine output. Interview with LPN #5, on 11/16/19 at 1:35 PM, revealed he cared for Resident #55 on 09/27/19, when the resident returned to the facility with the catheter. LPN #5 indicated he was advised by the hospital that the resident had the catheter because of surgery and a growth they removed from the penis, and the resident had stitches that fall off. LPN #5 stated he called the on call physician who advised him the facility physician would evaluate and see if resident needs catheter and discontinue if not. Continued interview revealed the physician order was supposed to have [DIAGNOSES REDACTED].#5 did not provide reason why he did not obtain physician's order for the catheter. Additional interview with LPN #5 revealed Resident #55's care plan should have been revised to include care of the catheter, after returning the facility with the catheter. LPN #5 stated the nurse on duty enters orders and then IDT (Interdisciplinary Team) does care plan and goes over everything in their meeting. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed when a resident returned to the facility with a catheter, the nurse should update the care plan. Per interview, the reason for updating the Care Plan was to know how to take care of the catheter and monitor the resident with the catheter. The MDS Coordinator stated she did not review the Care Plans the nurses put in place and she reviews Care Plans after each resident's MDS Assessment. Further interview revealed she had also seen Physician Orders that addressed when the catheter should be changed or for catheter care for residents in past. Continued interview revealed it was important to monitor residents with catheters, and if the catheter was not monitored, the resident could pull the catheter out or get infections. Interview with the Unit Manager on Resident #55's Unit, on 11/16/19 at 3:58 PM revealed when Resident #55 returned from the hospital with the catheter, Physician orders should have been obtained to include the size of the catheter, balloon size and [DIAGNOSES REDACTED]. However, she stated she did not find any documented evidence these things were completed when she reviewed Resident #55's record. Per interview, this could cause problems such as infection, as there was no documentation Resident #55 received catheter care. Interview with the DON, on 11/16/19 at 9:43 AM and 2:09 PM, revealed when Resident #55 returned from the hospital on [DATE], a Physician's order should have been obtained with diagnosis, on admission and the Care Plan should have been revised to address the catheter care. She further explained the catheter should have been monitored by nursing staff every shift, and this should have been on the Treatment Record. Continued interview revealed the IDT reviews every resident returning from the hospital and newly admitted residents, and review orders and ensure the Care Pan is updated. The DON stated the nurse admitting the resident should have obtained Physician's order's and initiated the Care Plan and then the IDT should have ensured it was in place. Per interview, nurses should do catheter care each shift, and typically there was a Physician's Order for catheter care every shift and this should be on the Care Plan. Interview with the Administrator, on 11/16/19 at 11:27 AM and 4:20 PM, revealed new orders were sent when a resident returned from the hospital to the facility with a catheter. The Administrator further stated the assessment was completed and orders should be clarified with the physician for [DIAGNOSES REDACTED]. Further interview revealed newly admitted residents were reviewed in IDT meeting and they ensured orders were in place. She stated she was not clinical but aware residents could get UTI's (Urinary Tract Infections) with catheters. Per interview, it was her expectation that staff follow policies and procedures of the facility, that residents have Care Plans to meet needs of the resident and that the Care Plans be followed. She stated it was her expectation that all resident care was provided and this be documented in the record. 3. (Refer to F[AGE]1) Review of facility policy titled Dental Services, dated last reviewed 06/05/18, revealed the facility must assist residents in obtaining routine and twenty four (24) hour emergency dental care. Continued review revealed the facility will assist the resident in making appointments and arranging for transportation to and from dentist's office. Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Resident #9 had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE], a Significant Change assessment, revealed Resident #9 was assessed as having a BI[CONDITION] (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Continued review revealed no items were assessed with [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of the Comprehensive Care Plan for Resident #9 revealed no documented evidence of a plan of care to address the resident's dental status. Record review revealed Resident #9 was seen by the dentist on 07/18/19. Further review of the documentation revealed the resident needed additional dental work for tooth #21 and #28. Per the dental evaluation documentation, Resident #9 had teeth #18, 24, 26, 29, and 30, which were documented non restorable and needed to be extracted by an oral surgeon. Continued review of the record revealed an Oral Surgery Referral, dated 07/18/19, for Resident #9. Record review revealed no documented evidence Resident #9 was evaluated by the oral surgeon per the referral 07/18/19 to through the date of survey 11/16/19. In addition, there was no documented evidence Resident #9's plan of care was revised to include the resident's dental needs. Observation and interview with Resident #9, on 11/12/19 at 12:35 PM and 11/13/19 at 10:17 AM, revealed the resident was observed to have some natural teeth. Interview with Resident #9 revealed he/she had seen the dentist in past at the facility but needed to see the dentist again. Resident #9 did not report any teeth causing pain at this time. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed the facility does not usually do referrals, such as the oral surgeon referral, on the Care Plan. She stated after the extractions the resident's Care Plan would be updated to include pain or follow up and instructions. Interview with the Social Services Assistant, on 11/15/19 at 3:12 PM, revealed she when a resident returned with a written order for referral to oral surgeon, the nurse received the order and completed an appointment sheet, then provided it to the appointment/transportation scheduler to set up the appointment. She stated it was then put in an appointment book. Subsequent interview on 11/16/19 at 2:12 PM revealed she did not know why the process was not completed at the time of referral on 07/18/19 for Resident #9. Interview with the Appointment/Transportation Scheduler, on 11/16/19 at 1:07 PM, revealed he was responsible for scheduling resident appointments and transportation. The Scheduler stated he had never received a referral for Resident #9. Interview with the Unit Manager 100 Unit, on 11/16/19 at 4:02 PM, revealed she was unsure of the policy but if paperwork was received for an appointment, the appointment should be scheduled the next business day. The Unit Manager stated she found no documentation Resident #9 was seen by the oral surgeon after the referral 07/18/19. She stated the nurse should have given the referral to the Appointment/Transportation Scheduler. Continued interview with the Unit Manager revealed potential problems with delay in the appointment could be pain, or weight loss if the resident wasn't eating an adequate amount of food. Interview with the DON, on 11/16/19 at 9:59 AM, revealed when Resident #9 returned to the facility with the consult/referral to oral surgeon, the nurses should have made the Appointment/Transportation Scheduler/Coordinator aware to schedule the appointment. She further stated Resident #9 should have had a Care Plan developed at the time the dental issue was identified by the nurse receiving documentation of the dental issue. Interview with the Administrator, on 11/16/19 at 11:18 AM and 4:20 PM, revealed she was unaware of any dental issues with Resident #9. She stated the process was if the dentist made a referral, the facility should make sure the follow up appointment was scheduled. The Administrator further stated dental issues should be on the resident's Care Plan. Continued interview revealed it was her expectation that staff follow policies and procedures of the facility.

Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #70. Resident #70 was to have his/her leg wrapped with an ace wrap and this was not done consistently. The findings include: Record review of the facility policy titled, Review of Physician Orders last revised on 11/06/19, revealed the Director of Nursing /designee would review the Electronic Medical Record (EMR) regarding documentation to support a change in condition and appropriate measures were provided, Record review of the clinical record revealed the facility admitted Resident #70 on 09/28/18 with [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/19 revealed Resident #70 had a Brief Interview of Mental Status (BI[CONDITION]) score of thirteen (13) which meant the resident did not have impaired cognition. Record review of the functions section on the MDS revealed Resident #70 needed extensive assist of one person for transfer, locomotion, dressing, eating, toileting, and hygiene. Record review further revealed Resident #70 had impaired range of motion on one side of the lower extremity and he/she had a prosthetic leg. Record review of the physician orders for 11/01/19 through 11/13/19, revealed the left lower extremity was to be cleansed with soap and water, moisturizer and [MED] applied and then the leg was to have a four (4) inch Ace wrap from the toes to the ankle and a six (6) inch Ace wrap from the ankle to the knee. This was to be done daily. Record review of the physician orders further revealed the [MEDEQUIP] and Ace wraps were to be removed once a day at bedtime. Review of the order on the Medication Administration Record [REDACTED]. Continued review revealed there was no application time for the morning Ace wrap application listed; everything was listed as nightly. Record review of the comprehensive care plan revealed a problem was listed for several non pressure open areas to the left lower extremity. Review of the goal was for the open areas to heal without complications. Record review of the approaches showed Ace wraps were to be applied as ordered. Observation of Resident #70, on 11/12/19 at 11:44 AM, revealed he/she was in physical therapy. Observation further revealed there were three small bandages on the left leg and the right leg was amputated and the resident had a prosthetic leg in place. Observation of Resident #70, on 11/13/19 at 12:12 PM, revealed the left leg was not wrapped with any type of bandage. Interview with Resident #70, on 11/12/19 at 11::44 AM, revealed the nurses were supposed to apply the Ace wraps in the morning and remove them at night, but they did not seem to know when to put the wraps on or when to take them off. Resident #70 stated the Ace wraps were to be applied to help keep the swelling down and when on his/her leg felt better. Interview with the MDS assistant coordinator, on 11/16/19 at 4:32 PM, revealed she was not the coordinator but the assistant and they had just hired a new MDS coordinator but she had not started yet. The MDS assistant coordinator stated the Ace wraps should have been applied because the wraps would provide pressure for better circulation. She revealed if the wraps were not applied it could cause the sores to worsen and more could development. Interview, on 11/15/19 at 10:30 AM, with the Director of Nursing (DON), revealed Resident #70 had a physician order for [REDACTED]. However after reviewing the MAR indicated [REDACTED]. She revealed there was no area for the day shift nurse to initial that the wraps were applied. The DON revealed the physician orders should have been followed for the safety and wellness of Resident #70. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed her job as the administrator was to oversee the well being of the residents and make sure the facility met regulatory expectations.

Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #51. Resident #51 had a physician order [REDACTED]. The physician was not notified until the next day that Resident #51 did not go out to the emergency room as the physician had ordered. The findings include: Review of Resident #51's clinical record revealed the facility admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with [DIAGNOSES REDACTED]. In addition, resident has intellectual [DIAGNOSES REDACTED]. Review of Resident #51's annual Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief interview for Mental Status score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of telephone order for Resident #51, date 08/31/19, revealed physician order [REDACTED].#5. Review of Resident #51's progress note, on 08/31/19 at 7:12 PM, revealed LPN #5 failed to notify physician, Advanced Practice Registered, ADON, and/or DON for direction after emergency services classified the resident's status as a non-emergency for directions on next steps. Continued review of the resident's progress notes, revealed Resident #51 was admitted to hospital the following day, 09/01/19 at 7:45 AM after complaints chest pain. Observation of Resident #51, on 11/12/19 at 11:39 AM, resident was in bed with eyes closes with oxygen in place and set on two (2) ml, fully dressed, and room was free from cutter. Observation of Resident #51, on 11/13/19 at 1:10 PM, resident was observed eating lunch with another resident. Brief interview with Resident #51, revealed he enjoyed living at the facility, however,did not remember going to the hospital. Resident #51 continued to wear cannula for oxygen. Interview with Resident #51, on 11/13/19 at 1:22 PM, revealed resident reported no concerns with the facility or the staff. Interview with LPN #5, on 11/16/19 at 3:37 PM, revealed he completed an assessment on Resident #51 after complaints of chest pain. He then obtained a physician order [REDACTED]. LPN #5 reported emergency services (E[CONDITION]) arrived, however, after their assessment deemed Resident #51 a non-emergency and refused to transport resident to the emergency room . Continued interview with LPN, revealed he failed to follow up with physician, APRN, and/or the DON to communicate E[CONDITION] did not transport Resident #51 to the emergency room due to non-emergency call. LPN #5 reported he forgot the process and procedure when physician's orders [REDACTED].#51. Interview with Direction of Nursing (DON), on 11/16/19 at 4:09 PM, revealed she was not the DON during Resident #51's change of condition. The DON states she was not aware of the incident regarding nursing staff lack of physician notification after denial of transportation to the emergency room . The DON stated it was important for the LPN to follow up with the physician due to the initial order was not followed. Phone interview with Medical Director (MD), on 11/16/19 at 6:26 PM, revealed if an order was to send a resident out to the hospital for chest pain, they expected nursing staff to follow the physician order. However, if the resident was viewed as a non-emergency by emergency services, she would expect another form of communication from the facility for review to determine if another order was warranted. Phone interview with former Unit Manager (UM) #3, on 11/16/19 at 7:46 PM, revealed she could not remember the details from the date of 09/01/19 however, her nursing documentation was accurate. She revealed the day after the first complaint of chest pain Resident #51 had complained again of chest pain, vitals were checked and deemed necessary to contact physician/APRN and request ambulance for transport. At that time, she called rural metro, who came right away to transport resident to the hospital. Unit Manager revealed she would expect nursing staff to contact the physician and/or the Director of Nursing for medical direction when physician orders [REDACTED]. Interview with the Administrator, on 11/16/19 at 8:11 PM, revealed she was notified on Monday 09/01/19, by Unit Manager #3, Resident #51 was hospitalized . She stated in her experience when emergency medical services responded to a call and deemed the resident a non-emergency, the resident would have to wait up 24-hours for transportation. She further stated, emergency medical services was not refusing residents however, nursing staff failed to contact the on-call physician, the DON, or the Administrator to make them aware of the situation.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide pain management for one (1) of four (4) sampled residents, Resident #1. Resident #1 complained of pain at 1:15 PM on 12/29/17; however, documentation revealed staff did not administer pain medication until 9:43 PM. In addition, x-ray results obtained on 12/29/17, revealed the resident had a [MEDICAL CONDITION] but the facility did not transport the resident to the hospital for treatment until 12/30/17. The findings include: Review of the facility's policy, Pain Management, not dated, revealed the facility would have a monitoring and person-centered care plan in place to address pain management to include resident's goals. The policy described recognizing pain when experienced and when circumstances could be anticipated, evaluating the existence of pain, as well as the management, or, prevention of pain consistent with professional standards. A pain scale from zero (0) to ten (10) could be used for residents that could understand the concept, or, the Wong-Baker faces could be utilized to determine the severity of pain. To treat pain, drugs appropriate to the current level of pain were to be used and increased accordingly to achieve a maximum benefit for residents. Pain evaluations were to be completed each shift on all residents and documented in the EzMAR (electronic medication administration record). If pain was identified, the resident was assessed and an SBAR (situation, background, assessment, and recommendation) document was completed, which included notification of the physician, Nurse Practitioner, or the Physician Assistant. As needed medications were monitored for their effectiveness. Review of Resident #1's closed medical record revealed the facility admitted the resident on 11/20/15, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident's pain was occasional and the pain intensity as moderate. Review of Resident #1's Plan of Care, dated 11/30/15, revealed the resident had the potential for pain related to a history of [MEDICAL CONDITION]. Interventions included monitoring and reporting signs and symptoms (S/S) of pain, such as crying/moaning, complaints of pain, medications as ordered, as well as the monitoring for the effectiveness of the pain medication. Review of Resident #1's Certified Nursing Assistant (CNA) Care Report, not dated, revealed the resident was non-ambulatory, and transferred with a mechanical lift with assistance of two (2) staff. Review of Resident #1's Event Note, a Situation Background Assessment Recommendation (SBAR), dated 12/29/17 at 5:56 PM, revealed new pain was identified during the assessment and occurred while the resident was repositioned during a brief change. The SBAR stated the nurse attempted to perform a Range of Motion (ROM) assessment and was unable to complete it because of the resident's complaint of pain. Licensed Practical Nurse (LPN) #1 notified the on call physician and received an order to obtain an x-ray of the right hip. No pain level was documented on the SBAR note, as per policy. The skin evaluation on the SBAR was marked as not clinically applicable to the change in condition being reported, and the functional status evaluation was marked as no changes observed. Review of Resident #1's Nursing Progress Notes, dated 12/29/17 at 10:43 PM, documented by LPN #2, revealed the resident's x-ray resulted a [MEDICAL CONDITION], and the Nurse Practitioner (NP) was notified of the results and gave an order to send the resident to the emergency room (ER) in the morning (12/30/17) for treatment. Review of Resident #1's Medication Administration Record (MAR), for December 2017, revealed a physician order, with a start date of 05/26/17, for [MEDICATION NAME] (pain medication) 10-325 Milligram (mg) tablet, give one (1) every four (4) hours as needed for pain. On 12/29/17, documentation revealed the resident received one (1) [MEDICATION NAME] tablet at 9:43 PM and his/her pain level was a five (5) on a scale of zero (0) to ten (10). Review of Resident #1's Narcotic Count Sheet, dated 12/09/17 to 01/03/18, revealed one (1) [MEDICATION NAME] was signed out on 12/29/17 at 6:00 AM, prior to the incident, and one (1) on 12/30/17 at 10:00 AM. There were no other pain assessments documented on the MAR. Review of Resident #1's hospital History and Physical Note, dated 12/30/17 at 6:02 PM, revealed the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Yesterday (12/29/17), he/she went to [MEDICAL TREATMENT] and was usually moved to the chair by a lift, but yesterday it was done manually. Post [MEDICAL TREATMENT], as usual the patient was drowsy and after waking up, he/she was changed and the patient suddenly started having right hip pain. X-ray performed at the facility showed a fracture and the resident was sent to the hospital for further evaluation. Per the resident, pain was worse on movement, and lying still, he/she did not have pain. Pain was continuous sharp ten (10) by ten (10) intensity. Interview with CNA #1, on 01/23/18 at 2:24 PM, revealed Resident #1 came back from his/her [MEDICAL TREATMENT] treatment about 10:00 AM to 10:30 AM on 12/29/17, and needed to be transferred from the [MEDICAL TREATMENT] chair back into his/her bed. According to CNA #1, she tried to find a second staff member to assist her with the mechanical lift transfer. However, CNA #1 stated she could not find anybody to help her and she transferred Resident #1 into the bed by herself, asked the resident if she needed a brief change, which the resident declined, and then left the room. The CNA stated about two (2) hours later, she went to the resident's room to check on him/her, and again, the resident declined a brief change and she left the room. Shortly before the end of her shift, CNA #1 stated she checked again if the resident required changing and he/she once more declined; however, the resident's spouse insisted she check the resident. CNA #1 lowered the head of bed and Resident #1 started to complain about pain in the hip and thigh area. CNA #1 asked the resident what was going on and the resident stated she did not know. A foul smell was noted by the CNA and she began the brief change by pulling the resident toward her with the lift sheet, rolled him/her over and completed perineal care, covered the resident who stated the his/her hip hurt and by then, the resident cried. CNA #1 stated she left the room and reported the pain to LPN #1. Interview with LPN #1, on 01/24/18 at 3:40 PM, via telephone, revealed she did not recall CNA #1 informing her of Resident #1's pain. She stated the resident's spouse reported the resident was in pain and needed pain medication about 4:00 PM to 5:00 PM. LPN #1 attempted to perform ROM, but the resident did not let her perform it. The resident told her he/she had pain after CNA #1 had changed his/her brief. LPN #1 stated she obtained orders for an x-ray and completed an SBAR assessment and gave report to the on-coming shift. However, she did not know what the outcome of the x-ray was because the results came in after her shift had ended. Further interview on 01/26/18 at 9:32 AM, revealed she completed the SBAR on 12/29/17 for Resident #1 and skipped over the pain intensity because she was distracted. She stated if the pain intensity was left out of the SBAR, it was an incomplete assessment, which meant the resident's pain continued untreated. She stated the spouse of the resident told her that he/she gave the resident pain medication and waited to see if the pain medicine worked. LPN #1 further stated when she gave shift report, she told the on-coming nurse, LPN #2, about the pain medication given by the spouse. However, she did not call the physician to clarify if the resident could receive any additional pain medication. Interview with CNA/Certified Medication Technician (CMT) #2, on 01/24/18 at 4:31 PM, revealed Resident #1's spouse told her at about 1:15 PM, that the resident was experiencing pain. She stated the resident said his/her hip began to hurt about an hour after getting to bed. CNA/CMT #2 stated the resident said the pain started right after his/her brief was changed. The CNA/CMT informed Registered Nurse (RN) #1 and the resident told RN #1, in presence of CNA/CMT #2, he/she had pain after CNA #1 changed his/her brief. RN #1 asked the resident if she needed pain medication; however, CNA/CMT #2 revealed she was not sure if the resident received pain medication. Interview with RN #1, on 01/25/18 at 11:33 AM, via telephone, revealed she did not care for Resident #1 on 12/29/17; however, she remembered the resident had complained of pain to CNA/CMT #2. The RN stated it seemed she found out from LPN #1 about an x-ray because the resident had complaint of hip pain. She stated LPN #1 also mentioned to her that the resident needed pain medication. She stated she could not understand why the facility waited so long to send the resident out to the hospital. RN #1 stated LPN #2 passed along in report to wait for a call from the DON or the corporate consultant to get the okay to send the resident out for further evaluation. In the meantime, she passed her medications and at around 10:30 AM, she got a call from the DON who told her LPN #2 was supposed to triage the care of Resident #1 since the NP had given an order to send the resident out the next morning. RN #1 stated she got a call from the corporate consultant about 11:00 AM on 12/30/17, and initiated the transfer. She further stated she had not received any instruction on how to keep the resident stable or, on how to transfer or reposition him/her. RN #1 stated she had not completed an actual pain assessment, but asked Resident #1 about his/her pain and gave pain medication the morning of 12/30/17. Continued interview with RN #1, on 01/26/18 at 10:10 AM, revealed she checked Resident #1's chart and saw the telephone order to send the resident out in the morning. RN #1 stated she and a CNA got the resident moved up in bed and made sure he/she was comfortable. She stated Resident #1's treatment was delayed for fifteen (15) to sixteen (16) hours. Interview with LPN #2, on 01/26/18 at 12:01 PM, revealed she received the x-ray results for Resident #1 between 10:00 PM to 12:00 AM, and notified the NP and the family. She then did a pain assessment on the resident, checked for the resident's comfort, and gave him/her pain medication. The NP had not given any instructions on how to move the resident, only to assure comfort measures. She stated during the morning, another resident coded and when she called to inform the DON, she informed the DON of Resident #1's x-ray results. LPN #2 stated she had the paperwork to transfer the resident ready, and told the on-coming nurse, RN #1, that the NP ordered the resident sent out in the morning (12/30/17). LPN #2 stated Resident #1 should have been sent out first thing in the morning to the hospital. She continued by stating it was ridiculous to wait that long, especially since Resident #1 was in pain. Interview with the ADON of the 200 Hall, on 01/26/18 at 8:25 AM, revealed LPN #1 informed her about Resident' #1's pain and knew the resident was hurting at about 3:45 PM on 12/29/17. LPN #1 told her the resident had pain when being turned and she instructed the nurse to complete an SBAR and call the physician. The ADON knew from report that Resident #1 told LPN #1 he/she had felt something pop when being turned over. Interview was attempted with the NP, on 01/26/18 at 11:54 AM; however, she declined to interview. Interview with the DON, on 01/25/18 at 3:48 PM, revealed a pain assessment had to include the location, type, and intensity of pain, and needed to differentiate if it was new pain versus chronic pain, so nurses knew when pain started. If any of the described factors were lacking, she considered it an incomplete pain assessment. She stated Resident #1 was known to have had pain on 12/29/17 at about 2:15 PM to 2:30 PM, and should have been assessed sooner because of his/her pain. She stated LPN #1 should have administered pain medication as needed and available on Resident #1's MAR. She further stated Resident #1's spouse gave the resident pain medication from the spouse's supply of pain medication and the nurse should have called the physician to clarify if additional pain medication could be safely administered. She stated not calling the physician for clarification delayed the pain management for seven (7) to eight (8) hours in her estimate, which could have caused physical harm to the resident. She further stated there was a break in the system caused by lack of timely communication to her in the change of condition of the resident and that caused an untimely transfer to the hospital and a delay in further evaluation and treatment of [REDACTED]. Interview with the Administrator, on 01/29/18 at 4:22 PM, revealed he was not aware of a pain management issue within the facility. He stated the welfare of the residents at the facility was his priority. The Administrator stated he was not aware Resident #1 did not receive pain medication timely, and would not have expected that. He stated he relied on the DON to oversee all clinical decisions.

