Every finding on record at Signature Healthcare of Elizabethtown

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free of significant medication errors for 1 of 10 sampled residents reviewed for narcotic administration, Resident (R)1. On 03/12/2026, R1 was administered 5 times the intended dose of Morphine (a schedule II opioid analgesic used to treat severe pain and misuse of the medicine can cause addition, overdose, or death) on three separate instances. R1 was pronounced dead on 03/12/2026 at 5:53 PM. The facility's failure to have an effective system to ensure residents were free from significant medication errors was likely to cause serious injury, impairment, or death to a resident. On 03/20/2026 Immediate Jeopardy was identified and determined to exist on 03/12/2026 in the area of 42 CFR 483.45, Pharmacy Services (F760) at a Scope and Severity of a J. Substandard Quality of Care (SQC) was identified.The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 03/21/2026, alleging removal of the IJ on 03/22/2026. The State Survey Agency (SSA) validated IJ was removed on 03/22/2026, prior to exit, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changesRefer to F609The findings include: Review of the facility's policy titled, Medication Administration, dated 01/2024, last revised 06/2025, revealed, If a dose seems inappropriate or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification.Review of the facility's policy titled, Physician's Orders, dated 06/2025, last revised 01/2026, revealed Licensed Nurses are expected to notify the physician with any concerns related to new physician orders or potential need for changes in orders.Review of the facility's policy titled, Medications Ordering and Receiving From Pharmacy Provider, 3.7 Medication and Medication Labels, dated 01/2025 revealed, If a prescriber's directions for use change or the label is inaccurate, the nurse may place a direction change, change of order-check chart or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information.When such a direction change label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the prescriber's order for current information.If directions for use change, the provider pharmacy is informed prior to the next refill of the prescription so the new container will show the accurate label.Closed record review of R1's Face Sheet revealed the facility admitted the resident on 09/30/2022, with diagnoses including chronic obstructive pulmonary disease (COPD), chronic pain and osteoarthritis. On 10/24/2025, R1 was placed on palliative care for chronic pain and COPD.Review of the quarterly Minimum Data Set (MDS), dated 12/22/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen out of fifteen indicating intact cognition.Review of R1's Comprehensive Care Plan revealed a problem of change in condition: oxygen saturation, blood pressure and heart rate fluctuations with problem start date 03/10/2026. Goal: Resolve without complications. Approaches: Diagnostics as ordered; labs as ordered, medications as ordered, monitor for changes and report as needed, and oxygen as ordered. (All approaches dated 03/10/2026).Further review of R1's Comprehensive Care Plan revealed a problem of requires use of oxygen with a problem start date 03/10/2026. Goal: The resident will have no adverse outcomes related to oxygen saturation through next review. Approaches included: elevate head of bed as needed for shortness of breath; labs as ordered; medication as ordered; notify physician with changes as needed; observe for signs and symptoms of respiratory distress; and, oxygen as ordered. (All approaches dated 03/10/2026).Continued review of R1's Comprehensive Care Plan revealed a problem of being at risk for pain: complains of right hip, pelvic, knees and back pain. Edited 03/12/2026. Goal: Resident will have relief or reduction in pain intensity within 1 hour after receiving interventions through the review date. Approaches included: administer pain medications per physicians orders (09/30/2022); complete pain screen on admission and as needed (PRN) (09/30/2022); observe effectiveness of pain medication (09/30/2022); provide comfort measures (09/30/2022); consult with pain management (10/26/2022); report to physician if resident does not experience reduction or relief of pain after one hour of receiving prescribed interventions (10/10/2023), medications and treatment per order (10/10/2023) and x-rays as ordered (10/21/2025).Review of R1's Resident Progress Notes, dated 03/11/2026, revealed R1 was diagnosed with pneumonia and had a significant health decline, as evidenced by decreased oxygenation saturation, shallow breathing, and lethargy. The Resident Progress Notes, dated 03/12/2026 at 2:17 AM, revealed early that morning, R1 was placed on hospice care, per family request. Review of R1's Physician Order Report, revealed a new order from the facility Nurse Practitioner (NP) was entered on 03/12/2026 at 7:03 AM. The new order written by Licensed Practical Nurse (LPN)1, revealed orders for 20 milligrams (mg)/5 milliliters (ml) of oral Morphine Solution, administer 0.25 ml (this was equal to 1mg).Review of the [Hosparus] Health Nursing Home Visit Record, revealed a verbal order from the Hospice Nurse, dated 03/12/2026 (not timed), to start Morphine 20 mg/5ml, take 1.25 ml every hour or as needed (this was an equivalent to 5mg).Review of R1's medical record revealed that the verbal orders given to LPN1 by the Nurse Practitioner and the Hospice Nurse were documented in the Medication Administration Record (MAR) to be 20 mg/5 ml of Morphine; however, the dosage of the two medications were different as one was an equivalent of 1mg of liquid Morphine while the other was an equivalent of 5mg. Further review revealed the medication that was delivered by pharmacy had a different concentration at 100mg/5ml with directions to administer .25 ml (which was an equivalent to 5mg and the intended dosage to administer to the resident).Review of the Controlled Drug Record Individual Patient's Narcotic Record as well as observation of a photograph of R1's bottle of Morphine on 03/19/2026 at 11:57 AM, revealed the medication delivered for R1's use was oral Morphine Sulfate 100 mg/5 ml Concentrate, with directions to give 0.25 ml equal to 5 mg, by mouth every hour as needed as per facility Nurse Practitioner's written order to pharmacy. Further review of this same record revealed it was stamped to indicate Directions changed. Refer to chart. Continued review revealed the oral Morphine Concentrate was administered to R1 on 03/12/2026 at 11:30 AM at .25 ml; 1:46 PM at 1.25 ml (this was an equivalent to 25mg); 3:11 PM at 1.25 ml; and 4:49 PM at 1.25 ml. Further review revealed CMT3 documented that she had administered the medication.Further closed record review of R1's Resident Progress Notes, revealed R1 was pronounced dead on 03/12/2026 at 5:53 PM.Per review of facility document Stakeholder Suspension Form, revealed CMT3 was placed on suspension and was not available for interview. Review of CMT3's statement, documented on 03/12/2026, revealed, I always observe the five rights to ensure I am giving the correct medication. Per the statement, after CMT3 gave the first dose of Morphine (.25), HN1 observed R1's response and then increased the order to 1.25 ml, using the order listing on the electronic MAR. CMT3 documented she double checked with HN1 the dose of 1.25 ml because she had never given that much before and HN1 stated it was correct.The State Survey Agency (SSA) surveyor attempted a telephonic interview with CMT3, on 03/22/2026 at 12:11 PM. This attempt, however, was unsuccessful and CMT3 did not return the surveyor's call.During an interview with LPN1, on 03/18/2026 at 9:35 AM, she stated, at the beginning of her shift on 03/12/2026 she was assessing R1, and the resident would hardly wake up. LPN1 stated the resident had pneumonia and decreased respirations. Further, LPN1 explained the family stated they wanted hospice on the morning of 03/12/2026, and she (LPN1) notified hospice and the facility NP. In further interview, LPN1 stated she informed the NP that hospice would not arrive until later, and the NP gave verbal orders which included, Morphine Concentrate at 0.25 ml every hour as needed. LPN1 stated once she got into the computer to place the order of 0.25 ml of Morphine, she thought it would automatically populate. However, several Morphine options were available to choose from and as a result, LPN1 called the NP back to clarify the order. LPN1 stated the NP gave an order for Morphine 20 mg/5ml. LPN1 stated she had ordered these medications on the computer before and did not have any concerns about the orders she had placed on 03/12/2026. During an interview with the facility Nurse Practitioner (NP), on 03/17/2026 at 9:26 AM, she stated the family made the decision to place R1 on hospice on the morning of 03/12/2026, after the resident had a health decline beginning earlier that week, was not responding as usual, became lethargic, and was diagnosed with pneumonia. The NP stated the morning of 03/12/2026, she (NP) gave LPN1 a verbal telephone order to give 0.25 ml of Morphine Concentrate, and when hospice arrived, they would assume care. The NP further stated LPN1 called her back on 03/12/2026 at approximately 6:30 AM to clarify the Morphine order and the NP restated the order to be Morphine Concentrate, which was 100 mg/5 ml, (not 20 mg/5ml as LPN1 documented), give 0.25 ml every hour or as needed. According to the NP, she then also placed a written order to pharmacy for oral Morphine Concentrate 100 mg/5 ml at 0.25 ml to equal 5 mg, every hour or as needed. The NP stated this was a common order for residents receiving end of life care. During an interview with the facility's Pharmacy Representative, on 03/17/2026 at 11:57 AM, he stated providers placed medication orders at their own discretion. He stated the pharmacy sent and dispensed medication based on what the provider prescribed. He explained, on 03/12/2026, the facility NP sent in an order for 100 mg/5 ml Morphine Concentrate. He stated the prescription request was sent at 6:56 AM, and the Morphine left the pharmacy at 8:08 AM and was received by the facility at 11:02 AM. He further stated the pharmacy did not fill scripts without a provider's order. The Pharmacy Representative stated it was up to the facility staff to ensure the correct order matched the correct medication prior to administering medication.During an interview with LPN2, on 03/18/2026 at 1:08 PM, she stated she was the nurse who received R1's medications on 03/12/2026 from pharmacy. She stated, We must sign for them, log them in the control binder. I compared the bottle of liquid Morphine to the actual order from pharmacy and looked at the computer and did not see any differences [between the bottle which showed 100 mg/5 ml vs the order in the electronic health record which showed 20 mg/5ml].During continued interview with LPN2, on 03/18/2026 at 1:08 PM, she stated she was unaware the orders in the electronic medical record (EMR) which were used for medication administration, and the labeled dose on the bottle of Morphine Concentrate, did not match until later that day when she called pharmacy to get a stat (immediate) order of another bottle of liquid Morphine. She stated she called pharmacy because she did not want to run out of medication as CMT3 had already given three doses of liquid Morphine at 1.25ml.During further interview with LPN2, on 03/18/2026 at 1:08 PM, she stated when the pharmacy inquired about the need for another bottle so soon, she mentioned the increased dose. The pharmacy responded, the dose was supposed to be 0.25 ml not 1.25 ml. LPN2 stated after she got off the phone with pharmacy, she notified the Unit Manager. LPN2 stated she did not believe there had been a medication error because the hospice nurse gave the order; however, she did not identify the increase in the hospice order was made based on the documentation on the Physician's Order Report (which showed 20 mg/5 ml, rather than the 100 mg/5 ml which was what was actually ordered, delivered to the facility, and administered to R1). During an interview with Hospice Nurse (HN)1, on 03/18/2026 at 1:19 PM, she stated she arrived at the facility on 03/12/2026 before 11:00 AM. HN1 stated the facility had ordered Morphine on their own prior to her arrival, but the medication had not yet arrived, and R1 was showing a lot of discomfort. HN1 explained, after speaking with the family, she (HN1) came out of R1's room and noted the Morphine had arrived, and staff were preparing to administer the first dose. HN1 stated she looked at the MAR and saw an order for Morphine Solution, 20 mg at 5 ml, give .25ml, which would equal 1mg. HN1 stated she observed CMT3 administer the first dose of Morphine to R1, who continued to show signs of discomfort. In response, HN1 stated she spoke with the hospice physician, who gave an order to increase the Morphine Solution to 5 mg.During continued interview with HN1, on 03/18/2026 at 1:19 PM, she stated she wrote on a paper document, labeled Nursing Home Visit Record, the new order to increase the Morphine Solution to 1.25 ml to equal 5 mg as needed, per physician's order. In further interview with HN1, she stated the new order to increase the Morphine was based on the Physician Order Report, which showed 20 mg/5 ml, and she did not see the facility NP's written order to the pharmacy or the label on the bottle of Morphine, (which both indicated 100 mg/5 ml).During an interview with the Unit Manager (UM), on 03/17/2026 at approximately 10:30 AM, she started on 03/12/2026 at 12:00 PM, when HN1 gave the hand-written order to increase the Morphine to 1.25ml to equal 5 mg, the Morphine order bothered her. The UM stated she brought her concern to the Assistant Director of Nursing (ADON) because she had not seen an order for 1.25 ml before. She further stated, later in the shift, she called hospice to question the order and faxed them requested documents. The UM stated after receipt of the fax confirmation, R1 passed away.During continued interview with the UM, on 03/17/2026 at approximately 10:30 AM, she stated she left for the day prior to receiving clarification as to the accuracy of the order. The UM stated after she left for the day, LPN2 called her, stating she could not locate R1's Morphine narcotic sheet (Controlled Drug Record Individual Patient's Narcotic Record) and HN2 wanted to review it. The UM stated upon arrival back to the facility, she located R1's Morphine narcotic sheet in front of the narcotic book and noted the coroner and the police were at the facility, which was not typical. She stated at this point, the Director of Nursing (DON) and Administrator removed CMT3 and did not allow her to complete the rest of her shift. In further interview with the UM, she stated CMTs received ongoing training in medication administration including the five rights of medication administration, as well as the process of receiving medications from suppliers. Per the UM, the five rights of medication administration which include verifying the right dose, apply to all staff that administer medication. During an interview with the ADON, on 03/17/2026 at 11:23 AM, she stated that on 03/12/2026, she instructed the UM to call hospice for clarification due to her concerns about the 12:42 order when the Morphine was increased due to how it was written, as well as the amount of 1.25 ml because the amount seemed like a lot to her. The ADON stated she was unaware the UM did not contact hospice for order clarification until 5:10 PM, shortly before R1's death. The ADON further stated, after leaving the facility, she received a call to return to the facility because HN2 had some concerns. During an interview with HN2, on 03/18/2026 at 12:34 PM, she stated on 03/12/2026, she received a call at approximately 5:30 PM to go to the facility. Per HN2, hospice customer support had received phone calls from the facility and had questions regarding doses of Morphine that were administered to R1. HN2 stated by the time she arrived at the facility, R1 had passed away. HN2 stated she notified hospice and was instructed to assess the situation, based on instructions from their legal team. HN2 stated she and the funeral home representative contacted the coroner and explained the situation. HN2 stated while there, she reviewed the Morphine narcotic log (Controlled Drug Record Individual Patient's Narcotic Record) and took pictures of R1's bottle of Morphine (with the label showing a dose concentration of 100 mg/5 ml rather than 20 mg/ml). HN2 stated she gave a brief history of what happened to the coroner, who called the police, and she left the facility. During an interview with the Police Department Detective, on 03/17/2026 at 12:55 PM, he stated he initially came to the facility because dispatch had stated the facility was not cooperative with the coroner, who had been called in after R1's death. The Detective stated HN2 took pictures of R1's medication over the concern of an overdose. He further stated the police retrieved and checked R1's Morphine and took the bottle into custody. The Detective stated law enforcement had custody of the medication. Observation of the police photographs confirmed that R1's Morphine label read 100 mg/5 ml in 18 ml bottle, with 14 ml of the concentrate remaining. The detective also stated there were recorded phone calls from facility staff calling hospice to verify milligrams of oral liquid Morphine and identifying there was an issue with a medication error for R1 with three doses of Morphine given at five times the ordered concentration.The SSA surveyor attempted to contact the coroner by phone on 03/18/2026 at 9:37AM and was unsuccessful, as he was out of town. A formal records request was sent on 03/16/2026 at 10:39 AM. Interviews with Registered Nurse (RN)1, on 03/17/2026 at 7:31 AM, RN2 on 03/17/2026 at 9:43 AM, and RN6 on 03/17/2026 at 9:51 AM, all revealed prior to administering medications, the person administering the medication should visually observe the medication container and compare it with both the computer order and narcotic sheet (if applicable). They stated if any of the information did not match, staff should immediately contact the provider or pharmacy for clarification.During an interview with the Registered Pharmacist (RPh), on 03/20/2026 at 8:34 AM, he stated when medications were delivered to the facility by pharmacy, a manifest was provided, and staff should verify that the medication the pharmacy delivered matched the manifest form and staff should sign to ensure correctness. However, the RPh stated, the medication that was delivered and the manifest form did not have anything to do with the medication order in the facility's computer EMR. The pharmacist stated, based on the concentration/bottle of Morphine delivered to the facility, R1 received 25 mg of Morphine (rather than 5 mg) on three separate administrations in approximately three hours. He stated this was five times the ordered dose in each administration. In further interview with the RPh, he stated this medication error could cause a resident to experience shortness of breath and sedation that could lead to death. During interview with the facility Director of Nursing (DON), on 03/22/2026 at 1:56 PM, she stated it was her expectation prior to medication administration, that staff would check the drug in hand and compare it to the computer order in the EMR. The DON stated, staff was to perform the five rights for medication administration, and if something did not match, the nurse or nurse supervisor was to be notified. She stated the five rights for medication administration included right patient, right drug, right dose, right route, and right time, and staff should follow this to prevent a medication error. The DON further stated when R1's Morphine order came into question; staff should have brought their concerns to the provider who ordered the medication and the Unit Manager. She stated there could be the risk of a medication error if staff failed to reach out to the pharmacy or the provider when there was a question about a medication dose.During an interview with the facility Medical Director, on 03/22/2026 at 2:06 PM, he explained it was his expectation for staff to reconcile medications prior to administration by looking at the medication and comparing it to the order in the computer. He stated it was his expectation staff would perform the five rights of medication administration prior to administering any medication. He further stated if the medication labels did not match the order, staff should contact the provider who wrote the order and clarify. The Medical Director further stated if there was a concern regarding a medication order, staff should clarify with the provider or the pharmacy. He stated staff should not continue with the administration of a medication if there was a concern with the medication order. During an interview with the facility Administrator, on 03/22/2026 at 2:25PM, she stated it was her expectation that prior to medication administration, staff would follow the five rights. The Administrator stated staff should check the bottle or package against the MAR and ensure they matched the resident, medication dose, and medication route. The Administrator added, if the CMT had a medication concern, they should go to their charge nurse, and if it was a nurse with a concern, they should directly contact the provider. She stated there was the risk of a medication error if staff failed to perform the five rights prior to medication administration. The Administrator stated when R1's Morphine order came into question; staff should have contacted the facility provider. She further stated there was the risk of a medication error if staff did not reach out to the pharmacy or the provider when there were questions about a medication order.