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of four (4) sampled residents, Resident #1. The facility assessed Resident #1 required the assist of two (2) staff with a mechanical lift for transfers, and was at risk for pain related to [MEDICAL CONDITION]. However, on 12/29/17, one (1) Certified Nursing Assistant (CNA) transferred Resident #1 from a chair to the bed without a second staff 's assistance. Approximately two (2) hours later, the resident complained of pain in his/her hip and was diagnosed with [REDACTED]. In addition, staff was to monitor and report signs and symptoms (S/S) of pain, and administer medications as ordered; however, pain management was delayed from approximately 2:15 PM, the time the resident complained of pain, to 9:43 PM on the day of the [MEDICAL CONDITION]. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed a person-centered comprehensive care plan included measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs and was developed for each resident. The care plan included how the facility would assist the resident to meet the resident's needs, goals, and preferences. The care plan was reviewed and updated to reflect the resident's status, and was updated at least quarterly or when changes for a resident occurred requiring revisions. The SBAR (situation, background, assessment, and recommendation) communication form was to serve as a change in condition. Licensed nurses or Nurse Practitioner would evaluate any changes through direct observation, physical examination, and vital signs at onset of the change and ordered by the physician. Review of the facility's policy, Resident Lift, not dated, revealed residents who were unable to transfer themselves independently or with minimum assistance should be transferred safely with a lift and required at least two (2) trained staff for transfer when using a lift. Review of the facility's policy, Pain Management, not dated, revealed each resident identified with pain would have ongoing assessments, a monitoring system, and a comprehensive person-centered plan of care to address pain management to include the resident's goals. The policy stated recognition, evaluation of existing pain, and the management and prevention would be consistent with professional standards and in accordance with the plan of care. A pain scale of 0-10 was used if residents understood the concept, and for residents who could not use the concept, the Wong-Baker faces was used to aid in determining the severity of pain. The Interdisciplinary team and the resident and/or representative collaborated to develop realistic measurable goals for treatment. Review of Resident #1's closed medical record revealed the facility admitted the resident on 11/20/15, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident required two (2) person physical assistance with surface-to-surface transfer between bed and chair, or wheelchair, and assessed the resident's pain to be occasional and the pain intensity was moderate. Review of Resident #1's Plan of Care, initiated 11/30/15, revealed the resident had the potential for pain related to a history of [MEDICAL CONDITION] with interventions to monitor and report S/S of pain such as crying/moaning, facial grimace, guarding, complaints of pain, medications as ordered, as well as the monitoring for the effectiveness of the pain medication. Further review revealed Resident #1 had Activities of Daily Living (ADL) Self Care Deficit, dated 11/30/15, and required extensive assist with bed mobility and locomotion. Interventions included assistance of two (2) staff persons for lift transfers. Review of Resident #1's CNA Care Report, not dated, revealed the resident was non-ambulatory, transferred with a mechanical lift with two (2) staff assistance, and required one (1) staff for repositioning. The [MEDICAL TREATMENT] days were Monday, Wednesday, and Friday. Review of a facility incident investigation, dated 12/29/17, revealed Resident #1 was found to have a right [MEDICAL CONDITION]; however, had no fall or trauma per the resident and staff. The resident's spouse informed Licensed Practical Nurse (LPN) #1 of the resident's pain around 4:00 PM. The resident stated the pain began around 2:15 PM during incontinent care and brief change. Resident #1 felt a pop and experienced pain. Actions implemented by the facility were re-education to nursing for following the CNA care plan, two (2) person transfer to include mechanical lifts. Review of Resident #1's Situation Background Assessment Recommendation (SBAR), dated 12/29/17 at 5:56 PM, documented by LPN #1, revealed new pain was identified during the assessment and occurred when staff repositioned the resident during a brief change. The nurse was unable to complete a Range of Motion (ROM) assessment because the resident complained of pain. LPN #1 notified the on call physician and an order was received to obtain an x-ray of the right hip. Staff did not document a pain level on the SBAR, as per policy. Staff documented the skin evaluation on the SBAR as not clinically applicable to the change in condition being reported, and documented the functional status evaluation as no changes observed. Review of Resident #1's Nursing Progress Notes, dated 12/29/17 at 10:43 PM, revealed the resident's x-ray results came back with a [MEDICAL CONDITION]. The Nurse Practitioner was notified and LPN #2 received an order to send the resident to the emergency room (ER) in the morning for treatment. Review of Resident #1's hospital History and Physical Note, dated 12/30/17 at 6:02 PM, revealed the resident went to [MEDICAL TREATMENT] yesterday (12/29/17), and usually moved to the chair by a lift, but yesterday it was done manually. The resident was drowsy after [MEDICAL TREATMENT] and after waking up, he/she was changed, and the resident suddenly started having right hip pain. The facility obtained an x-ray that showed a fracture and the resident was sent to the hospital for further evaluation. As per the resident, the pain was worse on movement, and when lying still, the resident did not have pain. Review of Resident #1's Medication Administration Record (MAR), for December 2017, revealed a physician order, with a start date of 05/26/17, for [MEDICATION NAME] (pain medication) 10-325 Milligram (mg) tablet, give one (1) every four (4) hours as needed for pain. Staff documented on 12/29/17, the resident was administered the [MEDICATION NAME] at 9:43 PM with a pain level of five (5) on a pain scale of zero (0) to ten (10). Review of the resident's Narcotic Count Sheet revealed staff signed out [MEDICATION NAME] on 12/29/17 at 6:00 AM, prior to the incident, and on 12/30/17 at 10:00 AM. There were no other pain assessments documented on the MAR. Interview with CNA #1, on 01/23/18 at 2:24 PM, revealed when Resident #1 returned from [MEDICAL TREATMENT] on 12/29/17 about 10:00 AM to 10:30 AM, he/she needed to be transferred from the [MEDICAL TREATMENT] chair into the bed. CNA #1 stated she transferred the resident using the mechanical lift by herself because she could not find another staff person to assist her. CNA #1 stated she knew it was not right to transfer the resident by herself and had not followed the resident's care plan. Continued interview with CNA #1 revealed she checked on Resident #1 at about 2:15 PM and changed the resident's brief. However, as she rolled Resident #1 over, he/she complained of pain in the hip/thigh area and told her the hip hurt. Then the resident cried and she reported Resident #1's pain to the nurse, LPN #1, who stated she (LPN #1) would be in with the resident in a minute. However, CNA #1 stated she was unsure if the nurse went to the resident's room as she left because it was the end of her shift. Interview with LPN #1 via telephone, on 01/24/18 at 3:40 PM, revealed Resident #1's spouse reported on 12/29/17, at about 4:00 PM to 5:00 PM, the resident was in pain and needed pain medication. She could not recall CNA #1 telling her about the resident's pain. Further interview with LPN #1, on 01/26/18 at 9:32 AM, revealed she completed an SBAR assessment on 12/29/17 for Resident #1, and skipped over the pain intensity because she was distracted. She further stated if the pain intensity was left out, the SBAR was incomplete, which meant the resident's pain was untreated, and she had not followed the care plan. She stated if CNA #1 transferred the resident by herself, the CNA had not followed the care plan because the resident was a two (2) staff person assist using the lift. Interview, on 01/24/18 at 4:31 PM, with CNA/Certified Medication Technician (CMT) #2, revealed Resident #1's spouse came up to her about 1:15 PM, and reported the resident's hip began to hurt about an hour after getting into bed. CNA/CMT #2 got Registered Nurse (RN) #1 to assess the resident; however, she was unsure if the RN administered pain medication. CNA/CMT #2 stated a mechanical lift required two (2) staff to transfer and CNA #1 had not followed the care plan and should have waited to transfer the resident until she found a staff person to assist her. Interview with CNA #3, on 01/24/18 at 10:32 AM, revealed if a resident required assist of two (2) with the mechanical lift transfers and only one (1) staff person performed the transfer, then the care plan was not followed. Interview with the Assistant Director of Nursing (ADON) of the 200 Hall, on 01/26/18 at 8:25 AM, revealed if a resident required a mechanical lift transfer, then two (2) staff was to perform the transfer. She stated sometimes staff did it without getting help and if one (1) staff person transferred a resident, the care plan was not followed. The ADON stated the pain assessment was very important because it let nursing staff know about the pain intensity and if not done, a resident's pain could be higher or they could have had more pain and internalized it. The ADON stated the care plan was not followed if the pain assessment was incomplete. She stated Resident #1's spouse approached her and told her he/she had been concerned about the resident's pain and the spouse gave the resident the spouse's pain medication. Interview with the Director of Nursing (DON), on 01/29/18 at 3:10 PM, revealed Resident #1's pain should have been assessed sooner and she expected the nurse to call the physician to clarify if additional pain medication could be administered after finding out the resident's spouse gave the resident his/her own pain medication. She further stated the pain management for Resident #1 was delayed for seven (7) to eight (8) hours, which resulted from an incomplete pain assessment. The DON stated the pain should have been assessed sooner, as the delay could have caused physical harm to the resident, and therefore the care plan was not followed. Interview with the Administrator, on 01/29/18 at 4:22 PM, revealed the clinical team established the care plans and he expected staff to follow the care plans so the welfare of the residents could be maintained.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the staff followed it's Abuse Policy to report and protect one (1) of twenty-seven (27) sampled residents (Resident #10) when it failed to report an allegation of physical abuse. On 04/14/15 during the resident's care plan meeting, Resident #10 reported an allegation of physical abuse involving Certified Nursing Assistant (CNA) #1. The resident stated CNA #1 threw him/her on the bed. Staff present at the meeting was aware of the requirements of the facility's Abuse Policy reporting guidelines; however, failed to report the allegation to the Director of Nursing or to the Administrator, and the CNA worked the evening shift (2:30 PM-10:30 PM) on 04/14/15 on the resident's unit. The facility's failure to ensure policy and procedures were implemented to ensure an allegation of abuse was reported and residents were protected from further abuse placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 04/16/15 and determined to exist on 04/14/15. The facility was notified of the Immediate Jeopardy on 04/16/15. The facility provided an acceptable Allegation of Compliance (AOC) on 04/17/15 which alleged removal of the Immediate Jeopardy on 04/18/15. The State Survey Agency verified Immediate Jeopardy was removed on 04/18/15 as alleged prior to exit. The scope and severity was lowered to a "D" in 42 CFR 483.13 Resident Behavior and Facility Practices (F226) while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the Abuse Policy, dated April 2013, revealed all allegations of abuse were to be reported immediately to the charge nurse. If the charge nurse was the suspected perpetrator the allegation would be reported to another licensed nurse and/or manager in the facility, or via phone. The charge nurse would immediately remove the suspected perpetrator from resident care areas, obtain the staff member's witness statement and immediately suspend the employee pending the outcome of the investigation. The charge nurse would immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate. Interview with Resident #10, on 04/15/15 at 9:45 AM, revealed on 04/14/15 during the resident's care plan meeting he/she reported CNA #1 had thrown the resident on the bed after the resident's shower. On 04/15/15 at 9:45 AM, the State Survey Agency reported the allegation to the Administrator after being informed by the resident of the allegation during interview. Interview with the Administrator, on 04/15/15 at 9:45 AM, revealed he had no knowledge of the allegation until it was reported to him by a State Surveyor. Review of the Care Plan Summary revealed, on 04/14/15 at 1:00 PM, the facility held a Care Plan Meeting for Resident #10 and family members. Present at the Care Plan Meeting were the Director of Social Services (DSS), the Assistant Director of Social Services (ASSD), Dietary Director (DD), Physical Therapy Assistant (PTA), Quality of Life Director (QLD), the Assistant Director of Nursing (ADON), and two (2) of the resident's family members. Interviews with the care plan team on 04/15/15 with the Director of Social Services at 10:25 AM, the Assistant Director of Social Services at 10:35 AM, the 200 Unit Assistant DON at 10:40 AM, Quality of Life Director at 2:30 PM, the PTA at 2:50 PM, and one of the two (2) family members present at the Care Plan meeting and interviewed on 04/20/15 and 04/21/15 by phone revealed, Resident #10 stated CNA #1 threw the resident on the bed. In addition, staff members and family members revealed during their interviews, the Administrator was not notified of the allegation because the Assistant DON stated she would take care of this; however, she did not. Interview with the 200 Unit Assistant DON, on 04/15/15 at 10:40 AM, revealed she did not follow the abuse policy and should have. She stated she should have gone to the Administrator; however, was leaving the facility to go to another city and was in a hurry. Additional interview with the Assistant DON, on 04/15/15 at 3:06 PM, revealed the staff had two hours to report allegations to the Administrator and DON. She stated she was unable to speak with the DON as he was in a meeting and she should have interrupted him or spoken with the Administrator. She further stated "she protected the resident by telling another nurse that the DON was in the building if she needed anything"; however, she did not tell the nurse about the allegation. Further interview revealed, per the Abuse policy, she should have reported the allegation to ensure resident safety before she left the building. Review of the staffing schedule revealed CNA #1 was a called in to work the second shift on 04/14/15 after the allegation was reported. Interview with the DON, on 04/15/15 at 8:15 AM, revealed he was not notified by the ADON of any allegation by Resident #10 stemming from the care plan meeting on 04/14/15. Another interview with the DON at 3:40 PM, revealed he was not notified until the Administrator notified him. Interview with the Administrator, on 04/15/15 at 5:00 PM, revealed staff should have followed the facility's policy and reported the allegation of abuse to him. The facility took the following actions to remove the Immediate Jeopardy as follows: 1. The resident's family was aware of the allegation made by the resident as they attended the care plan meeting when the allegation was made on 04/14/15. 2. The resident's Physician/Medical Director was notified of the allegation on 04/15/15 by the DON, with no injury identified. 3. The DON assessed the resident for injury on 04/15/15. 4. An investigation was initiated on 04/15/15 when the Administrator was notified. Regulating agencies were notified Office of the Inspector General (OIG) and Adult Protective Services (APS). The investigation was concluded and unsubstantiated on 04/16/15 and a follow-up report was sent to OIG. 5. The DON suspended CNA #1 on 04/15/15 at 12:18 PM. 6. The Administrator interviewed Resident #10, on 04/15/15 at 12:15 PM. 7. On 04/15/15, 04/16/15, and 04/17/15 Staff assigned to complete resident interviews were the Director of Social Services, Assistant Director of Social Services, and the Transitional Care Nurse/Staff Development. An Abaqis tool (a Quality Assurance tool) was used to interview seventy-three (73) residents with BIMS scores eight (8) to fifteen (15) regarding abuse and choices. 8. On 04/15/15, 04/16/15, and 04/17/15 forty-five (45) residents with BIMS scores zero (0) to eight (8) had skin assessments completed to observe for signs of abuse, there were no signs of abuse identified. The skin assessments were completed by the Director of Nursing, Assistant Director of Nursing, and Staff Development. The Director of Social Services and Assistant Director of Social Services, Medical Records Nurse and Staff Development made forty-five (45) calls to responsible parties of residents with BIMS of eight (8) or less, contact was made with thirty (30) responsible parties who voiced no care concerns. 9. On 04/17/15 a Resident Council Meeting was held by the Administrator to discuss abuse reporting, the facility's obligation to report, and how the facility would remedy the deficient practice. 10. On 04/15/15 a Quality Assurance Performance Improvement (QAPI) Committee meeting was held, in attendance: Medical Director, Director of Nursing, Administrator, Director of Social Services, Assistant Director of Social Services, and the Administrator in Training discussed the alleged event, reviewed the abuse Policy (no changes), and the Medical Director reviewed Resident #10's chart with no orders. 11. On 04/15/15 at 11:15 AM, immediate education was provided to the Administrator regarding the Abuse policy, by the Clinical Risk Manager. Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Physical Therapy Assistant, Assistant Director of Nursing (3), Director of Nursing, and Administrator in Training received training by the Clinical Risk Manager and the Administrator regarding the Abuse Policy. 12. On 04/15/15 at 12:45 PM, the Abuse Policy was used by the Clinical Risk Manager to educate the following: Minimum Data Assessment Nurses (2), Maintenance Director, Assistant Director of Nurses (3), Business Office manager, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director of Human Resources, the Dining Services Director, Transitional Care Nurse/Staff Development, Rehabilitation Services Manager, and Medical Records. 13. Education was provided by the Administrator, Director of Nursing, Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Assistant Director of Nursings (3), Staff Development, Medical Director, Business Office Manager, Administrator, Housekeeping, Chaplain, Respiratory Therapist, Human Resources, Dietary Manager, Rehabilitation Manager, Medical Records, Dietitian, and RN Supervisor, on 04/15/15 thru 04/17/15 to the current staff. The current staff totaled one hundred and sixty-three (163) out of one hundred and sixty-six (166) employees on the Abuse Policy. 14. Post education tests were provided and graded by the Administrator, Director of Nursing, Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Assistant Director of Nursing (3), Staff Development, Medical Director, Business Office Manager, Admissions, Housekeeping, Chaplain, Respiratory Therapist, Human Resources, Dietary Manager, Rehabilitation Manager, Medical Records, Dietitian, and RN Supervisor after education was completed by all staff. Staff on vacation or leave of absence would not be allowed to work until abuse education was completed. 15. The Staff Development would educate all new hires on abuse prior to starting their department orientation. 16. Effective 04/17/15 all Care Plan Meetings would be attended by the Administrator, Administrator in Training, Director of Nursing, or one of the two (2) MDS nurses. The next Care Plan Meeting is 04/21/15. Assigned staff will monitor feed back from residents and families. 17. Beginning 04/21/15, once a week 25% of residents with BIMS scores eight (8) or greater will be interviewed by the department head or interdisciplinary team regarding abuse. Also, 25% of residents with BIMS scores of below eight (8) will have skin assessments completed by nursing management. 18. There will be weekly QAPI meetings to review trending data with interviews, assessment and Care Plan Meetings, beginning 04/21/15. The State Survey Agency validated the removal of the Immediate Jeopardy on 04/23/15 prior to exit as follows: 1. Interview with Family Member #1, on 04/20/15 at 2:40 PM, revealed he/she was present in the Care Plan meeting, heard the allegation and confirmed this knowledge with the facility. Interview with Family Member #2, on 04/21/15 at 8:20 AM, revealed he/she was present in the Care Plan meeting and did not hear the allegation. 2. Interview with the Medical Director, on 04/15/15 at 1:15 PM, revealed she was notified of the abuse allegation by the Administrator and DON on 04/15/15 at 9:50 PM. 3. Interview, on 04/15/15 at 10:02 AM, and review of the skin assessment, revealed the DON assessed Resident #10 for possible injuries related to the allegation. The assessment was documented on a CNA Skin Care Sheet. No injuries were found. 4. Interview with the Administrator, on 04/15/15 at 1:41 PM, and review of the facility's notification to OIG and APS by fax revealed the allegation of abuse was reported and the investigation was initiated by the Administrator. On 04/16/15 at 7:32 PM a follow-up report of a completed investigation was faxed to OIG and APS. 5. Review of the Stakeholder Suspension Form, dated 04/15/15, revealed on 04/15/15 CNA #1 was suspended per a conference call by the DON. The Stakeholder Suspension Form was witnessed by the DON, HR, and ADM. 6. Interview with the ADM, on 04/21/15 at 1:30 PM, revealed he met with Resident #10 on 04/15/15 at 12:15 PM and he/she confirmed during the Care Plan meeting he/she stated CNA #1 threw him/her on the bed on 04/11/15. 7. Review of seventy-three (73) interview forms revealed on 04/15/15 thru 04/17/15 Abuse interviews were completed with seventy-three (73) residents with BIMS scores eight (8) to fifteen (15). Interviews with two (2) unsampled residents, Unsampled Resident A on 04/21/15 at 9:38 AM, Unsampled Resident B on 04/21/15 at 9:46 AM, and on 04/21/15 at 10:15 AM with Resident #10, revealed resident abuse interviews were conducted by the Director of Social Services and the Assistant Director of Social Services. 8. Review of the BIMS roster revealed on 04/22/15 a total of forty-five (45) of a one hundred and eighteen census (118) had BIMS scores less than eight (8). Review of the forty-five (45) skin assessment revealed all of these residents had skin assessments completed by the Assistant Director of Nursing, Staff Development, and Director of Nursing on 04/15/15 thru 04/17/15. Review of the spread sheet to document the phone calls revealed the Director of Social Services and the Assistant Director of Social Services, Medical Records Nurse and Staff Development made forty-five (45) attempts to contact responsible parties for abuse concerns. Thirty (30) of the forty-five (45) responsible parties were contacted with no voiced concerns of abuse. Interviews, on 04/22/15 with four (4) random responsible parties for Unsampled Resident J at 1:40 PM; at 1:43 PM for Unsampled Resident K; at 1:45 PM for Unsampled Resident L, and at 1:48 PM for Unsampled Resident M, verified they were called by the facility and they voiced no concerns related to abuse. 9. Review of the Resident Council Minutes, revealed on 04/17/15 at 5:00 PM, a Special Resident Council Meeting was held by the ADM to discuss the allegation and the importance of reporting abuse and the action the facility would initiate to remedy the deficient practice. Interview with the Administrator, on 04/22/15 at 3:08 PM, revealed during the Special Resident Council meeting he explained the deficient practice (IJ), encouraged the Council to report any suspected abuse, and explained how the deficiency would be corrected. Interviews with Unsampled Resident C, on 04/22/15 at 2:25 PM, Unsampled Resident E, on 04/22/15 at 2:40 PM, and Unsampled Resident D, on 04/22/15 at 2:47 PM, revealed there was a Special Resident Council Meeting on 04/17/15 with the ADM to discuss the survey, abuse reporting, obligations to report abuse, and how to remedy the deficient practice. 10. A QAPI meeting was held on 04/15/15 to discuss the allegation, review the Abuse Policy, and the Medical Director reviewed Resident #10's chart with no orders given. Review of the QAPI meeting sign-in sheet revealed the following were present: Medical Director, Director of Social Services, Assistant Director of Social Services, Administrator in Training, DON, and the Administrator. Review of the medical record for Resident #10 revealed no new orders written related to the allegation of abuse. Interview with the ADM, on 04/22/15 at 2:25 PM, revealed in the QAPI meeting on 04/15/15, a summary of the alleged event was verbally presented to the QAPI team. The Abuse Policy, dated March 2013, was reviewed with no changes. The Medical Director reviewed the chart of Resident #10, no orders were written. Interview with the Medical Director, on 04/22/15 at 2:32 PM, revealed she attended the QAPI meeting with review of Resident #10's medical record and medications with no new orders, and they reviewed the Abuse Policy with no changes. The ADM reviewed the allegation event with the team. 11. Review of the Abuse in-service sign-in sheet lead by the Clinical Risk Manager and the Administrator, on 04/15/15 at 11:15 AM, revealed the Quality of Life Director, Assistant Social Services Director, Director of Social Services, Physical Therapy Assistant, and 200 Unit ADON who were present at the care plan meeting at the time Resident #10 made an allegation of physical abuse were in-serviced on the abuse policy. The Administrator in Training and Director of Nursing were also educated at this meeting. Interview with the Administrator, on 04/21/15 at 1:12 PM, revealed he and the Corporate Director of Clinical Risk Management immediately in-serviced the Quality of Life Director, Assistant Director of Social Services, Director of Social Services, Physical Therapy Assistant, and 200 Unit Assistant Director of Nursing who were present at the care plan meeting and also the Administrator in Training and Director of Nursing. Interview with the Clinical Risk Manager, on 04/21/15 at 2:40 PM, revealed she in-serviced the Administrator prior to him assisting with training on 04/15/15. Interview with the Quality of Life Director, on 04/21/15 at 3:30 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could state the reporting process. Interview with the Director of Social Services, on 04/21/15 at 3:34 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could state the reporting process. Interview with the Assistant Director of Social Services, on 04/21/15 at 3:49 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could stated the reporting process. 12. Review of the Abuse in-service sign-in sheet lead by Clinical Risk Manager on 04/15/15 revealed, Staff Developmemt, MDS nurses (#1 and #2), Maintenance Director, ADON's (100 and 300 units), Business Office Manager, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director Human Resources, Dining Services Manager, Rehabilitation Services Manager, and Medical Records were present in the training. Interviews on 04/21/15 revealed the following stated they were educated on 04/15/15; Staff Development at 2:15 PM; Dining Service Manager at 2:25 PM; Business Office Manager at 2:30 PM; MDS #2 at 2:50 PM; Maintenance Director at 2:55 PM; Respiratory Therapist at 2:58 PM; Human Resource Director at 3:00 PM; House Keeping Supervisor at 2:15 PM; 100 Unit ADON at 3:17 PM; Rehabilitation Manager at 3:19 PM; Admissions Director at 3:21 PM; Medical Records at 3:21 PM; and, the 300 Unit ADON at 3:45 PM. 13. On 04/15/15 thru 04/17/15 current staff were educated on the Abuse Policy. The educators were the Administrator, Director of Nursing, Assistant Director of Nurses (3), Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Staff Development, MDS (#1 and #2), Maintenance Director, Business Office Director, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director of Human Resources, Dining Services Manager, Rehabilitation Manager, Medical Records, Registered Nurse Supervisor, and Dietitian. Interviews on 04/21/15 revealed the following stated 100% of their staff was in-serviced on abuse: Administrator at 1:12 PM, Director of Social Services at 1:40 PM, Assistant Director of Social Services at 1:50 PM, MDS #1 at 1:55 PM, Chaplain 2:10 PM, Staff Development at 2:15 PM, Dining Services Manager at 2:25 PM, Business Office Manager at 2:30 PM, Quality of Life Director at 2:45 PM, MDS #2 at 2:50 PM, Maintenance Director at 2:55 PM, Respiratory Therapist at 2:58 PM, Human Resource Director at 3:00 PM, Director of Nursing at 3:10 PM, Housekeeping Director at 3:15 PM, 100 Unit ADON at 3:17 PM, Rehabilitation Manager at 3:19 PM, Admissions at 3:21 PM, Medical Records at 3:23 PM, 300 Unit ADON at 3:45 PM, ADON 200 unit at 3:48 PM, and, on 04/22/15 telephone interviews with the Dietitian at 9:40 AM and the Registered Nurse Supervisor at 10:00 AM. Interviews on 04/21/15 with PTA #1 at 1:30 PM; on 04/22/15 with LPN #7 at 10:05 AM; LPN #6 at 10:10 AM; RN #3 at 10:15 AM; CNA #11 at 10:30 AM; Dietary Aide #1 at 10:40 AM; SLP #1 at 10:45 AM; Housekeeper #3 at 10:50 AM; CNA #10 at 10:52 AM; CNA/CMT #9 at 10:55 AM; and, CNA #8 at 11:00 AM revealed they had all be trained on the Abuse policy and were able to voice their responsibility for reporting allegation of abuse to the Administrator. 14 Review of 166 post tests on 04/21/15 revealed all 166 of the facility staff members had abuse in-services and completed the post test. 15. Interview with Human Resources, on 04/22/15 at 3:50 PM, revealed there had been no new hires from 04/15/15 through 04/22/15. 16. Interview with the Administrator, on 04/22/15 at 3:39 PM, revealed all future Care Plan Meetings would have assigned staff Administrator, Director of Nursing, MDS (#1 and #2), or Administrator in Training at all meetings. Review of the Care Plan Conference Summary revealed there were three (3) Care Plan Meetings on 04/21/15. At the first meeting the DON and MDS #1 were present. MDS #1 was present at the second and third meetings. 17. Review of the Abuse Assessment and Skin Assessments, dated 04/21/15, revealed twenty (20) abuse assessments were completed for residents with BIMS scores of eight (8) to fifteen (15) by the Administrator in Training and five (5) skin assessments were completed for residents with a BIMS scores of zero (0) to eight (8) by the 100 Unit ADON. Interview on 04/22/15 with Resident #19 at 9:30 AM, Unsampled Resident N at 9:25 AM, Unsampled Resident O at 9:35 AM, Unsampled Resident Q at 9:55 AM, Unsampled Resident R at 10:00 AM, Unsampled Resident #S at 10:40 AM, Unsampled Resident #T at 10:50 AM, revealed staff had completed an abuse assessments. Interview with the ADM, on 04/22/15 at 3:49 PM, revealed the facility would complete weekly abuse assessments for 25% of the residents with a BIMS score eight (8) to fifteen (15) and 25% skin assessment for residents with BIMS scores of zero (0) to eight (8). 18. Review of the QAPI minutes, on 04/22/15, revealed the facility had a QAPI meeting on 04/22/15 and discussed the actions put in place to correct the deficient practice. The minutes reflected five (5) skin assessments were complete and twenty (20) abuse assessments were completed so far. Interview with the Administrator, on 04/22/15 3:49 PM, revealed weekly QAPI meetings would be held to track and trend any abuse concerns.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the staff reported and protected one (1) of twenty-seven (27) sampled residents, (Resident #10), when staff failed to report an allegation of physical abuse to the Administrator and residents were not protected from potential further abuse. On 04/14/15 the facility received an allegation from Resident #10 regarding physical abuse by Certified Nursing Assistant (CNA) #1 towards Resident #10. The allegation stated Resident #10 was present in a care plan meeting on 04/14/15 with the Director of Social Services, Assistant Director of Social Services, Director of Dietary, Chaplain, Quality of Life Director, Physical Therapy Assistant, Assistant Director of Nursing and two (2) family members when the resident stated CNA #1 threw him/her on the bed. Staff present at the meeting was aware of the requirements of the facility's Abuse Policy reporting guidelines; however, failed to report the allegation to the Director of Nursing or Administrator, and CNA #1 worked the evening shift (2:30 PM-10:30 PM) on 04/14/15 on the resident's unit. The facility's failure to report and allegation of abuse and to protect residents from potential abuse after an allegation of abuse was reported to staff placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 04/16/15 and determined to exist on 04/14/15. The facility was notified of the Immediate Jeopardy on 04/16/15. The facility provided an acceptable Allegation of Compliance (AOC) on 04/17/15 which alleged removal of the Immediate Jeopardy on 04/18/15. The State Survey Agency verified Immediate Jeopardy was removed on 04/18/15 as alleged prior to exit. The scope and severity was lowered to a "D" in 42 CFR 483.13 Resident Behavior and Facility Practices (F225) while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's Abuse Policy, dated April 2013, revealed all allegations of abuse were to be reported immediately. Residents and families would be educated on signs of abuse and the reporting process. The name and phone numbers of reporting agencies would be posted. All abuse allegations would be investigated. Social Services and the Chaplain would follow up with the resident to monitor their emotional well-being. Review of the clinical record of Resident #1 revealed the facility admitted the resident on 08/27/14 with [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) on 09/03/14 and assessed the resident using a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) out of fifteen (15), which meant the resident was interviewable. Interview with Resident #10, on 04/15/15 at 9:45 AM, revealed on 04/14/15 during the resident's Care Plan Meeting, he/she reported CNA #1 threw the resident on the bed after the resident's shower on 04/11/15. On 04/15/15, following the resident interview at 9:45 AM, the Administrator was immediately notified by the State Survey Agency of the allegation of physical abuse alleged by Resident #10. The Administrator stated he had no knowledge of the allegation until it was reported to him by a State Surveyor. Upon notification CNA #1 was suspended immediately by the Director of Nursing (DON) and the investigation was initiated by the Administrator and DSS. Review of the facility's investigation, dated 04/15/15, revealed Resident #10 alleged that after the resident's shower, CNA #1 threw him/her in to the bed and he/she did not want to go. The resident stated the CNA stood him/her up and put him/her in bed on the resident's stroke side. The resident denied any injury and stated he/she did not hurt anywhere from the incident. The staff attending the Care Plan Meeting were interviewed as well as the alleged perpetrator. It further revealed the CNA was suspended by the DON, and the resident was interviewed during the skin assessment to determine any injury. The facility unsubstantiated the allegation. Neither the facility nor the State Survey Agency could verify the date the alleged allegation occurred based on the facility's staffing schedule and ADL schedule. Interviews with the Care Plan Team, on 04/15/15 at 10:25 AM with the Director of Social Services (DSS); at 10:35 AM with the Assistant Director of Social Services Director (ASSD); at 10:40 AM with the 200 Unit Assistant Director of Nursing (ADON); at 2:25 PM with the Dietary Director (DD); at 2:30 PM with the Quality of Life Director (QLD); at 2:50 PM with the Physical Therapy Assistant (PTA); via telephone, on 04/20/15 at 2:40 PM, with Family Member #1; and, on 04/21/15 at 8:20 AM, with Family Member #2 revealed they were all present at the Care Plan meeting and heard Resident #10 state CNA #1 threw him/her on the bed. In addition, staff members and family members revealed during their interviews, the Administrator had not been notified of the allegation because the ADON stated during the meeting she would take care of it; however, the ADON did not notify the Director of Nursing or Administrator, who were in the facility at the time. Interview with the 200 Unit ADON, on 04/15/15 at 3:05 PM, revealed the resident reported CNA #1 threw the resident onto the bed after a shower on Saturday. She further stated the report was received during the care plan meeting on 04/14/15 but she did not report it to the Administrator or DON on 04/14/15 before she left the building for the night. She stated she should have reported the allegation to ensure resident safety before she left the building. Per interview, she had to leave for an appointment and could not stay to report the allegation. A second interview with the 200 Unit ADON, on 04/15/15 at 4:20 PM, revealed she sent a text message to the DON, on 04/14/15 at 6:26 PM, telling him they needed to set-up a meeting with the CNA and Resident #10 due to a complaint made during the care plan meeting. However, the message did not include there was an allegation of physical abuse. However, the DON did not respond to the text. Interview with the DON, on 04/15/15 at 10:20 AM, revealed he confirmed he did not respond to the text message; however did not explain as to why. Review of both cell phone messages provided by the staff during survey revealed, the ADON and DON both had the text messages, dated 04/14/15, timed at 6:26 PM, present on their cell phones, which stated, "See if you can set up a meeting with me, CNA #1, Resident #10 and his/her family had a complaint against him today in the care plan meeting". Review of the staffing schedule, dated 04/14/14, revealed CNA #1 worked 2:30 PM until 10:30 PM on the 200 Unit where Resident #10 resided, after the allegation was made in the care plan meeting. Interview with the Administrator, on 04/15/15 at 5:00 PM, revealed he was made aware of the abuse allegation by the survey team, Resident #10 reported to the care plan team, that CNA #1 threw him/her on the bed. Statements were taken from the staff in attendance at the care plan meeting. Interviews were completed with the residents. He further stated the staff should have reported the allegation to him, and further stated by leaving the CNA in the building to work placed all the residents at risk for abuse. The facility took the following actions to remove the Immediate Jeopardy as follows: 1. The resident's family was aware of the allegation made by the resident as they attended the care plan meeting when the allegation was made on 04/14/15. 2. The resident's Physician/Medical Director was notified of the allegation on 04/15/15 by the DON, with no injury identified. 3. The DON assessed the resident for injury on 04/15/15. 4. An investigation was initiated on 04/15/15 when the Administrator was notified. Regulating agencies were notified Office of the Inspector General (OIG) and Adult Protective Services (APS). The investigation was concluded and unsubstantiated on 04/16/15 and a follow-up report was sent to OIG. 5. The DON suspended CNA #1 on 04/15/15 at 12:18 PM. 6. The Administrator interviewed Resident #10, on 04/15/15 at 12:15 PM. 7. On 04/15/15, 04/16/15, and 04/17/15 Staff assigned to complete resident interviews were the Director of Social Services, Assistant Director of Social Services, and the Transitional Care Nurse/Staff Development. An Abaqis tool (a Quality Assurance tool) was used to interview seventy-three (73) residents with BIMS scores eight (8) to fifteen (15) regarding abuse and choices. 8. On 04/15/15, 04/16/15, and 04/17/15 forty-five (45) residents with BIMS scores zero (0) to eight (8) had skin assessments completed to observe for signs of abuse, there were no signs of abuse identified. The skin assessments were completed by the Director of Nursing, Assistant Director of Nursing, and Staff Development. The Director of Social Services and Assistant Director of Social Services, Medical Records Nurse and Staff Development made forty-five (45) calls to responsible parties of residents with BIMS of eight (8) or less, contact was made with thirty (30) responsible parties who voiced no care concerns. 9. On 04/17/15 a Resident Council Meeting was held by the Administrator to discuss abuse reporting, the facility's obligation to report, and how the facility would remedy the deficient practice. 10. On 04/15/15 a Quality Assurance Performance Improvement (QAPI) Committee meeting was held, in attendance: Medical Director, Director of Nursing, Administrator, Director of Social Services, Assistant Director of Social Services, and the Administrator in Training discussed the alleged event, reviewed the abuse Policy (no changes), and the Medical Director reviewed Resident #10's chart with no orders. 11. On 04/15/15 at 11:15 AM, immediate education was provided to the Administrator regarding the Abuse policy, by the Clinical Risk Manager. Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Physical Therapy Assistant, Assistant Director of Nursing (3), Director of Nursing, and Administrator in Training received training by the Clinical Risk Manager and the Administrator regarding the Abuse Policy. 12. On 04/15/15 at 12:45 PM, the Abuse Policy was used by the Clinical Risk Manager to educate the following: Minimum Data Assessment Nurses (2), Maintenance Director, Assistant Director of Nurses (3), Business Office manager, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director of Human Resources, the Dining Services Director, Transitional Care Nurse/Staff Development, Rehabilitation Services Manager, and Medical Records. 13. Education was provided by the Administrator, Director of Nursing, Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Assistant Director of Nursings (3), Staff Development, Medical Director, Business Office Manager, Administrator, Housekeeping, Chaplain, Respiratory Therapist, Human Resources, Dietary Manager, Rehabilitation Manager, Medical Records, Dietitian, and RN Supervisor, on 04/15/15 thru 04/17/15 to the current staff. The current staff totaled one hundred and sixty-three (163) out of one hundred and sixty-six (166) employees on the Abuse Policy. 14. Post education tests were provided and graded by the Administrator, Director of Nursing, Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Assistant Director of Nursing (3), Staff Development, Medical Director, Business Office Manager, Admissions, Housekeeping, Chaplain, Respiratory Therapist, Human Resources, Dietary Manager, Rehabilitation Manager, Medical Records, Dietitian, and RN Supervisor after education was completed by all staff. Staff on vacation or leave of absence would not be allowed to work until abuse education was completed. 15. The Staff Development would educate all new hires on abuse prior to starting their department orientation. 16. Effective 04/17/15 all Care Plan Meetings would be attended by the Administrator, Administrator in Training, Director of Nursing, or one of the two (2) MDS nurses. The next Care Plan Meeting is 04/21/15. Assigned staff will monitor feed back from residents and families. 17. Beginning 04/21/15, once a week 25% of residents with BIMS scores eight (8) or greater will be interviewed by the department head or interdisciplinary team regarding abuse. Also, 25% of residents with BIMS scores of below eight (8) will have skin assessments completed by nursing management. 18. There will be weekly QAPI meetings to review trending data with interviews, assessment and Care Plan Meetings, beginning 04/21/15. The State Survey Agency validated the removal of the Immediate Jeopardy on 04/23/15 prior to exit as follows: 1. Interview with Family Member #1, on 04/20/15 at 2:40 PM, revealed he/she was present in the Care Plan meeting, heard the allegation and confirmed this knowledge with the facility. Interview with Family Member #2, on 04/21/15 at 8:20 AM, revealed he/she was present in the Care Plan meeting and did not hear the allegation. 2. Interview with the Medical Director, on 04/15/15 at 1:15 PM, revealed she was notified of the abuse allegation by the Administrator and DON on 04/15/15 at 9:50 PM. 3. Interview, on 04/15/15 at 10:02 AM, and review of the skin assessment, revealed the DON assessed Resident #10 for possible injuries related to the allegation. The assessment was documented on a CNA Skin Care Sheet. No injuries were found. 4. Interview with the Administrator, on 04/15/15 at 1:41 PM, and review of the facility's notification to OIG and APS by fax revealed the allegation of abuse was reported and the investigation was initiated by the Administrator. On 04/16/15 at 7:32 PM a follow-up report of a completed investigation was faxed to OIG and APS. 5. Review of the Stakeholder Suspension Form, dated 04/15/15, revealed on 04/15/15 CNA #1 was suspended per a conference call by the DON. The Stakeholder Suspension Form was witnessed by the DON, HR, and ADM. 6. Interview with the ADM, on 04/21/15 at 1:30 PM, revealed he met with Resident #10 on 04/15/15 at 12:15 PM and he/she confirmed during the Care Plan meeting he/she stated CNA #1 threw him/her on the bed on 04/11/15. 7. Review of seventy-three (73) interview forms revealed on 04/15/15 thru 04/17/15 Abuse interviews were completed with seventy-three (73) residents with BIMS scores eight (8) to fifteen (15). Interviews with two (2) unsampled residents, Unsampled Resident A on 04/21/15 at 9:38 AM, Unsampled Resident B on 04/21/15 at 9:46 AM, and on 04/21/15 at 10:15 AM with Resident #10, revealed resident abuse interviews were conducted by the Director of Social Services and the Assistant Director of Social Services. 8. Review of the BIMS roster revealed on 04/22/15 a total of forty-five (45) of a one hundred and eighteen census (118) had BIMS scores less than eight (8). Review of the forty-five (45) skin assessment revealed all of these residents had skin assessments completed by the Assistant Director of Nursing, Staff Development, and Director of Nursing on 04/15/15 thru 04/17/15. Review of the spread sheet to document the phone calls revealed the Director of Social Services and the Assistant Director of Social Services, Medical Records Nurse and Staff Development made forty-five (45) attempts to contact responsible parties for abuse concerns. Thirty (30) of the forty-five (45) responsible parties were contacted with no voiced concerns of abuse. Interviews, on 04/22/15 with four (4) random responsible parties for Unsampled Resident J at 1:40 PM; at 1:43 PM for Unsampled Resident K; at 1:45 PM for Unsampled Resident L, and at 1:48 PM for Unsampled Resident M, verified they were called by the facility and they voiced no concerns related to abuse. 9. Review of the Resident Council Minutes, revealed on 04/17/15 at 5:00 PM, a Special Resident Council Meeting was held by the ADM to discuss the allegation and the importance of reporting abuse and the action the facility would initiate to remedy the deficient practice. Interview with the Administrator, on 04/22/15 at 3:08 PM, revealed during the Special Resident Council meeting he explained the deficient practice (IJ), encouraged the Council to report any suspected abuse, and explained how the deficiency would be corrected. Interviews with Unsampled Resident C, on 04/22/15 at 2:25 PM, Unsampled Resident E, on 04/22/15 at 2:40 PM, and Unsampled Resident D, on 04/22/15 at 2:47 PM, revealed there was a Special Resident Council Meeting on 04/17/15 with the ADM to discuss the survey, abuse reporting, obligations to report abuse, and how to remedy the deficient practice. 10. A QAPI meeting was held on 04/15/15 to discuss the allegation, review the Abuse Policy, and the Medical Director reviewed Resident #10's chart with no orders given. Review of the QAPI meeting sign-in sheet revealed the following were present: Medical Director, Director of Social Services, Assistant Director of Social Services, Administrator in Training, DON, and the Administrator. Review of the medical record for Resident #10 revealed no new orders written related to the allegation of abuse. Interview with the ADM, on 04/22/15 at 2:25 PM, revealed in the QAPI meeting on 04/15/15, a summary of the alleged event was verbally presented to the QAPI team. The Abuse Policy, dated March 2013, was reviewed with no changes. The Medical Director reviewed the chart of Resident #10, no orders were written. Interview with the Medical Director, on 04/22/15 at 2:32 PM, revealed she attended the QAPI meeting with review of Resident #10's medical record and medications with no new orders, and they reviewed the Abuse Policy with no changes. The ADM reviewed the allegation event with the team. 11. Review of the Abuse in-service sign-in sheet lead by the Clinical Risk Manager and the Administrator, on 04/15/15 at 11:15 AM, revealed the Quality of Life Director, Assistant Social Services Director, Director of Social Services, Physical Therapy Assistant, and 200 Unit ADON who were present at the care plan meeting at the time Resident #10 made an allegation of physical abuse were in-serviced on the abuse policy. The Administrator in Training and Director of Nursing were also educated at this meeting. Interview with the Administrator, on 04/21/15 at 1:12 PM, revealed he and the Corporate Director of Clinical Risk Management immediately in-serviced the Quality of Life Director, Assistant Director of Social Services, Director of Social Services, Physical Therapy Assistant, and 200 Unit Assistant Director of Nursing who were present at the care plan meeting and also the Administrator in Training and Director of Nursing. Interview with the Clinical Risk Manager, on 04/21/15 at 2:40 PM, revealed she in-serviced the Administrator prior to him assisting with training on 04/15/15. Interview with the Quality of Life Director, on 04/21/15 at 3:30 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could state the reporting process. Interview with the Director of Social Services, on 04/21/15 at 3:34 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could state the reporting process. Interview with the Assistant Director of Social Services, on 04/21/15 at 3:49 PM, revealed she was trained by the Administrator and Clinical Risk Manager and could stated the reporting process. 12. Review of the Abuse in-service sign-in sheet lead by Clinical Risk Manager on 04/15/15 revealed, Staff Developmemt, MDS nurses (#1 and #2), Maintenance Director, ADON's (100 and 300 units), Business Office Manager, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director Human Resources, Dining Services Manager, Rehabilitation Services Manager, and Medical Records were present in the training. Interviews on 04/21/15 revealed the following stated they were educated on 04/15/15; Staff Development at 2:15 PM; Dining Service Manager at 2:25 PM; Business Office Manager at 2:30 PM; MDS #2 at 2:50 PM; Maintenance Director at 2:55 PM; Respiratory Therapist at 2:58 PM; Human Resource Director at 3:00 PM; House Keeping Supervisor at 2:15 PM; 100 Unit ADON at 3:17 PM; Rehabilitation Manager at 3:19 PM; Admissions Director at 3:21 PM; Medical Records at 3:21 PM; and, the 300 Unit ADON at 3:45 PM. 13. On 04/15/15 thru 04/17/15 current staff were educated on the Abuse Policy. The educators were the Administrator, Director of Nursing, Assistant Director of Nurses (3), Director of Social Services, Assistant Director of Social Services, Quality of Life Director, Staff Development, MDS (#1 and #2), Maintenance Director, Business Office Director, Admissions, Housekeeping Manager, Chaplain, Respiratory Therapist, Director of Human Resources, Dining Services Manager, Rehabilitation Manager, Medical Records, Registered Nurse Supervisor, and Dietitian. Interviews on 04/21/15 revealed the following stated 100% of their staff was in-serviced on abuse: Administrator at 1:12 PM, Director of Social Services at 1:40 PM, Assistant Director of Social Services at 1:50 PM, MDS #1 at 1:55 PM, Chaplain 2:10 PM, Staff Development at 2:15 PM, Dining Services Manager at 2:25 PM, Business Office Manager at 2:30 PM, Quality of Life Director at 2:45 PM, MDS #2 at 2:50 PM, Maintenance Director at 2:55 PM, Respiratory Therapist at 2:58 PM, Human Resource Director at 3:00 PM, Director of Nursing at 3:10 PM, Housekeeping Director at 3:15 PM, 100 Unit ADON at 3:17 PM, Rehabilitation Manager at 3:19 PM, Admissions at 3:21 PM, Medical Records at 3:23 PM, 300 Unit ADON at 3:45 PM, ADON 200 unit at 3:48 PM, and, on 04/22/15 telephone interviews with the Dietitian at 9:40 AM and the Registered Nurse Supervisor at 10:00 AM. Interviews on 04/21/15 with PTA #1 at 1:30 PM; on 04/22/15 with LPN #7 at 10:05 AM; LPN #6 at 10:10 AM; RN #3 at 10:15 AM; CNA #11 at 10:30 AM; Dietary Aide #1 at 10:40 AM; SLP #1 at 10:45 AM; Housekeeper #3 at 10:50 AM; CNA #10 at 10:52 AM; CNA/CMT #9 at 10:55 AM; and, CNA #8 at 11:00 AM revealed they had all be trained on the Abuse policy and were able to voice their responsibility for reporting allegation of abuse to the Administrator. 14 Review of 166 post tests on 04/21/15 revealed all 166 of the facility staff members had abuse in-services and completed the post test. 15. Interview with Human Resources, on 04/22/15 at 3:50 PM, revealed there had been no new hires from 04/15/15 through 04/22/15. 16. Interview with the Administrator, on 04/22/15 at 3:39 PM, revealed all future Care Plan Meetings would have assigned staff Administrator, Director of Nursing, MDS (#1 and #2), or Administrator in Training at all meetings. Review of the Care Plan Conference Summary revealed there were three (3) Care Plan Meetings on 04/21/15. At the first meeting the DON and MDS #1 were present. MDS #1 was present at the second and third meetings. 17. Review of the Abuse Assessment and Skin Assessments, dated 04/21/15, revealed twenty (20) abuse assessments were completed for residents with BIMS scores of eight (8) to fifteen (15) by the Administrator in Training and five (5) skin assessments were completed for residents with a BIMS scores of zero (0) to eight (8) by the 100 Unit ADON. Interview on 04/22/15 with Resident #19 at 9:30 AM, Unsampled Resident N at 9:25 AM, Unsampled Resident O at 9:35 AM, Unsampled Resident Q at 9:55 AM, Unsampled Resident R at 10:00 AM, Unsampled Resident #S at 10:40 AM, Unsampled Resident #T at 10:50 AM, revealed staff had completed an abuse assessments. Interview with the ADM, on 04/22/15 at 3:49 PM, revealed the facility would complete weekly abuse assessments for 25% of the residents with a BIMS score eight (8) to fifteen (15) and 25% skin assessment for residents with BIMS scores of zero (0) to eight (8). 18. Review of the QAPI minutes, on 04/22/15, revealed the facility had a QAPI meeting on 04/22/15 and discussed the actions put in place to correct the deficient practice. The minutes reflected five (5) skin assessments were complete and twenty (20) abuse assessments were completed so far. Interview with the Administrator, on 04/22/15 3:49 PM, revealed weekly QAPI meetings would be held to track and trend any abuse concerns.

Based on observation, interview, record review, and review of the facility's investigation, policy and procedures, and video surveillance it was determined the facility failed to have an effective system in place to ensure supervision of residents at risk for elopement. This failure affected one (1) of three (3) residents identified at risk for elopement out of the seven (7) sampled residents, (Resident #1). On 09/19/14 at 6:44 PM, Resident #1 exited the facility without staff knowledge. Interview and review of the facility's video surveillance revealed Resident #1 was near the exit door to the 100 Unit when staff entered the code to the exit door for two visitors to leave the facility, and Resident #1 exited the facility with the two (2) visitors. At approximately 6:52 PM, the Maintenance Director was returning to the facility and saw Resident #1 on the sidewalk of the two (2) lane street moving towards the intersection of a six (6) lane street. The Maintenance Director stopped to retrieve the resident when he saw the resident with Certified Occupational Therapy Assistant (COTA) #1. The Maintenance Director returned to the facility and called a Code Green to alert staff of the elopement of Resident #1. Staff was not aware Resident #1 had eloped until the code was called. The resident was returned to the facility at 6:58 PM and assessed with [REDACTED]. The facility's failure to ensure appropriate supervision of residents at elopement risk placed Resident #1 and other residents at risk in a situation that has caused or is likely to cause serious injury, harm, impairment or even death to a resident. The Immediate Jeopardy was identified 09/25/14 and determined to exist on 09/19/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance (AOC) on 09/30/14 that alleged removal of Immediate Jeopardy on 09/23/14. However, the State Survey Agency verified Immediate Jeopardy was removed on 10/03/14, after training of facility staff was verified completed on 10/02/14, at 42 CFR 483.25 Quality of Care (F323) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy titled Safety and Supervision of Residents, revised December 2007, revealed resident supervision was a core component of the systems approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Unsafe wandering was identified as a resident risk and environmental hazard. Review of the facility's policy titled Elopement/Wandering Residents, effective December 2010, revealed it was the intent of the facility to determine which residents had significant wandering behavior and enhance staff awareness as well as educate them on how to deal with such residents. Any resident displaying significant wandering behavior would be assessed for elopement/wandering risk and care planned appropriately. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of a four (4). The resident's functional status for mobility was assessed by the facility as non-ambulatory and requiring supervision on the unit and independent off the unit once in the electric wheelchair. Review of Resident #1's Elopement Risk Assessments dated 05/27/11, 07/08/13, 09/24/13, 10/30/13, and 01/06/14 revealed the facility assessed the resident wandered aimlessly; would leave the facility without informing staff; and, verbally expressed the desire to go home or stay near a exit door. Review of the Elopement Assessments, dated 05/30/14, 06/11/14, and 09/05/14, revealed the facility assessed Resident #1 had the ability to exit the building and was at risk for elopement. Review of the elopement risk/exit seeking care plan, initiated on 04/12/13 and last reviewed on 09/04/14, revealed the resident wandered the facility in his/her wheelchair and would often gravitate to exit doors. The interventions were to monitor for tail gaiting when visitors were in the building; use verbal and physical cues for redirection; diversional activities for exit seeking behavior; picture in elopement binder; and to monitor resident per facility policy. Review of the care plan meeting, dated 02/28/14, revealed Resident #1 had been identified as having exit seeking behaviors. Review of the care plan note, dated 09/04/14, revealed Resident #1's exiting seeking behaviors were because he/she wanted his/her spouse. Review of the facility's investigation revealed Resident #1 exited the 100 Unit door, on 09/19/14 at 6:44 PM, with a male family member and a phlebotomist technician when Certified Nursing Assistant (CNA) #3 entered the exit door code. The Maintenance Director was returning to the facility at approximately 6:52 PM when he observed Resident #1 in his/her electric wheelchair (w/c) on the sidewalk down the street from the facility. He parked his vehicle and saw COTA #1 with the resident. The Maintenance Director proceeded to the facility and called a Code Green and then went to Resident #1 and the COTA. The resident was returned to the facility at approximately 6:58 PM without injury. Observations, on 09/24/14 at 8:10 AM, of the route taken by Resident #1 upon exit from the facility revealed when the resident exited the facility property he/she propelled his/her electric wheelchair onto the sidewalk located at the right side of the facility front parking lot. This placed the resident parallel to the frontage road heading towards the intersection of a main road with six (6) lanes and a speed limit of forty-five (45) miles per hour. There was a traffic light at the intersection. Interview with the Maintenance Director, on 09/24/14 at 8:18 AM, revealed he was returning to the facility at approximately 6:44 PM on 09/19/14 when he saw Resident #1 on the sidewalk in an electric wheelchair rolling towards the busy main road. He parked his truck and began to walk towards the resident when he saw the COTA with the resident. He then got back in his truck continued to the facility, and once he entered the facility, he called a Code Green. Per interview, staff was not aware Resident #1 had eloped until the code was called. He estimated the resident was approximately 75 yards from the entrance to the facility's property. Driving measurement to the location was a tenth (10th) of a mile from the facility. Interview with COTA #1, on 09/25/14 at 6:50 PM, revealed as she left work and took a right onto the two lane road, the resident was in the electric wheelchair moving slowly. She stated she started to call her boss when the resident came to her with no problem. She started to push the resident when Maintenance arrived. She revealed the battery on the resident's chair was running down. She got the resident to her car and back to the facility. Observations during a facility tour, on 09/24/14 at 8:10 AM, revealed the facility had entrance doors at the main entrance, which had a vestibule, on the 100 Unit that had a vestibule also, and on the 300 Unit. The 200 Unit only had emergency exit doors. Each of the exit doors including the emergency exits had exit code panels. An exit door located in the main dining room had an exit code panel allowing access to the smoking patio which was a fenced area. In addition, each exit door on a window panel next to the door had a sign which read: "Please see a nurse before assisting any visitor out of the building." Each of the exit doors except on the 200 Unit had cameras. Review of the facility's video surveillance of the exit doors on the 100 Unit hallway revealed the inner door being pushed by Resident #1 in an electric wheelchair with his/her left hand on the door in front of a male visitor with the visitor's left hand on the door behind Resident #1's. They both appeared to be pushing the door at the same time. Once the resident and the now visualized male visitor entered the vestibule between the inside and outside door a third person, a female, was seen entering the vestibule before the outside exit door. The male visitor, once the inner door had been cleared, walked past Resident #1 and held open the outside door, allowing Resident #1 access to the outside into the parking area. After Resident #1 exited the facility he/she was not seen any more, time stamped on the video was 6:44 PM. The video did not show any staff in the area. Interview with Family Member #1, on 09/24/14 at 4:25 PM, revealed he had been at the facility visiting a relative. When he went to the 100 Unit exit door, Resident #1 was sitting in front of the door in his/her electric wheelchair. He stated he had asked a female who he thought was a staff member if she could open the door for him. However, she did not work for the facility. She joined him at the door and they stood behind Resident #1. When the staff member who was passing in the hallway punched the exit code Resident #1 pushed the unlocked inside door. He stated he did walk around Resident #1 and held the outside door open for him/her to exit. He did not think this was inappropriate since the facility staff member had punched the code with Resident #1 sitting in front of the locked door. He stated during his visits to the facility, persons he thought were residents were always entering and exiting the facility through the 100 Unit hallway doors. Interview on 09/25/14 at 9:20 AM, with the Phlebotomist who was identified as the female at the door with the visitor, revealed she had been at the facility obtaining laboratory specimens when a male visitor approached her and asked if she could open the 100 Unit exit door. She replied she could not open the door and joined him in front of the door, both of them standing behind Resident #1 who was sitting in front of the door. She further stated when the facility staff member punched in the door exit code, Resident #1 was the first person to exit into the vestibule before exiting the outside door. She further stated she was at the facility several times a week and there were always residents entering and exiting the facility from the 100 Unit hallway door. She had had no concerns related to Resident #1 exiting the facility for that reason. Interview with Certified Nursing Assistant (CNA) #3, on 09/24/14 at 11:30 PM, revealed she entered the exit code disarming the alarm on the 100 Unit exit door on the evening of 09/19/14. She further stated she did not see Resident #1 at the door when she deactivated the alarm and walked away. Interview with CNA #7, on 09/30/14 at 9:12 AM, revealed she was aware Resident #1 had been at risk for elopement prior to the elopement on 09/19/14. She indicated Resident #1 liked to go to the 100 Unit doors and believed the resident wanted to leave the facility. The aide indicated the resident's spouse would frequently visit and took Resident #1 outside. Additionally, the aide stated Resident #1 would only attempt to leave the facility through the 100 Unit doors. She indicated only staff had the door code and a staff member would have had to enter the code that allowed the resident to elope. The CNA further indicated staff were responsible to supervise residents, even if the visiting family were present. Interview with Registered Nurse (RN) #2, on 09/24/14 at 3:10 PM, revealed Resident #1 was constantly roaming the facility. He/she was seen approaching the exit doors. To his knowledge Resident #1 had not pushed on a door, but he acknowledged if a door was open Resident #1 was likely to go through it. Interview with COTA #1, on 09/25/14 at 4:24 PM, revealed Resident #1, constantly, during waking hours, roamed the facility and frequently sat in front of exit doors. Interview, on 09/29/14 at 3:05 PM, with RN #5 revealed a resident was at risk for elopement if the resident frequently sat at the doors, and stated he/she wanted to go home, what was the resident BIMS score, and if the resident was confused. She stated Resident #1 had a history of [REDACTED]. The nurse indicated Resident #1 was at risk for elopement due to his/her level of cognition. She stated if a resident with cognitive impairment left the facility the resident was at risk for an accident. The RN indicated only staff members had the exit door code, and family or visitors were not given the codes. The nurse further indicated a staff member would have had to enter the door code in order for Resident #1 to have exited the facility. On 09/29/14 at 3:44 PM, interview with the Activities Director (AD) revealed Resident #1 enjoyed looking out of the windows and doors. She stated the resident would ask for his/her spouse often and looked out of the 100 Unit door often for him/her. The AD indicated Resident #1 would go through any open door. She further indicated Resident #1 had eloped due to the resident left the facility unsupervised. The AD stated if a resident eloped, horrible things could happen to the resident or the resident could be hit by a car. She indicated all staff were responsible to supervise residents and visitors were not responsible for supervision of residents. On 09/29/14 at 2:31 PM, interview with the Therapy Director revealed it was unsafe for Resident #1 to leave the facility unsupervised. She stated he/she could have come across uneven terrain in the wheelchair, or among the vehicles driving down the street. The Therapy Director indicated the resident eloped as he/she had left the facility without staff knowledge and was cognitively impaired. She further indicated a resident that was cognitively impaired and left the facility without staff knowledge could be injured or killed. Interview with the Director of Nursing (DON), on 09/24/14 at 1:26 PM, revealed Resident #1 was constantly roaming the facility and he/she liked to sit in front of the exit door on the 100 Unit. She did not consider the behavior exit seeking, but stated Resident #1 would go through any opened door. Interview with the Administrator (ADM), on 09/24/14 at 1:30 PM, revealed when he interviewed CNA #3, she stated she did not see Resident #1 when she deactivated the 100 Unit door alarm. The ADM was aware Resident #1's left hand was seen on the video in front of the visitors. The ADM stated Resident #1 was constantly propelling his electric wheelchair to all areas of the facility, but to his knowledge he had never pushed a door open. He also acknowledged Resident #1 would go through any opened door. Interview and record review revealed the resident had exhibited exit seeking behaviors in March 2014. Interview with Licensed Practical Nurse (LPN) #2, on 09/25/14 at 10:00 AM, revealed she had placed Resident #1 on every fifteen (15) minute observations on 03/15/14 for agitation and exit seeking. The resident had been overheard to ask persons to let him/her out of the building. However, she felt ongoing observations of the resident were not necessary. Interview with RN #3, on 09/25/14 at 10:05 AM, revealed on 03/18/18 she had placed Resident #1 on every thirty (30) minute observations for agitation and exit seeking. However, she felt no other interventions were needed. Interview, on 09/26/14 at 3:02 PM, with the Social Services Director (SSD) revealed on 03/15/14 Resident #1 had exhibited exit seeking behavior in the past and had been sitting by a locked door in March 2014. She stated the resident's care plan was updated at that time with intervention of fifteen (15) minute checks for two (2) days, with no additional interventions added. She indicated the resident exhibited exit seeking behaviors often and roamed throughout the facility. Further interview with the DON, on 10/01/14 at 8:56 AM, revealed she had viewed the video of Resident #1's elopement on 09/19/14. She indicated she was unsure who had entered the exit door code as that portion of the doorway was not visible in the video. She stated visitors and residents were not given the exit door code and the root cause of Resident #1's elopement was determined the CNA had entered the door code and then left the area without ensuring the area was secured. The DON stated if the aide had stayed at the exit door until the door was closed the resident might not have eloped. She indicated the aide was distracted when she entered the door code that allowed Resident #1 and the visitors to exit the facility. She further stated if staff entered the door code and did not stay at the door, then any resident with the physical capability to exit the door would be able to leave the facility. She stated if staff remained at the door until the door was closed, then residents would not be able to exit. Further interview with the Administrator, on 10/01/14 at 10:42 AM, revealed the root cause of Resident #1's elopement determined the CNA had entered the door code at the exit door and did not stay at the door to ensure the door was secured. He stated visitors were not responsible to supervise residents. The Administrator stated he was aware of Resident #1's previous exit seeking behaviors as the resident would go to the exit doors. He indicated a resident determined at risk of elopement would have poor safety awareness or poor judgment. He further indicated if a resident at risk for elopement left the facility the resident could get lost or hit by a car. The facility provided an Allegation of Compliance (AOC) on 09/30/14 alleging the Immediate Jeopardy was removed on 09/23/14; however, the State Survey Agency verified that staff training was completed on 10/02/14. The facility took the following immediate steps to remove the Immediate Jeopardy: 1. At approximately 6:52 PM on 09/19/14, a COTA immediately went to the resident and assured his/her safety by observing for any obvious signs of injury and staying with him/her until another staff member arrived. The Maintenance Director went back to the facility to notify staff and activate the elopement protocols. All other residents were accounted for during the head count. Maintenance Director returned to assist the COTA and Resident #1 was returned to the facility at 6:58 PM. 2. A skin assessment and vital signs were completed by Resident #1's LPN and were within normal limits. Assessment did not reveal any signs of injury or trauma. 3. Resident #1's husband/wife was contacted by the LPN on 09/19/14 to inform him/her that his/her spouse had exited the facility. Physician and facility Medical Director was notified by the Director of Nursing (DON) on 09/19/14 of the event. 4. Upon review of the security camera footage by the Administrator and DON on 09/19/14, it was determined that Resident #1 was helped outside by a visiting family member. The visitor was called by the DON, on 09/19/14 and asked him about the incident. The visitor stated that he did hold the door for the resident to exit, but he was unaware the resident was not able to exit without staff assistance. Education was also provided to the family member regarding assisting residents outside of secured doors. 5. Information from the interview with visitor also identified the CNA that entered the code to release the maglock. The CNA was interviewed by the Administrator on 09/19/14 and education on elopement policy and procedures provided by the DON on 09/19/14. This education included staying observant of the surrounding area to ensure no resident exited when assisting a visitor in or out of the door. 6. A review of the Elopement books were completed on 09/19/14, by the DON and Staff Development Coordinator (SDC) to ensure the elopement risk forms for each resident identified at risk for elopement were accurate. Three (3) total residents were reviewed. 7. On 09/19/14, the Maintenance Director and Maintenance Assistant checked all exterior doors for proper function with no issues identified. Proper signage was in place at all doors. The sign read "Visitors: Please see a nurse before assisting any resident out of the facility." 8. On 09/19/14, the Administrator called in the door vendor to check overall operation of all exterior doors with no issues identified. This inspection was completed on 09/19/14. 9. An ADHOC-QAPI meeting regarding resident's elopement and plan of care that included MDS, Director of Nursing, Administrator, Social Services, Staff Development Coordinator and Medical Director occurred on 09/19/14. Resident's care plan was updated to reflect new interventions. Each resident was discussed to determine if they were affected by the elopement or if changes were needed to their elopement risk status. No additional residents were identified and the two (2) other "at risk" residents' care plans were reviewed with no changes. No changes were made to the policies reviewed. Policies reviewed were Elopement and Missing Persons. 10. Psychiatry, was informed of the event by the ADON on 09/22/14. The Nurse Practitioner (APRN), evaluated Resident #1 on 09/22/14 for any psychosocial needs related to the event. No recommendations were made. 11. In addition to Resident #1's spouse being notified of the event on 09/19/14, the resident's care plan was reviewed with the spouse on the morning of 09/20/14 by the Social Services Director (SSD), and a care plan meeting was held on 09/22/14 with the Interdisciplinary Team (IDT) and the DON. 12. Care plans for two (2) other residents previously identified as elopement risk were reviewed by the IDT on 09/19/14 to assess for any necessary changes. No changes were made to these care plans. 13. One hundred twenty-five (125) residents were reviewed by the IDT and DON on 09/19/14 to ensure no risk related to this particular event. No additional risk was identified. 14. A letter was added by the Director of Sales and Marketing on 09/20/14 to the admission packet for all new admissions and families. There were no new admissions until 09/22/14. The letter addressed reminding visitors not to assist residents out of the facility without the knowledge of staff. 15. A review of Resident #1's record revealed that care plan interventions were followed related to redirecting resident when he/she would navigate towards exit doors and these interventions had been effective up until the actual event on 09/19/14. 16. On 09/19/14, immediate education of all staff members working in facility was provided by the ADON, SDC, SSD, LPN or RN on the elopement policy, care plans and to be aware of the area around the doors to make sure that everyone entering and exiting the building were appropriate. Post-test competencies are also being administered with the training. By 09/22/14, 135 staff members were trained with 65 employees to be trained. This education would be provided to all employees in all departments including Administration, LPNs, RNs, CNAs, Dietary, Housekeeping, Therapy, Laundry, Activities and Social Services. This would continue until all staff members received the education. Post education competencies were completed by all staff when education was completed and had been completed by all staff who had worked to date. No staff would be permitted to work until training had occurred. 