Based on observation, interview, record review, and review of facility policy, the facility failed to report alleged violations involving abuse, neglect, mistreatment, or any reasonable suspicion of a crime, as required, to state agencies for 1 of 10 sample residents, Resident (R)1. (Refer to F760)The findings include:Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property revised 09/15/2023, revealed the Reporting Guidelines noted, Any abuse allegation must be reported to the State within two hours. Any reasonable suspicion of a crime with serious bodily injury must be reported to the State and Police. Per the policy, suspected crime is defined in the Elder Justice Act, and according to congress.gov, is a reasonable suspicion of a crime.Closed record review of R1's Face Sheet revealed the facility admitted the resident on 09/30/2022, with diagnoses of chronic obstructive pulmonary disease (COPD), chronic pain and osteoarthritis.Review of R1's Resident Progress Notes, dated 03/12/2026 at 2:17 AM, revealed early that morning, R1 was placed on hospice care, per family request. Review of R1's Progress Notes, dated 03/12/2026 at 7:03 AM, revealed Licensed Practical Nurse (LPN)1 documented the following, ARNP gave order Morphine concentrate .25ml q (every) 1hr (one hour) for pain.Review of the Physician Order Report, revealed a new order from the facility Nurse Practitioner (NP) was entered on 03/12/2026 at 7:03 AM for R1. This new order written by Licensed Practical Nurse (LPN)1, revealed orders for 20 milligrams (mg)/5 milliliters (ml) of oral Morphine Solution, administer 0.25 ml (equal to 1mg) to be given as needed for pain. Review of R1's [Hospice Name] Health Nursing Home Visit Record, revealed a verbal order from the Hospice Nurse, dated 03/12/2026 (not timed), to start Morphine 20 mg/5ml, take 1.25 ml (equal to 5mg) every hour or as needed, to be given as needed for pain and dyspnea. Review of R1's Controlled Drug Record Individual Patient's Narcotic Record as well as observation of a photograph of R1's bottle of Morphine on 03/19/2026 at 11:57 AM, revealed the medication delivered for R1's use on 03/12/2026 was oral Morphine Sulfate 100 mg/5 ml Concentrate, with directions to give 0.25 ml (equal to 5 mg), by mouth every hour as needed, as per facility Nurse Practitioner's written order to pharmacy. Additional review of this same record revealed it was stamped to indicate Directions changed. Refer to chart. Further review revealed the oral Morphine Concentrate was administered to R1 on 03/12/2026 at 11:30 AM at .25 ml; 1:46 PM at 1.25 ml; 3:11 PM at 1.25 ml; and 4:49 PM at 1.25 ml by Certified Medication Technician (CMT)3.Record review revealed on 03/12/2026, R1 was administered five times the ordered dose of Morphine, (a schedule II opioid analgesic used to treat severe pain, which had the potential to affect/decrease respiration) on three separate occasions.Review of R1's Resident Progress Notes, revealed the resident was pronounced dead on 03/12/2026 at 5:53 PM.Review of the facility document Stakeholder Suspension Form, CMT3 was placed on suspension and was not available for interview. The State Survey Agency (SSA) attempted to reach CMT3 unsuccessfully on 03/22/2026 by telephone.During an interview with a Detective from the local Police Department, on 03/17/2026 at 12:55 PM, he stated his initial response to the facility was because dispatch stated the facility was not cooperative with the coroner. The detective stated a Hospice Nurse had an issue, alleging there was shredding of paperwork, although he could not substantiate that. The Detective stated HN2 had pictures of R1's medication due to concern of an overdose. The Detective further stated when he responded to the facility on [DATE] at 8:00 PM, the coroner and funeral home representative were already at the facility. He stated the police double checked all R1's medications, retrieved the Morphine and took it into custody. The Detective also stated there was a recorded phone call from the facility Unit Manager (UM), calling hospice to verify milligrams of liquid Morphine, figuring out there was an issue for R1, stating three doses of Morphine were given at five times the ordered amount.In an interview with the facility Nurse Practitioner (NP), on 03/17/2026 at 9:26 AM, she stated the morning of 03/12/2026, she (NP) gave Licensed Practical Nurse (LPN)1 a verbal telephone order to administer 0.25 ml of Morphine Concentrate, and when hospice arrived, they would assume care. Further, the NP stated LPN1 called her back on 03/12/2026 at approximately 6:30 AM to clarify the Morphine order and the NP restated the order to be Morphine Concentrate, which was 100 mg/5 ml, (not 20 mg/5ml as LPN1 documented), give 0.25 ml every hour or as needed. The NP explained she also placed a written order to pharmacy for oral Morphine Concentrate 100 mg/5 ml at 0.25 ml to equal 5 mg, every hour or as needed.In an interview with LPN1, on 03/18/2026 at 9:35 AM, she stated, on 03/12/2026, the NP gave verbal orders which included, Morphine Concentrate at 0.25 ml every hour as needed. LPN1 stated once she got into the computer to place the order of 0.25 ml of Morphine, there were several Morphine options available to choose from and as a result, LPN1 called the NP back to clarify the order. LPN1 stated the NP then clarified the order as Morphine 20 mg/5ml.During an interview with Hospice Nurse (HN)1, on 03/18/2026 at 1:19 PM, she stated she wrote on a paper document, labeled Nursing Home Visit Record, the new order to increase the Morphine Solution to 1.25 ml to equal 5 mg as needed, per physician's order. In further interview with HN1, she stated the new order to increase the Morphine was based on the Physician Order Report, which showed 20 mg/5 ml, and she did not see the facility NP's written order to the pharmacy or the label on the bottle of Morphine, (which both indicated 100 mg/5 ml).In an interview with the Unit Manager (UM), on 03/17/2026 at approximately 10:30 AM, she stated on 03/12/2026 at 12:00 PM, when Hospice Nurse (HN)1 gave the hand-written order to increase the Morphine to 1.25ml equal 5 mg, she brought her concern to the Assistant Director of Nursing (ADON) because she had not seen an order for 1.25 ml before. She explained, later in the shift, (and documented by hospice at 5:10 PM), she called hospice to question the order and faxed them requested documents. Further, she stated she left for the day prior to receiving clarification as to the accuracy of the order. The UM further stated LPN2 called her, stating she could not locate R1's Morphine narcotic sheet (Controlled Drug Record Individual Patient's Narcotic Record) and HN2 wanted to review it. The UM stated when she returned to the facility, she noted the coroner and the police were at the facility.During an interview with the ADON, on 03/17/2026 at 11:23 AM, she confirmed that on 03/12/2026, she instructed the UM to call hospice for clarification due to her concerns about the order when the Morphine was increased due to how it was written, as well as the amount of 1.25 ml because the amount seemed like a lot to her. The ADON stated she was unaware the UM did not contact hospice for order clarification until 5:10 PM, shortly before R1's death. The ADON further stated, after leaving the facility, she received a call to return to the facility because HN2 had some concerns about the amount of Morphine that was administered to R1 prior to her death. The ADON stated she came back to the facility, and the police were there. The ADON further stated she only knew police were investigating whatever HN2 told them, and she assumed it was hospice that called the police, but she was not sure. In an interview with HN2, on 03/18/2026 at 12:34 PM, she stated when she asked facility staff to see the paperwork the previous hospice nurse (HN1) left, she was told the paper was shredded. HN2 also asked to see R1's Morphine narcotic log (Controlled Drug Record Individual Patient's Narcotic Record) and the facility staff were unable to locate the log. She stated the facility had already called a funeral home to pick up R1's remains. HN2 stated when she received the Morphine narcotic log she took pictures of R1's bottle of Morphine (with the label showing a dose concentration of 100 mg/5 ml rather than 20 mg/ml). HN2 stated she gave a brief history of what happened to the coroner, who called the police.The SSA surveyor attempted to contact the coroner on 03/18/2026 at 9:37AM and was unsuccessful. Additionally, a formal records request was sent on 03/16/2026 at 10:39 AM. In an interview with the Director of Nursing (DON), on 03/22/2026 at 1:56 PM, she stated alleged violations or incidents that should be reported to the Office of Inspector General (OIG) would be any type of abuse. The DON stated these allegations should be brought to the Administrator because she processed the report. When asked if the incident regarding R1 should have been reported by the facility to the state agencies, the DON replied, As far as I know, it was reported by police.In an interview with the Facility Administrator, on 03/22/2026 at 2:25 PM, she stated alleged violations or incidents that should be reported to the OIG/state agencies include abuse, neglect, misappropriation, fire, and any type of harm. She stated she or the DON could report the alleged violations. The Administrator confirmed she did not report allegations regarding R1 to the state agencies because she knew the police were going to report the incident. She stated the police said they were going to report the allegation. In an interview with the facility Medical Director, on 03/22/2026 at 2:06 PM, he stated reporting alleged violations or incidents to the SSA was not his area of expertise and he was not sure of the specifics. However, when asked if the incident regarding R1 should have been reported, he stated, Yes, probably so.

Based on interview, record review, facility document review, and facility policy review, the facility failed to notify the Nurse Practitioner (NP), Medical Director (MD) and management staff when the administration of an immediate (STAT, statim) order for medication was delayed due to not being received from the pharmacy timely. This failure affected 1 (Resident #105) of 1 resident reviewed for notifications. The findings included: A facility policy titled, Physicians Orders, revised 01/30/2026, indicated, 3. Licensed Nurses are expected to notify the physician with any concerns related to new physician orders or potential need for changes in orders. A Resident Face Sheet indicated the facility admitted Resident #105 on 12/06/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of chronic pain syndrome. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12 2025, revealed Resident #105 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had received scheduled pain medication but had not received PRN pain medications or was offered and declined during the assessment's five-day lookback period. Resident #105's Care Plan, included a problem statement dated 12/08/2025, that indicated the resident had complaints of pain related to Parkinson's radiculopathy, chronic pain syndrome, and a left wrist fracture. Interventions directed staff to administer pain medication as ordered (initiated 02/07/2026). During a concurrent interview and observation on 02/09/2026 at 11:21 AM, Resident #105 was observed to have an elastic bandage wrapped around their left hand/wrist area. Resident #105 stated that they had a fall on Saturday (02/07/2026) when they went to the bathroom without assistance and fell on their way back to their bed. Resident #105 stated since the fall their pain had been tolerable because staff had provided them with medication, ice/hot compress, and elevate their hand and now they are waiting on their ortho appointment to be scheduled. Resident #105's Resident Progress Notes, dated 02/07/2026 at 9:34 AM, revealed the resident had an unwitnessed fall while attempting to ambulate to the bathroom. The notes revealed the resident reported pain in their left wrist. The notes revealed that the provider was notified. Resident #105's Resident Progress Notes, dated 02/07/2026 at 2:27 PM, revealed a new order was received for x-rays to the resident's left wrist. The notes revealed the resident had received Tylenol for pain and discomfort that was somewhat effective. Resident #105's Resident Progress Notes, dated 02/07/2026 at 6:57 PM, revealed the x-ray results indicated the resident had a left wrist fracture. Per the notes, the provider was notified of the x-ray results and that the resident's pain was not resolved. The notes revealed that the staff were waiting for the provider's response. Resident #105's Resident Progress Notes, dated 02/07/2026 at 8:35 PM, revealed a new order for tramadol 50 milligrams (mg) by mouth every six hours as needed (pro re nata, PRN) for pain related to the resident's left wrist fracture was received.Resident #105's Resident Progress Notes, dated 02/08/2026 at 4:09 AM, revealed the resident received PRN Tylenol around 1:09 AM for left wrist pain with some relief noted. The notes revealed Licensed Practical Nurse (LPN) # 2 inquired two times around 11:30 PM (on 02/07/2026) and again around 4:00 AM (on 02/08/2026) as to when the delivery of tramadol would arrive since the medication had been ordered STAT (statim, immediate). Per the notes, a pharmacy technician indicated that the pharmacy had many requests for STAT orders and there was only one delivery driver on the weekend. The notes revealed staff were told that the medication was enroute to the facility. Resident #105's Resident Progress Notes, dated 02/08/2026 at 7:01 AM, revealed the resident received PRN tramadol for left wrist pain around 5:19 AM and it appeared to be more effective than Tylenol alone. A pharmacy Shipping Manifest, dated 02/07/2026, revealed a STAT order for tramadol 50 mg was ordered for Resident #105 and was received by the facility on 02/08/2026 at 5:14 AM. Resident #105's Medication Administration Record [MAR] for the timeframe from 02/01/2026 through 02/09/2026 revealed staff documented that the resident received tramadol 50 mg on 02/08/2026 at 5:19 AM. During a telephone interview on 02/10/2026 at 6:16 PM, LPN #2 stated she called the pharmacy twice to get an update on the delivery of the STAT tramadol order and was told by a pharmacy technician that they only had one delivery driver. She stated that the tramadol was received on 02/08/2026 at 4:19 AM. LPN #2 stated she did not notify the MD or NP of the delay of the medication (tramadol). During an interview on 02/11/2026 at 10:22 AM, the NP stated she sent a STAT order for tramadol for Resident #105 on 02/07/2026 at approximately 9:00 PM and had not been notified of the delay. The NP stated staff should have notified her of any delay in receiving the tramadol order for Resident #105. During a telephone interview on 02/11/2026 at 1:51 PM, LPN #3 stated he spoke to the NP, and the NP ordered a STAT order for tramadol (on 02/07/2026). LPN #3 stated he then called the pharmacy to confirm the STAT order for the tramadol had been received. LPN #3 stated he had no further involvement in this incident.During a telephone interview on 02/11/2026 at 3:01 PM, the MD stated he had not been notified of the delay in receiving the tramadol for Resident #105. During an interview on 02/12/2026 at 10:06 AM, The Director of Nursing (DON) stated she expected the nurse to document and notify management if medications were not received timely. The DON stated that the time for STAT orders should be received within four hours, and she expected the staff to notify the MD and/or NP if there was a delay in receiving medication from the pharmacy. During an interview on 02/12/2026 at 10:27 AM, the Assistant Director of Nursing (ADON) stated she expected staff to notify the MD, NP, and/or management staff if there was a delay in receiving orders from the pharmacy. During a telephone interview on 02/12/2026 at 4:15 PM, the Pharmacy Operations Manager stated the tramadol was ordered STAT on 02/07/2026 at 9:09 PM, and on the weekends they do not have many drivers but that the medication was received by the facility on 02/08/2026 at 5:14 AM. During an interview on 02/13/2026 at 9:30 AM, the Administrator stated she expected the staff to notify the NP, MD, and management staff when there was a delay in receiving any medication from the pharmacy. The Administrator stated she was not aware of the delay in receiving Resident #105's tramadol. The Administrator stated that it was unacceptable that staff did not call the NP or MD when the tramadol was not delivered promptly.