17. Of the remaining 65 employees as stated in the AOC, fifteen (15) are PRN therapy staff on the payroll, but work in other Signature locations other than East Louisville. This education had been ongoing with no staff member being allowed to work their shift prior to the education. 18. The SDC would ensure that all remaining staff members receive their training before they worked and would educate all new hires prior to starting orientation. The facility did not utilize agency staff. 19. On 09/19/14, a letter from the DON and Administration educated family members and residents to be aware of others who entered or exited the facility and check with nursing staff before they assisted residents in or out of the facility. The letter was placed in all resident rooms on 09/19/14 and placed in outgoing mail on 09/19/14 to all family representatives. 20. The facility began monitoring, on 09/19/14 at 8:45 PM, and had perform three (3) observations every 12 hour shift by the Administrator, DON, Department Head team, IDT and RN supervisors of staff monitor the area around the doors when they let families in or out. These audits would be collected daily by the Administrator and reviewed for tracking/trending in the next QA meeting. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 10/03/14, with a compliance date of 10/03/14 prior to exit as follows: 1. Review of the facility's investigation revealed COTA #1 was driving down the street and observed Resident #1 in his/her electric wheelchair (w/c) on the sidewalk. The COTA parked her vehicle and stayed with the resident until other staff arrived. The Maintenance Director had been driving to the facility and saw Resident #1 on the sidewalk in his/her electric wheelchair (w/c). Interview with COTA #1, on 10/01/14, revealed she was leaving the facility at approximately 6:50 PM on 09/19/14 and saw Resident #1 on the sidewalk headed toward a busy intersection. She stated she parked her vehicle and stayed with the resident until another staff member arrived. She stated the Maintenance Director arrived and they assisted Resident #1 back to the facility. Interview with the Maintenance Director, on 10/01/14, revealed on 09/19/14 at approximately 6:52 PM, he saw Resident #1 in his/her electric wheelchair on the sidewalk moving in the direction of a busy intersection. He stated he parked his vehicle and saw COTA #1 with the resident and then entered the facility and called a Code Green. In response to the Code Green, interviews with Licensed Practical Nurse (LPN) #4, on 10/02/14 at 7:40 PM, revealed he did a head count of residents on the 300 unit on 09/19/14 and all residents were accounted for and reported to the Maintenance Director. Interview with LPN #5, on 10/02/14 at 7:45 PM, revealed he completed a head count of residents on the 200 unit on 09/19/14 with all residents accounted for except Resident #1, and reported to the Maintenance Director. Interview with the Maintenance Director, on 10/03/14 at 8:45 AM, revealed the nurse on the 100 Unit had completed a head count and reported to him all residents were accounted for. Review of the facility head count revealed on 09/19/14 the elopement code was called at approximately 6:53 PM and a head count was completed on the 100, 200, and 300 Units with all residents accounted except Resident #1. 2. Review of the clinical record for Resident #1 revealed, on 09/19/14 a skin assessment and vital signs were completed by LPN #3 upon his/her return to the facility with no concerns noted. Interview with LPN #3, on 10/02/14 at 8:20 AM and 8:48 AM, revealed she completed a skin assessment on 09/19/14 of Resident #1 with no new injuries and the resident's vital signs were within normal limits. She indicated the resident went to bed upon return to the facility. 3. Review of Resident #1's clinical record revealed LPN #3 notified Resident #1's family member on 09/19/14. Interview with LPN #3, on 10/02/14 at 8:20 AM and 8:48 AM, revealed she notified Resident #1's family member on 09/19/14. Review of the clinical record for Resident #1 revealed the Director of Nursing (DON) notified Resident #1's physician (MD), who was also the facility Medical Director, on 09/19/14 of Resident #1's elopement. Interview with the MD, on 10/03/14 at 8:11 AM, revealed she was notified on 09/19/14 by the DON that Resident #1 had eloped. Interview, on 10/03/14 at 10:15 AM, with the DON revealed she notified the MD on 09/19/14 of Resident #1's elopement. 4. Review of the video revealed, on 09/19/14 at approximately 6:42 PM, of an exit door revealed Resident #1 exited the inner doors first in his/her electric w/c and was followed by a male visitor, then a female visitor. Review of facility record revealed the DON spoke to the male visitor, who was another resident's family member, and was educated regarding assisting residents out of the facility. Interview with the DON, on 10/03/14 at 10:15 AM, revealed she had seen the video and spoke to the male visitor and educated him regarding assisting residents out of the facility. 5. Review of a typed statement by the DON revealed when the DON spoke with the male visitor, and CNA #3 had been identified as the staff member who had entered the door code. The Administrator spoke with the CNA on 09/19/14 and education was provided to the CNA by the DON to ensure residents did not exit when assisting visitors in or out of the building. Interview with CNA #3, on 10/01/14 at 11:02 PM, revealed she had received elopement education on 09/19/14 to ensure proper closure of the exit doors. Interview with the DON, on 10/03/14 at 10:15 AM, revealed she had spoken to the aide and provided education on 09/19/14 to stay in the area when she entered the door code. 6. Review of a written statement by the Staff Development Coordinator (SDC) revealed the SDC reviewed the elopement binders on all three (3) unit nurse's stations and the front desk. The binders were accurate and up to date with the three (3) residents that had been identified at risk of elopement prior to 09/19/14. Interview with the Staff Development Coordinator, on 10/02/14 at 9:59 AM, revealed she reviewed all of the elopement binders and found the binders were accurate and up to date. Observation, on 10/01/14 at 4:10 PM, of the 100 Unit, on 10/01/14 at 4:20 PM of the 200 Unit, on 10/01/14 at 4:29 PM, of the 300 Unit and on 10/10/02/14 at 3:00 PM of the front desk elopement binders revealed they were accurate and up to date with the three (3) residents identified at risk for elopement listed in the binders. 7. Review of a typed statement by the Maintenance Director revealed the Maintenance Director checked all exit doors in the facility on 09/19/14 at approximately 7:15 PM. The doors were all functioning and the door codes changed. A sign requested visitors to see a nurse before assisting any resident out of the facility. Interview, on 10/01/14 at 3:21 PM, with the Maintenance Assistant revealed he assisted to check all exterior doors for function and reset the door codes. He stated each door had the visitor sign to see a nurse and the doors all functioned properly. Interview with the Maintenance Director, on 10/01/14, revealed he also checked the exterior door for function and the door codes had been changed. He stated the doors all functioned properly. Observation of the exterior doors, on 01/01/14 at 4:10 PM, revealed all exterior doors were locked and visitor signs posted. Observation of all facility exit doors, on 10/01/14 from 4:10 PM to 4:29 PM, revealed all doors were locked with a sign posted for visitors to see a nurse before assisting any resident out of the facility. 8. Review of a vendor letter revealed on 09/19/14 the security company's vendor conducted a check of all the exterior doors and determined they were functioning properly and the door code had been changed. Interview with the Maintenance Assistant, on 10/01/14 at 3:21 PM, revealed the vendor was called and checked the doors on 09/19/14. Interview with the Maintenance Director, on 10/01/14, revealed the professional company checked the doors for function and the code had been changed. 9. Review of facility records revealed a Quality Assurance (QA) meeting was held on 09/19/14 with the following members signed in: SDC, MDS Assistant, Maintenance Assistant, DON, MD (by phone), and the Administrator. Resident #1's care plan was reviewed with interventions added on 09/19/14. A facility census sheet, with each resident of the facility listed, was reviewed with specific questions asked to determine if any other resident was at risk for elopement with no additional residents identified at risk. The other two (2) residents who were previously identified and in the elopement binder were reviewed with no changes made. Policies reviewed included Elopement/ Wandering Residents and Missing Resident. Interviews with SDC on 10/02/14 at 9:59 AM, MDS Assistant on 10/02/14 at 2:12 PM, Maintenance Assistant on 10/02/14 at 1:10 PM, MD on 10/03/14 at 8:11 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM re

Based on interview, record review, review of the facility's investigation, facility's policy and procedures, it was determined the facility failed to have an effective system in place to ensure care plan interventions were implemented related to monitoring one (1) of three (3) residents identified at risk for elopement of the seven (7) sampled residents, (Resident #1). (Refer to F323) On 09/19/14 at 6:44 PM, Resident #1 exited the facility without staff knowledge. Interview and review of the facility's video surveillance revealed Resident #1 was near the exit door to the 100 Unit when staff entered the code to the exit door for two visitors to leave the facility, and Resident #1 exited the facility with the two (2) visitors. At approximately 6:52 PM, the Maintenance Director was returning to the facility and saw Resident #1 on the sidewalk of the two (2) lane street moving towards the intersection of a six (6) lane street. The Maintenance Director stopped to retrieve the resident when he saw the resident with Certified Occupational Therapy Assistant (COTA) #1. The Maintenance Director returned to the facility and called a Code Green to alert staff of the elopement of Resident #1. Staff was not aware Resident #1 had eloped until the code was called. The resident was returned to the facility at 6:58 PM and assessed with [REDACTED]. The facility's failure to ensure care plan interventions were implemented placed Resident #1 and other residents at risk in a situation that has caused or is likely to cause serious injury, harm, impairment or even death to a resident. The Immediate Jeopardy was identified 09/25/14 and determined to exist on 09/19/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance (AOC) on 09/30/14 that alleged removal of Immediate Jeopardy on 09/23/14. However, the State Survey Agency verified Immediate Jeopardy was removed on 10/03/14, after training of facility staff was verified completed on 10/02/14, at 42 CFR 483.20 Resident Assessment (F282) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy Safety and Supervision of Residents, revised 2007, revealed resident supervision was a core component of the systems approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessed needs and identified hazards in the environment. The policy further stated implementation of the interventions to reduce accident risks and hazards shall include ensuring that interventions are implemented and documented. Review of the facility's policy Elopement/Wandering Residents, effective December 2010, revealed any resident displaying significant wandering behaviors would be assessed for elopement/wandering risk and care planned appropriately. Care plans and individual behavior plans would address wandering as a specific problem. Review of the facility's investigation revealed Resident #1 exited the 100 Unit door, on 09/19/14 at 6:44 PM, with a male family member and a phlebotomist technician when Certified Nursing Assistant (CNA #3) entered the exit door code. The Maintenance Director was returning to the facility at approximately 6:52 PM when he observed Resident #1 in his/her electric wheelchair (w/c) on the sidewalk down the street from the facility. He parked his vehicle and saw COTA #1 with the resident. The Maintenance Director proceeded to the facility and called a Code Green and then went to Resident #1 and the COTA. The resident was returned to the facility at approximately 6:58 PM without injury. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 11/25/13 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) with a cognitive score of a four (4). The resident's functional status for mobility was assessed by the facility as non-ambulatory and requiring supervision on the unit and independent off the unit once in the electric wheelchair. Review of Resident #1's Elopement Risk/Exit Seeking Care Plan, dated 04/12/13 and last reviewed on 09/04/14, revealed Resident #1's care plan had been initiated for elopement evidenced by the resident wandering the facility. The resident exhibited behaviors such as gravitating towards exit doors and asking staff to go outside. The goal of the care plan was for the resident not to elope the facility and the resident would be monitored for his/her whereabouts on an ongoing basis. Approaches listed were: monitor for tailgating; use verbal/physical cues for redirection; seek mental health referral; refer to social services as needed; reassess elopement risk at least quarterly; and, provide direct staff supervision when attending out-of-facility activities. The care plan noted on 03/15/14 Resident #1 had been placed on every fifteen (15) minute check observations for forty-eight hours and on 03/18/14 the resident had been placed on every thirty (30) minute check observations for twenty-four hours related to exit seeking behavior. On 04/12/13 Resident #1 had been added to the Elopement Binder per facility policy. Staff interviews revealed staff was to monitor Resident #1; however, there was no guidance as to the frequency. Interview with CNA #7, on 09/30/14 at 9:12 AM, revealed if a resident was an elopement risk the staff would monitor the resident and keep the resident from exiting the facility. The CNA further indicated all residents were supervised all the time and residents at risk of elopement were supervised constantly; however, there were no specific time frames to monitor residents. She stated staff would keep their eyes on the residents. Interview with Registered Nurse (RN) #1, on 09/30/14 at 9:37 AM, revealed the facility did not have a standard to supervise residents and the supervisions were not documented. Additionally, there were no standards to visualize residents at risk for elopement unless the resident was placed on fifteen (15) minute checks. The RN stated the facility prevented resident elopement through frequent monitoring, the locked exit doors, and use of re-direction and activities. Interview with the SSD, on 09/30/14 at 12:35 PM, revealed a resident at risk of elopement should be supervised by all staff and the resident should not exit the facility without staff supervision. Interview with the Assistant Director of Nursing (ADON), on 09/30/14 at 2:53 PM, revealed he expected staff to visualize residents every two (2) hours, although that was not a facility policy. The ADON stated staff did not document when they made the two (2) hour rounds. He indicated if a resident was at risk for elopement, supervision was at the discretion of the DON. Interview with the Director of Nursing (DON), on 09/24/14 at 1:26 PM, revealed the facility had a general policy for resident supervision and all staff were responsible to supervise residents. She stated she was unsure if the policy specified specific times residents should be visualized and staff did not document when residents had been seen. The DON stated she monitored staff supervision of residents through general observations of staff when she conducted rounds of the facility at least once a day and throughout the day. The DON indicated she did not document when she completed daily rounds. Interview with the Administrator, on 10/01/14 at 10:42 AM, revealed he could not recall if the facility policy specified how frequently staff should visualize any resident or residents at risk for elopement. The facility provided an Allegation of Compliance (AOC) on 09/30/14 alleging the Immediate Jeopardy was removed on 09/23/14; however, the State Survey Agency verified that staff training was completed on 10/02/14. The facility took the following immediate steps to remove the Immediate Jeopardy: 1. At approximately 6:52 PM on 09/19/14, a COTA immediately went to the resident and assured his/her safety by observing for any obvious signs of injury and staying with him/her until another staff member arrived. The Maintenance Director went back to the facility to notify staff and activate the elopement protocols. All other residents were accounted for during the head count. Maintenance Director returned to assist the COTA and Resident #1 was returned to the facility at 6:58 PM. 2. A skin assessment and vital signs were completed by Resident #1's LPN and were within normal limits. Assessment did not reveal any signs of injury or trauma. 3. Resident #1's husband/wife was contacted by the LPN on 09/19/14 to inform him/her that his/her spouse had exited the facility. Physician and facility Medical Director was notified by the Director of Nursing (DON) on 09/19/14 of the event. 4. Upon review of the security camera footage by the Administrator and DON on 09/19/14, it was determined that Resident #1 was helped outside by a visiting family member. The visitor was called by the DON, on 09/19/14 and asked him about the incident. The visitor stated that he did hold the door for the resident to exit, but he was unaware the resident was not able to exit without staff assistance. Education was also provided to the family member regarding assisting residents outside of secured doors. 5. Information from the interview with visitor also identified the CNA that entered the code to release the maglock. The CNA was interviewed by the Administrator on 09/19/14 and education on elopement policy and procedures provided by the DON on 09/19/14. This education included staying observant of the surrounding area to ensure no resident exited when assisting a visitor in or out of the door. 6. A review of the Elopement books were completed on 09/19/14, by the DON and Staff Development Coordinator (SDC) to ensure the elopement risk forms for each resident identified at risk for elopement were accurate. Three (3) total residents were reviewed. 7. On 09/19/14, the Maintenance Director and Maintenance Assistant checked all exterior doors for proper function with no issues identified. Proper signage was in place at all doors. The sign read "Visitors: Please see a nurse before assisting any resident out of the facility." 8. On 09/19/14, the Administrator called in the door vendor to check overall operation of all exterior doors with no issues identified. This inspection was completed on 09/19/14. 9. An ADHOC-QAPI meeting regarding resident's elopement and plan of care that included MDS, Director of Nursing, Administrator, Social Services, Staff Development Coordinator and Medical Director occurred on 09/19/14. Resident's care plan was updated to reflect new interventions. Each resident was discussed to determine if they were affected by the elopement or if changes were needed to their elopement risk status. No additional residents were identified and the two (2) other "at risk" residents' care plans were reviewed with no changes. No changes were made to the policies reviewed. Policies reviewed were Elopement and Missing Persons. 10. Psychiatry, was informed of the event by the ADON on 09/22/14. The Nurse Practitioner (APRN), evaluated Resident #1 on 09/22/14 for any psychosocial needs related to the event. No recommendations were made. 11. In addition to Resident #1's spouse being notified of the event on 09/19/14, the resident's care plan was reviewed with the spouse on the morning of 09/20/14 by the Social Services Director (SSD), and a care plan meeting was held on 09/22/14 with the Interdisciplinary Team (IDT) and the DON. 12. Care plans for two (2) other residents previously identified as elopement risk were reviewed by the IDT on 09/19/14 to assess for any necessary changes. No changes were made to these care plans. 13. One hundred twenty-five (125) residents were reviewed by the IDT and DON on 09/19/14 to ensure no risk related to this particular event. No additional risk was identified. 14. A letter was added by the Director of Sales and Marketing on 09/20/14 to the admission packet for all new admissions and families. There were no new admissions until 09/22/14. The letter addressed reminding visitors not to assist residents out of the facility without the knowledge of staff. 15. A review of Resident #1's record revealed that care plan interventions were followed related to redirecting resident when he/she would navigate towards exit doors and these interventions had been effective up until the actual event on 09/19/14. 16. On 09/19/14, immediate education of all staff members working in facility was provided by the ADON, SDC, SSD, LPN or RN on the elopement policy, care plans and to be aware of the area around the doors to make sure that everyone entering and exiting the building were appropriate. Post-test competencies are also being administered with the training. By 09/22/14, 135 staff members were trained with 65 employees to be trained. This education would be provided to all employees in all departments including Administration, LPNs, RNs, CNAs, Dietary, Housekeeping, Therapy, Laundry, Activities and Social Services. This would continue until all staff members received the education. Post education competencies were completed by all staff when education was completed and had been completed by all staff who had worked to date. No staff would be permitted to work until training had occurred. 17. Of the remaining 65 employees as stated in the AOC, fifteen (15) are PRN therapy staff on the payroll, but work in other Signature locations other than East Louisville. This education had been ongoing with no staff member being allowed to work their shift prior to the education. 18. The SDC would ensure that all remaining staff members receive their training before they worked and would educate all new hires prior to starting orientation. The facility did not utilize agency staff. 19. On 09/19/14, a letter from the DON and Administration educated family members and residents to be aware of others who entered or exited the facility and check with nursing staff before they assisted residents in or out of the facility. The letter was placed in all resident rooms on 09/19/14 and placed in outgoing mail on 09/19/14 to all family representatives. 20. The facility began monitoring, on 09/19/14 at 8:45 PM, and had perform three (3) observations every 12 hour shift by the Administrator, DON, Department Head team, IDT and RN supervisors of staff monitor the area around the doors when they let families in or out. These audits would be collected daily by the Administrator and reviewed for tracking/trending in the next QA meeting. Through observation, interview, and record review the State Survey Agency (SSA) validated the AOC, on 10/03/14, with a compliance date of 10/03/14 prior to exit as follows: 1. Review of the facility's investigation revealed COTA #1 was driving down the street and observed Resident #1 in his/her electric wheelchair (w/c) on the sidewalk. The COTA parked her vehicle and stayed with the resident until other staff arrived. The Maintenance Director had been driving to the facility and saw Resident #1 on the sidewalk in his/her electric wheelchair (w/c). Interview with COTA #1, on 10/01/14, revealed she was leaving the facility at approximately 6:50 PM on 09/19/14 and saw Resident #1 on the sidewalk headed toward a busy intersection. She stated she parked her vehicle and stayed with the resident until another staff member arrived. She stated the Maintenance Director arrived and they assisted Resident #1 back to the facility. Interview with the Maintenance Director, on 10/01/14, revealed on 09/19/14 at approximately 6:52 PM, he saw Resident #1 in his/her electric wheelchair on the sidewalk moving in the direction of a busy intersection. He stated he parked his vehicle and saw COTA #1 with the resident and then entered the facility and called a Code Green. In response to the Code Green, interviews with Licensed Practical Nurse (LPN) #4, on 10/02/14 at 7:40 PM, revealed he did a head count of residents on the 300 unit on 09/19/14 and all residents were accounted for and reported to the Maintenance Director. Interview with LPN #5, on 10/02/14 at 7:45 PM, revealed he completed a head count of residents on the 200 unit on 09/19/14 with all residents accounted for except Resident #1, and reported to the Maintenance Director. Interview with the Maintenance Director, on 10/03/14 at 8:45 AM, revealed the nurse on the 100 Unit had completed a head count and reported to him all residents were accounted for. Review of the facility head count revealed on 09/19/14 the elopement code was called at approximately 6:53 PM and a head count was completed on the 100, 200, and 300 Units with all residents accounted except Resident #1. 2. Review of the clinical record for Resident #1 revealed, on 09/19/14 a skin assessment and vital signs were completed by LPN #3 upon his/her return to the facility with no concerns noted. Interview with LPN #3, on 10/02/14 at 8:20 AM and 8:48 AM, revealed she completed a skin assessment on 09/19/14 of Resident #1 with no new injuries and the resident's vital signs were within normal limits. She indicated the resident went to bed upon return to the facility. 3. Review of Resident #1's clinical record revealed LPN #3 notified Resident #1's family member on 09/19/14. Interview with LPN #3, on 10/02/14 at 8:20 AM and 8:48 AM, revealed she notified Resident #1's family member on 09/19/14. Review of the clinical record for Resident #1 revealed the Director of Nursing (DON) notified Resident #1's physician (MD), who was also the facility Medical Director, on 09/19/14 of Resident #1's elopement. Interview with the MD, on 10/03/14 at 8:11 AM, revealed she was notified on 09/19/14 by the DON that Resident #1 had eloped. Interview, on 10/03/14 at 10:15 AM, with the DON revealed she notified the MD on 09/19/14 of Resident #1's elopement. 4. Review of the video revealed, on 09/19/14 at approximately 6:42 PM, of an exit door revealed Resident #1 exited the inner doors first in his/her electric w/c and was followed by a male visitor, then a female visitor. Review of facility record revealed the DON spoke to the male visitor, who was another resident's family member, and was educated regarding assisting residents out of the facility. Interview with the DON, on 10/03/14 at 10:15 AM, revealed she had seen the video and spoke to the male visitor and educated him regarding assisting residents out of the facility. 5. Review of a typed statement by the DON revealed when the DON spoke with the male visitor, and CNA #3 had been identified as the staff member who had entered the door code. The Administrator spoke with the CNA on 09/19/14 and education was provided to the CNA by the DON to ensure residents did not exit when assisting visitors in or out of the building. Interview with CNA #3, on 10/01/14 at 11:02 PM, revealed she had received elopement education on 09/19/14 to ensure proper closure of the exit doors. Interview with the DON, on 10/03/14 at 10:15 AM, revealed she had spoken to the aide and provided education on 09/19/14 to stay in the area when she entered the door code. 6. Review of a written statement by the Staff Development Coordinator (SDC) revealed the SDC reviewed the elopement binders on all three (3) unit nurse's stations and the front desk. The binders were accurate and up to date with the three (3) residents that had been identified at risk of elopement prior to 09/19/14. Interview with the Staff Development Coordinator, on 10/02/14 at 9:59 AM, revealed she reviewed all of the elopement binders and found the binders were accurate and up to date. Observation, on 10/01/14 at 4:10 PM, of the 100 Unit, on 10/01/14 at 4:20 PM of the 200 Unit, on 10/01/14 at 4:29 PM, of the 300 Unit and on 10/10/02/14 at 3:00 PM of the front desk elopement binders revealed they were accurate and up to date with the three (3) residents identified at risk for elopement listed in the binders. 7. Review of a typed statement by the Maintenance Director revealed the Maintenance Director checked all exit doors in the facility on 09/19/14 at approximately 7:15 PM. The doors were all functioning and the door codes changed. A sign requested visitors to see a nurse before assisting any resident out of the facility. Interview, on 10/01/14 at 3:21 PM, with the Maintenance Assistant revealed he assisted to check all exterior doors for function and reset the door codes. He stated each door had the visitor sign to see a nurse and the doors all functioned properly. Interview with the Maintenance Director, on 10/01/14, revealed he also checked the exterior door for function and the door codes had been changed. He stated the doors all functioned properly. Observation of the exterior doors, on 01/01/14 at 4:10 PM, revealed all exterior doors were locked and visitor signs posted. Observation of all facility exit doors, on 10/01/14 from 4:10 PM to 4:29 PM, revealed all doors were locked with a sign posted for visitors to see a nurse before assisting any resident out of the facility. 8. Review of a vendor letter revealed on 09/19/14 the security company's vendor conducted a check of all the exterior doors and determined they were functioning properly and the door code had been changed. Interview with the Maintenance Assistant, on 10/01/14 at 3:21 PM, revealed the vendor was called and checked the doors on 09/19/14. Interview with the Maintenance Director, on 10/01/14, revealed the professional company checked the doors for function and the code had been changed. 9. Review of facility records revealed a Quality Assurance (QA) meeting was held on 09/19/14 with the following members signed in: SDC, MDS Assistant, Maintenance Assistant, DON, MD (by phone), and the Administrator. Resident #1's care plan was reviewed with interventions added on 09/19/14. A facility census sheet, with each resident of the facility listed, was reviewed with specific questions asked to determine if any other resident was at risk for elopement with no additional residents identified at risk. The other two (2) residents who were previously identified and in the elopement binder were reviewed with no changes made. Policies reviewed included Elopement/ Wandering Residents and Missing Resident. Interviews with SDC on 10/02/14 at 9:59 AM, MDS Assistant on 10/02/14 at 2:12 PM, Maintenance Assistant on 10/02/14 at 1:10 PM, MD on 10/03/14 at 8:11 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they attended a QA meeting held on 09/19/14 and reviewed and updated Resident #1's care plan, reviewed all facility residents for risk of elopement, reviewed the care plans for the other two (2) residents previously identified at risk of elopement with no changes made, and reviewed the policies for Elopement and Missing Resident with no changes made. Observation of Resident #1, on 10/01/14 at 4:27 PM, Resident #5, on 10/02/14 at 3:30 PM, and Resident #6, on 10/02/14 at 3:35 PM, revealed the three (3) identified residents made no attempts at exit seeking behavior and staff was supervising. 10. Review of the psychiatric note, dated 09/22/14, revealed Resident #1 was seen by the APRN on 09/22/14 related to the elopement with no changes made to the resident's current medications. Interview with the APRN, on 10/02/14 at 2:33 PM, revealed she saw Resident #1 on 09/22/14 with no issues identified. Interview with the Psychiatrist, on 10/02/14 at 3:38 PM, revealed he was notified on 09/22/14 of Resident #1's elopement by the DON and he requested the APRN to see the resident. The Psychiatrist had no concerns and medications were not changed. 11. Review of a social service note, dated 09/20/14, revealed social services contacted Resident #1's family member to review the resident's care plan and schedule a care plan meeting for 09/22/14. Review of the care plan conference summary revealed a care plan meeting was conducted on 09/22/14 with the family member present. Interview with the Social Services Director (SSD), on 10/02/14 at 1:40 PM, revealed she contacted Resident #1's family member to schedule a care plan meeting, which was 09/22/14. Interview with the Assistant Director of Nursing (ADON) for the 200 Unit, on 10/02/14 at 2:20 PM, revealed he attended the care plan meeting on 09/22/14 with Resident #1's family member. 12. Review of nurse's notes revealed the QA meeting on 09/19/14 reviewed the care plans for the other two (2) residents previously identified at risk of elopement with no changes made. Review of the two (2) resident care plans revealed no new interventions after the 09/19/14 elopement by Resident #1. Interviews with Staff Development Coordinator, on 10/02/14 at 9:59 AM, MDS Assistant on 10/02/14 at 2:12 PM, Maintenance Assistant on 10/02/14 at 1:10 PM, MD on 10/03/14 at 8:11 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they attended a QA meeting held on 09/19/14 and reviewed the care plans for the other two (2) residents previously identified at risk of elopement with no changes made. 13. Review of the facility census sheet for 09/19/14 and a list of questions used as the assessment tool revealed all residents were reviewed in the QA meeting on 09/19/14 for risk of elopement with no additional residents identified. Interviews with Staff Development Coordinator, on 10/02/14 at 9:59 AM, MDS Assistant on 10/02/14 at 2:12 PM, Maintenance Assistant on 10/02/14 at 1:10 PM, MD on 10/03/14 at 8:11 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they attended a QA meeting held on 09/19/14 and reviewed all residents of the facility with no new residents identified at risk of elopement. 14. Review of a facility admission packet revealed a letter that requested visitors not assist any resident out of the facility. The Director of Sales and Marketing was unreachable for interview. Interview with the DON, on 10/03/14 at 10:15 AM, revealed the letter had been included in the admission packet for new residents. Review of the facility daily census sheet for 09/20/14 and 09/21/14 revealed the facility had no new admissions. Interview, on 10/03/14 at 2:25 PM, with the Administrator revealed the facility no new admissions after the elopement until 09/22/14. 15. Review of Resident #1's care plan revealed new interventions were implemented after his/her elopement during the QA meeting on 09/19/14. Interviews with SDC, on 10/02/14 at 9:59 AM, MDS Assistant on 10/02/14 at 2:12 PM, Maintenance Assistant on 10/02/14 at 1:10 PM, MD on 10/03/14 at 8:11 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they attended a QA meeting held on 09/19/14 and reviewed and updated Resident #1's care plan to include the use of the manual wheelchair and a therapy referral. The DON stated she had reviewed Resident #1's clinical record on 09/19/14 to determine what change needed to be made to the care plan, and decided by the QA meeting that night. 16. Review of the facility staff roster and education post-tests revealed the facility began education of staff on 09/19/14 on the elopement policy. A total of two hundred (200) employees in all departments were being educated, with 154 staff trained by 09/22/14. The most recent employee was trained on 10/02/14, with thirty-two (32) PRN staff and one (1) full time employee on medical leave who needed to be trained. Review of employee schedules across departments compared to post-tests revealed staff were trained prior to or upon return to work. Interviews with thirty-one (31) staff: CNA #8 on 10/01/14 at 2:10 PM, Laundry Aide on 10/01/14 at 2:17 PM, CNA #9 on 10/01/14 at 2:24 PM, Assistant Dietary Manager on 10/01/14 at 2:27 PM, Activities Director on 10/01/14 at 2:32 PM, Physical Therapy (PT) #2 on 10/01/14 at 2:36 PM, Maintenance Director on 10/1/14 at 3:35 PM, COTA #1 on 10/01/14 at 4:24 PM, CNA #10 on 10/01/14 at 2:11 PM, CNA # 11 on 10/01/14 at 2:17 PM, Registered Nurse (RN) #1 on 10/01/14 at 2:24 PM, Licensed Practical Nurse (LPN) #6 on 10/01/14 at 2:27 PM, Cook on 10/01/14 at 2:32 PM, LPN #7 on 10/01/14 at 2:36 PM, Dietary Aide on 10/1/14 at 2:40 PM, PT #3 on 10/01/14 at 3:00 PM, Maintenance Assistant on 10/01/14 at 3:21 PM, CNA #1 on 10/01/14 at 3:37 PM, CNA #2 on 10/01/14 at 3:58 PM, Evening Supervisor #1 on 10/1/14 at 8:15 PM, CNA #3 on 10/01/14 at 11:02 PM, LPN #3 on 10/02/14 at 8:20 AM, ADON 300 Unit on 10/02/14 at 1:02 PM, SSD on 10/02/14 at 1:40 PM, ADON 200 Unit on 10/02/14 at 2:20 PM, LPN #4 on 10/02/14 at 7:40 PM, LPN #5 on 10/02/14 at 7:45 PM, Business Office Manager (BOM) on 10/03/14 at 8:45 AM, HR Director on 10/03/14 at 8:50 AM, Receptionist on 10/03/14 at 8:54 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they were trained prior to working their scheduled shift on the elopement policy, what to do if there was an elopement, to stay at the exit door when they assisted anyone to enter or exit the facility and completed a post test. 17. Review of the staff roster and education post tests revealed thirty-two (32) PRN staff needed to be trained. Review of a letter sent to the remaining staff that needed to be trained, on 09/30/14, by certified mail revealed staff needed to complete the training by 10/10/14. Review of a list of staff that needed to be trained revealed thirty-two (32) employees required training. Interview with SDC, on 10/02/14 at 9:59 AM, revealed training for staff began on 09/19/14 of the elopement policy with care plan and to stay at the door until the door was closed. Interview with the DON, on 10/03/14 at 10:15 AM, and the Administrator, on 10/03/14 at 2:25 PM, revealed a letter was sent by certified mail to remaining staff that education needed to be completed by 10/10/14. The DON stated the employee schedules were compared with the list of remaining staff daily for the following day to ensure staff were trained as they came to work. Review of a list of staff that needed to be trained revealed thirty-two (32) employees required training. Interview with SDC, on 10/02/14 at 9:59 AM, revealed she had tracked who needed to be trained and monitored daily, along with the DON. She stated the facility did not use agency staff. 18. Review of a letter by the DON, dated 09/20/14, revealed visitors were asked not to assist any resident out of the facility and seek assistance from a nurse. Interview with the DON, on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM, revealed the letter was placed in all resident rooms on 09/20/14 and was also mailed to all resident families. 19. Review of the facility staff roster, employee schedules across departments, and post-tests, revealed staff were trained prior to or upon return to work. All but thirty-two (32) PRN and one (1) full time employee on medical leave had been trained prior to working their next scheduled shift. Interviews with thirty-one (31) staff CNA #8 on 10/01/14 at 2:10 PM, Laundry Aide on 10/01/14 at 2:17 PM, CNA #9 on 10/01/14 at 2:46 PM, Assistant Dietary Manager on 10/01/14 at 2:27 PM, Activities Director on 10/01/14 at 2:32 PM, Physical Therapy (PT) #2 on 10/01/14 at 2:36 PM, Maintenance Director on 10/01/14 at 3:35 PM, COTA #1 on 10/01/14 at 4:27 PM, CNA #10 on 10/01/14 at 2:11 PM, CNA # 11 on 10/01/14 at 2:17 PM, Registered Nurse (RN) #1 on 10/01/14 at 2:24 PM, Licensed Practical Nurse (LPN) #6 on 10/01/14 at 2:27 PM, Cook on 10/01/14 at 2:32 PM, LPN #7 on 10/01/14 at 2:36 PM, Dietary Aide on 10/1/14 at 2:40 PM, PT #3 on 10/01/14 at 3:00 PM, Maintenance Assistant on 10/01/14 at 3:21 PM, CNA #1 on 10/01/14 at 3:37 PM, CNA #2 on 10/01/14 at 3:58 PM, Evening Supervisor #1 on 10/1/14 at 8:15 PM, CNA #3 on 10/1/14 at 11:02 PM, LPN #3 on 10/02/14 at 8:20 AM, ADON 300 Unit on 10/02/14 at 1:02 PM, SSD on 10/02/14 at 1:40 PM, ADON 200 Unit on 10/02/14 at 2:20 PM, LPN #4 on 10/02/14 at 7:40 PM, LPN #5 on 10/02/14 at 7:45 PM, BOM on 10/03/14 at 8:45 AM, HR Director on 10/03/14 at 8:50 AM, Receptionist on 10/03/14 at 8:54 AM, DON on 10/03/14 at 10:15 AM, and the Administrator on 10/03/14 at 2:25 PM revealed they were trained prior to working their scheduled shift on

Based on observation, interview, record review, review of the facility's investigation and policy and procedures, and the Centers for Medicare and Medicaid (CMS) RAI Manual 3.0, it was determined the facility failed to assess the use of a high back, reclining wheelchair as a potential restraint for one (1) of seven (7) sampled residents, Resident #1. The facility staff replaced Resident #1's electric wheelchair with a manual operating, high back, reclining seat, wheelchair (w/c) after the resident eloped from the facility on 09/19/14. Additionally, the w/c locks on the manual w/c were located on the back of the w/c, out of the reach of the resident, and observed in the locked position on 09/29/14. The facility's failure to ensure restraint assessment and interventions were implemented placed Resident #1 and other residents at risk in a situation that has caused or is likely to cause serious injury, harm, impairment or even death to a resident. The Immediate Jeopardy was determined to exist on 09/19/14 at a scope and severity of a "J" at 42 CFR 483.13 Resident Behaviors and Facility Practice (F221) with Substandard Quality of Care at 42 CFR 483.13 Resident Behaviors and Facility Practice and the facility was notified of the Immediate Jeopardy on 10/28/14. The facility provided a second acceptable credible Allegation of Compliance (AOC) to address the Immediate Jeopardy at 42 CFR 483.13 Resident Behaviors and Facility Practice (F221) on 10/31/14 alleging removal of Immediate Jeopardy on 10/29/14. The State Survey Agency verified Immediate Jeopardy was removed on 10/29/14 as alleged at 42 CFR 483.13 Resident Behaviors and Facility Practice (F221) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy Federal Resident/Patient Rights, reviewed August 2009, revealed the resident had the right to be free from any physical restraints that were not required to treat the resident's medical symptoms and were not administered for the purpose of discipline or convenience. Review of the facility's policy Restraints/Emergency Application, effective December 2010, revealed safety devices were used as a temporary emergency device to provide safety and prevent injury to a resident. Documentation should include the reason for use and other alternative interventions that had been used with outcomes. Review of the facility's policy Physical Restraint Reduction Program, effective December 2010, revealed residents should be free of any physical restraints imposed for the purpose of discipline or staff convenience. The facility would not use restraints except when other alternatives were not appropriate. Use of physical restraints would only be considered to treat a medical symptom/ condition and as a last resort after a trial period where alternative, less restrictive measures had been used and proven unsuccessful. Also, restraints would be used with informed consent of the resident or legal representative. A physical restraint was any mechanical device which restricted the resident's freedom of movement. The facility would evaluate the resident's condition prior to the use of a restraint for potential concerns using the pre-restraint assessment. The restraint would be explained in advance to the resident and family and an informed consent for use of the restraint should be obtained. A restraint would be care planned with a goal to reduce the use of the restraint. The facility should use other nursing measures, diversion programs, activity programs, and supervision to control behavior when possible. Review of the CMS RAI Version 3.0 Manual, dated 05/13, Section P-1, revealed physical restraint was defined as any manual, physical, or mechanical device the resident could not remove easily and restricted freedom of movement. Restraints should be used as a short-term, temporary intervention to treat a resident's medical symptoms and should not be used for discipline or convenience. Before a resident was restrained the facility must determine the presence of a medical symptom that required the restraint and how the restraint would treat the medical symptom, protect the resident's safety, and assist the resident to attain or maintain his/her highest practicable level of physical and psychosocial well-being. The assessment should be used to identify specific reasons for the restraint. The resident care plan based on the conclusions of the assessment should address the underlying physical or psychological condition that led to the restraint with a goal to eliminate the restraints use by employing alternatives. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 05/27/11. The admission Minimum Data Set (MDS) assessment for Resident #1 was completed on 06/03/11, and the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6). The facility readmitted the resident on 11/26/13 with [DIAGNOSES REDACTED]. The facility completed an annual MDS assessment on 02/03/14 with a BIMS score of eight (8). The facility completed a quarterly MDS on 09/06/14 with a BIMS score of four (4). The facility assessed the resident's functional status as independent for locomotion to other areas of the facility and self-sufficient in his/her electric w/c. Record review revealed, on 09/19/14, Resident #1 exited the facility without staff knowledge and was found off the facility property, propelling his/her electric wheelchair towards the intersection of a six (6) lane highly traveled street. Review of Resident #1's elopement risk assessment, dated 09/19/14, revealed the facility and Medical Director (MD) chose to allow Resident #1 only the use of the electric w/c when one to one (1:1) with family, when they were available in the facility. Review of the facility's Pre-Restraining Assessment form, dated 09/19/14 for Resident #1, revealed the form should be completed to adequately assess all aspects of a resident's well-being prior to the use of physical restraints in order to identify the least restrictive intervention. The facility assessed the resident with no concerns of falling forward or sideways, the resident did not slide down, or slump, all while seated due to the resident being a double [MEDICAL CONDITION]. The facility assessment also revealed no medical factors affected the resident's behavior; however, a recent elopement in the power w/c was added. The assessment recommendation stated to allow the resident to only use the power chair when family visited due to the need for 1:1 supervision when in the power chair. Review of Resident #1's care plan revealed the care plan was revised on 09/19/14 after the resident's elopement, with an intervention to encourage the resident to use the regular w/c versus the motorized w/c, schedule a family care plan meeting, and refer to Occupational Therapy for w/c positioning. Additionally, the resident could be up in the power chair when family visited; otherwise, the resident should use the high back reclining w/c for safety and positioning. The care plan did not specify how long to use the manual wheelchair; a plan to assess Resident #1 for reduction of the high back w/c; the location of the manual w/c locks; or if any other alternative interventions were used with the outcomes. The updated facility care plan for self-care, on 09/19/14, specified to use a manual w/c with the electric w/c discontinued. The care plan for activities, revised 09/19/14 per physician (MD) order, revealed the facility would provide 1:1 activity visits twice per week for socialization. A Care Plan Conference Summary, dated 09/22/14, revealed Resident #1's family was present for the meeting, and they had concerns for Resident #1's quality of life since the use of the electric w/c would be limited; however, the resident would be able to use the electric w/c when he/she had visitors. Review of the quarterly Social Services notes for Resident #1, dated 05/05/14, 06/07/14, revealed the resident used an electric w/c for mobility. A quarterly Social Service Review on 09/06/14 revealed the resident was at risk for elopement and he/she used an electric w/c. On 09/20/14, a Social Services note revealed the resident's family was informed that Resident #1 would use a manual w/c and could only use the electric w/c when he/she had visitors. The family member was informed the resident would be given a high back reclining w/c and was referred to therapy for positioning. Review of the facility's therapy screening form, dated 09/20/14, completed by Certified Occupational Therapy Assistant (COTA) #2 revealed Resident #1 had been referred for therapy due to an incident report, related to Resident #1's elopement on 09/19/14. The resident was identified with difficulty using the manual w/c and had been previously in a power w/c. Resident #1 required assessment for w/c positioning and safety with a speech therapy evaluation for cognition. Review of the Occupation Therapy Evaluation and Plan of Treatment, completed on 09/22/14, revealed Resident #1 had a [DIAGNOSES REDACTED]. A short term goal included to increase the ability to self-propel twenty (20) feet to increase functional mobility throughout the facility, with a long term goal of one hundred (100) feet. The resident was assessed to have intact fine motor and gross motor coordination. The facility assessed the resident with total dependence for w/c mobility and management in the manual w/c. The assessment noted the resident had run into doors and walls when using the electric w/c. A Speech Therapy Evaluation and Plan of Treatment, dated 09/22/14, revealed the resident was referred due to a recent elopement. The assessment determined the resident appeared at baseline cognitively. Review of a blank facility Electric Wheelchair/ Motorized Scooter Assessment form, not dated, revealed an assessment would include cognition, physical, and functional areas to determine if the resident had demonstrated an acceptable or unacceptable ability to safely operate the electric w/c. The facility did not provide any completed Electric Wheelchair Assessments for Resident #1 since the facility initially admitted the resident on 05/27/11. Review of the Psychiatrist note, dated 09/22/14, revealed Resident #1 recognized he/she was in a different chair. The resident was quite mobile in the electric w/c and the facility was concerned about the resident's ability to travel within the facility quickly which was the incentive for moving the resident to a manual w/c when he/she did not have visitors. Upon request, the facility did not provide a resident or family consent for the use of a restraint. Observation, on 09/24/14 at 7:52 AM, revealed the resident was sitting in a manual, high back, reclining seat, wheelchair in the dining room for breakfast. Interview with Resident #1, on 09/25/14 at 3:45 PM, revealed he/she was "scolded" for leaving the facility and the facility "took his/her chair away". Observation, on 09/26/14 at 3:38 PM, of Resident #1's electric w/c revealed the chair was stored in the 200 Unit's locked medication room. On 09/26/14 at 3:48 PM and 09/29/14 at 11:46 AM, observations of Resident #1 revealed he/she was in bed with eyes closed. A manual high back reclining w/c with anti-tippers was next to the bed. The w/c was partially hidden by the privacy curtain. Observation, on 09/29/14 at 12:00 PM, of Resident #1 revealed staff wheeled the resident to the dining room. At 1:20 PM the resident was sitting in a manual w/c next to his/her bed watching TV At 2:25 PM the resident was sitting in the hallway at the double doors. At 2:50 PM the resident was outside smoking. The w/c locks were located behind the resident and the resident could not reach the locks to release them. Observation of Resident #1, on 09/29/14 at 12:04 PM, revealed the resident was in the manual w/c on the 200 Unit hallway. The resident was a bilateral above the knee [MEDICAL CONDITION]. The resident's w/c was pushed by staff to the dining room. Observation, on 09/29/14 at 2:23 PM, Resident #1 was in the manual w/c in the 200 Unit hallway. At 2:26 PM the Assistant Director of Nursing (ADON) for the 200 Unit pushed the resident's w/c toward the dining room and out to the smoking patio. The ADON locked the resident's w/c once the resident was pushed out to the smoking patio. The w/c locks were located behind the resident at the back of the w/c. Observation at 2:46 PM of the smoking patio revealed Resident #1 was independently smoking and the w/c locks were in the locked position. On 09/29/14 at 3:23 PM, observation of Resident #1 revealed the resident was unable to reach the locks at the back of the w/c. Observation of Resident #1, on 09/29/14 at 4:04 PM, revealed the resident was in the assisted dining room for a movie activity and was talking with the Activities Director (AD). The AD then unlocked the w/c locks and pushed the resident to the 200 Unit nurse's station for the resident to speak with the unit ADON. On 09/30/14 at 9:12 AM, interview with CNA #7 revealed the resident was in a manual w/c and she was unaware of the resident using an electric w/c when the family visited. Additionally, the aide stated she did not know where Resident #1's electric w/c was kept. The CNA stated the manual w/c locks were located at the back of the resident's w/c and the resident would not be able to reach the locks. She indicated if the w/c locks were used and the resident could not reach the locks, the resident would not be able to go anywhere, or get around the facility. Continued interview, on 09/29/14 at 3:23 PM, with Resident #1 revealed he/she did not get around very well since he/she was no longer in the electric w/c. The resident stated when the electric w/c was taken away he/she felt "naked". Additionally, Resident #1, stated the facility "scolded" him/her for leaving the building. Resident #1 indicated he/she was unable to unlock the w/c when the locks were used. The resident stated he/she missed his/her electric w/c. Interview, on 09/26/14 at 3:02 PM, with the Social Services Director (SSD) revealed Resident #1 had eloped from the facility on 09/19/14. She stated the resident displayed safety concerns in the electric w/c as he/she was able to roll around and get out of the building as quickly as he/she did. The SSD indicated she was unaware if staff placed the resident in the electric w/c when the family visited. She further indicated she had viewed the facility video which showed how quickly Resident #1 had moved from the unit and out the door. The SSD stated the facility took the resident's electric w/c and would provide it when the resident would have 1:1 supervision when the family visited. She further stated the resident was safer in the manual w/c as he/she was not able to get around the facility as quickly. The SSD further indicated she was unsure if Resident #1 was still as mobile as he/she had been in the electric w/c. On 09/26/14 at 3:35 PM, interview with the 200 Unit ADON revealed Resident #1's family visited the resident earlier in the week; however, the family was not offered the use of the electric w/c and the family would need to request it. The ADON indicated Resident #1 was not as quick in the manual w/c as he/she was in the electric w/c. Interview, on 09/26/14 at 3:50 PM, with COTA #1 revealed Occupational Therapy (OT) Services had started for Resident #1 after the elopement. She stated there was a difference in mobility for Resident #1 in the manual w/c. The resident was not able to go everywhere in the building like when he/she had been in the electric w/c. The COTA further indicated the resident could self-propel in the manual w/c twenty-five (25) feet. She stated the resident's mobility was limited and she was unsure if the resident would be able to propel an entire hall. On 09/29/14 at 3:05 PM, interview with Registered Nurse (RN) #5 revealed she had not seen Resident #1 on the 300 Unit as much as she used to see him/her when he/she was in the electric w/c. Interview with RN #2, on 09/24/14 at 3:10 PM, revealed Resident #1 was constantly roaming the facility before the electric w/c was taken away. Interview with COTA #1, on 09/25/14 at 4:24 PM, revealed Resident #1, constantly, during waking hours, roamed the facility and frequently sat in front of exit doors before the electric w/c was taken away. On 09/26/14 at 4:18 PM, interview with the Assistant Dietary Manager revealed he supervised the scheduled 2:30 PM smoke time for residents. He stated Resident #1 would normally attend the 2:30 PM smoke break, and would arrive around 1:30 PM. The Assistant Dietary Manager revealed he had not seen Resident #1 smoke at the 2:30 PM smoke time since the resident's electric w/c had been replaced with the manual w/c. Interview, on 09/29/14 at 2:31 PM, with the Therapy Director revealed she was unaware who made the decision to place Resident #1 in a manual w/c; however, the Director of Nursing (DON) made a referral after Resident #1 eloped from the facility on 09/19/14 for therapy to evaluate the resident. The Therapy Director indicated the therapy assessment for Resident #1 was completed on 09/22/14. She further indicated the resident could use the electric w/c when a family member was with him/her. She stated it was unsafe for Resident #1 to leave the building without staff and unsupervised. Interview, on 09/29/14 at 3:44 PM, with the Activities Director (AD) revealed after Resident #1 eloped from the facility the facility staff put the resident on 1:1 visits from the Activity Department for socialization. She indicated she participated in the care plan meeting with the resident's family on 09/22/14. The AD further indicated if the resident remained in the power chair, he/she would need someone to be with him 1:1 so he/she would not elope from the facility again. The AD revealed the manual w/c helped to prevent elopement as the resident was slower in the manual w/c. Interview with RN #1, on 09/30/14 at 9:37 AM, revealed Resident #1 needed to be in a high back w/c unless the family visited and requested the motorized w/c. She further revealed the facility did not want the resident to access the electric w/c or try to get to it. RN #1 stated Resident #1 was faster in the electric w/c and his/her mobility in the manual w/c was slow. She indicated the resident did not go to the places he/she used to and wandered less. The RN stated the resident used to take him/herself to smoke and activities; however, staff now had to escort him/her. She indicated with the locks on the back of the w/c the resident would not be able to unlock the w/c. Additionally, the nurse stated if the resident could not unlock the w/c then the w/c would be a restraint. Continued interview with the SSD, on 09/30/14 at 12:35 PM, revealed Resident #1's family did not initially agree to the change in the w/c. She also stated when a family visited a resident and took the resident outside, the family was responsible to supervise the resident. The SSD indicated the manual w/c prevented elopement as the w/c reduced the resident's speed. She further indicated the resident got around quickly in the electric w/c and the manual w/c slowed him/her down. On 09/30/14 at 1:34 PM, interview with COTA #1 revealed Resident #1 was not in a position to lock the w/c as he/she did not transfer independently. She stated if staff locked the w/c the resident would need to ask someone to unlock the w/c. The COTA indicated Resident #1's manual w/c was the only chair available at the time. She further indicated when an assessment was completed the assessment would include use of the w/c locks. She stated the resident had not been assessed after the elopement for continued use of the electric w/c. The COTA further stated when the w/c was locked it could be a restraint, as well as anything that could limit or inhibit the resident's ability to move. She stated Resident #1's manual w/c was structurally different from the other reclining w/cs in the facility. Interview with the 200 Unit ADON, on 09/30/14 at 2:53 PM, revealed the facility intervention after Resident #1 eloped was to take away his/her electric w/c, although the resident moved around well in the electric w/c. He stated the resident was not as mobile or as quick in the manual w/c. The ADON indicated the manual w/c locks were located on the back of the w/c and he was unaware of the resident attempting to self -transfer. He further indicated the resident's mobility was less in the manual w/c when compared to the electric w/c. The ADON stated the manual w/c was safer for the resident as the electric w/c was so fast. He further indicated he was unaware of a plan by the facility for the resident to return to the electric w/c. The ADON stated he had not asked Resident #1 to try to un-lock the manual w/c locks located at the back of the w/c. He indicated if the locks were used and the resident could not reach the locks, the resident would be immobile and restrained. On 10/01/14 at 8:56 AM, interview with the Director of Nursing (DON) revealed that on 09/19/14 Resident #1 had gone from one end of the building to the other end and exited the facility within four (4) to five (5) minutes. She stated the facility considered fifteen (15) minute checks and 1:1 supervision; however, the facility decided to give the resident a manual w/c to use instead of the electric w/c. The DON indicated on 09/20/14 therapy was asked to see the resident to determine positioning, maneuvering, and if the resident was safe in the manual w/c. She further indicated a therapy assistant completed a screen of Resident #1 on 09/20/14; however, a therapist was not at the facility until 09/22/14. The DON indicated the resident's electric w/c was changed to a manual w/c due to Resident #1 having moved so quickly from one end of the building to the other. It was determined a high back reclining w/c would slow down the resident and help prevent the resident from eloping from the facility. She further indicated the electric w/c contributed to the resident's elopement. The DON indicated the facility would encourage the resident to use the manual w/c; however, the resident did not have to use it. She further indicated the electric w/c was stored in the medication room and the resident did not have access to it. She stated the resident could use the electric w/c when the family visited as the resident would need 1:1 due to his/her ability to go anywhere in the facility. The DON could not state why the resident could not use the electric w/c when 1:1 with activities, when the resident could use the electric w/c when 1:1 with family. The DON indicated Resident #1 was the only resident in the facility with locks at the back of the w/c and this was the only w/c available at the time. She indicated if the resident could not reach the locks at the back of the w/c, and the locks were applied, the resident's movement would be restricted. She also indicated any device that restricts movement would be considered a restraint. The DON had completed a pre-restraint assessment for the high back reclining w/c; however, she did not consider the locks at the back of the w/c as part of the assessment and did not determine if the high back reclining w/c was or was not a restraint. She stated she knew the manual w/c would slow the resident down. She further indicated the change to the manual w/c was the only intervention put into place after Resident #1 eloped from the facility. She stated Resident #1 had reported to her he/she liked the new w/c, but if the resident wanted the electric w/c, then therapy would need to assess the resident for safety and maneuverability. The DON further indicated she was unsure if Resident #1 was aware he/she had the option to use the electric w/c. Interview, on 10/01/14 at 10:42 AM, with the Administrator revealed the Interdisciplinary Team (IDT) met on 09/19/14 after the elopement and determined Resident #1's electric w/c would be changed to a manual w/c for safety. He further indicated the safety need of the manual w/c was due to the facility video showed the resident had moved from one (1) end of the building to the other in approximately four (4) minutes and would require 1:1 at all times in the electric w/c to ensure the resident's safety. The Administrator indicated he was unsure of the reason the facility chose to replace the resident's electric w/c with a manual w/c instead of using 1:1 supervision. He further indicated the care plan for Resident #1 to encourage use of the manual w/c meant to recommend the manual w/c and did not mean the resident had to use it. He stated he was unaware if Resident #1 was aware he/she could request the electric w/c. The Administrator further stated he was unaware if Resident #1 was able to use the manual locks located at the back of the w/c, and indicated he, the Administrator, would not be able to use the locks in their location. He indicated if the locks were used and the resident could not reach the locks, then they would be considered a restraint as they would limit his/her mobility. He stated the type of w/c Resident #1 used affected his/her ability to exit the facility. The Administrator indicated Resident #1 had a quicker ability to exit in the electric w/c then in the manual w/c. He stated if the resident wanted his/her electric w/c back, the facility would need to complete an electric w/c assessment. Interview with the Nurse Consultant (NC), on 09/26/14 at 4:30 PM, revealed Resident #1's family was not happy with the change to a manual w/c and was not in agreement to use it. She stated the facility felt it was a good move to place the resident in a manual w/c. The NC indicated the resident could use the electric w/c when the family was at the facility and the family requested it. The facility provided an acceptable Allegation of Compliance (AOC) on 10/31/14 alleging removal of Immediate Jeopardy on 10/29/14. The facility took the following steps: 1. Resident #1's high back reclining wheelchair had brakes installed in the rear of the chair. On 09/30/14, the facility Maintenance Director conducted an audit of all high back reclining wheelchairs with no other chairs identified as having the breaks out of the residents' reach. 2. Resident was assessed by the Psychiatric Advanced Practice Registered Nurse (APRN) on 09/22/14 for any psychosocial effects related to his/her high back reclining chair. APRN notes indicated that he/she was sitting in the wheelchair, reading at the bedside and that he/she was engaged in the conversation. APRN notes indicated no recommendations as resident was of his/her normal cognition with no noted negative effects of the new wheelchair. 3. Quality of Life Director (QOL) assessed Resident #1 on 09/20/14. QOL Director's notes indicated that she would provide 1:1 visits twice weekly during his/her transition period to ensure adequate activity and programming. The goal of these visits were to provide sensory stimulation and socialization. 4. On 10/01/14, the facility held a QA meeting with the Medical Director, Administrator, Director of Nursing, Social Worker, Rehab, Maintenance Director, MDS nurse, ADON and Nurse Consultant. In this meeting, Resident #1 was discussed regarding the placement of the brakes on his/her chair, therapy interventions which consisted of working on upper body strength, manual chair mobility and positioning. Resident #1's therapy assessment was reviewed from 09/30/14, regarding his/her ability to maneuver the manual chair independently throughout the facility and from unit to unit and the determination was made to schedule a safety assessment with the power chair. The QA team also discussed any additional interventions needed in addition to activities and therapy involvement and no other interventions were initiated at this time. QA team determined to review Resident #1 comprehensively every 30 days x 3 months, then quarterly to determine his/her psychosocial needs, alternative activities and nursing interventions for any needed changes. The Restraint and Resident Rights policy was also reviewed and no Policy and Procedure changes were made. 5. On 10/01/14, after the QA meeting, the Maintenance Director relocated the brakes that were previously located in the back to the front of the wheelchair. After the brakes were moved, the resident was assessed for restraints by the DON, dated 10/01/14, and it was determined that the wheelchair did not constitute a restraint as resident was able to use the brakes on command and he/she was able to propel the wheelchair independently from one unit to the next. The DON also made an observation on 10/01/14 of the resident correctly using the wheelchair brakes 5 out of 5 times. Resident was being observed 5 times weekly to ensure his/her consistent ability to use the wheelchair brakes by the DON, ADON and RN's. This would be documented on a calendar form and would be reviewed by the Administrator or DON weekly. 6. Therapy attempted to complete an Electric Wheelchair motorized scooter assessment on 10/01/14 with the resident and family. At that time the family was not able to come in, but did schedule for 10/02/14. This was again attempted on 10/02/14 with the family and resident declining assessment. The assessment was completed on 10/03/14 with the family present. As of the assessment on 10/03/14, it was determine by the therapist that the resident exhibited inconsistent performance with the electric chair placing him/her and others at risk. 7. On 10/06/14, 10/13/14, 10/20/14, and 10/27/14 the DON, ADON, Social Services and the Minimum Data Set (MDS) Coordinator reviewed resident's care plan for any needed changes and to address any concerns identified specific to Resident #1. It was determined that resident's care plan was current and appropriate. He/she was continuing to improve his/her mobility in his/her wheelchair, continued to work with therapy, still attended dining room for meals as well as activities of choice. It was determined by the DON that care plan reviews would occur monthly x 3 then quarterly thereafter. 8. On 10/27/14, one hundred and twenty (120) residents were assessed for restraints by the DON, ADON and RN's. Considerations were made to the different types of restraints which included standard wheelchairs, high back wheelchairs, high back reclining wheelchairs, Broda chairs, geri chairs, seat belts and side rails. Only one (1) resident was identified as having a restraint. This resident previously had been identified and currently had an existing care plan for his/her restraint. This resident's care plan was reviewed on 10/28/14 by the MDS Coordinator and no changes were made to the care plan. The MDS Coordinator was educated on Resident Rights, restraint application and care plans on 10/28/14 by the Corporate Consultant. 9. On 09/30/14, immediate education of all staff members working in the facility was completed by the Staff Development Coordinator on the wheelchair brake placement as well as not locking of wheelchair brakes except for transfers and for patient safety. On 10/28/14, the facility was informed the level of deficiency has changed from "D" level to and "IJ" level. As a result of the change in scope and severity, the facility has changed its training and this education would be ongoing with no staff member being allowed to work their shift prior to the education being completed. This education covered restraint policy and procedure and included the types of restraints, when to utilize the restraints, assessing restraints, obtaining physician orders [REDACTED]. This education would be provided to all employees in all departments including Administration, LPNs, RNs, CNAs, Dietary, Housekeeping, Therapy, Laundry, Activities, and Social Services. The training was provided by the DON, ADON, RNs, Administration and Department Heads. By 10/28/14, one hundred and thirty-five (135) staff members had been trained with sixty-three (63) employees to be trained. This would continue until all staff members received the education. The Staff Development Coordinator would ensure that all remaining staff members received their training before working and would educate all new hires during orientation. The facility does not u

Based on observation, interview, and review of the facility policy, it was determined the facility failed to be administrated in a manner that used resources effectively and efficiently to ensure the infection control program was implemented to prevent the transmission of highly infectious diseases. The facility failed to have an effective infection control program evidenced by ineffective monitoring of a visitor to the facility who was non-compliant with use of Personal Protective Equipment (PPE); inconsistent availability of PPE; improper hand hygiene by staff; lack of glove use during eye medication administration; breaks in clean technique during perineal and wound care; and lack of PPE utilization during laundry processing. This affected five (5) of twenty-four (24) sampled residents (Residents #3, #10, #13, #17, and #20) and two (2) unsampled residents (Residents L and M). (Refer to F441) On 02/12/14, Resident #17 was placed in droplet precautions after testing positive for [MEDICAL CONDITION] (MRSA) and the facility provided the Personal Protective Equipment (PPE) of gowns, masks, and gloves. Observations on 03/06/14 and 03/07/14 revealed Family Member #1 did not put on the PPE prior to entering the resident's room consistently and once in the room did not wear the PPE appropriately. Interview on 03/07/14 revealed the facility had knowledge the family member was non-compliant with wearing the PPE and left each day to return to the community. However, the facility failed to monitor the use of the PPE and did not ensure the family member was compliant with usage. Observations revealed Family Member #1 continued to be non-compliant with isolation precautions on 03/07/14 after surveyor intervention. The facility's failure to administer effectively and use it resources effectively to attain the highest practicable physical, mental and psychosocial well-being of all residents relating to Infection Control has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was identified, on 03/07/14 and determined to exist on 02/12/14. Immediate Jeopardy was identified at 42 CFR 483.20 Resident Assessment, F282 at a Scope and Severity of a "J"; 42 CFR 483.65 Infection Control, F441 and 42 CFR 483.75 Administration F490 and F520 at a Scope and Severity of a "K". The facility was notified of the Immediate Jeopardy on 03/07/14 and the Immediate Jeopardy was determined to be ongoing. The findings include: Review, on 03/07/14, of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions (Dated 2001 and Revised August 2014) revealed the Infection Preventionist, the Administrator and/or the Medical Director shall have the administrative authority, accountability, and responsibility to institute all actions necessary to control or prevent infections within the facility. Interview, on 03/06/14 at 1:20 PM with the facility's Staff Development/Infection Control Nurse, revealed she was responsible for infection control in-service education for all newly hired employees and existing staff members. Further, she provided isolation in-service education to staff every three months. Continued interview with the Staff Development Nurse revealed when newly diagnosed infections were identified and required isolation, she made sure proper signage was posted and Personal Protective Equipment (PPE) was available at the Resident's door. She stated she reviewed the resident's clinical record to obtain confirmation of the [DIAGNOSES REDACTED]. She also provided education to staff assigned to care for the resident(s) in isolation, including staff that provided dietary and housekeeping services. She also stated nursing staff was responsible for educating visitors on the use of PPE. However, observations revealed the facility's infection control program was inconsistently implemented by evidence of non-compliance with isolation precautions by both staff and a visitor, with hand hygiene and glove change during skin assessment, wound treatment, and perineal care, and by the lack of PPE use by laundry staff when when handling linens from those residents in precautions. Interview, on 03/07/14 at 2:05 PM, with the Director of Nursing (DON), revealed the Staff Development/Infection Control Nurse, the Unit Assistant Director of Nursing (ADON) and any licensed nurses on the unit were responsible to ensure isolation precautions were observed by all direct care staff and visitors, but ultimately she held herself responsible for ensuring that residents, visitors, and staff remained free from highly infectious diseases. The DON further stated the situation regarding Resident #17's family member was concerning to her because of the potential risk for transmission of disease to the visitor, other residents, and even into the community, and she was aware Family Member #1 needed frequent reminders about wearing PPE. However, there was no evidence the facility had taken action to address the issue with Resident #17's family member. Interview with the Administrator, on 03/07/14 at 8:30 AM, revealed a mock survey had been conducted in February 2014 and deficient practice was identified with hand hygiene and wearing of personal protective equipment. However, he had not taken any corrective action to address these infection control issues. Further interview, on 03/07/14 at 2:15 PM, revealed he had not been made aware of Family Member #1's noncompliance with the use of PPE until this week during the standard survey. He stated this matter would not typically be addressed in morning meetings, but he was concerned. Since learning this information, he had discussed the matter with the ADON, the Staff Development Nurse, and the DON, but did not realize the severity of the issue until now.