Based on interview, record review, and review of facility policy, the facility failed to complete the Kentucky (KY) Adult Caregiver Misconduct Registry checks prior to beginning employment on 2 of 3 contracted dietary employees, Dietary Aide (DA) 1 and [NAME] 1. DA 1 began employment at the facility on 09/04/2024, and [NAME] 1 began employment on 09/11/2024. However, the facility failed to complete the KY Caregiver Misconduct Registry checks for both employees prior to employment, as the check were not completed until 10/24/2024, during the State Survey Agency (SSA) survey. The findings include: Review of the Kentucky Revised Statutes (KRS) 209.032 regulations 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. Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property revised 09/15/2023, revealed the facility conducted screenings 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 Aide Abuse Registry. Further review revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the facility's screening process. Review of the Contracted Employee Policy, under section 12. Criminal Background Checks, revealed the contracted agency must perform a criminal background check (including State Abuse Registries and the National Sex Offender Registry). Per review, the contracted agency was to perform the checks on each of its respective personnel (including, without limitation, any of its contractors and agents who were to perform services or duties on-site at any facility) in accordance with Federal and State requirements. Continued review revealed the checks were to be performed in order to verify that such individuals who had contact with facility residents or had access to residents' medical records had not been found to have engaged in improper or illegal conduct relating to the elderly, children, or vulnerable individuals. Review of the personnel file for DA 1 revealed he was employed by the facility through a contracted company on 09/04/2024. Further review revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) check was not completed until 10/24/2024. Review of the personnel file for [NAME] (C) 1 revealed she was employed by the facility through a contracted company on 09/11/2024. Further review revealed however, the KACMR check was not completed until 10/24/2024. In interview with the Director of Nursing (DON) on 10/25/2024 at 9:35 AM, she stated the facility was contract or agency free or were almost contract or agency free as of July 2024. She stated the facility no longer used contract or agency employees and had not done that since July 2024. The DON further stated she had no knowledge of the background checks completed for new hires. In interview with Dietary District Manager (DDM) 1 on 10/25/2024 at 10:05 AM, he stated all the dietary staff were employees of a contracted company. He stated those employees were subject to the same background checks and any other state regulated checks prior to employment. DDM 1 stated if those checks were not done, the said potential employee would not be employed. Per DDM 1 in interview, both the contracted dietary employees' KACMR checks had, in fact, been done, just not before they were allowed to start working. He further stated he had not been aware the KACMR checks for DA 1 and [NAME] 1 were completed minutes before their files were produced for review by the SSA. In interview with the Administrator on 10/25/2024 at 10:40 AM, she stated contracted staff were responsible for their own background checks. She stated the contracted company had a district manager who worked in the facility with the dietary manager. The Administrator stated she did not know the exact procedure, but they (contract agency) was required to meet the same guidelines as the facility for whomever they hired. She stated she did not know their (contract agency) procedures; however, could find out through their corporate office as corporate did the facility's checks. She said it was an issue if the checks were not done, and the potential employee would not be hired. The Administrator stated she would email the facility's learning department and call the corporate office to check to see if the KACMR checks were mistakenly misfiled on the two employees in question (DA 1 and [NAME] 1). She reported the purpose of the KACMR checks was to keep people with misconduct from working in the facility. Per the Administrator in interview, she was not able to come up with a hypothetical potential issue if the checks were not being completed (as required). She stated someone employed directly by the facility would not be allowed to work because the policy for all facility employees to have the checks done prior to beginning work. The Administrator further stated she would have to look at the contract company's policy regarding background checks for potential new employees. She implied she was not the person responsible for overseeing the pre-employment checks for any contracted staff, and stated corporate was supposed to be taking care of that. In interview on 10/25/2024 at 11:33 AM, the Administrator reported employees were not able to be paid if the KACMR check had not been completed. She stated she was waiting for corporate to respond regarding the possible misfiled KACMR checks for DA 1 and [NAME] 1. In interview on 10/25/2024 at 12:45 PM, the Administrator reported she had been unable to locate the KACMR checks on the two contracted dietary employees (DA 1 and [NAME] 1). 51281

Based on observation, interview, record review, and review of facility's policy, it was determined that the facility failed to ensure residents were treated with dignity and respect in a manner that enhanced the resident's quality of life for one (1) of seven (7) sampled resident residents (Resident #2). The facility failed to honor Resident #2's right to refuse taking his/her medication. On 06/18/2023, Registered Nurse (RN) #3 was observed by staff holding Resident #2's nose during medication administration. The RN was overheared telling Resident #2, see there you go, after making him/her take the medication. On 10/27/2023 observation revealed Resident #2 was in his/her room, in bed sitting up, looking at television. Resident #2 was non-verbal so he/she was unable to be interviewed. In interview on 10/27/2023 at 9:01 AM, with [NAME] Clerk said Resident #2 says some words sometimes. The facility failed to honor resident's right to refuse take medications. The findings include: Review of the facility's policy titled, Resident Rights, last revised September 2023, revealed all residents had the right to be treated with respect and dignity. Continued review revealed resident's rights were to be promoted and protected by the facility. Further review revealed the facility would make every effort to support each resident in exercising his/her right to assure that the resident was always treated with respect, kindness, and dignity. Review of Resident #2's Admission Record revealed the facility admitted the resident on 08/21/2021, with diagnoses of Dementia with Agitation, Muscle Weakness, Cognitive Communication Deficit, Dysphagia, Heart Failure, Paranoid Personality Disorder, and Parkinson's Disease. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of a possible fifteen (15), which indicated he/she was severely cognitively impaired. Continued review of the MDS, section E, regarding Behaviors, revealed the facility assessed Resident #2 had no indicators of Psychosis, and no behavioral symptoms directed toward others. Review of Resident #2's Comprehensive Care Plan revealed the facility care planned the resident's risk for behaviors such as refusal of care and medication from time to time. Continued review revealed interventions which included when Resident #2 was agitated with care or medication administration staff were to step back, allow time for the resident to calm down, and then re-approach. Review of the facility's investigation written witness statements revealed three (3) staff members including the perpetrator, RN #3, gave statements, that Resident #2 had not wanted to take his/her medication so the perpetrator pushed Resident #2's chin upward and pinched his/her nose so that the resident would swallow the medication. Observation on 10/27/2023 at 10:53 AM, revealed Certified Medical Technician (CMT) #6 assisted an un-sampled resident with his/her liquid medication administration. Continued observations revealed during the process of receiving the liquid medication administration the resident became choked. Further observation revealed CMT #6 stopped to ensure the resident had stopped choking. Further observation revealed CMT #6 asked the resident if he/she wanted to continue taking his/her medication. Additional observation revealed after the resident had recovered, CMT #6 continued to administer his/her medication until gone. During an interview on 10/27/2023 at 10:57 AM, CMT #6 stated the facility educated staff on residents' rights which included abuse and dignity; however, she had not provided care for Resident #2. The CMT stated anytime a resident became agitated or refused medication, she asked the resident why he/she was refusing, then tried to re-engage the resident later and if he/she continued to refuse she documented why the resident refused. CMT #6 stated she attempted to meet the needs of the resident on his/her cognitive level. The State Survey Agency (SSA) Surveyor was unable to reach RN #3 via telephone for an interview. In interview on 10/30/2023 at 11:24 AM, Registered Nurse (RN) #2 stated she worked at the facility on an as needed (PRN) basis. RN #2 stated if a resident refused to take their medication and staff attempted to force him/her to take it that was a form of abuse. The RN further stated it was the resident's right to refuse medication, and she documented why the resident refused to take the medication. Additionally, after reviewing the care plan for Resident #2, she stated staff might need to reapproach the resident later and try to administer the medication. RN #2 further stated she had never seen a resident forced to take their medication. In interview on 10/31/2023 at 10:34 AM, the Director of Nursing (DON), stated she received a call from Certified Nursing Assistant (CNA) #8, on 06/18/2023, stating he witnessed Registered Nurse (RN) involved in the incident hold Resident #2's nose to make him/her take their medication. The DON stated the CNA reported overhearing the RN telling Resident #2, see there you go. She stated she instructed staff to have the RN escorted out of the facility and for Resident #2 to be assessed. The DON stated the following day, 06/19/2023, she and the Administrator contacted the RN who said she did not remember holding Resident #2's nose. She stated the RN told them it was time for her to retire from nursing and would not comment anymore about the incident. The DON further stated it was never appropriate to hold a resident's nose and force him/her to take medication. During an interview on 10/31/2023 at 11:16 AM, the Administrator stated she received a call about the abuse allegation regarding Resident #2. She stated there had been a phone interview with RN#3 about not honoring the resident's refusal of medications. The Administrator stated the RN reported she was unable to remember making Resident #2 take his/her medications. She stated however, other staff witnessed the incident. The Administrator stated the RN had decided that day to resign from her position at the facility. In additional interview the Administrator stated Resident #2 had been assessed with no decline in his/her psychosocial wellbeing or skin injury noted. She further stated the facility treated all residents with dignity and respect all the time.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent resident to resident altercations for three (3) of seven (7) sampled residents (Residents #1, #3, and #4). The facility failed to provide adequate supervision to ensure Residents #4 was protected from abuse by Resident #3. On 06/04/2023 at 12:07 PM, Resident #3, who had a history of physical aggression towards staff, hit Resident #4 once across the face, while agitated for an unknown reason. Resident #4 was observed to have a raised area on his/her lip after the incident. The facility failed to provide adequate supervision per Resident #3's care plan for the safety to other residents. On 10/11/2023 at 2:00 PM, Resident #3 was sitting in the Bistro area, and had pulled the table cloth off the dining room table when Resident #1 redirected Resident #3 and attempted to take the table cloth away. Resident #3 then hit Resident #1 on his/her right leg approximately six (6) to seven (7) times before staff could separate residents. After the incident, Resident #1 was assessed by nursing staff but no injuries were found. The finding include: Review of the facility's policy titled, Safety and Supervision of Resident, revised 09/15/2023, revealed resident safety and supervision that was appropriate based on the individual resident's needs were facility-wide priorities. Per review, when accident hazards were identified, the facility was to evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. Further review revealed the facility was to complete a root cause analysis and determine an intervention based on the root cause. 1. Review of Resident #3's record revealed the facility admitted the resident on 11/14/2023, with diagnoses which included Atherosclerotic Heart Disease; Chronic Kidney Disease, Stage two (2); and Alzheimer's Disease. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitive impaired. Continued review of the MDS, section E, titled Behaviors, revealed Resident #3 had experienced Psychosis, and exhibited behavioral symptoms directed toward others. Review of Resident #3's Comprehensive Care Plan (CCP) the facility had care planned the resident for behaviors. Continued review revealed the interventions for behaviors included every fifteen (15) minute checks; medication changes; and to maintain a calm environment and approach to the resident. Review of facility investigation revealed On 06/04/2023, Resident #3 and Resident #4 where in the hallway when Resident #3 rolled up to Resident #4 in his/her wheelchair and hit him/her in the mouth. Resident #4 sustained a raised area located on his/her lip. Review of Resident #3's Psychiatry Progress Note dated 10/20/2023, revealed the resident continued to display irritability at times. Continued review of the Note revealed Resident #3 also had verbal and physical aggression toward staff and other residents. Further review revealed Resident #3 was currently prescribed Depakote as a mood stabilizer and Citalopram for anxiety and depression. Observation of Resident #3 on 10/27/2023 at 9:49 AM, revealed the resident was sitting in his/her wheelchair in the facility's Bistro area, propelling himself/herself around the room. In interview on 10/27/2023 at 9:50 AM, Resident #3 stated he/she had friends at the facility; however, could not recall their names. Resident #3 could not recall any altercations with other residents or staff. In addition, Resident #3 was unable to recall the names of family, friends, or staff. 2. In interview on 10/27/2023 at 8:54 AM, Resident #1 stated while in the Bistro area he/she attempted to take the tablecloth away from Resident #3, after he/she had removed it from the table. Resident #1 stated Resident #3 had been angry at that time and used his/her fist hitting Resident #1's right leg six (6) to seven (7) times. Resident #1 continued to state that Resident #3 had cognitive deficits and would not remember the incident. Resident #1 stated Resident #3 was moved to the other side of the building after the incident. In addition, Resident #1 stated he/she was assessed by nursing staff which revealed no injuries. 3. In interview on 10/27/2023 at 2:02 PM, Resident #4 indicated she/he did not remember having an altercation with another resident. Resident #4 stated he/she got along with everyone including staff at the facility. In interview on 10/27/2023 at 2:07 PM, Certified Nursing Assistant (CNA) #2 stated Resident #4 had a history of alcoholism before his/her admission to the facility and he/she had been confused. In continued interview CNA#2 stated Resident #4 liked to visit other residents. She stated she did not remember any aggressive behaviors occurring between residents; however, further stated all abuse was reported to the Administrator or/and DON. Interview on 10/31/2023 at 9:32 AM, Licensed Practical Nurse (LPN) #3 reported there were documented resident-to-resident altercations which included incidents over loud televisions, visitors, or lights being on. The LPN stated staff reminded the residents to be respectful of each other. In continued interview LPN #3 stated most of the disagreements were with residents who had cognitive issues. LPN #3 further stated if the situation warranted, residents could have their room changed, or be placed on one (1) on one (1) supervision or every fifteen (15) minute checks. In interview on 10/31/2023 at 10:34 AM, the Director of Nursing (DON) stated she received a report on 06/04/2023 at 1:05 PM that Resident #3 had hit Resident #4 in the mouth, injuring his/her lip. The DON stated the facility was unable to figure out the root cause of the altercation. In continued interview the DON stated it was possible Resident #4 reminded Resident #3 of someone from his/her past experiences. The DON stated at that time the facility decided the best interventions for Resident #3 were every fifteen (15) minute checks, psychotherapy, and Celexa (an antidepressant) 20 mg. In addition, the DON stated the facility decided staff would monitor and document Resident #3's aggressive behaviors. In continued interview, on 10/31/2023 at 10:34 AM, the DON stated it was reported on 10/11/2023, when Resident #3 was in the dining room, he/she was involved in another altercation with Resident #1. The DON stated at that time the Assistant Director of Nursing (ADON) was notified; however, she was no longer employed at the facility. In continued interview the DON stated Resident #1 had taken a tablecloth away from Resident #3 after he/she had taken it off the dining table. Per the DON, Resident #3 thought the tablecloth was his/her own personal item and proceeded to hit Resident #1. The DON stated after the altercation, Resident #3 was continued on the every fifteen (15) minute checks, medication changes were made, and staff increased his/her activities. According to the DON, the Interdisciplinary Team (IDT) members were still trying to find Resident #3's triggers for his/her aggressive behaviors. In addition, the DON stated Resident #1 had been educated and encouraged not to approach other residents and to contact staff if he/she had concerns. In interview on 10/31/2023 at 11:16 AM, the Administrator stated Resident #3 had been diagnosed with Dementia and was followed by psychiatry, along with the Advanced Practice Registered Nurse (APRN) who had adjusted the resident's medications. The Administrator stated she had directed staff to document Resident #3's behaviors while he/she was on fifteen (15) minute checks. In continued interview the Administrator stated Resident #3 had no concept of what he/she was doing; however, staff was educated on how to assist the resident and provide necessary supervision. The Administrator stated Resident #1 had been educated to get staff to assist with addressing any concerns he/she had with others. Per the Administrator, Resident #1 had a habit of inserting himself/herself into other residents' visits with their families, their personal business, and other residents' private affairs. The Administrator stated her staff had been educated on Dementia care and reporting abuse. In interview on 11/03/2023 at 2:46 PM, the APRN stated Resident #3 had been diagnosed with acute Dementia with cognitive impairments. The APRN stated Resident #3 had been adjusting to his/her medication changes, and staff was instructed to document, monitor, and immediately notify the APRN of any aggressive behavior concerns. She stated the facility could not prevent behaviors of any resident; however, interventions had been implemented for Resident #3 to prevent repeat behaviors. In addition, she stated it had been five (5) months since Resident #3 had any negative behaviors which was an improvement. The APRN stated the goal of the facility was to keep all residents safe, including Resident #3.