Based on observation, interview, record review, policy review, and the facility's Allegation of Compliance (AOC), it was determined the Immediate Jeopardy (IJ) identified during the annual survey, concluded on 03/07/14, had been removed related to the facility's failure to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of two (2) residents in isolation precautions (Resident #17). In addition, multiple breaks in technique were observed during the 03/07/14 annual survey related to hand hygiene, glove use, eye medication administration, laundry process, and use of Personal Protective Equipment (PPE). This had affected five (5) of twenty-four (24) sampled residents (Residents #3, 10, 13, 17, and 20), and two (2) of thirteen (13) Unsampled Residents (Unsampled Residents L and M). An acceptable AOC was received on 03/20/14 alleging removal of the IJ on 03/10/14. Based on the findings of the revisit, it was determined the IJ was removed on 03/10/14, as alleged, with remaining noncompliance at a scope and severity of an "E" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: The facility provided an Allegation of Compliance (AOC) on 03/20/14 alleging Immediate Jeopardy (IJ) was removed on 03/10/14; the facility took the following immediate steps to remove the IJ: 1. Review of the clinical record revealed a head-to-toe clinical assessment was completed for Resident #17 by a licensed nurse. 2. On 03/07/14, Resident #17's visitor was re-educated on proper use of Personal Protective Equipment. 3. On 03/07/14, The Signature Care Consultant posted signage on Resident #17's door that read,"Visitors- Please report to the nurses station before entering." Nursing management staff was responsible to ensure that signage stayed in place. On 03/07/14 a sign that alerted staff to the specific type of isolation and required personal protective equipment will be placed inside the isolation cart directly located outside of the residents door. The isolation specific instructions will not be visible to the general public. 4. Resident #17's visitor arrived at the facility daily at approximately 9:30 AM and will be met by staff at the facility's entrance. The visitor's personal belongings will be placed in a plastic bag and he/she will be escorted by staff to Resident #17's room, and assisted by nursing, social services, admissions personnel, or the chaplain with donning PPE. A sitter will stay with Resident #17 during the visit and ensure the visitor adheres to infection control policies and procedures, per the physician's orders [REDACTED]. The visitor's personal belongings will be removed from the bag and returned to him/her. 5. The 1:1 sitter intervention was removed on 03/14/14 when Resident #17 was cleared from Isolation Precautions. 6. Education was started on 03/07/13 and was concluded on 03/09/14, which included infection control, use of personal protective equipment (PPE), hand washing, linen/laundry handling, cross-contamination, isolation precautions for specific infections, quality assurance and care plans. This education, was taught to all staff by Nursing Administration, RN Supervisors, Social Services, Dietary Administration, Signature Care Consultant and the Administrator. 7. Medication and wound care training's were provided from 03/07/14-03/09/14 to Licensed Nurses by Administrative Nursing Personnel and the Signature Care Consultant. 8. Licensed nurses, Certified Nursing Assistants (CNAs), and Occupational Therapists (OTs) were educated on peri care from 03/07/14 to 03/09/14. Training was conducted by Nursing Administration and The Signature Care Consultant. 9. Post education testing and skills competencies (hand washing, linen handling, wound care, peri care, med pass, and donning of PPE) were started with all staff on 03/07/14 with completion on 03/09/14. 10. Signature East Louisville currently employees 197 staff members, one staff currently on leave, and with no agency staff. 11. No staff were allow to return to work without the mandated education listed above. 12. Newly hired staff will be educated during the orientation process by the Staff Development Nurse. 13. Compliance observations of staff occurred three times daily via an Infection Control Monitoring Checklist, in order to ensure adherence to infection control policies and procedures. Checklists will be kept in the AOC book in the Administrator's office. 14. Policy and Procedure Revisions, no changes as determined, on 03/08/14, by the Corporate Regional Vice President. 15. Findings would be discussed with the QA Committee to determine the need for further recommendations and additional follow-up. The DON would ensure completion of the audits, and follow up as needed. The Administrator would review the findings of the daily infection control audits Sunday through Saturday. On 03/26/14 the State Survey Agency (SSA) verified through observation, interview and record review, removal of Immediate Jeopardy (IJ) on 03/10/14, as alleged by the facility. 1. Review of Resident #17's clinical record revealed a head-to-toe assessment was completed by a licensed nurse on 03/07/14. Interview with Registered Nurse (RN) #1, on 03/25/14 at 2:35 PM, revealed she was the nurse who did a head-to-toe assessment on Resident #17 on 03/07/14. 2. Review of Resident #17's clinical record revealed the resident's visitor was educated in the proper use of Personal Protective Equipment (PPE) on 03/07/14, as care planned. Reinforcement of that education was documented on 03/08/14 and 03/09/14 in the social services notes by Social Services Director. The Social Services notes revealed the visitor expressed dissatisfaction with having to wear the PPE, but complied with the instructions. During the time Resident #17 remained in Isolation after 03/07/14, a sitter was assigned to be with the resident to assist the visitor with PPE use/compliance. Interview, on 03/25/14 at 3:35 PM, with Certified Nursing Assistant (CNA) #4 revealed she was assigned as the sitter when Resident #17's visitor was in the room, and she validated Resident #17's visitor was educated on use of PPE and proper handwashing, and complied with the instructions during each visit. 3. Record review revealed signage was posted on Resident #17's door, that directed visitors to report to the nurses' station for instructions before entering the resident's room. Nursing Management consisting of the Director of Nursing (DON), Assistant Directors of Nursing (ADONs), and the Regional Vice President (RVP), monitored signage through observations to ensure it stayed on the resident's door throughout the remaining time the resident was in isolation, and that the isolation cart was stocked with PPE and contained directions specific to Droplet Isolation. 4. Review of Resident #17's clinical record revealed his/her visitor was closely monitored, daily, for compliance with PPE use, until an order was obtained to discontinue Droplet Isolation on 03/14/14. Interview, on 03/25/14 at 3:35 PM, with Certified Nursing Assistant (CNA) #4 revealed she received infection control re-education after the identified IJ on 03/07/14, which included instruction in isolation precautions and proper hand washing technique. CNA #4 stated she was assigned to sit with Resident #17 to ensure the resident's visitor donned PPE prior to entering the room, kept it on, appropriately disposed of the PPE, and washed his/her hands before leaving the room. CNA #4 stated the visitor complied with the isolation requirements. 5. Review of the Resident #17's clinical record and care plan revealed the 1:1 sitter intervention was removed on 03/14/14 upon discontinuation of the Droplet Isolation for Resident #17, with standard precautions in place thereafter. Observation, on 03/25/14 at 11:07 AM, revealed Resident #17 seated in his/her wheel chair with the visitor seated in a chair in the room. Standard precautions were in effect. 6. Interview, on 03/26/14 at 10:22 AM, with LPN #2 revealed he attended several inservices that related to infection control on the weekend after the IJ was announced on 03/07/14. Interview, on 03/26/14 at 10:12 AM, with RN #2 revealed she had received infection control in-service education on 03/12/14 after returning from time off from work. Interview, on 03/26/14 at 10:31 AM, with CNA #3 revealed that on 03/08/14 she received re-education on infection control including isolation precautions. CNA #3 stated if she saw a visitor about to enter an isolation room, she would ask them to speak to a unit's nurse before visiting the resident. 7. Observation, on 03/25/14 at 8:25 AM, on tour of (Rosemont Street Hall) revealed an Isolation Cart at the Doorway of one room. Two residents resided in the room. The cart outside the door contained disposable gowns, disposable gloves, red bags, and a laminated instruction card with contact isolation instructions. Signage was posted on the resident's door that read, "Visitors, report to the nurse before entering the room." Interview, on 03/25/14 at 9:30 AM, with the ADON for the 200 Hall revealed Resident #26 had been transferred from the facility on 03/22/14 for evaluation/treatment at an acute care hospital. Review of Resident #26's clinical record revealed he/she had been transferred to the hospital on [DATE] for evaluation of a change in mental status. Review of Resident #25's clinical record revealed he/she had been transferred to the hospital for evaluation of itching and pain/with a [DIAGNOSES REDACTED]. Upon return to the facility, later that same day, the resident's physician ordered Contact Isolation Precautions. Further review of the clinical record (nurses' notes), on 03/25/14, revealed Resident #25's, daughter was notified by phone on, 03/25/14, of the resident's change in status, received further education in isolation precautions and PPE use when she came to visit that same day, and that the daughter voiced understanding of the instructions. Record review, on 03/25/14 at 11:00 AM, revealed logs at the 200 hall nurses' station that documented hourly monitoring of Resident #25's room/staff for adherence to infection control practice. Observation, on 03/25/14 at 8:30 AM, during tour of the Kentucky Pride Hall, revealed an Isolation Cart outside Resident #27's doorway. The cart contained disposable gowns, disposable gloves, red bags, and a laminated instruction card for contact isolation precautions. Signage posted at the door read, "Visitors, report to the nurse before entering the room." Review, on 03/25/14, of the clinical record revealed Resident #27 was placed in Contact Isolation on 03/17/14 for potential Clostridium Difficile (C. diff), with a positive [DIAGNOSES REDACTED] lab report on 03/18/14. Further review, of Resident #27's clinical record (nurses' notes) revealed the resident's daughter and grandson were educated on 03/18/14, regarding PPE use and the disease requiring Resident #27 to be in Contact Isolation. Nurses' notes revealed the family members voiced understanding of the information. Record review, on 03/25/14 at 8:35 AM revealed logs at the 300 hall nurses' station, that documented hourly monitoring of Resident #27's room/staff for adherence to infection control practice. 8. Review, of sign in sheets, training binders, and the post-tests completed by employees revealed infection control re-education began on 03/07/14, immediately after the IJ was identified. Staff that did not work on 03/07/14 received infection control re-education including instruction on isolation precautions, use of PPE, and proper handwashing technique upon reporting to work their next scheduled shift. Each staff member who received infection control in-service training was required to prove competency via a written post test, and a return demonstration of proper hand washing technique. The facility had prepared sub binders that contained documentation of those who attended wound care and medication administration trainings for licensed nurses, and perineal care re-education for licensed nurses, CNAs, and Occupational Therapists (OTs). The binders contained policies and sign-in sheets documenting the attendees. Review of the completed post-tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests fifteen (15) employees received training and were tested on [DATE], one (1) staff person was trained/tested on [DATE] and one staff person was trained/tested [DATE]. Interview, on 03/25/14 at 1:30 PM, with the facility's Signature Care RN Consultant, revealed staff that were not trained while on duty on 03/07/14, were required to attend an infection control inservice, take a post test, and perform a return demonstration of proper hand washing technique before reporting to their assigned hallway to work. The Signature Care RN Consultant stated additional in-services were conducted later in the shift for employees which included re-education in proper wound care techniques, perineal care, medication administration, and safe handling of soiled linen. Observation, on 03/25/14 at 8:30 AM, revealed CNA #4 sanitized her hands and donned appropriate PPE at Isolation room [ROOM NUMBER]. CNA #4 knocked on the resident's door before carrying in a paper (disposable) tray of breakfast items. Interview, on 03/25/14 at 3:35 PM, with CNA #4 revealed she received infection control re-education after the identified IJ on 03/07/14, which included instruction in isolation precautions and proper hand washing technique. CNA #4 stated she was assigned to sit with Resident #17 for the two (2) days Resident #17 remained in Droplet Isolation. CNA #4 stated she was to ensure Family Member #1 donned PPE on entering the resident's room, kept it on, appropriately disposed of the PPE and washed her/her hands before leaving the room. CNA #4 stated Family Member #1 complied with the isolation requirements. Review, on 03/26/14 at 11: 05 AM, of the clinical record for Resident #28, revealed he/she had been placed in Contact Isolation for potential scabies. Nurses notes revealed the resident had three (3) small pin dot scabs on her upper torso and an order for [REDACTED]. Observation, on 03/26/14 at 11:00 AM, revealed three (3) housekeeping staff persons were wearing PPE while cleaning room [ROOM NUMBER] on the Kentucky Pride Hallway where Isolation Precautions had been put into effect. Interview, on 03/25/14 at 3:50 PM, revealed Housekeeper #3 received re-education in infection control about two weeks ago, but could not remember the exact date. She stated she would don PPE as indicated on the isolation instruction card in the cart before entering the room. She would knock on the resident's door and clean. After completing the tasks she would remove the PPE, place it in the lined barrel in the room, wash her hands at the resident's sink. Housekeeper #3 stated upon cleaning her hands she used a clean paper towel to touch faucet handles. Interview, on 03/25/14 at 4:32 PM, with Laundry Services/House Keeping Staff #5, revealed she was instructed, in handwashing and proper use of PPE while processing soiled linen in the facility's laundry department, on 03/07/14. Laundry Staff Person #5 stated she was instructed to put on a disposable gown, gloves, and goggles when placing the soiled linen/towels/clothing in the washers. Interview, on 03/26/14 at 10:12 AM, with RN #2, revealed, she received infection control education, including hand washing with a required return demonstration, when she reported to work on 03/12/14, after having time off from work. RN #2 stated she understood her role in educating visitors in proper isolation precautions before and during a visit to a resident in isolation. She stated the sign posted on the resident's door directed the visitor(s) to see a nurse for guidance before entering the isolation room. Interview, on 03/25/14 at 3:45 PM, with LPN #1 revealed she was trained on 03/10/14 upon reporting to work. She stated she was not allowed to work on her unit until she attended the required infection control inservice, completed a post-test, and demonstrated proper hand washing procedure. LPN #1 stated she received additional infection control in-service education related to resident care later in that day, which were taught by the MDS nurse. Interview, on 03/25/14 with RN #1, revealed she received re-education on 03/11/14, after returning from time off from work. RN #1 stated she was not allowed to report to her unit to work until she had received re-education in infection control, which addressed Isolation Precautions, hand washing, with a required return demonstration. 9. Review of the completed post-tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests fifteen (15) employees received training and were tested on [DATE], one (1) staff person was trained/tested on [DATE] and one staff person was trained/tested [DATE]. Interview, on 03/25/14 at 1:30 PM, with the facility's Signature Care RN Consultant, revealed staff that were not trained while on duty on 03/07/14, were required to attend an infection control inservice, take a post test, and perform a return demonstration of proper hand washing technique before reporting to their assigned hallway to work. The Signature Care RN Consultant stated additional in-services were conducted later in the shift for employees which included re-education in proper wound care techniques, perineal care, medication administration, and safe handling of soiled linen. Review of the sign in sheets and curriculum in the sub-binder for medication administration training revealed from 03/07/14-03/09/14, Licensed Nurses received medication administration and wound care re-education that included observance of infection control practices. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. Interview, on 03/25/14 at 1:30 PM, with the facility's Signature Care RN Consultant, revealed staff that were not trained while on duty on 03/07/14, were required to attend an infection control inservice, take a post test, and perform a return demonstration of proper hand washing technique before reporting to their assigned hallway to work. The Signature Care RN Consultant stated additional in-services were conducted later in the shift for employees which included re-education in proper wound care techniques, perineal care, medication administration, and safe handling of soiled linen. Review, of the Care 2 Learn Online Education Infection Control Tests completed by staff revealed infection control re-education began on 03/07/14, immediately after the IJ was identified. Each test revealed the name of the employee and date the test was taken. Staff that did not work on 03/07/14 received infection control re-education including instruction on isolation precautions, use of PPE, and proper handwashing technique upon reporting to work their next scheduled shift. Each staff member who received infection control in-service training was required to prove competency via completion of the multiple choice test questions. A return demonstration of proper hand washing technique was also required before the employees could return to their assigned units. Further review, on 03/25/14, of the dated post tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests, fifteen (15) employees received training and were tested on [DATE] and two (2) staff were trained/tested after 03/10/14, due to their scheduled time off from work. None of these employees were allowed to report to their units to work before completing the required training, testing, and return demonstration. 10. Review of the Employee Listing/Signature Payroll Services list provided by the administrator, revealed the facility employed 194 staff members. Interview, on 03/25/14 at 10:15 AM, with the facility's administrator revealed the facility did not employee agency staff. 11. Interview, on 03/25/14 at 1:30 PM, with the Signature Care RN Consultant revealed after the IJ was announced on 03/07/14, and prior to reporting to their assigned units to work, all staff members were required to attend an infection control in-service, complete the Care 2 Learn Infection Control Multiple Choice Test, and demonstrate competency in proper hand washing technique. 12. Interview, on 03/26/14 at 1:00 PM, with the Administrator revealed the facility had no new staff hired from 03/11/14 to 03/26/14. Review of the Employee Listing/Signature Payroll Services list provided by the administrator, revealed the facility employed 194 staff members. Interview, on 03/25/14 at 10:15 AM, with the facility's administrator revealed the facility did not employee agency staff. 13. Review, of the Infection Control Monitoring Checklists revealed administrative staff were assigned to monitor infection control compliance three (3) times daily after the identified IJ of 03/07/14. Staff were monitored for observance of Isolation Precautions, skin/wound treatment technique, peri care technique, observance of proper hand hygiene across all facility departments and disciplines, linen handling by nursing and laundry staff, and hand hygiene and eye drop administration during med pass. Review of the Allegation of Compliance book, on 03/25/14 at 11:00 AM, revealed the Infection Control Monitoring Checklists had been completed three (3) times daily on each unit. Observation, on 03/25/14 at 8:30 AM, during tour of the facility, revealed The Staff Development Nurse was observing and assisting CNA #4 as she donned PPE before carrying a paper tray of breakfast items into Resident #27's room, who was in Contact Isolation. Observation, on 03/26/14 at 11:05 AM, revealed a Corporate Staff Person observing housekeepers who were cleaning Resident #28's room, who was in Contact Isolation. All housekeeping staff in the room appropriately donned PPE prior to entering the room. Record review, on 03/25/14 and 03/26/14, revealed logs at the 200 and 300 hall nurses' stations, that documented hourly monitoring of Resident #25, Resident #27 and Resident #28 for staff adherence to infection control practice. Record review revealed as of 03/27/14 the facility had provided 110 nursing staff with the required infection control in-service education with five (5) nursing staff members who still needed this required in-service education. Four (4) Certified Nursing Assistants (CNAs) had not received the infection control in-service. A registered letter was mailed on 03/21/14 to all who had not received the training to make them aware of this requirement. Review of the sign in sheets and curriculum in sub binder for perineal (peri) care revealed from 03/07/09- 03/09/14, Licensed Nurses, CNAs, and Occupational Therapists (OTs) were re-educated in peri care. Training was conducted by Nursing Administration and Signature Care RN Consultant. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. Interview, on 03/25/14 with RN #1, revealed she received re-education on 03/11/14, after returning from time off from work. RN #1 stated she was not allowed to report to her unit to work until she had received re-education in infection control, which addressed Isolation Precautions, hand washing (with a required return demonstration). RN #1 stated she was also required to demonstrate competency via a written post test, RN #1 stated she also attended perineal, wound care, and medication administration training later during her shift. Interview, on 03/26/14 at 10:22 AM with LPN #3, revealed he received re-education in infection control immediately upon reporting to work on 03/08/14. LPN #3 stated as soon as he clocked in to work his shift, the DON provided infection control training that included hand washing, linen handling, proper use of PPE, how to treat potentially biohazardous waste, properly sanitizing a glucometer, and other medication pass procedures. Interview, on 03/26/14 at 10:31 AM with CNA #3, revealed she received re-education in infection control on 03/08/14. CNA #3 stated she was not allowed to report to her unit to work until she had an in-service on infection control which included hand-washing with a required return demonstration. CNA #3 stated she noticed many administrative staff were in the building, and she was required to attend other in-services later that day that related to infection control and resident care. Interview, on 03/25/14 at 3:45 PM, with LPN #1 revealed when she entered the door of the facility on 03/10/14 to work the first shift, she was met by the DON, and told she was not to work on her unit until she received infection control training and demonstrated proper hand washing technique. LPN #1 stated she received additional in-service education related to peri care, med pass, and wound care later in the shift. 14. Infection control audits for handwashing, glove changes, cleaning of equipment, eye medication administration, and infection control in the laundry services department were conducted daily for one week after identification of the IJ on 03/07/14 and were to continue weekly for 12 weeks to ensure staff's adherence to policies. 15. Review of sign in sheets for Quality Assurance meeting held 03/08/14, after the IJ was idenetified on 03/07/14. The documentation revealed the purpose of this meeting was to activate processes to remove the IJ with particular emphasis on ensuring the faciltiy adhered to all of its infection control policies and procedures. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed the facility had a Quality Assurance meeting on 03/08/14 to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures, and met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of two (2) residents in isolation precautions. (Resident #17). In addition, multiple breaks in technique were observed in hand hygiene, glove use, eye medication administration, laundry process, and use of Personal Protective Equipment (PPE). This affected five (5) of twenty-four (24) sampled residents (Residents #3, 10, 13, 17, and 20), and two (2) of thirteen (13) Unsampled Residents (Unsampled Residents L and M). On 02/12/14, the facility placed Resident #17 in isolation utilizing droplet precautions due to Methicillian Resistant Staphylococcus Aureus (MRSA) of the sputum. Staff and a visitor were observed entering the isolation room without donning Personal Protective Equipment (PPE) and/or sanitizing their hands prior to and upon exiting the room. The visitor was observed to touch objects in the resident's room and sit on the resident's bed without utilizing PPE. The facility's failure to have an effective infection control program to help prevent the development and transmission of disease and infection was likely to cause serious injury, harm, impairment, or death to residents in the facility. This also affected staff, visitors and the community. Immediate Jeopardy was identified at 42 CFR 483.65 (F441) Infection Control on 03/07/14 and was determined to exist on 02/12/14. The Immediate Jeopardy was determined to be ongoing at exit of survey on 03/07/14. The findings include: Review of the facility's policy titled Visitation and Infection Control (Revised August 2012), revealed visitation was permitted during transmission-based precautions, and visitors having very close contact with the resident would be trained regarding appropriate use of infection control barriers such as PPE. Visitors must follow instructions from the charge nurse on duty regarding infection control practice and visitation restrictions. Review of the facility's policy titled Isolation-Categories of Transmission-Based Precautions, (Revised August 2012), revealed droplet precautions would be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. Masks were to be worn upon entering the room, staff and visitors would be alerted to the type of precautions the resident required, and when possible dedicate non-critical resident care equipment such as stethoscopes to a single resident to avoid sharing between residents. Review of the Droplet Precaution instruction sheet, (undated) posted for staff and visitors on Resident #17's room revealed, everyone must clean hands when entering and leaving the room, wear a mask, wear eye protection if splash or spray to eyes is likely, and if contact with body fluids is likely, use a gown, glove, mask, and eye protection. 1. Review of Resident #17's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission to the facility, Resident #17 accidentally aspirated a detergent ball, resulting in respiratory failure and a ventilator dependent status. Once stabilized at an acute care hospital, the resident continued to require suctioning every two hours and as needed, and this care was provided by the facility's Respiratory Therapist (RT) and Licensed Nurses. On 02/04/14 the facility transferred Resident #17 to an acute care hospital for evaluation of thick yellow secretions and a moderate amount of bleeding at the stoma. While hospitalized , sputum cultures tested positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). [MEDICATION NAME] 600 mg, twice daily for 10 days, was prescribed and the resident was transferred back to the facility on [DATE]. The resident completed the antibiotic therapy on 02/24/14, but remained in Droplet Precautions. On 03/04/14, an additional sputum culture revealed the resident tested positive for MRSA, and the pulmonologist ordered another course of antibiotic therapy on 03/06/14. Observation, on 03/04/14 at 8:36 AM, during initial tour of the facility's 300 Hall, revealed an isolation cart at Resident #17's door with signage posted that indicated Resident #17 was under Droplet Isolation Precautions. Interview on tour, on 03/04/14 at 9:04 AM, with Licensed Practical Nurse (LPN) #4 revealed Resident #17 was in droplet isolation due to having MRSA infection of the sputum. She stated a suction machine and air compressor were in the room as the resident had a trach. Observation of Resident #17, on 03/04/14 at 9:04 AM, revealed the resident had a tracheostomy (trach) and was lying in the bed. A suction machine and oxygen (O2) concentrator were in the room. Family Member #1 was observed to enter the room wearing a long coat and carrying bags. The family member did not apply any PPE. Observation, on 03/06/14 at 9:37 AM, revealed Family Member #1 was in Resident #17's room. Family Member #1 was wearing a disposable gown that covered the front of his/her clothing, but was not tied in the back, and the mask was not covering his/her nostrils. Family member #1 was not wearing disposable gloves and was touching buttons on the television in the room. Observation, on 03/06/14 at 10:23 AM, revealed Resident #17 was in bed, and Family Member #1 was seated at the resident's bedside wearing a disposable gown, a mask which was now covering his/her nostrils, but was not wearing disposable gloves. Interview, on 03/06/14 at 10:25 AM, revealed Family Member #1 stated he/she had not received any instruction from the facility's nursing staff on using PPE, and really did not understand why it was necessary to wear a gown and mask while in the resident's room. Family Member #1 stated the staff had not given him/her any information about the infection and why it required this type of precaution. Interview, on 03/06/14 at 3:45 PM, with the Unit Manager/Assistant Director of Nursing (ADON), 300 Hall, revealed the signage on the door of Resident #17's room informed staff and visitors of what to put on while in the room, and the nursing staff had discussed use of PPE with Family Member #1 who visited Resident #17 daily. The ADON stated Family Member #1 had been wearing PPE, but she was not sure the family member always wore gloves while in the room, and it was possible that surfaces in the room could be contaminated. Further observation, on 03/07/14 at 9:01 AM, revealed the resident's family continued to be non-compliance with the Droplet Precautions. Observations revealed an isolation cart containing disposable gowns, gloves, and masks was stationed at Resident #17's doorway. Signage for Droplet Isolation Precautions was posted on the door. Family Member #1 entered Resident #17's room wearing a long coat and carrying three bags, did not don PPE or sanitize his/her hands before entering the room. He/she placed an article of clothing on the resident's over bed table, stayed in the room, and closed the resident's door. Interview, on 03/07/14 at 10:20 AM with the Staff Development/Infection Control Nurse, revealed nursing staff was responsible for educating visitors on the use of PPE. The Staff Development Nurse stated this type of education should be documented in the nurses' notes, and she was sure Family Member #1 had been educated on several occasions regarding PPE use. However, staff caring for Resident #17 believed Family Member #1 had difficulty remembering to put on PPE because he/she had to be frequently reminded to use PPE. If staff members saw Family Member #1 not wearing the PPE, they assisted him/ her with donning the protective equipment. The Staff Development Nurse stated she did not know of any family or friends of Resident #17 who could perhaps speak to Family Member #1 and reinforce the use of the PPE. The Staff Development Nurse stated Family Member #1 always entered the front door of the facility and was required to sign in, so the receptionist would be aware each time this visitor entered the building. Review of the Resident #17's clinical record revealed no documented evidence that Family Member #1 had been educated on the use of PPE. Interview, on 03/07/14 at 2:05 PM with the DON, revealed that when a visitor such as Family Member #1 was non-compliant with use of PPE, then staff was to continue to educate the visitor and monitor the situation. The DON further stated this situation was concerning to her because of the potential risk for transmission of disease by visitors, and she was aware Family Member #1 needed frequent reminders about wearing PPE. The DON stated she was aware Resident #17 had a daughter, but she had not contacted the daughter about this situation. The DON stated the facility had explored instructing the receptionist to notify 300 Hall staff when Family Member #1 signed in to visit, so he/she could be assisted with donning the PPE upon arrival at Resident #17's room, but the facility had not yet implemented this plan. Interview, on 03/07/14 at 2:15 PM, with the facility's Administrator revealed he had not been made aware of Family Member #1's noncompliance with use of PPE until this week during the standard survey. He stated this matter would not typically be addressed in morning meetings but he was very concerned about this matter. Since learning this information, he had discussed the matter with the ADON, the Staff Development Nurse and the DON, but did not realize the severity of the issue until now. Additional observations revealed staff failed to follow the Droplet Precautions. Observation, on 03/04/14 at 4:10 PM, revealed a staff person delivering clean linen to Resident #17's room. The staff person donned a gown and mask, but did not put on gloves before entering the room. Further observations revealed there were no gloves available in the isolation cart. Observation, on 03/06/14 at 8:25 AM, revealed Resident #17 remained in Droplet Isolation, and facility's RT was administering care. The resident's eyes were open, and he/she had a tracheostomy with oxygen perfusing at 3 L/min. Interview with the RT, on 03/06/14 at 8:28 AM, revealed she had suctioned Resident #17. Continued observation, on 03/06/14 at 8:35 AM, revealed the RT disposed of her PPE in Resident #17's room, sanitized her hands, picked up her plastic clip board that had been on a dresser in the resident's room, and carried it and her stethoscope to the 300 Hall nurses' station. The RT placed her clipboard on the nurses' station desk, obtained a Medline Micro-Kill disinfectant wipe and cleaned her stethoscope. She picked up the clipboard she had placed on the countertop and cleaned it with a Micro-Kill wipe, but did not disinfect the area of the countertop where she had placed her clipboard. Interview, on 03/06/14 at 3:05 PM, with the facility's RT, revealed Resident #17 does cough, was suctioned every two hours, and as needed. Therefore, droplets from his/her respiratory tract could land on surfaces in the room, and the resident remained in Droplet Isolation because sputum cultures continued to reveal MRSA in the resident's respiratory tract. The RT stated all persons entering Resident #17's room should follow Droplet Precautions. Staff and visitors should wear a gown and a mask, and if touching surfaces in the room, gloves should be worn to prevent the potential of infecting oneself and others. The RT stated it was her personal preference to use her own stethoscope while caring for Resident #17, but ideally a stethoscope should be dedicated for use in a Droplet Isolation room. In addition, the RT stated she should have disinfected her clip board before placing it on the nurses' station desktop or disinfected that area of the desk after it had been potentially contaminated. Continued interview, on 03/06/14 at 3:45 PM, with the Unit Manager/Assistant Director of Nursing (ADON), 300 Hall, revealed inconsistencies in the use of PPE, and not properly sanitizing one's hands when entering and exiting isolation rooms, would increase the potential for the spread of those infections. 2. Review, on 03/06/14, of the clinical record for Resident #10 revealed he/she was to receive [MEDICATION NAME], two drops, four times daily, for conjunctivitis in his/her right eye. Observation, on 03/05/14 at 8:35 AM during a medication pass on the 200 Hall, revealed Registered Nurse (RN) #2 did not wash her hands or don gloves prior instilling the eye drops into Resident #10's right eye. After administering the eye drops, RN #2 did not wash her hands with soap and water, but exited the resident's room and used hand sanitizer at the med cart. Interview, on 03/07/14 at 10:47 AM with RN #2, revealed she should have washed her hands and donned gloves prior to administering the [MEDICATION NAME] eye drops to Resident #10. In addition, RN #2 stated she should have washed her hands with soap and water after administering the eye drops, and she did not. RN #2 stated the potential problem with not washing her hands and using gloves was the potential for spreading Resident #10's contagious eye infection to other residents, herself, and other staff. Interview, on 03/06/14 at 2:30 PM with the ADON for the 200 Hall, revealed RN #2 should have washed her hands and donned clean gloves prior to administering [MEDICATION NAME] eye drops to Resident #10. In addition, she should have used soap and water to clean her hands after administering the medication. The problem with not [MEDICATION NAME] hand washing and glove use would be the potential for spreading the infection to other residents and staff. 3. Review of the facility policy, Laundry and Linen, revised November 2011, revealed all soiled linen should be considered potentially hazardous. Employees sorting or washing linens should wear a gown and gloves. Observation of the laundry room, on 03/06/14 at 9:16 AM, revealed a zip top type of bag hanging on a wall with a gown, gloves, and mask. A box of gloves was observed on a shelf in the clean linen area of the laundry room. Interview with Laundry Aide (LA) #2, on 03/06/14 at 9:21 AM, revealed all facility and resident laundry from rooms in isolation precautions was mixed in with linens and personal laundry from residents who were not in isolation. He stated the last time he had worn PPE was about six (6) months ago when there was a potential for bed bugs in the facility. The LA stated the PPE was to prevent the spread of disease. On 03/07/14 at 11:35 AM and 2:07 PM, interview with the Director of Nursing (DON) revealed all laundry from rooms in isolation precautions were treated the same as all other linen. She stated if laundry staff did not wear PPE when handling non-infectious linen, then they would not need PPE to handle other laundry; however, all linens should be considered infectious. The DON stated the Staff Development Coordinator conducted orientation for all employees, however, was unsure if training of laundry staff included infection control and use of PPE. She indicated laundry staff should wear PPE when handling linens and laundry due to the potential for staff to become contaminated from infectious laundry. Interview, on 03/07/14 at 2:07 PM, with the Administrator revealed he was unsure how laundry was processed. He indicated all laundry should be handled as if it were contaminated and laundry aides should use universal precautions. 4. Review of the clinical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13 was being followed by a wound care specialist. In addition, the facility's nursing staff was to administer ordered treatments to pressure ulcers on the right ischial area of the hip and the coccyx. Observation, on 03/04/14, at 5:45 PM of Resident #13's wound care treatment, revealed RN #1 broke clean technique several times. RN #1 did not prepare a clean field prior to placing the treatment supplies on the resident's over bed table, and on multiple occasions during the wound care, the RN #1 failed to properly wash her hands. Each time RN #1 washed her hands in the resident's bathroom, she turned off the faucets with her bare hands. RN #1 placed two unopened 4 x 4 packets on top of the toilet seat lid in the resident's bathroom, washed her hands, left the water running and donned clean gloves. RN #1 opened another 4 x 4 packet, not one of the packets on the toilet, dampened the 4 x 4, and then turned off the faucet with her gloved hand. RN #1 used her contaminated gloved hand to then place the dampened 4 x 4 on Resident #13's coccyx wound. Interview, on 03/07/14 at 9:20 AM, with RN #1 stated she should have turned off the water faucets with a paper towel when delivering care to Resident #13. In addition, RN #1 stated she should not have turned off faucets with clean gloves on, and she should not have provided wound care to Resident #13 without first removing those gloves, washing her hands, and donning clean gloves. RN #1 stated she should not have cleansed the resident's coccyx wound with the 4 x 4 after it had been touched by her soiled glove because such breaks in clean technique would cause contamination of the resident's wound. 5. Observation, on 03/05/14 at 11:00 AM, during a medication pass on the 300 Hall, revealed RN #1 washed her hands prior to administering Un-sampled Resident M's [DEVICE] supplement and medication, but turned off the faucets with her bare hands. RN #1 washed her hands before exiting the resident's room, but again, turned off the faucet with her bare hands. Interview, on 03/07/14 at 9:20 AM, with RN #1 stated she should have turned off the water faucets with a paper towel. 6. Observation, on 03/04/14 at 6:15 PM, on the 200 Hall, CNA #2 entered Un-sampled Resident L's room, delivered a meal tray, washed her hands in the resident's bathroom, turned off the faucet with her bare hands and then returned to assist the resident with cutting up his/her food. Interview, on 03/06/14 at 3:10 PM with CNA #2, revealed she knew to turn off faucet handles with a paper towel after completing hand washing, and the problem with not observing all steps in the hand washing process was the potential for cross-contamination and exposing residents and staff to unwanted infections. CNA #2 stated she had received two (2) hand washing in-services during her six (6) months of employment at the facility. 7. Observation during a skin assessment with LPN #1, on 03/04/14 at 3:00 PM, revealed the nurse assessed Resident #3's skin from head to toe. The nurse put on clean gloves without performing hand hygiene. Then LPN #1 moved from head, face, shoulders, chest, to the abdomen. The nurse removed the resident's brief and touch the resident's buttocks, perineum, and inner thighs. The resident had a superficial open area on the left buttocks with the pressure ulcer closed on the right buttocks. The nurse touched the buttocks with the same gloves. When barrier cream was not found on the resident's buttocks nor the brief, the nurse searched the room for the barrier cream with the same gloves. LPN #1 touched the resident's night stand, chest, and bed with the gloves used to touch the perineum. The nurse continued with the skin assessment and touch the resident's arms, legs, and feet with the same gloves. The nurse then changed her gloves and applied clean gloves without performing hand hygiene. LPN #1 then covered and repositioned the resident. Interview, with LPN #1 on 03/04/14 at 3:08 PM, revealed she recognized she had failed to change gloves when going from an area considered dirty (perineal area) to other body areas. She stated she should have washed her hands between glove changes. She indicated she was aware of the CDC guidelines and facility policy on hand hygiene and glove change. She stated she would have usually changed her gloves. 8. Observation of perineal care and incontinent care for Resident #20, on 03/06/14 at 10:03 AM, revealed Certified Nursing Assistant (CNA) #6 used the same soiled gloves used to clean fecal matter to assist the resident with dressing. The CNA was observed searching through the residents sock drawer and hygiene products wearing the same soiled gloves. Interview with CNA #6, on 03/06/14 at 10:28 AM, revealed the CNA did not realize she was using the soiled gloves while dressing the resident. The CNA revealed she started working at the facility a month ago and did receive education on infection control during the orientation process. Interview, on 03/06/14 at 1:20 PM revealed the Staff Development Nurse was responsible for tracking and trending infections, providing in-service education and ongoing training to staff members in infection control measures, which included in-services on isolation precautions every three (3) months. The infection control nurse stated the Corporation did not provide specific expectations on how she was to track/trend or aggregate data regarding infections within the facility. Continued interview, on 03/07/14 at 2:05 PM with the DON, revealed the Staff Development/Infection Control Nurse, the Unit ADON's and any licensed nurses on the unit were responsible to ensure isolation precautions were observed by all direct care staff and visitors, but ultimately, she held herself responsible for maintaining a safe infection control program at the facility. The nursing administration and all nurses were responsible for ensuring visitors were instructed on how to use PPE, but again, she held herself responsible for ensuring that residents, visitors, and staff remained free from highly infectious diseases.

Based on observation, interview, record review, review of facility's policy, and the facility's Allegation of Compliance (AOC), it was determined the Immediate Jeopardy (IJ) identified during the annual survey, concluded on 03/07/14, had been removed related to the facility's Quality Assurance (QA) Committee failure to identify quality deficiencies and develop and implement appropriate plans of action to correct identified quality deficiencies. During the 03/07/14 annual survey it was determined the facility received the findings of the mock survey, conducted in January 2014, the third week of February 2014 which identified deficiencies with hand hygiene and wearing of Personal Protective Equipment (PPE). However, the facility had not developed or implemented action plans to correct the identified quality deficiencies. An acceptable AOC was received on 03/20/14 alleging removal of the IJ on 03/10/14. Based on the findings of the revisit, it was determined the IJ was removed on 03/10/14, as alleged, with remaining noncompliance at a scope and severity of an "E" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: The facility provided an Allegation of Compliance (AOC) on 03/20/14 alleging Immediate Jeopardy (IJ) was removed on 03/10/14; the facility took the following immediate steps to remove the IJ: 1. Quality Assurance (Ad Hoc) Meeting held on 03/08/14. The purpose of meeting was to ensure all infection control policies were adhered to for removal of the Immediate Jeopardy (IJ) Status. Actions taken: Discussed infection control policies/procedures; investigated root cause of infection control policy infraction; identified tasks necessary to prevent future infection control infractions; and, Department Directives/Assignments made for tasks/interventions to address the current infection control infraction and to prevent future infractions. The Performance Improvement (PI) Plan was reviewed for further recommendations. The PI plan was approved by the QA committee and the Medical Director. 2. The Administrator was to oversee the QA committee meetings in conjunction with the DON, the IDT, the Medical Director, and the VP of Operations. The Regional Nurse Consultant will provide oversight daily x 5 days for one week, then once weekly for 4 weeks, and then monthly for 3 months. 3. The Administrator and DON received in-service education from the VP of Operations on 03/08/14 regarding the requirements for the quality assurance process. In addition, the DON, Staff Development Nurse, ADON, Unit Manager, MDS Nurse, Medical Records, Signature Care Consultant, the RD,and the Certified Dining Manager received training for the QA process, with the identified concerns, on 03/08/14. 4. On 03/08/14, The Administrator met with the administrative team and imitated a process to introduce, develop, and implement plans for the identified concerns. Concerns were to be addressed daily in the morning meetings, plans were developed, and teams were assigned to correct the concerns. Infection control check lists and monitoring audits were assigned to the DON, ADON, Licensed Nurses, Admissions Director, and the Assistant Administrator, with subsequent evaluation of the plan's effectiveness. 5. Findings would be discussed with the QA Committee to determine the need for further recommendations and additional follow-up. The DON would ensure completion of the audits, and follow up as needed. The Administrator would review the findings of the daily infection control audits Sunday through Saturday. On 03/26/14 the State Survey Agency (SSA) verified through observation, interview and record review, removal of Immediate Jeopardy (IJ) on 03/10/14, as alleged by the facility. 1. Review of sign in sheets for Quality Assurance meeting held 03/08/14, after the IJ was identified on 03/07/14. The documentation revealed the purpose of this meeting was to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures. In addition, the QA committee met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. The next QA meeting was scheduled for 03/28/14. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed the facility had a Quality Assurance meeting on 03/08/14 to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures, and met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. Interview, on 03/25/14 at 1:30 PM with the facility's Regional RN Consultant, revealed she had conducted a QA Process in-service with additional facility staff members on 03/10/14, and a Sign-In Sheet documented members in attendance. In addition, the RN Consultant stated she was in the process of monitoring the QA committee's work per the schedule outlined in the AOC. 2. Review of sign in sheets for Quality Assurance meeting held 03/08/14, after the IJ was identified on 03/07/14. The documentation revealed the purpose of this meeting was to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures. In addition, the QA Committee met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. The next QA meeting was scheduled for 03/28/14. The Administrator is to oversee the infection control policy adherence and care plan audit processes to ensure results are forwarded to the QA Committee for weekly then monthly review and assure continued compliance during identified time frames. Interview, on 03/26/14 at 1:00 PM, with the facility's Administrator revealed he received the infection control audits and reviewed them with the DON, daily, to ensure proper follow up occurred as indicated. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed the facility had a Quality Assurance meeting on 03/08/14 to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures, and met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. Interview, on 03/25/14 at 1:30 PM with the facility's Regional RN Consultant, revealed she had conducted a QA Process in-service with additional facility staff members on 03/10/14, and a Sign-In Sheet documented members in attendance. In addition, The RN Consultant stated she was in the process of monitoring the QA committee's work per the schedule outlined in the AOC. 3. Review of the Quality Assurance Process Training sign in sheet revealed this inservice was held on 03/08/14, and conducted by the Corporation's Regional Vice President. Copies of the policies reviewed during this meeting were attached and reviewed. The DON and Administrator attended this inservice. 4. Review of the facility's Performance Improvement Plan with Abaqis curricula, provided as part of the QA training of 03/08/14, revealed the Administrator was a required member of the facility's Performance Improvement (PI) Committee. The PI Committee would be comprised of the Administrator, along with other administrative staff, and at least two other facility employees. The facility would identify and monitor activities that focus on processes that significantly affect resident outcomes. This ongoing monitoring by the Administrator and The Signature Care Consultant would establish the facility's baseline and the predictability of various outcomes. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed he and The Signature Care Consultant would identify and monitor activities that focus on processes that significantly affect resident outcomes which would establish a baseline and the predictability of various outcomes. Interview with Registered Nurse (RN) Consultant, on 03/25/14 at 1:30 PM, revealed she conducted a QA process in-service on 03/10/14 for additional facility employees, and was in the process of monitoring the QA Committee's work by the schedule defined in the AOC. Review, on 03/25/14 of the facility's AOC revealed the Administrator met with the administrative team on 03/08/14 to plan for removal of the IJ called on 03/07/14. Persons in attendance included the Medical Director (by phone), the Administrator, the DON, the Staff Development Coordinator, the Nurse Practitioners, the RVP, and The Signature Care Consultant. The AOC revealed infection control check lists and monitoring audits were assigned to the DON, ADONs, other licensed nurses, the Admissions Director, and the Assistant Administrator. Time parameter for re-educating staff on infection control and ensuring competency in the topic was 03/07/13-03/09/13 with alleged compliance on 03/10/14. Review of employees' re-education post tests regarding infection control which began on 03/07/14 revealed most staff were trained by 03/09/14. Review of the employees' post tests revealed fifteen (15) employees were trained on 03/10/14, one employee on 03/11/14, and one employee on 03/12/14. None of the employees were allowed to work on their assigned units until they attended the infection control in-service and proved their competency via a written post test and a return demonstration of proper hand washing technique. 5. Review of attendance sheets for the Quality Assurance (QA) inservice training was conducted on by Corporate Vice President on 03/08/14 with the Administrator and DON in attendance. A second QA inservice was held on 03/10/14 by the Regional RN Consultant. The Sign In Sheet revealed twenty-one (21) staff persons were in attendance at this session, which included staff who would be conducting audits and monitoring for infection control policy adherence across all units in the facility. Signatures of the Staff Development/Infection Control Nurse, the Assistant Administrator, the ADON/Unit Managers, other Licensed Nurses, the facility's Registered Dietician (RD), and the Administrator were listed. Review of the AOC revealed the purpose of these meetings was to implement processes for removal of the IJ identified on 03/07/14 during the standard survey, and included implementing procedures to ensure to ensure staff adherence to infection control policies and procedures. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed there was a Quality Assurance (QA) inservice training conducted by the Corporate Vice President on 03/08/14 with the Administrator and DON in attendance. He stated a second QA inservice was held on 03/10/14 by the Regional RN Consultant. He further stated the purpose of these meetings was to implement processes for removal of the IJ identified on 03/07/14 during the standard survey, and included implementing procedures to ensure to ensure staff adherence to infection control policies and procedures. Review of the Infection control audits for handwashing, glove changes, cleaning of equipment, eye medication administration, and infection control in the laundry services department revealed they were conducted daily for one (1) week after identification of the IJ on 03/07/14. The audits were to continue weekly for twelve (12) weeks to ensure policy adherence. Review of the audits of the staff members' compliance with the Interdisciplinary Team (IDT)/CNA care plans revealed they were conducted during provision of resident care, daily for thirty (30) days. Any variance to care as planned was addressed immediately with re-education or disciplinary action. Licensed staff completed post-test competency training on IDT and CNA care plans. As of 03/27/14 ninety-five (95) staff had completed the post-test with twenty (20) staff remaining who had not completed the post-test competency. Care plan adherence audits were to continue after the initial daily audits for thirty (30) days, weekly for thirty (30) days, and then as determined by the QA Committee to ensure compliance. The Administrator is to oversee the infection control policy adherence and care plan audit processes to ensure results are forwarded to the QA Committee for weekly then monthly review and assure continued compliance during identified time frames. Interview, on 03/26/14 at 1:00 PM, with the facility's Administrator revealed he received the infection control audits and reviewed them with the DON, daily, to ensure proper follow up occurred as indicated.

Based on observation, interview, record review, and review of facility policy it was determined the facility's Quality Assurance (QA) Committee failed to identify quality deficiencies, and to develop and implement appropriate plans of actions to correct identified quality deficiencies. A mock survey was conducted at the nursing facility the last week in January 2014. The facility received the findings of the mock survey the third week of February 2014 that identified deficiencies with hand hygiene and wearing of Personal Protective Equipment (PPE). However, the facility had not developed or implemented action plans to correct the identified quality deficiencies. Based on the findings of the standard survey, the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of two (2) residents in isolation precautions (Resident #17). In addition, multiple breaks in technique were observed in hand hygiene, glove use, eye medication administration, laundry process, and use of Personal Protective Equipment (PPE). (Refer to F441 and F490) On 02/12/14, Resident #17 was placed in droplet precautions after testing positive for [MEDICAL CONDITION] (MRSA). The facility provided the necessary PPE of gown, mask, and gloves. Observations revealed Family Member #1 did not consistently put on the PPE prior to entering the resident's room and once in the room did not wear the PPE appropriately. The facility had knowledge the family member was non-compliant with wearing the PPE and leaving each day to return to the community. The facility failed to monitor the use of the PPE and did not ensure staff and visitors were compliant with usage. The facility's failure to have an effective system in place to ensure the QA committee functioned according to their policy to identify quality deficiencies, develop plans of action, and implement the plans of action placed residents in a situation that has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was identified on 03/07/14 and determined to exist on 02/12/14. Immediate Jeopardy was identified at 42 CFR 483.20 Resident Assessment, F282 at a Scope and Severity of a "J"; 42 CFR 483.65 Infection Control, F441; and 42 CFR 483.75 Administration F490 and F520 all at a Scope and Severity of a "K". The facility was notified of the Immediate Jeopardy on 03/07/14 and the Immediate Jeopardy was determined to be ongoing. The findings include: Review of the Performance Improvement Plan with Abaqis, not dated, provided by the facility as their policy for Quality Assurance, revealed this plan was synonymous with the Center for Medicare/Medicaid (CMS) regulatory QA requirements. Under the section Standard of Practice, the policy stated the facility was to conduct an on-going performance improvement (PI) program to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. The facility would examine both outcomes and processes relevant to these outcomes with the objective of improving overall performance. The facility would identify areas for Performance Improvement monitoring and resources to be used. These monitoring activities should focus on processes that significantly affect resident outcomes. During review of the facility's Quality Assurance (QA) Committee, it was determined the facility failed to identify quality deficiencies and develop and implement appropriate plans of actions to correct any identified quality deficiencies. A mock survey was conducted at the nursing facility the last week in January 2014. The facility received the findings of the mock survey the third week of February 2014 that reviewed deficiencies with hand hygiene and wearing of personal protective equipment (PPE). Observation, interview, and record review during the standard survey revealed the facility's infection control program was inconsistently implemented. Observation revealed non-compliance with isolation precautions by both staff and a visitor regarding Resident #17. Infection control concerns were also identified with hand hygiene and glove change during skin assessment, wound treatment, perineal care, and the lack of PPE use by laundry staff. Interview with the Administrator and Director of Nursing, on 03/07/14 at 8:30 AM, revealed infection control issues were discussed at the quarterly QA meetings. Infections were tracked and trended with graphs and charts of all infections in the facility. The Administrator revealed a mock survey was conducted by the Corporation the last week in January. He shared there were problems identified in hand hygiene and the use of the PPE. However, the Administrator stated he did not get the results of the mock survey until the third week of February (Feb. 17-21, 2014) and was still working on plans of action and had not yet implemented any actions to address the deficiencies that were cited. He stated the last QA meeting was held on 02/06/14 before he received the deficiencies from the mock survey. Therefore, the QA committee had not met to discuss action plans to correct those deficiencies.

Based on observation, interview, policy review, and the facility's Allegation of Compliance (AOC), it was determined the Immediate Jeopardy (IJ) identified during the annual survey, concluded on 03/07/14, had been removed related to the Administration's failure to have an effective infection control program as evidenced by ineffective monitoring of a visitor to the facility who was non-compliant with use of Personal Protective Equipment (PPE); inconsistent availability of PPE; improper hand hygiene by staff; lack of glove use during eye medication administration; breaks in clean technique during perineal and wound care; and lack of PPE utilization during laundry processing. An acceptable AOC was received on 03/20/14 alleging removal of the IJ on 03/10/14. Based on the findings of the revisit, it was determined the IJ was removed on 03/10/14, as alleged, with remaining noncompliance at a scope and severity of an "E" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: The facility provided an Allegation of Compliance (AOC) on 03/20/14 alleging Immediate Jeopardy (IJ) was removed on 03/10/14; the facility took the following immediate steps to remove the IJ: 1. Education was started on 03/07/13 and was concluded on 03/09/14, which included infection control, use of personal protective equipment (PPE), hand washing, linen/laundry handling, cross-contamination, isolation precautions for specific infections, quality assurance and care plans. This education, was taught to all staff by Nursing Administration, RN Supervisors, Social Services, Dietary Administration, Signature Care Consultant and the Administrator. 2. Medication and wound care trainings were provided from 03/07/14-03/09/14 to Licensed Nurses by Administrative Nursing Personnel and the Signature Care Consultant. 3. Licensed nurses, Certified Nursing Assistants (CNAs), and Occupational Therapists (OTs) were educated on peri care from 03/07/14 to 03/09/14. Training was conducted by Nursing Administration and The Signature Care Consultant. 4. Post education testing and skills competencies (hand washing, linen handling, wound care, peri care, med pass, and donning of PPE) were started with all staff on 03/07/14 with completion on 03/09/14. 5. Signature East Louisville currently employees 197 staff members, one staff currently on leave, and with no agency staff. 6. No staff were allow to return to work without the mandated education listed above. 7. Newly hired staff will be educated during the orientation process by the Staff Development Nurse. 8. Compliance observations of staff occurred three times daily via an Infection Control Monitoring Checklist, in order to ensure adherence to infection control policies and procedures. Checklists will be kept in the AOC book in the Administrator's office. 9. Quality Assurance (Ad Hoc) Meeting held on 03/08/14. The purpose of meeting was to ensure all infection control policies were adhered to for removal of the Immediate Jeopardy (IJ) Status. Actions taken: Discussed infection control policies/procedures; investigated root cause of infection control policy infraction; identified tasks necessary to prevent future infection control infractions; and, Department Directives/Assignments made for tasks/interventions to address the current infection control infraction and to prevent future infractions. The Performance Improvement (PI) Plan was reviewed for further recommendations. The PI plan was approved by the QA committee and the Medical Director. 10. The Administrator was to oversee the QA committee meetings in conjunction with the DON, the IDT, the Medical Director, and the VP of Operations. The Regional Nurse Consultant will provide oversight daily x 5 days for one week, then once weekly for 4 weeks, and then monthly for 3 months. 11. The Administrator and DON received in-service education from the VP of Operations on 03//08/14 regarding the requirements for the quality assurance process. In addition, the DON, Staff Development Nurse, ADON, Unit Manager, MDS Nurse, Medical Records, Signature Care Consultant, the RD,and the Certified Dining Manager received training for the QA process, with the identified concerns, on 03/08/14. 12. On 03/08/14, The Administrator met with the administrative team and initiated a process to introduce, develop, and implement plans for the identified concerns. Concerns were to be addressed daily in the morning meetings, plans were developed, and teams were assigned to correct the concerns. Infection control check lists and monitoring audits were assigned to the DON, ADON, Licensed Nurses, Admissions Director, and the Assistant Administrator, with subsequent evaluation of the plan's effectiveness. 13. Findings would be discussed with the QA Committee to determine the need for further recommendations and additional follow-up. The DON would ensure completion of the audits, and follow up as needed. The Administrator would review the findings of the daily infection control audits Sunday through Saturday. On 03/26/14 the State Survey Agency (SSA) verified through observation, interview and record review, removal of Immediate Jeopardy (IJ) on 03/10/14, as alleged by the facility. 1. Review of the facility's care plan in-service sign in sheets and curriculum for that in-service revealed care plan implementation/revisions training was conducted on 03/09/14 by the facility's Regional Registered Nurse (RN) Consultant. A copy of the sign-in sheet (attendees) was provided which included names of the ADONs, the Staff Development/Infection Control Nurse, and other licensed nurses. Copies of the curriculum included the following policies: Interdisciplinary team care planning process (Dated 12-2010); Interdisciplinary Team Care Assessments (Dated 12-2010); Daily Review of physician's orders [REDACTED]. Content of the At Risk Meetings Policy stated the meetings were conducted to focus the Interdisciplinary Team (IDT) on care standards, problem solving, care planning, intervening upon a change in a resident's condition, and communication across the IDT. Further review of documentation from this training revealed care plans of residents with changes in status would be reviewed daily in clinical meetings by the IDT. Any changes deemed necessary would be completed and then care plans would be monitored by the DON, ADONs, and the Minimum Data Set (MDS) nurses. Review, of sign in sheets, training binders, and the post-tests completed by employees revealed infection control re-education began on 03/07/14, immediately after the IJ was identified. Staff that did not work on 03/07/14 received infection control re-education including instruction on isolation precautions, use of PPE, and proper handwashing technique upon reporting to work their next scheduled shift. Each staff member who received infection control in-service training was required to prove competency via a written post test, and a return demonstration of proper hand washing technique. The facility had prepared sub-binders that contained documentation of those who attended wound care and medication administration trainings for licensed nurses, and perineal care re-education for licensed nurses, CNAs, and Occupational Therapists (OTs). The binders contained policies and sign-in sheets documenting the attendees. Review of the completed post-tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests fifteen (15) employees received training and were tested on [DATE], one (1) staff person was trained/tested on [DATE] and one staff person was trained/tested [DATE]. Interview, on 03/25/14 at 1:30 PM, with the facility's Signature Care RN Consultant, revealed staff that were not trained while on duty on 03/07/14, were required to attend an infection control inservice, take a post test, and perform a return demonstration of proper hand washing technique before reporting to their assigned hallway to work. The Signature Care RN Consultant stated additional in-services were conducted later in the shift for employees which included re-education in proper wound care techniques, perineal care, medication administration, and safe handling of soiled linen. Interview, on 03/26/14 at 10:22 AM, with LPN #2 revealed he attended a care plan inservice 03/08/14-03/09/14 along with several other inservices that related to infection control on the weekend after the IJ was announced on 03/07/14. Interview, on 03/26/14 at 10:12 AM, with RN #2 revealed she had received care plan and infection control in-service education on 03/12/14 after returning from time off from work. RN #2 stated licensed nurses were responsible for educating visitors in consistent use of PPE. Interview, on 03/26/14 at 10:31 AM, with CNA #3 revealed that on 03/08/14 she received re-education on infection control including isolation precautions. CNA #3 stated if she saw a visitor about to enter an isolation room, she would ask them to speak to a unit's nurse before visiting the resident. Observation, on 03/25/14 at 8:30 AM, revealed CNA #4 sanitized her hands and donned appropriate PPE at Isolation room [ROOM NUMBER]. CNA #4 knocked on the resident's door before carrying in a paper (disposable) tray of breakfast items. Interview, on 03/25/14 at 3:35 PM, with CNA #4 revealed she received infection control re-education after the identified IJ on 03/07/14, which included instruction in isolation precautions and proper hand washing technique. Observation, on 03/26/14 at 11:00 AM, revealed three (3) housekeeping staff persons were wearing PPE while cleaning room [ROOM NUMBER] on the Kentucky Pride Hallway where Isolation Precautions had been put into effect. Interview, on 03/25/14 at 3:50 PM, revealed Housekeeper #3 received re-education in infection control about two weeks ago and she would don PPE as indicated on the isolation instruction card in the cart before entering the room. She would knock on the resident's door and clean. After completing the tasks she would remove the PPE, place it in the lined barrel in the room, wash her hands at the resident's sink. Housekeeper #3 stated upon cleaning her hands she used a clean paper towel to touch faucet handles. Interview, on 03/25/14 at 4:32 PM, with Laundry Services/House Keeping Staff #5, revealed she was instructed, in handwashing and proper use of PPE while processing soiled linen in the facility's laundry department, on 03/07/14. Laundry Staff Person #5 stated she was instructed to put on a disposable gown, gloves, and goggles when placing the soiled linen/towels/clothing in the washers. Interview, on 03/26/14 at 10:12 AM, with RN #2, revealed, she received infection control education, including hand washing with a required return demonstration, when she reported to work on 03/12/14, after having time off from work. RN #2 stated she understood her role in educating visitors in proper isolation precautions before and during a visit to a resident in isolation. She stated the sign posted on the resident's door directed the visitor(s) to see a nurse for guidance before entering the isolation room. Interview, on 03/25/14 at 3:45 PM, with LPN #1 revealed she was trained on 03/10/14 upon reporting to work. She stated she was not allowed to work on her unit until she attended the required infection control inservice, completed a post-test, and demonstrated proper hand washing procedure. LPN #1 stated she received additional infection control in-service education related to resident care later in that day, which were taught by the MDS nurse. Interview, on 03/25/14 with RN #1, revealed she received re-education on 03/11/14, after returning from time off from work. RN #1 stated she was not allowed to report to her unit to work until she had received re-education in infection control, which addressed Isolation Precautions, hand washing, with a required return demonstration. 2. Review of the sign in sheets and curriculum in the sub-binder for medication administration training revealed from 03/07/14-03/09/14, Licensed Nurses received medication administration and wound care re-education that included observance of infection control practices. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. 3. Review of the sign in sheets and curriculum in sub binder for perineal (peri) care revealed from 03/07/09- 03/09/14, Licensed Nurses, CNAs, and Occupational Therapists (OTs) were re-educated in peri care. Training was conducted by Nursing Administration and Signature Care RN Consultant. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. Interview, on 03/25/14 with RN #1, revealed she received re-education on 03/11/14, after returning from time off from work. RN #1 stated she was not allowed to report to her unit to work until she had received re-education in infection control, which addressed Isolation Precautions, hand washing (with a required return demonstration). RN #1 stated she was also required to demonstrate competency via a written post test, RN #1 stated she also attended perineal, wound care, and medication administration training later during her shift. Interview, on 03/26/14 at 10:22 AM with LPN #3, revealed he received re-education in infection control immediately upon reporting to work on 03/08/14. LPN #3 stated as soon as he clocked in to work his shift, the DON provided infection control training that included hand washing, linen handling, proper use of PPE, how to treat potentially biohazardous waste, properly sanitizing a glucometer, and other medication pass procedures. Interview, on 03/26/14 at 10:31 AM with CNA #3, revealed she received re-education in infection control on 03/08/14. CNA #3 stated she was not allowed to report to her unit to work until she had an in-service on infection control which included hand-washing with a required return demonstration. CNA #3 stated she noticed many administrative staff were in the building, and she was required to attend other in-services later that day that related to infection control and resident care. 4. Review, of the Care 2 Learn Online Education Infection Control Tests completed by staff revealed infection control re-education began on 03/07/14, immediately after the IJ was identified. Each test revealed the name of the employee and date the test was taken. Staff that did not work on 03/07/14 received infection control re-education including instruction on isolation precautions, use of PPE, and proper handwashing technique upon reporting to work their next scheduled shift. Each staff member who received infection control in-service training was required to prove competency via completion of the multiple choice test questions. A return demonstration of proper hand washing technique was also required before the employees could return to their assigned units. Further review, on 03/25/14, of the dated post tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests, fifteen (15) employees received training and were tested on [DATE] and two (2) staff were trained/tested after 03/10/14, due to their scheduled time off from work. None of these employees were allowed to report to their units to work before completing the required training, testing, and return demonstration. 5. Review of the Employee Listing/Signature Payroll Services list provided by the administrator, revealed the facility employed 194 staff members. Interview, on 03/25/14 at 10:15 AM, with the facility's administrator revealed the facility did not employee agency staff. 6. Interview, on 03/25/14 at 1:30 PM, with the Signature Care RN Consultant revealed after the IJ was announced on 03/07/14, and prior to reporting to their assigned units to work, all staff members were required to attend an infection control in-service, complete the Care 2 Learn Infection Control Multiple Choice Test, and demonstrate competency in proper hand washing technique. 7. Interview, on 03/26/14 at 1:00 PM, with the Administrator revealed the facility had no new staff hired from 03/11/14 to 03/26/14. 8. Review, of the Infection Control Monitoring Checklists revealed administrative staff were assigned to monitor infection control compliance three (3) times daily after the identified IJ of 03/07/14. Staff were monitored for observance of Isolation Precautions, skin/wound treatment technique, peri care technique, observance of proper hand hygiene across all facility departments and disciplines, linen handling by nursing and laundry staff, and hand hygiene and eye drop administration during med pass. Review of the Allegation of Compliance book, on 03/25/14 at 11:00 AM, revealed the Infection Control Monitoring Checklists had been completed three times daily on each unit. 9. Review of attendance sheets for the Quality Assurance (QA) inservice training was conducted on by Corporate Vice President on 03/08/14 with the Administrator and DON in attendance. A second QA inservice was held on 03/10/14 by The Regional RN Consultant. The Sign In Sheet revealed twenty-one (21) staff persons were in attendance at this session, which included staff who would be conducting audits and monitoring for infection control policy adherence across all units in the facility. Signatures of the The Staff Development/Infection Control Nurse, the Assistant Administrator, the ADON/Unit Managers, other Licensed Nurses, the facility's Registered Dietician (RD), and the Administrator were listed. Review of the AOC revealed the purpose of these meetings was to implement processes for removal of the IJ identified on 03/07/14 during the standard survey, and included implementing procedures to ensure staff adherence to infection control policies and procedures. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed there was a Quality Assurance (QA) inservice training conducted by Corporate Vice President on 03/08/14 with the Administrator and DON in attendance. He stated a second QA inservice was held on 03/10/14 by The Regional RN Consultant. He further stated the purpose of these meetings was to implement processes for removal of the IJ identified on 03/07/14 during the standard survey, and included implementing procedures to ensure to ensure staff adherence to infection control policies and procedures. 10. Review of sign in sheets for Quality Assurance meeting held 03/08/14, after the IJ was identified on 03/07/14. The documentation revealed the purpose of this meeting was to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures. See Item #17 for a list of staff in attendance. In addition, the QA committee met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. The next QA meeting was scheduled for 03/28/14. Interview with the Administrator on 03/26/14 at 1:00 PM revealed the facility had a Quality Assurance meeting on 03/08/14 to activate processes to remove the IJ with particular emphasis on ensuring the facility adhered to all of its infection control policies and procedures, and met on 03/14/14 and 03/18/14 to review the facility's documentation of compliance with infection control policies and procedures. Interview, on 03/25/14 at 1:30 PM with the facility's Regional RN Consultant revealed she had conducted a QA Process in-service with additional facility staff members on 03/10/14, and a Sign-In Sheet documented members in attendance. In addition, the RN Consultant stated she was in the process of monitoring the QA committee's work per the schedule outlined in the AOC. 11. Review of the Quality Assurance Process Training sign in sheet revealed this inservice was held on 03/08/14, and conducted by the the Corporation's Regional Vice President. Copies of the policies reviewed during this meeting were attached and reviewed. 12. Review of the facility's Performance Improvement Plan with Abaqis curricula, provided as part of the QA training of 03/08/14, revealed the Administrator was a required member of the facility's Performance Improvement (PI) Committee. The PI Committee would be comprised of the Administrator, along with other administrative staff, and at least two other facility employees. The facility would identify and monitor activities that focus on processes that significantly affect resident outcomes. This ongoing monitoring by the Administrator and The Signature Care Consultant would establish the facility's baseline and the predictability of various outcomes. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed he and The Signature Care Consultant would identify and monitor activities that focus on processes that significantly affect resident outcomes which would establish a baseline and the predictability of various outcomes. Review, on 03/25/14 of the facility's AOC revealed the Administrator met with the administrative team on 03/08/14 to plan for removal of the IJ called on 03/07/14. Persons in attendance included the Medical Director (by phone), the Administrator, the DON, the Staff Development Coordinator, the Nurse Practitioners, the RVP, and The Signature Care Consultant. The AOC revealed infection control check lists and monitoring audits were assigned to the DON, ADONs, other licensed nurses, the Admissions Director, and the Assistant Administrator. Time parameter for re-educating staff on infection control and ensuring competency in the topic was 03/07/13-03/09/13 with alleged compliance on 03/10/14. 13. Interview, on 03/26/14 at 1:00 PM, with the facility's Administrator revealed he received the infection control audits and reviewed them with the DON, daily, to ensure proper follow up occurred as indicated.