Based on observations, interviews, record review and facility policy review, it was determined the facility failed to prevent the possible spread of COVID-19 for one (1) of eighteen (18) sampled residents (Resident #230). Resident #230, who had not received the COVID-19 vaccine, was admitted to the facility on [DATE]. Observation of Resident #230 and the resident's room on 06/29/2021 revealed the facility failed to place the resident in isolation, per the facility's policy; and, failed to place appropriate signage and Personal Protective Equipment (PPE) outside the resident's door. The findings include: Review of the facility's policy, Novel Coronavirus (COVID-19) dated 06/02/2021, revealed the facility would place all new admissions to the facility who were not fully vaccinated for COVID-19 in isolation and on droplet precautions for fourteen (14) days. Review of Resident #230's medical record revealed the facility admitted the resident on 06/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an E-mail notification dated 06/25/2021 at 1:41 PM sent from the Admissions Coordinator to the Director of Nursing (DON), Infection Control Nurse, and Administrator, revealed Resident #230 had not received the COVID-19 vaccination. Review of Resident #230's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #230's Baseline Care Plan for infection control dated 06/28/2021, revealed the resident was to be in isolation and on infection precautions as warranted per the resident's condition and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident #230 on 06/29/2021 at 1:00 PM and 4:11 PM revealed the resident was sitting up on the side of the bed in his/her room. Continued observation revealed there was no identifier on the resident's room door or in an adjacent area indicating the resident was in isolation or on droplet precautions and no Personal Protective Equipment (PPE) was available for use prior to entering the resident's room. Interview with Registered Nurse (RN) #2, on 07/01/2021 at 10:30 AM, revealed when the facility admitted a resident not vaccinated for COVID-19, the facility automatically placed the resident in isolation and on droplet precautions for fourteen (14) days. RN #2 stated the facility should have placed Resident #230 in isolation and on precautions upon admission. Interview with the Infection Control Nurse (ICN), on 07/01/2021 at 12:41 PM, revealed the facility placed newly admitted residents who were not COVID-19 vaccinated in isolation and on precautions. Further interview revealed the Admissions Coordinator sent out an email related to the new admission's vaccine status. The ICN stated the Administration and the Interdisciplinary Team (IDT) discussed all new admissions and their vaccination status daily in the morning meeting. Continued interview with the ICN revealed staff documented new admissions and their vaccination status on the huddle sheet at the nurse's station, so all staff would be aware. Further interview with the ICN revealed staff should have placed Resident #230 in isolation upon arrival. She stated she was not aware of what occurred that made the facility miss placing the resident in isolation and on precautions. Interview with Licensed Practical Nurse (LPN) #4, on 07/01/2021 at 4:05 PM, revealed she was on duty when Resident #230 arrived to the floor on 06/25/2021. Continued interview with the LPN revealed she was aware of the facility's policy on newly admitted residents, and knew Resident #230 was not vaccinated for COVID-19. However, LPN #4 stated she forgot and failed to place an isolation kit/PPE on/at the resident's door. Interview with the Admissions Coordinator on 07/01/2021 at 10:45 AM, revealed she sent out the email to the department heads related to Resident #230's vaccination status prior to admission. The Admission Coordinator stated staff should have placed the resident in isolation and on precautions. Interview with the Director of Nursing (DON), on 06/30/2021 at 3:56 PM, revealed the facility admitted Resident #230 on 06/25/2021, who was not vaccinated for COVID-19. Further interview with the DON revealed unvaccinated new admissions were placed in isolation and on precautions for fourteen (14) days. The DON stated staff should have placed the isolation/PPE kit on the resident's door immediately upon arrival. Interview with the Administrator, on 07/01/2021 at 5:41 PM, revealed all the department heads received an email regarding any new admissions with their vaccination status. Further interview revealed staff should have known and placed Resident #230 in isolation. The Administrator stated the Huddle team members discussed new admissions and their vaccination status each morning in the huddle meeting, but he did not know the staff failed to follow the policy for Resident #230.

Based on interview, record review, and review of facility policy, it was determined the facility failed to adequately supervise one (1) of three (3) sampled residents (Resident #3) to prevent sexual behaviors towards another resident (Resident #4). Resident #3 was identified to have sexually inappropriate behavior with three (3) residents, one on 03/24/19, one on 05/31/19;and one(1) on 07/21/19; however, the facility failed to put any increased supervision in place to ensure the resident was not left alone with other residents. The findings include: Review of a facility policy Safety and Supervision of Resident, last Reviewed 05/31/18, revealed the interdisciplinary care team shall analyze information obtained from assessments and observations to identify an specific accident hazards or risks for that resident. The Care team shall target interventions to reduce the potential for accidents. Record review revealed the facility admitted Resident #3 on 08/27/14 with diagnoses which included Non-Alzheimer's Dementia, Anxiety, Depression, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Prostatic [CONDITION(S)]. Review of the Quarterly Minimum Data Set (MDS) Assessment , dated 10/18/19, revealed the facility assessed Resident #3's cognition as severely impaired with Brief Interview for Mental Status ( BIMS) score of five (5) which indicated the resident was not interviewable. Review of the facility's Verification of Investigations, dated 03/24/19, revealed a Certified Nurse Aide (CNA) witnessed Resident #3 with his/her hand up another resident's shirt. Further review revealed Resident #3 was placed on 1:1 until accepted into a behavioral health hospital. Review of the facility's Verification of Investigation, dated 05/12/19, revealed Resident #3 was found in another resident's room standing at side of bed over the other resident prior to removal by a CNA that heard resident in the bed yell out. Further review revealed Resident #3 was sent to Behavioral Health hospital and medications were adjusted prior to return to the facility. Review of an Occurrence Investigation completed by Registered Nurse (RN) #3, on 07/21/19, and facility's Verification of Investigation, dated 07/26/19, revealed Resident #4 was found very upset and crying outside of dining room by a CNA. Resident #4 stated Resident #3 grabbed his/her hand and rubbed his/her leg, then Resident #3 put his/her hand under Resident #4's shirt and rubbed his/her breasts. Review of Event Report for Resident #3, dated 07/21/19 at 12:37 PM, revealed Resident #3 was left alone around a female resident without staff supervision as the answer to the question, what precipitated the altercation?. Review of Comprehensive Care Plan for Sexually Inappropriate Behaviors dated 07/21/19, revealed care plan was updated at that time for 1:1 supervision while out of room and fifteen minute checks while in bed until sent out for psychiatric evaluation (sent out 07/23/19) and on return, 07/26/19, resident was placed on fifteen minute checks for 72 hours, refer to social service director and chaplain as needed, which was what was done after the first two (2) incidents. Further review revealed new interventions to offer newspaper to read, offer a snack, and encourage to draw, . Review of Comprehensive Care Plan for [CONDITION(S)] Drug Use, dated 07/23/19, revealed medication change related to increase in inappropriate behaviors, with interventions to attempt a gradual dose reduction if not contraindicated, monitor for drug use effectiveness and adverse consequences, and monitor my mood and response to medication. However, there were no interventions put in place to address the fact the resident goes a couple of months without an incident which is after the seventy-two hours on increased supervision and the resident being left alone with a resident of the opposite sex which was the precipitating factor for the 07/21/19, the facility had identified. Interview with the Administrator, on 12/18/19 at 10:19 AM, revealed the incident occurred before he assumed the role as Administrator and had only reviewed the investigations. He stated when the incident was reported on 07/21/19 the resident was put on one to one supervision until resident could be sent to another facility for psychiatric evaluation and medication adjustment. Further interview with Administrator, on 12/20/19 at 3:03 PM, revealed the Director of Nursing, and Social Services Director with input from floor staff and review of incidents determines final interventions in care plans. He stated floor staff input immediate interventions but interdisciplinary team determine the care plans that continue. He revealed In this incident due to hospitalization and report from hospital there did not appear to be a need for additional level of supervision beyond the 72 hours after return to facility as no behaviors observed and no recommendations from the psychiatrist that discharged from the hospital for higher level of supervision based on behaviors at hospital and response to medications.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 05/29/19, revealed food stored in the walk-in freezer was not dated. Review of the facility Census and Condition, dated 05/29/19, revealed seventy-one (71) of seventy-six (76) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Food Storage, last revised 11/01/14, revealed all products should be dated upon receipt and when they are prepared. Observation of the walk-in freezer during initial tour, on 05/29/19 at 11:20 AM, revealed one (1) bag of hush puppies and two (2) bags of french fries not dated. Interview with Dietary Aide #1, on 05/30/19 at 5:17 PM, revealed all items stored in the freezer should be dated and labeled. Interview with the Dietary Manager, on 05/29/19 at 11:30 AM, revealed she expected all food items in the freezer to be dated. She stated the cook was going to use those items today.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure four (4) of twenty-one (21) sampled residents care plans were revised related to nutrition, or falls (Residents #11, #70, #32 and #10) . Resident #10 had a Significant Weight Loss from 12/10/18 to 05/13/19 (154 pounds {lbs} to 113.5 lbs) with multiple interventions attempted by the physician, the Dietician, family members and staff; however, the staff failed to revise the Comprehensive Care Plan related to the significant weight loss to include goal, and interventions that were attempted. In addition, Resident #11, #70, and #32 had multiple falls, however, the facility failed to revised the care plan to address the root cause of the falls to try to prevent future falls. The findings include: Review of the facility's policy Comprehensive Care Plans, not dated, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problems area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. 1. Record review revealed the facility admitted Resident #10 on 02/21/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/22/19 revealed the facility assessed Resident #10's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Resident #10's Comprehensive Care Plan, dated 02/26/19, for: I am at nutritional risk: I am a picky eater, I like bananas, pudding, and ice cream revealed a goal I will have no significant weight changes by next review. Further review revealed interventions to weigh and monitor per protocol and provide diet, snack, and supplement as ordered. Review of Resident #10's Medical Nutrition Review dated 02/26/19 revealed his/her weight was down 7.5 % in one (1) month. Supplemented with promod 30 milliliters (ml) (a protein supplement) two times a day (BID), Medplus 120 ml BID, and Vitamin C juices BID. Review of Resident #10 physician's orders [REDACTED]. Review of Point Click Care (PCC) electronic charting system for weights and vital sign recordings revealed Resident #10 weighed 154 pounds (lbs) on 12/10/18 and 113.5 lbs on 05/13/19; a 26.3 percent (%) weight loss in six (6) months. However, further review of the Comprehensive Care Plan, dated 02/26/19 revealed there were no revisions to address the resident's significant weight loss or the interventions put in place to address the weight loss. Observation on 05/31/19 at 7:46 AM revealed staff assisted Resident #10 with breakfast but he/she refused all food and drink at the time of the observation. Further observation revealed the Certified Nurse Aide (CNA) spoke in Spanish to try to encourage intake, but without success. Interview on 05/31/19 at 9:24 AM with Resident #10's daughter and Power of Attorney (POA) related to weight loss, stated the resident was extremely stubborn at this time and she realized you cannot make him/her eat and have tried. She stated she felt staff tried every possible intervention to encourage him/her to eat but without success. Interview with Licensed Practical Nurse (LPN) #1, Charge Nurse, on 05/31/19 at 4:00 PM revealed the goal and interventions listed on Resident #10's care plan no longer apply, and should have been updated. Interview with the Director of Nursing (DON) on 05/31/19 at 5:11 PM revealed the Interdisciplinary Team (IDT) team goes over all orders in the morning meeting and it is the responsibility of the IDT team, the MDS Coordinator, and Unit Managers to update care plans. She stated all interventions attempted should have been added on the care plan, but none were, and she did not know what could have happened that they were not. 2. Record review revealed the facility readmitted Resident #11 on 02/09/19 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 02/22/19, revealed the facility assessed Resident #11's cognition as severely impaired with a BIMS score of three (03), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, Falls Risk, dated 02/21/17, revealed the resident was at risk for injury related to falls due to balance problems during transition, fall history, and dementia with mood disorder. Further review revealed interventions for staff to use fall risk screen, report falls to physician and responsible party, observe for side effects that cause gait disturbance, ensure call light within reach, ensure adequate lighting provided, keep high traffic areas clear of clutter, refer to therapy as needed, non-skid strips to bathroom floor and both sides of bed, encourage resident to sit closer in the dining room, encourage rest, and proper footwear. In addition, review of the CNA Care Plan not dated revealed interventions listed were observe for appropriate footwear, orient to room and surroundings, offer to lay down after meals, fall mat, and check for incontinence if resident appears restless. Review of the Facility Fall Incident Reports dated 02/08/19, 05/08/19, 05/11/19, and 05/22/19 revealed Resident #11 sustained falls; however, further review of the Comprehensive Care Plan and CNA Care Plan, revealed there was no documented evidence the care plans were revised with an intervention to address the root cause of each fall and to try to prevent further falls. In addition, review of Facility Fall Incident Report dated 04/13/19 revealed Resident #11 had a fall and the facility's identified post fall intervention was for Restorative Nursing; however, further review of the Comprehensive and CNA Care Plans revealed there was no documented evidence the care plan was revised to include Restorative services and further record review revealed no documented evidence Restorative Care was provided. 3. Record review, revealed the facility readmitted Resident #70 on 10/10/18 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 04/26/19, revealed the facility assessed Resident #70's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, Falls Risk, dated 10/23/18, revealed the resident was at risk for injury related to falls due to history of falls and intellectual disabilities. Further review revealed interventions for staff to observe for appropriate footwear, encourage activities, refer to therapy as needed, orient to room and surroundings as needed, dycem to wheelchair, alarm to chair, offer to lay own after meals, doll/stuffed animal for security, fall mat, ensure proper position in wheelchair, and check for incontinence when resident appears restless. In addition, review of the CNA Care Plan not dated revealed interventions for a raised toilet seat, call light within reach, non-skid strips to bathroom floor, nonskid socks, and toilet every two hours. Review of Facility Fall Incident Reports dated 01/21/19, 03/26/19 and 04/04/19 revealed the cause of all three (3) falls was related to Resident #70 sliding out of his wheelchair. In addition, review of Facility Fall Incident Reports dated 02/25/19, 03/11/19, 03/22/19, 03/23/19, and 04/19/19 revealed the cause of these falls was related to Resident #70 having unwitnessed falls in room. Lastly, review of Facility Fall Incident Reports dated 04/18/19 and 04/19/19 revealed these falls occurred as a result of Resident #70 having a [MEDICAL CONDITION] and falling out of wheelchair. However, further review of the Comprehensive Care Plan, dated 10/23/19 and CNA Care Plan not dated revealed the care plans were not revised with interventions to prevent falls from wheelchair after the 01/21/19, 03/26/19 and 04/04/19 falls, for unsupervised falls from bed and in room after the 03/11/19, 03/22/19, 03/23/19, and 04/19/19 falls; and to address falls and prevent injuries related to [MEDICAL CONDITION] for the 04/18/19 and 04/19/19 falls. 4. Record review, revealed the facility readmitted Resident #32 on 07/20/18 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 03/22/19, revealed the facility assessed Resident #32's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, Falls Risk, dated 08/02/18, revealed the resident was at risk for injury related to falls dementia, history of [MEDICAL CONDITION], recent stroke, right sided weakness, wandering, communication deficit, and poor safety awareness. Further review revealed interventions in place were to provide adequate lighting, refer to therapy as needed, provide family education on safety awareness, keep bedside tables out of reach for safety, observe for appropriate footwear, fall mats, anti-roll backs to wheelchair, and bed and chair alarms. In addition, review of the CNA Care Plan under safety/falls risk, not dated, revealed there were interventions to provide chair and bed alarm, right arm tray on wheelchair, and leans to right side in wheelchair. Review of Facility Fall Incident Reports dated 02/20/19, 03/09/19, 03/10/19, 04/24/19, 05/15/19, 05/21/19, 05/22/19, and 05/26/19 revealed the cause of all of the falls was related to Resident #32 attempting unassisted transfers and/or unwitnessed falls in room due to inadequate supervision. However, further review of the Comprehensive Care Plan dated 08/02/18, and CNA Care Plan not dated revealed there were no revisions to the care plan to try to prevent further falls due to the resident attempting unassisted transfers and falling in room after the 02/20/19, 03/09/19, 03/10/19, 04/24/19, 05/15/19, 05/21/19, 05/22/19, and 05/26/19 falls. Interview with LPN #4 on 05/31/19 at approximately 7:25 PM revealed nursing is responsible for completing the resident assessment, investigation, documentation and immediate care plan intervention related to a resident fall. LPN #4 stated the information then goes to the IDT team and they identify additional interventions if necessary and ensure the care plan is updated. LPN #4 stated he was unsure who was responsible for updating the care plan if the IDT team failed to do so. Interview with LPN #5 on 05/31/19 at approximately 7:30 PM revealed nursing is responsible for assessing resident, notifying physician and responsible party, documentation and identifying interventions after a resident has a fall in the facility. LPN #5 stated the information then goes to the IDT team and they look at the falls information and ensure completion of everything, to include identifying interventions and ensuring the care plan was updated. LPN #5 stated the IDT team is the final set of eyes that review the falls and ensure the care was updated to reflect new interventions identified. Interview with the DON on 05/31/19 at 5:11 PM revealed the IDT team goes over all orders in the morning meeting and it is the responsibility of the IDT team, the MDS Coordinator, and Unit Managers to update care plans. She stated all interventions attempted should have been added on the care plan, but none were, and she did not know what could have happened that they were not.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident's right to personal privacy and confidentiality during personal care for one (1) of twenty-one (21) sampled residents (Resident #28). Staff failed to pull the privacy curtain for Resident #28 while providing care and another staff entered the room, without knocking or introducing herself prior to entering the room, exposing the resident to the outer hallway. The findings include: Review of facility policy titled, Resident Rights, dated 06/30/17, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. When providing care and services, the stakeholder will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to:. Privacy and confidentially. The facility will make every effort to support each resident in exercising his/her right to ensure that the resident is always treated with respect, kindness, and dignity. Record review revealed the facility readmitted Resident #28 on 03/19/19 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 05/24/19, revealed with Brief Interview for Mental Status (BIMS) score of ninety-nine (99) which indicated the resident was not interviewable. Observation on 05/29/19 at 3:05 PM revealed Certified Nurse Aide (CNA) #2 closed the door but failed to close the privacy curtain prior to providing care to Resident #28. Further observation revealed CNA #3 quickly entered the the resident's room during this time but failed to knock on the door or introduce herself, exposing Resident #28 to the outer hallway. Interview with CNA #2 on 05/29/19 at 3:15 PM revealed she forgot to pull the privacy curtain and knew it should always be pulled when giving resident care to protect the privacy of the resident. Interview with CNA #3 on 05/29/19 at 3:20 PM revealed she was looking for another resident, and was in a hurry so failed to knock on the door or introduce herself, but knew that was what she should have done. Interview with the Director of Nursing (DON) on 05/31/19 at 7:27 PM revealed she expected staff to always provide privacy while giving resident care, and they are taught this in CNA training and through annual competencies.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the comprehensive care plan was implemented for one (1) of twenty-one (21) sampled residents (Residents #3). Observation during a lunch meal on 05/30/19, revealed Certified Nurse Aide (CNA) #1 did not spoon liquids to Resident #3, as care planned. The findings include: Review of the facility's policy Comprehensive Care Plans, not dated, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problems area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Record review revealed the facility admitted Resident #3 on 05/31/18, with diagnoses, which included Dementia and [MEDICAL CONDITION]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/11/19, revealed the facility was unable to complete a Brief Interview of Mental Status (BIMS), as Resident #3 is rarely/never understood. Further review of the Quarterly MDS revealed Resident #3 required extensive assistance of one (1) staff for eating. Review of a Physician's telephone order, dated 05/22/19 revealed all nectar thick liquids are to be given with a spoon. Review of Resident #3's Comprehensive Care Plan dated 06/06/18, revealed the resident to be nutritionally at risk with interventions to include nectar thick liquids given with spoon. Observation on 05/30/19 at 1:06 PM, revealed CNA #1 was assisting Resident #3 with his/her lunch meal. Further observation revealed she placed the drinks to Resident #3's mouth and did not spoon the liquids to the resident. Continued observation revealed Resident #3 coughed several times after taking drinks from the cup. After the surveyor viewed Resident #3's dietary slip, CNA #1 then began to spoon the liquids to Resident #3. Interview with CNA #1 on 05/30/19 at 1:25 PM, revealed she should have spooned the liquids to the resident because it stated to do so on the dietary slip. CNA #1 stated this keeps the resident from coughing so much. Interview with the Director of Nursing (DON) on 05/31/19 at 8:21 PM, revealed she expected the aides to follow the residents care plans and to be aware of any changes on the dietary slips.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled residents maintained acceptable parameters of nutritional status (Resident #8). On 05/13/19, the facility identified a significant weight loss of 10.5% for Resident #8, however, the facility failed to place Resident #8 on weekly weights after identifying a significant weight loss. The findings include: Review of the facility policy, Weight Monitoring, revised 09/28/17, revealed if significant weight change is identified the Registered Dietician will be notified as appropriate, for any recommendations. Residents will be weighed weekly for four (4) weeks, and reviewed until the resident's weight has stabilized or the issue is resolved through other parameters. Record review revealed the facility admitted Resident #8 on 02/19/19, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 02/26/19, revealed the facility assessed Resident #8's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Review of Resident #8's Comprehensive Care Plan for Nutritionally at Risk due to use of diuretics dated 03/05/19, revealed a goal for the resident's weight to remain within five (5) pounds plus or minus current weight through next review date with interventions to monitor weight for significant weight loss, chewing/swallowing problems and Registered Dietician (RD) to evaluate and treat as needed. Review of Resident #8's Weight Record revealed the resident weighed 157 pounds on 04/10/19 and 140.50 pounds on 05/13/19, which was a significant weight loss of 10.50 percent in one (1) month. However, further review of the record revealed the resident was not placed on weekly weights per facility policy. Review of the Weight Record revealed Resident #8's weight was not obtained again until 05/30/19, at which time the resident weighed 137.5 pounds. Interview with the Registered Dietitian (RD) on 05/31/19 at 1:11 PM, revealed he had identified Resident #8's weight loss on 05/13/19 and he added fortified foods to add more calories since the resident's intake was at sixty (60) percent or greater with all meals. The RD stated the resident should have been placed on weekly weights, but for some reason it may have been overlooked. He stated the residents weight was obtained as recently as 05/30/19. Interview with the Director of Nursing (DON) on 05/30/19 at 8:21 PM, revealed she would have expected a resident with significant weight loss to be placed on weekly weights. She stated this could be a nursing measure, one put in place by the RD, or the physician. The DON stated somehow it was missed by all disciplines.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration and pneumonia for one (1) of one (1) sampled resident with a feeding tube (Residents #84). Observation revealed a licensed staff failed to check for tube placement prior to administering flushes and medications to Resident #84's gastrostomy tube. The findings include: Review of the facility's policy, titled Medication Administration Through Enteral Feeding Tubes, dated (MONTH) (YEAR), revealed nursing should verify tube placement per facility protocol prior to flushing the tube and administering medications. Record review revealed the facility readmitted Resident #84, on 02/15/19, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 05/05/19, revealed the facility was unable to complete a Brief Interview of Mental Status (BIMS), as Resident #84 is rarely/never understood. Further review of the MDS assessment, Section G revealed the resident was totally dependent on staff for all care needs. Review of the Comprehensive Care Plan for potential for complications related to using/having a feeding tube revealed interventions to include check tube placement by draw back aspiration and auscultation prior to administering any bolus enteral feeding. Observation during a medication pass, on 05/29/19 at 11:57 AM, revealed Registered Nurse (RN) #1 did not check for tube placement prior to administering flushes and medications to Resident #84's gastrostomy tube. Interview with Registered Nurse (RN) #1, on 05/31/19 at 12:51 PM, revealed she knew she should have checked for placement of the tube prior to administering flushes and medications. Interview with the Director of Nursing (DON), on 05/31/29 at 8:21 PM, revealed she expected nurses to check tube placement prior to administering any fluids and/or medications to prevent aspiration.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. On 05/30/19, observation of one (1) of three (3) medication carts on the A, B, and C Hall, revealed medication was not dated when opened. The findings include: Review of the facility's policy titled, Medications With Special Expiration Date Requirements, dated (MONTH) 2010, revealed the date of opening should be noted on the container/vial. Observation of the C Hall medication cart, on 05/30/19 at 4:22 PM, revealed an opened bottle of [MEDICATION NAME] not dated, with approximately one-fourth (1/4) of liquid remaining. Interview with Licensed Practical Nurse (LPN) #1, on 05/30/19 at 4:24 PM, revealed all liquid medications should be dated when opened. Interview with the Director of Nursing (DON), on 05/30/19 at 5:19 PM, revealed she expected the nurses to date liquid medications when opened to ensure it is not used beyond the expiration date.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the comprehensive care plan for one (1) of twenty-two (22) sampled residents, Resident #46. The facility did not revise the care plan after Resident #46 exited the building unsupervised. The findings include: Review of the facility's policy, Care Plans - Comprehensive, not dated, revealed a person-centered comprehensive care plan that included measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs, would be developed for each resident. The nurse/Interdisciplinary Team was responsible for the review and updating of the care plan. The care plan should reflect the current status of the resident and be updated with changes in the residents' status. Review of the facility's policy, Elopement/Wandering, reviewed 07/13/16, revealed an elopement/wandering assessment was completed at admission and quarterly thereafter, and care plans and individual behavior plans would address wandering and patterns identified and causes determined (if any) would be addressed. Review of the facility's policy, Care of Wandering Resident, undated, revealed the plan of care should also provide safety within the facility, prevent the resident from eloping, and identify, decrease, or eliminate stressors that triggered wandering. Review of the medical record for Resident #46 revealed the facility admitted the resident on 02/09/18, with [DIAGNOSES REDACTED]. Review of Resident #46's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of three (3) out of fifteen (15) and determined the resident not interviewable. The resident exhibited wandering behavior one (1) to three (3) days, which placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside the facility). Review of a Nursing Note, dated 02/13/18 at 7:22 PM, revealed Resident #46 attempted to exit the back door of the facility and staff re-directed the resident before he/she could exit. The facility placed a Wanderguard device to the resident's left ankle. Review of the Comprehensive Care Plan for Resident #46, revealed the plan was updated on 02/14/18, for exit seeking/elopement with a goal to not exit the facility unattended. The interventions included Wanderguard placement and to check placement, picture in the wonder notebooks, diversional activity kit in the resident's room for use when actively exit seeking, and psychiatry to evaluate and treat as needed. Review of a Nursing Note, dated 02/23/18 at 6:51 AM, revealed staff observed Resident #46, with Wanderguard intact, exit seeking on the South side of the building and an alarm went off. Interview with Certified Nursing Assistant (CNA) #2, on 03/21/18 at 6:10 AM, revealed Resident #46 walked around the facility frequently and would push at exit doors. CNA #2 stated Resident #46 did exit the building sometime in (MONTH) but was unsure of the exact date. CNA #2 stated she entered the building around 5:00 AM and was informed Resident #46 was missing. When CNA #2 entered the dining room, she stated she saw Resident #46 outside the windows of the dining room. However, continued review of Resident #46's care plan revealed it was not updated after the resident exited the facility on 02/23/18. Observation, on 03/20/18 at 11:04 AM, revealed Resident #46 ambulating in the hallway coming from the South Unit to the North Unit. At 11:54 AM, the resident was in the North Unit common area with a Wanderguard bracelet observed on his/her right ankle. At 2:12 PM, Resident #46 was walking in the hallway leading from the North unit to the South unit. Interview with Licensed Practical Nurse (LPN) #2, on 03/22/18 at 2:30 PM, revealed any licensed staff could update/revise resident care plans and it might be necessary with a new order. Interview with LPN #1, on 03/22/18 at 3:38 PM, revealed the resident specific care plan directed the care for the resident. She stated it was initiated at admission, and updated to reflect the current status of the resident. LPN #1 stated if a resident goal was not met, then interventions should be updated and any nurse could initiate changes to the care plan. Interview with the MDS Coordinator, on 03/22/18 at 10:22 AM, revealed resident care plans were initiated upon admission based on nursing assessments, diagnoses, physician orders, and medications. She stated any staff on the Interdisciplinary Team could update or revise the care plan at any time. Interview with the Social Services Director, on 03/22/18 at 10:28 AM, revealed staff updated all resident care plans at least quarterly. She stated a resident exiting the building should prompt a revision to the care plan. Interview with the Unit Manager (UM), on 03/22/18 at 3:49 PM, revealed the purpose of the resident care plan was to show the resident needs and were initiated at admission and updated as needed, such as medication changes or changes in resident condition. The UM stated an outdated care plan would not allow the delivery of the correct care for the resident. Additionally, the UM stated any nurse could update or revise a resident care plan and a resident elopement should prompt revision to the care plan. Interview with the Administrator, on 03/22/18 at 4:20 PM, revealed the resident care plan was initiated upon resident admission and it allowed staff to provide the appropriate care to the resident. The Administrator stated changes to the care plan could be made by any nurse to reflect as needed changes, and resident preferences.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free from accidents and/or hazards for one (1) of twenty-two (22) sampled residents, Resident #46. Resident #46 exited the facility unsupervised. In addition, two (2) of five (5) medication carts and one (1) of two (2) medical emergency treatment carts were unlocked and unattended on multiple observations. The findings include: 1. Review of the facility's policy, Elopement/Wandering, reviewed 07/13/16, revealed an elopement/wandering assessment was completed at admission and quarterly thereafter, and care plans and individual behavior plans would address wandering and patterns identified and causes determined (if any) would be addressed. Review of the facility's policy, Care of Wandering Resident, undated, revealed the plan of care should also provide safety within the facility, prevent the resident from eloping, and identify, decrease, or eliminate stressors that triggered wandering. Review of the medical record for Resident #46 revealed the facility admitted the Resident on 02/09/18, with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of three (3) out of fifteen (15) and determined the resident not interviewable. The resident exhibited wandering behavior one (1) to three (3) days that placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside the facility). Review of a Nursing Note, dated 02/13/18 at 7:22 PM, revealed Resident #46 attempted to exit the back door of the facility and staff re-directed the resident before he/she could exit. The facility placed a Wanderguard device to the resident's left ankle. Review of an Elopement Risk Evaluation, dated 02/13/18, revealed Resident #46 was at risk for elopement. Review of a Nursing Note, dated 02/23/18 at 6:51 AM, revealed staff observed Resident #46, with Wanderguard intact, exit seeking on the South side of the building and an alarm sounded. Observations, on 03/20/18 at 11:04 AM, revealed Resident #46 ambulating in hall. Observations, on 03/20/18 at 2:12 PM, revealed Resident #46 walking in the hallway leading from the North Unit to the South Unit. Interview with Certified Nursing Assistant (CNA) #2, on 03/21/18 at 6:10 AM, revealed on 02/23/18, she came into the building from break and staff was actively looking for Resident #46 and CNA # 2 stated she was told Resident #46 was missing. CNA #2 stated she walked into the dining room and observed Resident #46 outside the window. Interview with CNA #1, on 03/21/18 at 6:21 AM, revealed Resident #46 typically wandered around the facility and tried to open doors. Interview with Licensed Practical Nurse (LPN) #3, on 03/21/18 at 6:26 AM, revealed she entered the building around 5:00 AM on 02/23/18, and heard door alarms sounding. LPN #3 stated she entered the dining room with CNA #2 and observed Resident #46 outside the dining room windows. Interview with LPN #2, on 03/22/18 at 8:25 AM, revealed Resident #46 wandered around the building and she checked on the resident periodically. LPN #2 stated on 02/23/18 at around 5:00 AM, she heard a door alarm sound. She stated she entered the dining room and observed Resident #46 outside the door from the dining room to the outside. LPN #2 stated she last saw Resident #46 approximately ten (10) minutes prior to the alarm sounding. She stated she typically kept Resident #46 with her, but could not verbalize why the resident was unsupervised prior to being located outside the dining room door. Interview with the Administrator, on 03/22/18 at 4:20 PM, revealed she received a phone call from the facility alerting her Resident #46 was outside the building. 