Based on observation, interview, record review and review of policy and procedures and the facility's Allegation of Compliance (AOC), it was determined the Immediate Jeopardy (IJ) identified during the annual survey, concluded on 03/07/14, had been removed related to implementation of written plans of care affecting two (2) of twenty-four residents (24) sampled residents (Residents #3 and #17). The facility had failed to ensure droplet isolation precautions were consistently implement for Resident #17 who had a [DIAGNOSES REDACTED].#3 per the plan of care. An acceptable AOC was received on 03/20/14 alleging removal of the IJ on 03/10/14. Based on the findings of the revisit, it was determined the IJ was removed on 03/10/14, as alleged, with remaining noncompliance at a scope and severity of a "D" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Allegation of Compliance (AOC) revealed the facility took the following immediate steps to remove the IJ: 1. Resident #17's care plan was reviewed and updated in daily clinical meetings until an order to discontinue isolation was obtained. 2. Additional residents have been placed in isolation. Care plans for these residents have been reviewed and updated, as needed. These residents were observed every sixty (60) minutes to ensure infection control practices were followed. 3. Care plans were reviewed and updated on 03/07/14 and 03/08/14 by the Interdisciplinary Team (IDT) which included the Administrator, Assistant Administrator, Director of Nursing, The Assistant Director of Nursing, Social Services, Minimum Data Set (MDS) Nurses, Dietary, and the Quality of Life/Transitional Care Nurse. 4. Education was started on 03/07/13 and was concluded on 03/09/14, which included infection control, use of personal protective equipment (PPE), hand washing, linen/laundry handling, cross-contamination, isolation precautions for specific infections, quality assurance and care plans. This education, was taught to all staff by Nursing Administration, RN Supervisors, Social Services, Dietary Administration, Signature Care Consultant and the Administrator. 5. Medication and wound care trainings related to Resident #3 were provided from 03/07/14-03/09/14 to Licensed Nurses by Administrative Nursing Personnel and the Signature Care Consultant. 6. Licensed nurses, Certified Nursing Assistants (CNAs), and Occupational Therapists (OTs) were educated on perineal care from 03/07/14 to 03/09/14. Training was conducted by Nursing Administration and The Signature Care Consultant. 7. Post education testing and skills competencies (hand washing, linen handling, wound care, perineal care, medication pass, and donning of PPE) were started with all staff on 03/07/14 with completion on 03/09/14. 8. Signature East Louisville currently employees 197 staff members, one staff currently on leave, and with no agency staff. 9. No staff was allowed to return to work without the mandated education listed above. 10. Newly hired staff will be educated during the orientation process by the Staff Development Nurse. 11. Policy and Procedure Revisions, no changes as determined, on 03/08/14, by the Corporate Regional Vice President. 12. On 03/08/14, The Administrator met with the administrative team and initiated a process to introduce, develop, and implement plans for the identified concerns. Concerns were to be addressed daily in the morning meetings, plans were developed, and teams were assigned to correct the concerns. 13. Care plan adherence audits were to continue after the initial daily audits for thirty (30) days, weekly for thirty (30) days, and then monthly for a period of time to be determined by administration and Quality Assurance (QA) to ensure compliance. 14. Findings would be discussed with the QA Committee to determine the need for further recommendations and additional follow-up. The DON would ensure completion of the audits, and follow up as needed. 15. Oversight of the Care Plan Competency Audits would be conducted by the Administrator and the QA team. The State Survey Agency (SSA) verified through observation, interview and record review, the removal of Immediate Jeopardy (IJ) on 03/10/14, as alleged by the facility. 1. Review of the care plan for Resident #17 revealed the 1:1 sitter intervention was added on 03/08/14. Discontinuation of the Droplet Isolation and the 1:1 sitter occurred on 03/14/14, with resumption of standard precautions during the resident's care. 2. Review of the care plans for residents with changes in status revealed they were reviewed daily in clinical meetings by the Interdisciplinary Team (IDT). Any applicable changes deemed necessary were completed and then care plans were monitored by the DON, ADONs, and the MDS nurses. 3. Review of Resident #17's clinical record/care plan revealed the care plan was reviewed and updated daily, and as needed until the physician discontinued Droplet Isolation Precautions on 03/14/14. Review of the facility's care plan in-service sign in sheets and curriculum for that in-service revealed care plan implementation/revisions training was conducted on 03/09/14 by the facility's Regional Registered Nurse (RN) Consultant. A copy of the sign-in sheet (attendees) was provided which included names of the ADONs, the Staff Development/Infection Control Nurse, and other licensed nurses. Copies of the curriculum included the following policies: Interdisciplinary team care planning process (Dated 12-2010); Interdisciplinary Team Care Assessments (Dated 12-2010); Daily Review of physician's orders [REDACTED]. Content of the At Risk Meetings Policy stated the meetings were conducted to focus the Interdisciplinary Team (IDT) on care standards, problem solving, care planning, intervening upon a change in a resident's condition, and communication across the IDT. Further review of documentation from this training revealed care plans of residents with changes in status would be reviewed daily in clinical meetings by the IDT. Any changes deemed necessary would be completed and then care plans would be monitored by the DON, ADONs, and the Minimum Data Set (MDS) nurses. Review of the infection control inservice revealed as of 03/27/14 one hundred and ten (110) nursing staff received the education with five (5) nursing staff who still needed the required education. Four (4) CNAs had not received the education. A registered letter was mailed on 03/21/14 to all those who had not received the training to make them aware of the requirement. Interview, on 03/26/14 at 10:22 AM, with LPN #2 revealed he attended a care plan inservice 03/08/14-03/09/14 along with several other inservices that related to infection control on the weekend after the IJ was announced on 03/07/14. LPN #2 stated he thought he understood the care planning process and would define the care plan as a plan to care for the resident. New interventions or revisions added to a resident's care plan should be monitored by the nursing staff for implementation and should be recorded via 'hot charting' every shift for a certain number of days. Hot charting should reflect if the new interventions were implemented and if they were effective. Interview, on 03/26/14 at 10:12 AM, with RN #2 revealed she had received care plan and infection control in-service education on 03/12/14 after returning from time off from work. RN #2 stated the primary purpose of the care plan was to provide an individualized plan to guide resident care. RN #2 stated she would expect to see an isolation care plan in place when isolation was ordered, and this information should also be on the CNA care plan. RN #2 stated licensed nurses were responsible for educating visitors in consistent use of PPE. Interview, on 03/26/14 at 10:31 AM, with CNA #3 revealed that on 03/08/14 she received re-education on infection control including isolation precautions. CNA #3 stated she was aware CNA care plans were kept at the nurses' station for her review, and she would expect to see isolation precautions on the CNA care plan if a resident had been placed in isolation. CNA #3 stated if she saw a visitor about to enter an isolation room, she would ask them to speak to a unit's nurse before visiting the resident. 4. Review, of sign in sheets, training binders, and the post-tests completed by employees revealed infection control re-education began on 03/07/14, immediately after the IJ was identified. Staff that did not work on 03/07/14 received infection control re-education including instruction on isolation precautions, use of PPE, and proper handwashing technique upon reporting to work their next scheduled shift. Each staff member who received infection control in-service training was required to prove competency via a written post test, and a return demonstration of proper hand washing technique. The facility had prepared sub binders that contained documentation of those who attended wound care and medication administration trainings for licensed nurses, and perineal care re-education for licensed nurses, CNAs, and Occupational Therapists (OTs). The binders contained policies and sign-in sheets documenting the attendees. Review of the completed post-tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests fifteen (15) employees received training and were tested on [DATE], one (1) staff person was trained/tested on [DATE] and one staff person was trained/tested [DATE]. Interview, on 03/25/14 at 1:30 PM, with the facility's Signature Care RN Consultant, revealed staff that were not trained while on duty on 03/07/14, were required to attend an infection control inservice, take a post test, and perform a return demonstration of proper hand washing technique before reporting to their assigned hallway to work. The Signature Care RN Consultant stated additional in-services were conducted later in the shift for employees which included re-education in proper wound care techniques, perineal care, medication administration, and safe handling of soiled linen. Observation, on 03/25/14 at 8:30 AM, revealed CNA #4 sanitized her hands and donned appropriate PPE at Isolation room [ROOM NUMBER]. CNA #4 knocked on the resident's door before carrying in a paper (disposable) tray of breakfast items. Interview, on 03/25/14 at 3:35 PM, with CNA #4 revealed she received infection control re-education after the identified IJ on 03/07/14, which included instruction in isolation precautions and proper hand washing technique. CNA #4 stated she was assigned to sit with Resident #17 for the two (2) days Resident #17 remained in Droplet Isolation. CNA #4 stated she was to ensure Family Member #1 donned PPE on entering the resident's room, kept it on, appropriately disposed of the PPE and washed her/her hands before leaving the room. CNA #4 stated Family Member #1 complied with the isolation requirements. Review, on 03/26/14 at 11:05 AM, of the clinical record for Resident #28, revealed he/she had been placed in Contact Isolation for potential scabies. Nurses notes revealed the resident had three (3) small pin dot scabs on his/her upper torso and an order for [REDACTED]. Observation, on 03/26/14 at 11:00 AM, revealed three (3) housekeeping staff persons were wearing PPE while cleaning room [ROOM NUMBER] on the Kentucky Pride Hallway where Isolation Precautions had been put into effect. Interview, on 03/25/14 at 3:50 PM, revealed Housekeeper #3 received re-education in infection control about two weeks ago, but could not remember the exact date. She stated she would don PPE as indicated on the isolation instruction card in the cart before entering the room. She would knock on the resident's door and clean. After completing the tasks she would remove the PPE, place it in the lined barrel in the room, wash her hands at the resident's sink. Housekeeper #3 stated upon cleaning her hands she used a clean paper towel to touch faucet handles. Interview, on 03/25/14 at 4:32 PM, with Laundry Services/House Keeping Staff #5, revealed she was instructed, in handwashing and proper use of PPE while processing soiled linen in the facility's laundry department, on 03/07/14. Laundry Staff Person #5 stated she was instructed to put on a disposable gown, gloves, and goggles when placing the soiled linen/towels/clothing in the washers. Interview, on 03/26/14 at 10:12 AM, with RN #2, revealed, she received infection control education, including hand washing with a required return demonstration, when she reported to work on 03/12/14, after having time off from work. RN #2 stated she understood her role in educating visitors in proper isolation precautions before and during a visit to a resident in isolation. She stated the sign posted on the resident's door directed the visitor(s) to see a nurse for guidance before entering the isolation room. Interview, on 03/25/14 at 3:45 PM, with LPN #1 revealed she was trained on 03/10/14 upon reporting to work. She stated she was not allowed to work on her unit until she attended the required infection control inservice, completed a post-test, and demonstrated proper hand washing procedure. LPN #1 stated she received additional infection control in-service education related to resident care later in that day, which were taught by the MDS nurse. Interview, on 03/25/14 with RN #1, revealed she received re-education on 03/11/14, after returning from time off from work. RN #1 stated she was not allowed to report to her unit to work until she had received re-education in infection control, which addressed Isolation Precautions, hand washing, with a required return demonstration. 5. Review of the sign in sheets and curriculum in the sub-binder for medication administration training revealed from 03/07/14-03/09/14, Licensed Nurses received medication administration and wound care re-education that included observance of infection control practices. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. 6. Review of the sign in sheets and curriculum in sub-binder for perineal (peri) care revealed from 03/07/09- 03/09/14, Licensed Nurses, CNAs, and Occupational Therapists (OTs) were re-educated in peri care. Training was conducted by Nursing Administration and Signature Care RN Consultant. One licensed nurse received this training on 03/11/14 and one on 03/12/14 when they returned to work. 7. Review, on 03/25/14, of the dated post tests revealed a concern regarding "all training" completed prior to the AOC date of 03/10/14. Copies of the post tests for the employees trained on or after 03/10/14 were obtained. According to dates on the post tests, fifteen (15) employees received training and were tested on [DATE] and two (2) staff were trained/tested after 03/10/14, due to their scheduled time off from work. None of these employees were allowed to report to their units to work before completing the required training, testing, and return demonstration. 8. Review of the Employee Listing/Signature Payroll Services list provided by the administrator, revealed the facility employed 194 staff members. 9. Interview, on 03/25/14 at 1:30 PM, with the Signature Care RN Consultant revealed after the IJ was announced on 03/07/14, and prior to reporting to their assigned units to work, all staff members were required to attend an infection control in-service, complete the Care 2 Learn Infection Control Multiple Choice Test, and demonstrate competency in proper hand washing technique. 10. Interview, on 03/26/14 at 1:00 PM, with the Administrator revealed the facility had no new staff hired from 03/11/14 to 03/26/14. 11. Review of the Quality Assurance Process Training sign in sheet revealed this inservice was held on 03/08/14 and conducted by the corporation's Regional Vice President. Copies of the policies reviewed during this meeting were attached and reviewed. 12. Review of the facility's AOC binder revealed the Administrator met with the administrative team on 03/08/14 to make assignments for the audits. The audits were completed daily and acted upon by the facility. 13. Care plan adherence audits were to continue after the initial daily audits for thirty (30) days, weekly for thirty (30) days, and then monthly for a period of time to be determined by administration and Quality Assurance (QA) to ensure compliance. 14. Review of the facility's Performance Improvement Plan with Abaqis curricula, provided as part of the QA training of 03/08/14, revealed the Administrator was a required member of the facility's Performance Improvement (PI) Committee. The PI Committee would be comprised of the Administrator, along with other administrative staff, and at least two other facility employees. The facility would identify and monitor activities that focus on processes that significantly affect resident outcomes. This ongoing monitoring by the Administrator and The Signature Care Consultant would establish the facility's baseline and the predictability of various outcomes. Interview with the Administrator, on 03/26/14 at 1:00 PM, revealed he and The Signature Care Consultant would identify and monitor activities that focus on processes that significantly affect resident outcomes which would establish a baseline and the predictability of various outcomes. 15. Interview, on 03/26/14 at 1:00 PM, with the facility's Administrator revealed he received the infection control audits and reviewed them with the DON, daily, to ensure proper follow up occurred as indicated.

Based on observation, interview, record and policy reviews, the facility failed to have an effective system to ensure care was provided in accordance with the written plans of care for two (2) of twenty-four (24) sampled residents. (Residents #3 and #17). On 02/21/14, the facility placed Resident #17 in droplet isolation precautions for a [DIAGNOSES REDACTED]. Resident #17's Droplet Isolation Care Plan stated staff would wear gloves during all care, and family members would be educated regarding the disease process that required the need for Droplet Isolation Precautions. However, Staff and Family Member #1 were observed entering the droplet isolation room without donning (PPE) and/or sanitizing their hands prior to and upon exiting the room. The visitor was observed to touch objects in the resident's room and sit on the resident's bed without utilizing PPE. Further, an interview with Family Member #1 revealed he/she had not received staff instruction on use of PPE and did not understand why it was necessary to wear a gown, gloves, and a mask while in the resident's room. In addition, Resident #3 was not provided barrier cream administration as care planned. The facility's failure to have an effective system in place to ensure staff followed care plan interventions to assure isolation precautions was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was identified at 42 CFR 483.20 Resident Assessment on 03/07/14 and was determined to exist on 02/12/14. The Immediate Jeopardy was determined to be ongoing at exit of survey on 03/07/14. The findings include: Review, on 03/07/14 of the facility policy titled Interdisciplinary Team Plan of Care (Dated 12-2010), revealed each resident would be involved in the development and review of his/her plan of care along with his/her family member(s). Resident, family members or other responsible persons would be invited to attend the interdisciplinary conferences. Further, responsibility for each intervention conducted and documentation of the resident's response and progress toward goals would be decided and designated by the interdisciplinary team. All members of he interdisciplinary team (Nursing, Social Services, Rehabilitation Services, Nutrition Services, and Activities) would receive copies of the resident's care plan. 1. Review of Resident #17's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was ventilator dependent and required suctioning every two hours and as needed. This procedure was provided by the facility's Respiratory Therapist (RT) and Licensed Nurses. On 02/04/14 the facility transferred Resident #17 to an acute care hospital and while hospitalized the resident's sputum cultures tested positive for [MEDICAL CONDITION] (MRSA). Antibiotic therapy was ordered and the resident was transferred back to the facility on [DATE] and placed on Droplet Precautions Isolation. The resident completed the antibiotic therapy on 02/24/14, but remained in Droplet Precautions. On 03/04/14, an additional sputum culture revealed the resident tested positive [MEDICAL CONDITION], and another course of antibiotic therapy was ordered on [DATE]. Review of Resident #17's care plan, dated 02/12/14, revealed a care plan was for developed for Isolation Precautions (droplet) that included a component stating the facility would explain the need for isolation and the pathophysiology of the infection to the resident, family members, and/or the responsible party. The care plan also indicated gloves should be worn with all care. Review of the infection care plan stated the staff was to encourage good clean hygiene techniques to avoid cross contamination, especially hand washing before meals and after bowel movements. Observation, on 03/04/14 at 8:36 AM, during initial tour of the facility's 300 Hall, revealed an isolation cart at Resident #17's door with signage posted that indicated Resident #17 was under Droplet Isolation Precautions. Observation, on 03/06/14 at 9:37 AM, revealed Family Member #1 was in Resident #17's room. Family Member #1 was wearing a disposable gown that covered the front of his/her clothing, but was not tied in the back, and the mask was not covering his/her nostrils. Family Member #1 was not wearing gloves and was touching buttons on the television in the room. Observation, on 03/06/14 at 10:23 AM, revealed Resident #17 was in the bed, and Family Member #1 was seated at the resident's bedside wearing a disposable gown, a mask which was now covering his/her nostrils, but was not wearing clean gloves. Interview, on 03/06/14 at 10:25 AM, revealed Family Member #1 stated he/she had not received any instruction from the facility's nursing staff on using PPE, and really did not understand why it was necessary to wear a gown and mask while in the resident's room. Family Member #1 stated the staff had not given him/her any information about the infection and why it required isolation. Additional observation, on 03/06/14 at 8:25 AM, revealed Resident #17 remained in Droplet Isolation, and the facility's RT was administering care. The resident's eyes were open, and he/she had a [MEDICAL CONDITION] with oxygen perfusing at 3 L/min. An enteral feeding (Nepro) was infusing at 40 ml per hour. Interview, on 03/06/14 at 8:28 AM, with the RT revealed she had suctioned Resident #17. Further interview, on 03/06/14 at 3:05 PM with the facility's RT, revealed that Resident #17 does cough, was suctioned every two hours, and as needed. Therefore, droplets from his/her respiratory tract could land on surfaces in the room, and the resident remained in Droplet Precaution Isolation because sputum cultures continued to [MEDICAL CONDITION] in the resident's respiratory tract. The RT stated all persons entering Resident #17's room should follow Droplet Precautions. Staff and visitors should wear a gown and a mask, and if touching surfaces in the room, gloves should be worn to prevent the potential of infecting oneself and others. The RT stated she had provided many reminders to the family member of Resident #17 to wear PPE including gloves. Interview, on 03/06/14 at 3:45 PM, with the Unit Manager/Assistant Director of Nursing (ADON), 300 Hall, revealed the signage on the door of Resident #17's room informed staff and visitors of what to put on while in the room, and the nursing staff had discussed the use of PPE with Family Member #1 who visited Resident #17, daily. The ADON stated Family Member #1 had been wearing PPE, but she was not sure he/she always wore gloves while in the room, and it was possible that surfaces in the room could be contaminated. Further observation, on 03/07/14 at 9:01 AM, revealed Family Member #1 entered Resident #17's room wearing a long coat and carrying three (3) bags, and again failed to don PPE or sanitize his/her hands before entering the room. The visitor was observed to place an article of clothing on the resident's over bed table and close the resident's door. Interview, on 03/07/14 at 10:20 AM, with the Staff Development/Infection Control Nurse, revealed nursing staff were responsible for educating visitors on the use of PPE. The Staff Development Nurse stated this type of education should be documented in the nurses' notes, and she was sure Family Member #1 had been educated on several occasions on the use of PPE. However, staff caring for Resident #17 believed Family Member #1 had trouble remembering this information because he/she had to be frequently reminded to use PPE. If staff members saw Family Member #1 not wearing the PPE, they assisted him/ her with donning the protective equipment. Review, on 03/07/14, of the nurses' notes in Resident #17's clinical record did not reveal evidence that Family Member #1 had been educated in the use of PPE. Interview, on 03/07/14 at 2:05 PM with the DON, revealed the Staff Development/Infection Control Nurse, the Unit ADON's and any licensed nurses on the units were responsible to ensure isolation precautions were observed by all direct care staff and visitors, but ultimately she was responsible for ensuring all components of Resident #17's Droplet Isolation Care Plan were implemented. The DON stated when a visitor such as Family Member #1 was non-compliant with use of PPE, then staff was to continue to educate the visitor and monitor the situation. 2. Review of Resident #3's clinical record revealed the resident had resided at this nursing facility since November 2010. The most current list of [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, conducted on 12/05/13, revealed the facility had assessed the resident to have a severe cognition impairment and was totally dependent on staff for eating, bed mobility, and transfers. The resident was assessed to be incontinent of bladder and bowel and was dependent on staff to provide incontinent care. Review of the pressure ulcer care plan, dated 11/25/13, revealed the resident had a pressure ulcer on the left and right buttock with interventions to provide incontinent care and apply barrier cream. Observation of a skin assessment of Resident #3, with LPN #1, on 03/04/14 at 3:00 PM, revealed when the nurse removed the disposable brief, the brief was dry without any barrier cream on the brief or on the resident's buttocks. The nurse indicated the nurse aide had just performed incontinent care. The nurse stated she had applied the barrier cream to the resident's buttocks earlier that day. Review of the Treatment Record (TAR) revealed the nurse had initialed she had applied the barrier cream but there was no time indicated. Interview with LPN #1, on 03/04/14, at 3:08 PM, revealed she did not see any barrier cream on the resident's buttocks during the skin inspection. She searched the resident's room and did not find any skin barrier cream. Interview with CNA #7, on 03/06/14 at 9:40 AM, revealed she was the CNA who was responsible for Resident #3 on 03/04/14. She stated she had not applied skin barrier cream that day but had applied lotion instead. She stated she did not know to apply the skin barrier cream and there had not been any skin barrier cream in the resident's room. She stated she does review the CNA care plans. Interview with the 100 Unit Manager, on 03/06/14 at 9:45 AM, revealed the nurse aides have access to the skin barrier cream from central supply and should have obtained the barrier cream prior to 03/04/14. She stated the facility had recently changed skin products and the lotion that the CNA had used before would not have protected the resident's skin from moisture. The Unit Manager stated the CNA's were responsible for reviewing each resident's care plan prior to caring for the residents. Review of the CNA care plan for March 2014, revealed the resident was to be checked and changed every two hours and as needed. The resident's skin was to be cleaned with a cleanser and barrier cream was to be applied after each incontinent episode.