2. Review of the facility's policy, Storage of Medication, dated (MONTH) (YEAR), revealed the medication supply would be accessed only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by person with authorized access. Observation, on 03/20/18 at 8:53 AM, revealed a medication cart unlocked and unattended on the North Unit, outside room [ROOM NUMBER]. Observation, on 03/22/18 at 8:08 AM, revealed a medication cart unlocked and unattended on the North Unit, outside room [ROOM NUMBER]. Interview with LPN #1, on 03/22/18 at 3:38 PM, revealed it was never appropriate to leave a medication cart unlocked and unattended as anyone, including residents, could access the medications or the medications could disappear. LPN #1 stated staff were regularly trained on medication cart security, but was not able to verbalize why a medication cart would be left unlocked and unattended. Interview with the Unit Manager (UM), on 03/22/18 at 3:45 PM, revealed a medication cart should never be left unlocked and unattended. The UM stated a locked cart prevented a resident from accessing medications that might lead to an allergic reaction, overdose, or missing medications. The UM stated the facility trained staff at orientation regarding medication cart security. She stated she constantly watched to ensure staff locked the carts, but was not aware of any formal audit of medication cart security. Interview with the Administrator, on 03/22/18 at 4:20 PM, revealed medication carts were to be locked at all times when unattended for the safety of the residents. The Administrator stated there was no formal audit of medication cart security and staff received training during orientation and as needed. The Administrator was not able to verbalize why medication carts were left unlocked and unattended. 3. Review of the facility's policy, Safety and Supervision of Resident, undated, revealed safety risks and environmental hazards were to be identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Observation, on 03/20/18 at 12:04 PM, 03/21/18 at 9:28 AM, and 03/22/18 at 1:38 PM, revealed a crash cart in the North Unit common area had two (2) small top drawers, one (1) medium middle drawer, and two (2) large bottom drawers. The top two (2) drawers were unlocked and contained five (5) 22 gauge intravenous needles, one (1) pair of bandage scissors, one hundred (100) alcohol swabs, and two (2) Normal Saline flush syringes. Interview with the MDS Coordinator, on 03/22/18 at 1:38 PM, revealed the crash carts on the North and South units were used to house supplies. She revealed the carts were supposed to be locked when not in use. She stated the facility had cognitively impaired residents and she was concerned about the drawers being unlocked because they contained sharps. Interview with the Staff Development Nurse, on 03/22/18 at 1:44 PM, revealed the night shift nurse was responsible for ensuring the cart was locked after performing the daily counts. She stated residents should not have access to the cart because they could stick themselves with the sharp items. She further stated residents should not have access to alcohol swabs or Saline flushes. Interview with the Interim Director of Nursing, on 03/22/18 2:35 PM via telephone, revealed the crash carts on the North and South Units contained intubation supplies, syringes, and a suction machine located on the top of the cart. She stated it was concerning to learn drawers containing unsafe items had been left unlocked in a common area. She stated there were approximately eight (8) residents who were cognitively impaired and she would be concerned for some of them to have access to sharp and hazardous items due to their poor safety awareness. She revealed residents could stab themselves, or someone else, with the needles or scissors.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure controlled substances, that required refrigeration, were stored within a locked, permanently affixed box within the refrigerator in one (1) of two (2) medication rooms. In addition, two (2) of five (5) medication carts were unlocked and unattended by staff. The findings include: 1. Review of the facility's policies, Controlled Medication Storage, dated (MONTH) (YEAR), revealed controlled medications requiring refrigeration were stored within a locked, permanently affixed box within the refrigerator. Observation of the South Unit Medication Room, on 03/22/18 at 2:00 PM, revealed the refrigerator contained one (1) opened bottle of [MEDICATION NAME] 2 milligram per milliliter, not in a locked container within the refrigerator. Interview with Licensed Practical Nurse (LPN) #4, on 03/22/18 at 2:00 PM, revealed all refrigerated narcotics should be stored in a locked box inside a locked refrigerator to prevent unauthorized persons from having access to the medications because narcotics should be kept secured. Interview with the Unit Manager (UM), on 03/22/18 at 2:15 PM, revealed best practice was to have narcotics requiring refrigeration under double lock in the refrigerator when not in use. The purpose would be to prevent unauthorized persons from having access to the narcotics. Interview with the Interim Director of Nursing (DON) via telephone, on 03/22/18 at 2:45 PM, revealed narcotic medications requiring refrigeration should be stored in a double locked refrigerator. Nurses had been trained on how to store refrigerated narcotic medication. The Interim DON also stated refrigerated narcotics should be doubled locked to prevent unauthorized staff or others from having access to the medications or taking them from the refrigerator and using them. Refrigerated narcotics needed to be under lock and key due to possible use of the drug by persons other than the resident for whom they were ordered. Interview with the Administrator, on 03/22/18 at 3:20 PM, revealed the nursing staff had been trained on storage of refrigerated narcotics. She stated it was important to have refrigerated narcotics under a double locked system to prevent someone from mixing up medications and to keep the medications secured. She stated it was important to keep resident medications secured to maintain a controlled and secure environment, and prevent mishandling of narcotic medications. 2. Review of the facility's policy, Storage of Medication, dated (MONTH) (YEAR), revealed the medication supply would be accessed only by licensed nursing personnel, pharmacy personnel, and staff lawfully authorized to administer medications. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Continued review revealed medication storage conditions were monitored on a regular basis as a random quality assurance check. Observation, on 03/20/18 at 8:53 AM, revealed a medication cart on the North Hall, outside resident room [ROOM NUMBER], was unlocked and unattended. Observation, on 03/22/18 at 8:08 AM, revealed a medication cart on the North Hall, outside resident room [ROOM NUMBER], was unlocked and unattended. Interview with LPN #1, on 03/22/18 at 3:38 PM, revealed it was never appropriate to leave a medication cart unlocked and unattended. Staff locked medication carts to prevent anyone from accessing the medications. LPN #1 was not able to verbalize why a medication cart was left unlocked and unattended. Interview with the UM, on 03/22/18 at 3:49 PM, revealed staff should lock medication carts, and never leave an unlocked cart unattended, in order to prevent resident access. The UM stated she watched for unlocked and unattended medication carts but did not perform a formal audit of medication cart security. Interview with the Administrator, on 03/22/18 at 4:20 PM, revealed medication carts should never be left unlocked and unattended by staff for the safety of the residents and the security of the medications. The Administrator stated the Quality Assurance process did not previously identify any issues with medication cart security.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program for one (1) of twenty-two (22) sampled residents, Resident #61. Observations revealed staff not wearing required Personal Protective Equipment (PPE) in Resident #61's room while he/she was on isolation precautions. The findings include: Review of the facility's Infection Control Policy and Procedure Manual, revised (MONTH) 2012, revealed contact precautions required gloves and gown and droplet precautions required the addition of a mask. Review of Resident #61's medical record revealed the facility admitted the resident on 03/16/18, with [DIAGNOSES REDACTED]. Review of Resident #61's Physician order [REDACTED]. Observation of Registered Nurse (RN) #1, on 03/20/18 at 11:51 AM, revealed she entered Resident #61's room without donning PPE. Observation, on 03/21/18 at 8:32 AM, revealed an office staff person in Resident #61's room and not wearing a gown, mask, or gloves. Observation of Licensed Practical Nurse (LPN) #1, on 03/21/18 at 10:26 AM, revealed she performed patient care in Resident #61's room without donning PPE. Observation of Certified Nursing Assistant (CNA) #3, on 03/21/18 at 10:40 AM, revealed he entered and stood at the foot of Resident #61's bed without donning PPE, and discussed the resident's choice of a beverage. Observation of the Advanced Practice Registered Nurse (APRN), on 03/22/18 at 9:02 AM, revealed she was in Resident #61's room performing an assessment while wearing gloves and a gown, but not a mask. Interview with CNA #4, on 03/22/18 at 9:21 AM, revealed staff was informed of infection control precautions in shift change report, and signage and PPE located at Resident #61's door. CNA #4 also revealed the facility educated her on droplet and contact isolation PPE use. She stated when staff did not use PPE; there could be cross-contamination and the potential to spread disease to others. Interview with CNA #5, on 03/22/18 at 10:41 AM, revealed she was informed of residents on infection precautions at the beginning of her shift. She stated she would wear a gown, gloves, and a mask for residents under both contact and droplet precautions. CNA #5 stated the facility provided education about infection precautions upon hire and she attended classes at school. She further stated not using PPE could lead to the spread of infection to everyone. Interview with LPN #1, on 03/21/18 at 2:35 PM, revealed Resident #61 was on droplet precautions and staff was to wear a mask, gown, and gloves while in his/her room. Continued interview on 3/22/18 at 11:08 AM, revealed she was informed of infection precautions during report from the previous shift's nurse and she passed that information on to the CNAs. LPN #1 revealed the facility provided infection control training during her orientation and via online continuing education. LPN #1 stated it was possible she entered Resident #61's room without PPE and it would have been due to her being very nervous about surveyors in the building. She further stated the facility expected everyone to wear PPE and her actions could lead to the spread of infection. Interview with LPN #4, on 03/22/18 at 9:04 AM, revealed infection control precautions were by physician order [REDACTED]. She further stated the Talent Manager provided training for all staff at initial hire orientation, computer training, and periodic updates, which staff must read and sign. The facility expected staff to wear PPE every time staff entered a resident's room while they were on infection control precautions. LPN #4 also stated, without PPE use, she was concerned about the spread of infection, especially to persons who were already immunocompromised (susceptible to infection). Interview with RN #1, on 03/22/18 at 2:10 PM, revealed management expected staff to don gloves, gown, and masks in droplet isolation rooms. She further stated she learned about infection precautions when she saw PPE hanging on the resident's door, through shift-change report, and review of the physician orders. The RN revealed not using PPE could lead to the spread of germs and infection, and residents and/or staff could be exposed to [MEDICAL CONDITIONS]. She stated she might have forgotten to wear PPE when giving Resident #61's his/her noon medication. RN #1 stated she would have put the medication cup down without touching anything, but she should have worn PPE as Resident #61 could have coughed on her. Interview with the Quality of Care Director, on 03/22/18 at 10:50 AM, revealed the facility informed her of any residents on precautions by PPE hanging on the resident's door, and during clinical meetings that occurred every weekday. She also stated the facility provided training on infection control two (2) to three (3) times yearly. The Quality of Care Director revealed breaks in infection control technique could lead to the spread of infection to other residents. Interview with the Unit Manager (UM), on 03/22/18 at 1:46 PM, revealed she learned about infection precautions by observing the PPE bag on a resident's door and by reading the nurses' notes. She further stated all staff received infection control education during orientation and by reviewing training folders placed in the nurses' stations by the Talent Manager. The UM stated staff should wear gloves, a gown, and a mask in a room where the resident was under droplet isolation precautions. She stated failing to do so could lead to transfer of germs. Interview with the Talent Manager, on 03/22/18 at 1:54 PM, revealed she taught infection control to staff two (2) to four (4) times yearly and staff must demonstrate knowledge of infection control procedures yearly. The Talent Manager stated her and the Administrator tracked staff compliance with PPE use. The Talent Manager stated staff should wear gloves, a gown, and a mask in a droplet precaution room to avoid the spread of infection. Interview with the Interim Director of Nursing (DON), on 03/22/18 at 2:33 PM, via telephone revealed staff conveyed infection precautions by hanging PPE on the door, posting a sign to see the nurse, and communication with other staff via the shift report. The DON stated she expected staff to use gloves, gown, and a mask in droplet isolation rooms to avoid transmission of disease. The DON also stated the facility trained all staff, not just clinical staff, concerning infection control.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' dignity was maintained for two (2) of three (3) sampled residents, Resident #1 and #2, and one (1) of three (3) unsampled residents, Unsampled Residents B. Observation revealed residents' urinary catheter bags not covered and visible to other residents and visitors. The findings include: Review of the facility's policy, Resident Rights, undated, revealed each resident was to be treated with respect, kindness, and dignity. The facility did not provide a policy related to providing dignity for residents with urinary catheter bags. Observation of Resident #1, on 07/07/17 at 08:23 AM, 9:00 AM, 9:53 AM, and 10:53 AM, revealed the resident in bed with a urinary catheter bag hanging on the left side of the bed frame and visible from the hallway to other residents and visitors. The urinary bag was not covered and clear yellow fluid was visible in the bag. Review of Resident #1's clinical record revealed the facility readmitted the resident on 07/04/16, with [DIAGNOSES REDACTED]. Observation of Unsampled Resident B, on 07/07/17 at 8:55 AM, revealed the resident in bed with a urinary catheter bag hanging on the left side of the bed frame visible from the hallway to other residents and visitors. The bag was not covered and clear yellow fluid was visible in the bag. Review of Unsampled B's clinic record revealed the facility admitted the resident on 03/21/17, with [DIAGNOSES REDACTED]. Observation of Resident #2, on 07/07/17 at 10:40 AM, revealed the resident in bed with a urinary catheter bag hanging from the bed frame visible from the hallway to other residents and visitors. The bag was not covered and clear yellow fluid was visible in the bag. Observations at 11:45 AM and 12:40 PM, revealed the resident in a wheelchair beside his/her bed with the urinary catheter bag continuing to hang on the bed frame and visible from the hallway. The bag was not covered and clear yellow fluid was visible in the bag. Observation at 1:35 PM, revealed the resident in bed with the urinary catheter bag hanging from the bed frame visible from the hallway. The bag was not covered and clear yellow fluid was visible in the bag. Review of Resident #2's clinical record revealed the facility readmitted the resident on 04/16/16, with [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #1, on 07/07/17 at 2:39 PM, revealed every resident with a urinary catheter was supposed to have the bag covered with a dignity bag. A physician order [REDACTED]. She did not know who was responsible for ensuring a dignity bag was in place, but if she noticed a catheter bag was uncovered, she would place the bag in a dignity bag. RN #1 did not know if the facility had ever provided training to staff about ensuring urinary catheter bags were kept in dignity bags. Interview with Certified Nursing Assistant (CNA) #2, on 07/07/17 at 2:51 PM, revealed all nursing staff was responsible for providing dignity to residents. CNA #2 stated staff should cover urinary catheter bags for privacy and dignity, and prevent infection if the catheter bag contacted the floor. CNA #2 further stated uncovered catheter bags in the dining room were unappetizing to surrounding residents. Interview with Licensed Practical Nurse (LPN) #3, on 07/07/17 at 2:43 PM, revealed the facility kept urinary catheter bags covered to maintain dignity for the resident. LPN #3 stated uncovered catheter bags could be an embarrassment to the resident, as well as unappetizing to other residents when in the dining room. LPN #3 stated all nursing staff was responsible to ensure dignity covers were on urinary catheter bags on admission, when a urinary catheter was initiated, and daily. Interview with the Director of Nursing (DON), on 07/07/17 at 3:49 PM, revealed the facility did not have policies on dignity and urinary catheter bags. The DON stated staff placed dignity covers on urinary catheter bags to maintain the dignity of residents. The DON stated the facility educated staff often about maintaining a dignity cover over urinary catheter bags. She stated she did not audit to ensure staff placed dignity covers on urinary catheter bags. Interview with Administrator, on 07/07/17 at 4:00 PM, revealed dignity covers on urinary catheter bags ensured the privacy and dignity of the resident. The Administrator stated all nursing staff was responsible for placement of dignity covers on the bags. The Administrator further stated the facility educated staff upon hire, yearly, and as needed, about resident dignity. She revealed the facility conducted Quality Assurance meetings monthly and uncovered urinary catheter bags had not been a topic of concern for review.

Based on observation, interview, review of facility policy, and review of the medical record, it was determined the facility failed to provide passive range of motion and restorative services for two (2) of twenty-one (21) sampled residents (#1 and #2). The facility assessed and determined on 05/06/11 that Resident #1 would benefit from passive range of motion. The facility failed to develop a treatment plan, failed to care plan for passive range of motion, and failed to provide passive range of motion for Resident #1. On 08/04/11 the facility assessed Resident #1 as having developed contractures to the right wrist and right hand. In addition, the resident developed a cut to the right palm of the hand where the resident's fingernails had caused injury due to new onset of contractures. The facility failed to provide restorative services as recommend by the therapy department for Resident #2. The findings include: Review of the facility's policy Specialized Rehabilitative Services, dated 10/31/09, revealed Restorative nursing is provided by the nursing staff. In addition, documentation supports the referral to therapy services. Documentation was to include: Therapy referred to, change or decline observed, signs and symptoms of the change or decline observed and related diagnosis, if known. Interview with the North Unit Manager, on 08/04/11 at 10:10 AM, revealed she oversee's the Restorative Program. Residents are referred to Restorative if they are not picked up by therapy or discharged from therapy. They don't usually look at the therapy assessments and recommendation, only the new orders written by therapy. Review of the medical record for Resident #1 revealed the facility admitted the resident on 05/05/11 with the following Diagnoses: [REDACTED]. Review of the Physical Therapy Evaluation for Resident #1 completed on 05/06/11 revealed no voluntary movement observed except for right knee flexion. The clinical summary section of the evaluation stated the patient had the [DIAGNOSES REDACTED]. Patient could benefit from positioning in Geri chair and passive range of motion. Review of the Occupational Therapy (OT) Evaluation for Resident #1 completed on 05/06/11 revealed the therapist assessed the resident's passive range of motion within normal limits, no contractures present, patient non responsive and does not respond to stimuli. The OT evaluation clinical summary stated evaluation only, no treatment recommended, patient would benefit from being put up in a Geri chair and Passive Range of Motion. Review of the condition change form, dated 05/06/11 and completed after the OT evaluation, revealed the therapist documented, OT evaluation complete, no further treatment recommendation at this time. Review of the medical record for Resident #1 revealed no new orders, treatment, or care plan updates regarding range of motion following the assessment completed by OT on 05/06/11. Interview with OT #1, on 08/04/11 at 11:00 AM, revealed she had completed the assessment for Resident #1 on 05/06/11. They could not pick the resident up for therapy because the resident was non responsive and there was no opportunity for improvement. OT #1 went on to say they had to have two (2) different areas for Restorative to pick them up and that's why she did not refer this resident to Restorative. She told nursing verbally Resident #1 did not meet the requirements for Therapy or Restorative and nursing said they would do passive range of motion during the residents bath. OT #1 could not recall who she told in nursing about her findings. She thought the resident had a potential to develop contractures when she completed her assessment on 05/06/11, because of the resident's condition. Interview with the North Unit Manager, on 08/04/11 at 2:10 PM, revealed she stated it was not true the residents must have a need in two or more area's to be on restorative. The restorative programs had residents with only one area and are receiving restorative. Nursing can recommend restorative, but they didn't put Resident #1 on, because the resident didn't have contractures. If the resident's are not on therapy or restorative they should be getting range of motion by the CNA's. Resident #1 was not care planned for any type of range of motion and it was not on the CNA's assignment sheet. The North Unit Manager acknowledged Resident #1 should have had some type of range of motion to prevent contractures. She stated she had recommended Resident #1 be evaluated many times in the morning stand up meeting, but Therapy did not agree. Review of the medical record for Resident #1 revealed no documentation of any communication regarding therapy evaluations or referrals from nursing. Review of the admission Minimum Data Set (MDS) assessment, dated 05/25/11 revealed the facility assessed Resident #1 as non interviewable and required total dependence with assist of 2 for bed mobility, transfers, and dressing. Review of the Comprehensive Care Plan for Resident #1, initiated on 05/25/11, revealed the resident had impaired communication related to [MEDICAL CONDITION], and impaired mobility. The care plan detailed staff was to reposition every two hours, provide total assistance for all grooming/hygiene care, and staff was to anticipate all needs. There was no documented interventions for any type of range of motion for Resident #1. Review of the Certified Nursing Assistant assignment sheet for Resident #1 revealed no documented evidence that staff was to provide range of motion for this resident. Observation of Resident #1, on 08/02/11 at 11:45 AM, revealed the resident resting in bed, sleeping, with eyes closed. The resident was non verbal but would open eyes. No staff was observed providing range of motion for this resident. Observation, on 08/02/11 at 1:05 PM, of the skin assessment for Resident #1, completed by Licensed Practical Nurse (LPN) #5, revealed the right hand was gripped tightly and had a fowl odor. LPN #5 opened the right hand and found the palm was red with a 0.9cm by 0.2cm open cut. The resident's fingernails were long. Interview with LPN #5, at the time of the skin assessment, revealed Resident #1 was to have gloves to both hands at all times to prevent injury, but she didn't know where they were. Review of the Comprehensive Care Plan revealed Resident #1 had an intervention dated 06/23/11 to wear gloves at all times to prevent injury, remove only for bathing. Review of the OT Evaluation completed on 08/04/11 revealed the facility has assessed Resident #1 as having right wrist and hand contracture. Interview with OT #1 on 08/04/11 at 11:00 AM revealed she felt Resident #1 did not get passive range of motion because the resident now has contractures of the right wrist and hand. Interview with CNA #6, on 08/02/11 at 2:30 PM, revealed she had worked at the facility for one week. She had an assignment sheet she gets that tells her what the care needs are for each resident. She stated it would tell them who gets splints and who gets turned every two (2) hours. Interview with CNA #7, on 08/02/11 at 2:45 PM, revealed he had cared for Resident #1 frequently and was familiar with the needs of Resident #1. He receives the information on how to care for the residents from the CNA assignment sheets. Resident #1 is scheduled for showers on Mondays and Thursdays and receives bed baths on other days. He had no knowledge that Resident #1 was to wear gloves for protection, or to prevent injury. He stated he did not trim the nails for Resident #1. When asked about Range of Motion for Resident #1, CNA #7 stated if the resident received Range of Motion it was done by Restorative. Interview with CNA #12, on 08/04/11 at 9:50 AM, revealed she reviews the CNA assignment sheet and that tells her what is required for eating, turning the resident, how the resident is to be transferred, and any splints that are applied. Interview with CNA #3, on 08/04/11 at 9:55 AM, revealed she reviews the CNA assignment sheet and that's how she knows what the care needs are for residents. Review of the CNA assignment sheets revealed no instruction to perform Passive Range of Motion for Resident #1. 2. Clinical record review revealed the facility admitted Resident #2 on 11/21/08 with the following Diagnoses: [REDACTED]. The Resident began Hosparus care on 05/11/11. Review of the annual MDS assessment completed on 08/31/10 revealed the resident had limited range of motion with partial loss of voluntary movement to the neck. A Physical Therapy (PT) discharge summary, dated 12/30/10, stated the resident's right cervical had neck flexion which measured negative 22 degrees from the neutral position after heat and stretching. A restorative program had been initiated for passive range of motion (PROM) and stretching to the right cervical area. Continued review of the PT notes revealed the resident was only able to tolerate 5 minutes with a towel roll and was resistant to therapy. The documented reason for discharge was the resident had met the maximal potential of therapy. Physician orders [REDACTED]. Review of a condition change form (within the nurses notes) dated 12/30/10 revealed the resident was to begin restorative therapy for PROM and positioning. Review of the most current MDS assessment completed on 05/20/11 revealed the resident had a range of motion impairment to bilateral upper and lower extremities and required one to two person assist with activities of daily living. Review of the resident's comprehensive care plan, dated 06/03/11, revealed a problem of impaired physical mobility related to Alzheimer's, falls, physical restraints, decreased vision, and a pelvic belt when up in the chair. The facility set a goal for impaired physical mobility with the intent the resident would not develop further complications of immobility such as pressure sores, contractures and pneumonitis. Interventions included; turn and reposition; monitor for evidence of complications: contractures, venous stasis, blood clot, pneumonia, urinary tract infection and report. Additional interventions included: bed mobility with 1-2 assist; transfer with gait belt and 1-2 assist; tab alarm; Broda pedal chair for mobility with pelvic belt; Broda chair with bilateral shin guards, torso support, arm protectors when up in Broda chair; cervical collar while up and in bed; and bolster pillows to bed. The resident's comprehensive plan of care did not reflect PROM or restorative therapy. Review of current physician orders [REDACTED]. Review of the current certified nursing assistant (CNA) flowsheet revealed no evidence the staff was to provide PROM. The restorative nursing book revealed there was no restorative plan developed and no written evidence that restorative nursing had been provided. Observations of Resident #2, on 08/02/11 at 3:15 PM, 08/03/11 at 10:00 AM and 11:00 AM, revealed the resident up in a Broda chair without the cervical collar applied. Observation during a skin assessment performed by licensed practical nurse (LPN) #1, on 08/03/11 at 5:30 PM, revealed the resident lying in bed with the neck flexed toward the right side and a cervical pillow around the neck. Interview with LPN #1 revealed the resident had a right sided flexion contracture. Interview, on 08/04/11 at 8:30 AM, with the North Unit Manager revealed she was responsible for the restorative program. She was not aware of Resident #2's need to receive restorative services. Interview with CNA #1, on 08/04/11 at 2:25 PM, revealed she was assigned to the resident on 08/02/11. When asked about the cervical collar not being in place, she stated the cervical collar had been sent out to be washed and there was not another cervical collar available. She was able to say when the cervical collar should be applied, however, she could not say what potential negative outcome or problems could occur with the resident by not wearing the cervical collar as ordered. Interview, on 08/04/11 at 3:30 PM, with the South Unit Manager revealed failure to perform PROM as ordered could potentially cause contracture of the joints or worsen current contractures. Interview, on 08/04/11 at 3:40 PM, with the North Unit Manager revealed she was not in charge of the restorative program at the time the order was received. When she resumed responsibility for the program, she did not receive a plan of care for the resident. After reviewing the restorative order, dated 12/30/10, the North Unit Manager stated it did not appear the order was transcribed and communicated to the nursing restorative department. Interview, on 08/04/11 at 3:45 PM, with the Therapy Manager revealed recommendations are given to the nursing department upon discharge from skilled therapy. To ensure communication, the restorative department signs the recommendations and a copy is filed with the therapy department. However, the therapy department does not keep the signed copy after three months if the resident is no longer active with the physical therapy department. Interview with the Director of Nursing (DON), on 08/04/11 at 4:00 PM revealed she was normally notified when a resident was discharged from skilled therapy and recommended to the restorative program. The DON stated she was not aware Resident #2 was to be on the restorative program. Further interview with the DON at 5:00 PM revealed she was unable to locate any evidence that restorative therapy had ever been initiated. Refer to F282 and F309

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision to prevent accidents for one resident (#8) of four sampled residents. (#8, #9, #10, and #11). The facility failed to follow the "Elopement Policy". These failures resulted in Resident #8, who the facility assessed as at risk for elopement, exited the facility without staff knowledge. The resident was successful in ambulating approximately three tenths of a mile, in 15 degree weather, in the snow, wearing socked feet to a local hospital emergency room . The resident sustained [REDACTED]. The facility failure to provide supervision and appropriate assistive devices placed residents at risk for serious injury, harm, impairment or death. The findings include: Review of the "Elopement Policy" and "Wandering Resident Bracelet Testing" revealed the Licensed Nurse should: 1. Assess resident for risk and/or identify residents with a current history of elopement; 2. If resident at risk and/or has a history of elopement, place a wandering resident bracelet/device on the resident. Review of medical record revealed the facility admitted Resident #8 on 09/14/09 with [DIAGNOSES REDACTED]. Review of admission assessment history revealed the resident had previously eloped while at home prior to admission to the facility. The resident had been assessed as being confused and unable to accurately recall events. The facility developed a care plan on 09/02/09 which assessed Resident #8 as being at risk for wandering and elopement related to impaired safety awareness, disorientation to place, and schizophrenia. Review of the 08/23/10 Annual Minimum Data Set (MDS) Assessment revealed the facility had assessed and determined the resident was independent with minimal assist for ambulation; however, had an unsteady gait. Review of the annual RAPS (resident assessment protocol summary) dated 08/30/10 revealed the facility had assessed and determined Resident #8 had triggered for cognition and mood with short and long term memory problems and Dementia with mood disorders. The RAP summary also detailed the resident was at risk for declining progressive dementia. The Mood RAP detailed the resident was identified as having persistent anger, sad worried facial expressions. Review of the last elopement assessment dated [DATE] identified Resident #8 at risk for elopement with the following care plan interventions: 1. Picture on Adventure Club; 2. Check wander guard placement at night; 3. Check wander guard placement every shift; 4. Redirect to sit down in chair when agitated and; 5. Offer diversional activity of interest such as music, small group activity. Review of the facility investigation dated 12/14/10 revealed Resident #8 wanders, has a history of elopement with impaired decision making skills that decrease safety awareness. The resident was last seen in the North Lobby at 12:05 a.m. on 12/13/10. The facility was notified by the local hospital emergency room at 12:26 a.m. on 12/13/10 that the resident had arrived at the emergency room , clothed wearing pants, a shirt, a jacket and socks. There was no evidence that resident had the wander guard bracelet applied to his/her person. The investigative report detailed fifteen (15) staff members who were unaware the resident was missing, having not witnessed the incident or hearing any alarms from any exit doors. The investigation detailed that Resident #8 exited the building through the north back entrance. On 12/15/10 at 8:35 a.m., LPN #2 revealed the resident had been agitated earlier in the evening around 7:30 p.m. screaming and yelling, "Santa Claus is a crook" and "Santa Claus shot me". LPN #2 stated the staff administered Haldol for agitation to Resident #8. The LPN stated the resident was calmer by 8:30pm and was eating pizza in the lobby and watching television. LPN #2 revealed that staff usually kept him/her at the nurse's station most evenings until he/she became tired; the LPN also stated the resident had behaviors and would run up and down the hall yelling at times; however, that night the resident just sat in his/her wheelchair at the nurses station/lobby. LPN #2 stated the resident was last seen in the north lobby at 12:05 a.m. on 12/13/10. She revealed the medication delivery came around midnight at which time she was checking in the medications with her back to the north hallway making her unaware of Resident #8 exiting the building. She stated the hospital reported to her that the resident arrived in the emergency room at 12:26 a.m. and told them where he/she lived (Woodland Terrace); she stated the resident's name was labeled on his/her clothing for identification. LPN #2 also revealed the resident told her he/she ran all the way to the hospital because he/she was sick. The resident also told her that he/she fell on the way and scraped both knees. The LPN #2 revealed the facility assessment of Resident #8 upon his/her return to the facility identified the resident sustained [REDACTED]. On 12/15/10 at 8:00 a.m., CNA #1confirmed that Resident #8 had been last seen around 12:05 a.m. on 12/13/10 in the lobby and revealed she was responsible for Resident #8 that night. CNA #1 revealed she made bed check rounds around midnight; however, there were two residents reported to need assistance which pulled her away from the north hall rear exit. She also stated the other CNA was on the front hall in a room with another resident and would not have been able to see Resident #8 leave through the rear north door. CNA #1 stated she would not have seen Resident #8 exit the building; she also revealed she did not know the resident was gone until the hospital called. She was assigned to check the doors after they were aware of Resident #8's elopement at which time she identified the rear north hall door was unlocked and opened without alarming. CNA #1 stated that Resident #8's room had only his/her wheelchair with the wander guard still attached to the wheelchair. Review of the investigative report dated 12/14/10 revealed CNA #6, who also worked on the north hall on 12/13/10 night shift revealed she remembered Resident #8 sitting in the lobby in the wheelchair, and noted that the resident had predominately been mobile in the wheelchair. Interview with the Maintenance Director, on 12/14/10 at 6:30 p.m., and review of the door system information in the investigative report revealed he checks door security systems weekly by using a maintenance task sheet. The task sheet includes verifying magnetic door switches intact, alarm buzzers functioning, keypads functional, wire connections secure, magnetic locks secure and aligned properly, system sounds alarm after 3 seconds of continuous pressure to door or panic hardware, and alarm sounds if magnetic lock does not engage. Review of the task sheets revealed that all the facility doors, including the north rear door, were checked and verified to work properly on 12/03/10 and 12/10/10. Further review of the investigation revealed the wander guard system is checked for function every night for all residents identified as at risk for elopement. The check was completed around 9:00 p.m. on 12/12/10 and the door was functioning properly at approximately 10:00 p.m. when another staff member exited the door using the code. Further review of the investigative report revealed that all doors were checked to ensure proper operation by licensed nurses at which time the north rear enxit was identified as malfunctioning. The report stated magnets were not engaging to ensure proper door closure. While the facility completed all the door and alarm checks as per their policy, there was no evidence that the facility ensured they were following their Elopement policy by applying the wander guard bracelet to the resident as it was only applied to the resident's wheelchair. Furthermore, despite the efforts of the facility's use of assistive devices (i.e. wander guard and door alarms), the facility did not ensure staff supervised the resident to prevent elopement. Thus resulting in Resident #8 successfully exiting the facility without staff knowledge. Further review of the investigative report and interview with the Administrator, on 12/14/10 at 8:30 p.m., revealed the facility took the following immediate action: 1. A head count for the entire facility by licensed nurses completed at 12:40 a.m. on 12/13/10, and all residents were accounted. 2. Resident's at risk for elopement were checked for proper wander guard placement, verified functioning of all wander guard bracelets and increased monitoring was initiated on all wander risks. 3. LPN #2 immediately positioned a staff person to monitor the door monitor and ensure all residents' safety until the doors could be repaired. 4. The Maintenance Director arrived at 1:30 a.m. and verified all doors operational except for the rear north exit door. 5. The Administrator arrived at 2:15 a.m. and completed education of policy and procedure, related to Elopement/Missing Resident for all staff on site at approximately 5:00 a.m. 6. The facility notified the Van guard representative at 2:45 a.m. regarding the door malfunction. Van guard arrived on site at 4:50 a.m. Vanguard Alarm System technician arrived and corrected the situation. Reported that these systems are low voltage systems and are susceptible to power disturbances or a weather disturbance, which could lead to the system resetting itself back to default mode (in default mode the system does not actively lock the door or alarm when they are opened). This was verified with RF technologies, the manufacturer of the door system, who suggested a reconfiguration of the system, which was completed at 2:30 p.m. by Vanguard on 12/13/10. In addition, the report determined the system of preventative maintenance was in place for ensuring door security and facility monitors the door system weekly per the preventative maintenance program. The system for preventative maintenance on the wander guards is that they are checked daily by the licensed nurses for proper functioning. 7. Interview with the Director of Nursing (DON) on 12/14/10 revealed Resident #8 returned to the facility at 3:30 a.m. on 12/13/10 and the facility initiated one to one supervision for Resident #8. A head to toe assessment was completed on resident #8 confirming scrapes to both knees with no complaints of pain. The facility applied a wander guard to Resident #8's lower extremity and maintained the wander guard to the resident's wheelchair. Both wander guards are checked daily for function, although the resident did have a history of removing medical devices. or injury and a nursing assessment was performed by the hospital and the facility upon arrival. The DON also revealed the care plan included interventions for behavior episodes which have been successfully implemented to redirect resident and alleviate behaviors. Interventions have been implemented to address the elopement risk of the resident. Observation of Resident #8 on 12/14/10 at 7:30 p.m. revealed the resident lying in bed with Oxygen at 2 liters per nasal cannula and sleeping. The resident had the wander guard bracelet applied to his/her lower extremity. CNA #3 was observed sitting with resident #8 for one to one supervision. Interview with CNA #3, at 7:30 p.m. revealed the resident had exhibited no further attempts at elopement and there had been someone sitting with the resident since the resident returned to the facility. Review of the clinical record for Resident's #9, #10, and #11 on 12/14 - 12/15/10 revealed the residents had been assessed for risk of elopement and had wander guard bracelets. Resident #10 was admitted on [DATE] and had a past history of wandering and was on every 15 minutes checks to include checking for placement of the wander guard. Resident #9 was newly admitted on [DATE] and had been assessed as an elopement risk due to constantly standing by the doors and talking about needing to get the car keys to drive home. Resident #9 was observed by therapy on 11/15/10 attempting to leave the facility. Staff intervened at which time the facility initiated one to one supervision of Resident #9. Interview with the Administrator revealed the resident was on the waiting list for placement in an Alzheimer Unit at the present time. Observation of Resident #9, on 12/14/10 at 7:30 p.m., revealed the resident was walking up and down the hallway with a staff member at the resident's side at all times. Interview with the Administrator on 12/15/10 at 2:30 p.m. and review of the investigative report regarding the Performance Improvement meeting revealed a Performance Improvement (PI) Meeting was held on 12/13/10 with the Administrator, Maintenance Director, Unit Manager, Social Services Director, Case Manager, Activities Director, Business Office Manager, and Admissions Coordinator in attendance. A separate PI meeting was also held with the Medical Director, who was involved with the incident, and could not be there at the time of the meeting; however signed the minutes to the meeting. The following additional measures were verified as completed prior to the state agency entrance into the facility: *Update Resident #8's care plan to reflect elopement *Update CNA assignment sheet to reflect 1:1 care *Update all care plans, treatment administration record and CNA assignment sheet to include specific placement of wander guard relative to resident body *Every shift charting for 72 hours on Resident #8 *All residents identified at risk elopement/wandering were reassessed. *Licensed Nurses had completed door function audit every 2 hours between 1600-0700. Continued checks of door function were assigned and scheduled for nursing services and Maintenance. *Validation of wander/elopement assessment complete and up to date pictures are located in the book. *Daily check to insure proper signage at each door for a period of one month *Vanguard arrived at facility successfully administered system reconfiguration. *Education was completed for all facility staff on 12/13/10 related to Elopement Procedures, Wander Guards. *Medical Director notified and reviewed PI Committe minutes on 12/13/10 Interview with the Administrator on 12/15/10 at 2:30 p.m. revealed there had been no policy changes to the current elopement policy. Interviews with facility staff on 12/14/10 at 9:25 p.m., and 9:35 p.m,; LPN #1, RN#1, CNA's #2, #3, #4, and #5; on 12/15/10 at 8:00 a.m. and 8:35 a.m. CNA's # 1, and LPN #2 revealed they had been in-serviced on 12/13/10 on the elopement policy and procedure, proper functioning of the door alarm system and wander guard system. All staff was able to demonstrate the procedures. Door alarm checks with the Maintenance Director, on 12/14/10 at 7:30 p.m. and again on 12/15/10 at 9:00 a.m. revealed the north rear door was functioning properly as well as the wander guard system when residents with wander guards approached doors. Resident #8's medical record was reviewed on 12/14 - 12/15/10 to verify updates of the care plan regarding elopement, CNA assignment sheet, Treatment Administration Record to include specific placement of wander guard relative to the resident's body, and 72 hour charting. All residents identified at risk for elopement (9 residents) were reassessed. Door function audits were reviewed and validation of the updated pictures in the adventure club book. Proper signage was verified on all exit doors, and evidence of work order with Vanguard verified with copies for system configuration. Elopement, behavior, and wander guard in-services conducted on 12/13/10 were reviewed for all staff with a plan in place to educate weekend staff (roster sheet with date and next shift to be worked), which is to be completed by administration before coming back to work. Performance improvement minutes date, time, staff in attendance, and discussion of items covered was reviewed and verified staff signatures and dates. The facility, after having investigated the incident, immediately implemented the elopement policy by conducting resident head counts, checked all doors and placed staff at the north rear door which was not functioning. After Resident #8 returned to the facility, the resident was assessed and placed on one to one supervision, and the wander guard was placed on the resident's person. All residents identified at risk for elopement were reassessed. Immediate training and education was conducted at 5:00 a.m. by the Administrator on elopement procedures, missing resident procedures, wander guard procedures, and door alarm systems. A QA meeting was held on 12/13/10 with notification to the medical director to identify and assess corrective action for supervision and prevention of accidents. Immediate Jeopardy was determined to exist on 12/13/10 in 42 CFR 483.25 (F323 S/S "J") resulting in substandard quality of care. After quality review it was determined Immediate Jeopardy was removed and the facility remained in non-compliance at 42 CFR 483.25 (F323) deficiency remained at a S/S "D".

Based on observation, record review, and interview, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with medical orders, the comprehensive assessment and plan of care for one (1) of twenty two (22) sampled residents (#20). The facility failed to provide pain medication in a timely manner to Resident #20, as the first dose was not administered until approximately 20 hours after Resident #20 was admitted . Resident #20 was documented as having an 8 out of 10 pain level scored the day of admission. The facility failed to follow the Pain Management Policy as it related to pain persisting and the need for pharmacological intervention. In addition, there was a three (3) day delay in providing incentive spirometer treatments (medical equipment used to measure how well resident's lungs are filling with air during breathing), after the resident had a collapsed lung, as ordered at time of admission for Resident #20. The findings include: Policy Review revealed Pain Management Policy (PRO ) #8 date 04/28/09 "Consult with the physician for a change in condition, pain persisting or recurring despite treatment or there is a need for pharmacological intervention, or change in pharmacological intervention." Record review of the facility's Hosparus Nursing Facility Agreement (HNFA) Version 11/2008 revealed a plan of care is developed for each resident using an interdisciplinary approach and the care plan will be jointly developed and agreed upon which is consistent with the hospice philosophy and is responsive to the unique needs of the resident. The facility's HNFA revealed the plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. The facility's HNFA revealed the plan of care is to include the facility's services, identification of the Hospice Services, including the interventions for pain management and symptom relief. Record review revealed that Resident #20 was admitted on [DATE] at approximately 4:40pm with [DIAGNOSES REDACTED]. Resident #20 had been involved in a tractor rollover accident and was treated at a local hospital for ten days prior to transfer to facility for rehabilitation services. LPN #1 completed the Pain Assessment on Resident #20 at 4:40pm on 02/19/10 and documented that Resident #20 had a pain score of 8 on a 10 point scale. The assessment detailed that Resident #20 verbalized or exhibited non-verbal symptoms of pain which was present at time of admission. LPN#1 documented the resident experienced pain on the right side of the resident's chest, left leg and had chronic pain. Further, the resident described the pain as an ache, tender and throbbing. The assessment detailed the resident was grimacing and moaning and specified the cause of pain was multiple rib fractures and movement causes and increases pain. Resident #20's acceptable level of pain was a 4 out of 10. Resident #20 had an order for [REDACTED]. Record review revealed a Nurse's Note on 02/19/10 at 11:00pm signed by LPN #1 which indicated Resident #20 complained of pain to touch and right heel pain. Record review revealed the facility had a copy of a prescription dated 02/19/10 from a local hospital for [MEDICATION NAME] 5/500 mg, one to two by mouth every four to six hours as needed for pain. Record review revealed a note cosigned by LPN #2 to use one [MEDICATION NAME] 5/500 mg tablet from Emergency Drug Kit and indicated the prescription was left in the narcotics Emergency Drug Kit. Record review revealed Resident #20 received the first dose of [MEDICATION NAME] 5/500 mg at 1:00pm on 2/20/10 at which time Resident # 20 rated his/her pain at a 6 out of 10. This first dose was administered approximately 20 hours after Resident #20 was admitted . Interview with LPN #1 on 10/28/10 at 1:20pm revealed that while she did remember Resident #20, she could not remember if the resident complained of pain or asked for pain medication. Interview with Resident #20's family member, on 10/28/10 at 4:20pm revealed Resident #20 did not receive pain medication until after the family member arrived to the facility on [DATE] and requested the medication for Resident #20. The family member reported that he/she was told by a nurse at the facility that the medication had not yet arrived. The pharmacy had already delivered for that day and there would be no more deliveries for two days since it was the weekend. Interview on 10/28/10 at 7:25pm with Resident #20 revealed that he/she had never had such a bad night. When asked if he/she had pain that night the resident stated yes he/she was hurting and had tried to get some help. When asked if he/she had requested pain medication the resident stated "I couldn't get nobody in there to ask for nothin." Resident #20 was asked if he/she reported pain when the nurse did the initial assessment, and the resident stated he/she did not remember the initial assessment. The resident reported that some girl came in and he/she told the girl that he/she was in pain and needed to go to the bathroom but the girl stated she was not going to break her back, the resident stated that he/she never saw anyone else. The resident stated he/she thought that was around 9:00pm. Resident #20 stated pain medications were not received. Interview with Director of Nursing on 10/28/10 at 3:30pm revealed that if a resident had a reported pain level 8 the expectation would be for the resident to receive pain medication within one (1) hour. She revealed that a nurse could get medication from the EDK (emergency drug kit) with a doctor's order and pharmacy okay. For Schedule 2 narcotics, the nurses can get an emergency supply from Walgreen ' s within four (4) hours as long as there was a handwritten prescription on hand. Record review revealed the facility had a copy of a prescription dated 02/19/10 from a local hospital for an order for [REDACTED]. Interview with LPN #1 on 10/28/10 at 5:45pm revealed that she did not remember using the Incentive Spirometer on Resident #20. Interview with Director of Nursing on 10/28/10 at 3:30pm revealed that the expectation would be that incentive spirometer treatments would be started within the first hour after the resident arrived at facility with orders. She stated that with an order for [REDACTED].